Patient emergency health-care use before hospital admission for COVID-19 and long-term outcomes in Scotland: a national cohort study.

BACKGROUND: It is unclear what effect the pattern of health-care use before admission to hospital with COVID-19 (index admission) has on the long-term outcomes for patients. We sought to describe mortality and emergency readmission to hospital after discharge following the index admission (index discharge), and to assess associations between these outcomes and patterns of health-care use before such admissions. METHODS: We did a national, retrospective, complete cohort study by extracting data from several national databases and linking the databases for all adult patients admitted to hospital in Scotland with COVID-19. We used latent class trajectory modelling to identify distinct clusters of patients on the basis of their emergency admissions to hospital in the 2 years before the index admission. The primary outcomes were mortality and emergency readmission up to 1 year after index admission. We used multivariable regression models to explore associations between these outcomes and patient demographics, vaccination status, level of care received in hospital, and previous emergency hospital use. FINDINGS: Between March 1, 2020, and Oct 25, 2021, 33 580 patients were admitted to hospital with COVID-19 in Scotland. Overall, the Kaplan-Meier estimate of mortality within 1 year of index admission was 29·6% (95% CI 29·1-30·2). The cumulative incidence of emergency hospital readmission within 30 days of index discharge was 14·4% (95% CI 14·0-14·8), with the number increasing to 35·6% (34·9-36·3) patients at 1 year. Among the 33 580 patients, we identified four distinct patterns of previous emergency hospital use: no admissions (n=18 772 [55·9%]); minimal admissions (n=12 057 [35·9%]); recently high admissions (n=1931 [5·8%]), and persistently high admissions (n=820 [2·4%]). Patients with recently or persistently high admissions were older, more multimorbid, and more likely to have hospital-acquired COVID-19 than patients with no or minimal admissions. People in the minimal, recently high, and persistently high admissions groups had an increased risk of mortality and hospital readmission compared with those in the no admissions group. Compared with the no admissions group, mortality was highest in the recently high admissions group (post-hospital mortality HR 2·70 [95% CI 2·35-2·81]; p<0·0001) and the risk of readmission was highest in the persistently high admissions group (3·23 [2·89-3·61]; p<0·0001). INTERPRETATION: Long-term mortality and readmission rates for patients hospitalised with COVID-19 were high; within 1 year, one in three patients had died and a third had been readmitted as an emergency. Patterns of hospital use before index admission were strongly predictive of mortality and readmission risk, independent of age, pre-existing comorbidities, and COVID-19 vaccination status. This increasingly precise identification of individuals at high risk of poor outcomes from COVID-19 will enable targeted support. FUNDING: Chief Scientist Office Scotland, UK National Institute for Health Research, and UK Research and Innovation.

Prospective validation of the 4C prognostic models for adults hospitalised with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol.

PURPOSE: To prospectively validate two risk scores to predict mortality (4C Mortality) and in-hospital deterioration (4C Deterioration) among adults hospitalised with COVID-19. METHODS: Prospective observational cohort study of adults (age ≥18 years) with confirmed or highly suspected COVID-19 recruited into the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) WHO Clinical Characterisation Protocol UK (CCP-UK) study in 306 hospitals across England, Scotland and Wales. Patients were recruited between 27 August 2020 and 17 February 2021, with at least 4 weeks follow-up before final data extraction. The main outcome measures were discrimination and calibration of models for in-hospital deterioration (defined as any requirement of ventilatory support or critical care, or death) and mortality, incorporating predefined subgroups. RESULTS: 76 588 participants were included, of whom 27 352 (37.4%) deteriorated and 12 581 (17.4%) died. Both the 4C Mortality (0.78 (0.77 to 0.78)) and 4C Deterioration scores (pooled C-statistic 0.76 (95% CI 0.75 to 0.77)) demonstrated consistent discrimination across all nine National Health Service regions, with similar performance metrics to the original validation cohorts. Calibration remained stable (4C Mortality: pooled slope 1.09, pooled calibration-in-the-large 0.12; 4C Deterioration: 1.00, -0.04), with no need for temporal recalibration during the second UK pandemic wave of hospital admissions. CONCLUSION: Both 4C risk stratification models demonstrate consistent performance to predict clinical deterioration and mortality in a large prospective second wave validation cohort of UK patients. Despite recent advances in the treatment and management of adults hospitalised with COVID-19, both scores can continue to inform clinical decision making. TRIAL REGISTRATION NUMBER: ISRCTN66726260.

Characterisation of in-hospital complications associated with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol UK: a prospective, multicentre cohort study.

BACKGROUND: COVID-19 is a multisystem disease and patients who survive might have in-hospital complications. These complications are likely to have important short-term and long-term consequences for patients, health-care utilisation, health-care system preparedness, and society amidst the ongoing COVID-19 pandemic. Our aim was to characterise the extent and effect of COVID-19 complications, particularly in those who survive, using the International Severe Acute Respiratory and Emerging Infections Consortium WHO Clinical Characterisation Protocol UK. METHODS: We did a prospective, multicentre cohort study in 302 UK health-care facilities. Adult patients aged 19 years or older, with confirmed or highly suspected SARS-CoV-2 infection leading to COVID-19 were included in the study. The primary outcome of this study was the incidence of in-hospital complications, defined as organ-specific diagnoses occurring alone or in addition to any hallmarks of COVID-19 illness. We used multilevel logistic regression and survival models to explore associations between these outcomes and in-hospital complications, age, and pre-existing comorbidities. FINDINGS: Between Jan 17 and Aug 4, 2020, 80 388 patients were included in the study. Of the patients admitted to hospital for management of COVID-19, 49·7% (36 367 of 73 197) had at least one complication. The mean age of our cohort was 71·1 years (SD 18·7), with 56·0% (41 025 of 73 197) being male and 81·0% (59 289 of 73 197) having at least one comorbidity. Males and those aged older than 60 years were most likely to have a complication (aged ≥60 years: 54·5% [16 579 of 30 416] in males and 48·2% [11 707 of 24 288] in females; aged <60 years: 48·8% [5179 of 10 609] in males and 36·6% [2814 of 7689] in females). Renal (24·3%, 17 752 of 73 197), complex respiratory (18·4%, 13 486 of 73 197), and systemic (16·3%, 11 895 of 73 197) complications were the most frequent. Cardiovascular (12·3%, 8973 of 73 197), neurological (4·3%, 3115 of 73 197), and gastrointestinal or liver (0·8%, 7901 of 73 197) complications were also reported. INTERPRETATION: Complications and worse functional outcomes in patients admitted to hospital with COVID-19 are high, even in young, previously healthy individuals. Acute complications are associated with reduced ability to self-care at discharge, with neurological complications being associated with the worst functional outcomes. COVID-19 complications are likely to cause a substantial strain on health and social care in the coming years. These data will help in the design and provision of services aimed at the post-hospitalisation care of patients with COVID-19. FUNDING: National Institute for Health Research and the UK Medical Research Council.

Non-steroidal anti-inflammatory drug use and outcomes of COVID-19 in the ISARIC Clinical Characterisation Protocol UK cohort: a matched, prospective cohort study.

BACKGROUND: Early in the pandemic it was suggested that pre-existing use of non-steroidal anti-inflammatory drugs (NSAIDs) could lead to increased disease severity in patients with COVID-19. NSAIDs are an important analgesic, particularly in those with rheumatological disease, and are widely available to the general public without prescription. Evidence from community studies, administrative data, and small studies of hospitalised patients suggest NSAIDs are not associated with poorer COVID-19 outcomes. We aimed to characterise the safety of NSAIDs and identify whether pre-existing NSAID use was associated with increased severity of COVID-19 disease. METHODS: This prospective, multicentre cohort study included patients of any age admitted to hospital with a confirmed or highly suspected SARS-CoV-2 infection leading to COVID-19 between Jan 17 and Aug 10, 2020. The primary outcome was in-hospital mortality, and secondary outcomes were disease severity at presentation, admission to critical care, receipt of invasive ventilation, receipt of non-invasive ventilation, use of supplementary oxygen, and acute kidney injury. NSAID use was required to be within the 2 weeks before hospital admission. We used logistic regression to estimate the effects of NSAIDs and adjust for confounding variables. We used propensity score matching to further estimate effects of NSAIDS while accounting for covariate differences in populations. RESULTS: Between Jan 17 and Aug 10, 2020, we enrolled 78 674 patients across 255 health-care facilities in England, Scotland, and Wales. 72 179 patients had death outcomes available for matching; 40 406 (56·2%) of 71 915 were men, 31 509 (43·8%) were women. In this cohort, 4211 (5·8%) patients were recorded as taking systemic NSAIDs before admission to hospital. Following propensity score matching, balanced groups of NSAIDs users and NSAIDs non-users were obtained (4205 patients in each group). At hospital admission, we observed no significant differences in severity between exposure groups. After adjusting for explanatory variables, NSAID use was not associated with worse in-hospital mortality (matched OR 0·95, 95% CI 0·84-1·07; p=0·35), critical care admission (1·01, 0·87-1·17; p=0·89), requirement for invasive ventilation (0·96, 0·80-1·17; p=0·69), requirement for non-invasive ventilation (1·12, 0·96-1·32; p=0·14), requirement for oxygen (1·00, 0·89-1·12; p=0·97), or occurrence of acute kidney injury (1·08, 0·92-1·26; p=0·33). INTERPRETATION: NSAID use is not associated with higher mortality or increased severity of COVID-19. Policy makers should consider reviewing issued advice around NSAID prescribing and COVID-19 severity. FUNDING: National Institute for Health Research and Medical Research Council.

The impact of web-based and face-to-face simulation education programs on nurses' response to patient deterioration: A multi-site interrupted time series study.

BACKGROUND: Nurses' response to patient deterioration in acute hospital wards is a priority issue. Simulation education programs improve nurses' knowledge and confidence, but the translation into better care is largely unknown for both web based (WB) and face to face (F2F) simulation programs. AIM: To measure the impact of simulation education on nurses' response to patient deterioration in acute medical ward settings, and to compare the impact of WB and F2F versions. DESIGN: An interrupted time series, non-randomised trial across four medical wards in Victoria, Australia. Wards were allocated to either web-based or face-to-face versions of the same simulation program, FIRST2ACT. Interrupted time series measurement for six fortnights both before and after the intervention were used to measure and compare responses to deterioration. Responses to patient deterioration were extracted from medical records and grouped into outcomes for escalation (e.g. initiation of clinical review), assessment and observation (e.g. increased recording of vital signs, conscious state and pain scores) and clinical interventions (e.g. oxygen administration). RESULTS: 126 nurses (89%) participated across the four wards. 946 patient records (506 in the F2F; 440 in the WB group) were included in analyses. There were significant and sustained improvements between pre and post samples in outcomes for escalation (13.0% to 28.8%; p = 0.000) and assessment and observation (conscious state recorded increased from 91.1% to 100%; p = 0.000, and pain score recorded increased from 97.8% to 99.8%; p = 0.000). There were no differences between the web-based and face-to-face groups except in appropriate oxygen application which increased by 7.7% in the F2F group and decreased by 11.8% in the WB group (p = 0.046). CONCLUSIONS: There was a significant improvement in nurses' response to patient deterioration following both versions of simulation, indicating that both have a role to play in supporting nurses' response to patient deterioration.

Development and validation of the ISARIC 4C Deterioration model for adults hospitalised with COVID-19: a prospective cohort study.

BACKGROUND: Prognostic models to predict the risk of clinical deterioration in acute COVID-19 cases are urgently required to inform clinical management decisions. METHODS: We developed and validated a multivariable logistic regression model for in-hospital clinical deterioration (defined as any requirement of ventilatory support or critical care, or death) among consecutively hospitalised adults with highly suspected or confirmed COVID-19 who were prospectively recruited to the International Severe Acute Respiratory and Emerging Infections Consortium Coronavirus Clinical Characterisation Consortium (ISARIC4C) study across 260 hospitals in England, Scotland, and Wales. Candidate predictors that were specified a priori were considered for inclusion in the model on the basis of previous prognostic scores and emerging literature describing routinely measured biomarkers associated with COVID-19 prognosis. We used internal-external cross-validation to evaluate discrimination, calibration, and clinical utility across eight National Health Service (NHS) regions in the development cohort. We further validated the final model in held-out data from an additional NHS region (London). FINDINGS: 74 944 participants (recruited between Feb 6 and Aug 26, 2020) were included, of whom 31 924 (43·2%) of 73 948 with available outcomes met the composite clinical deterioration outcome. In internal-external cross-validation in the development cohort of 66 705 participants, the selected model (comprising 11 predictors routinely measured at the point of hospital admission) showed consistent discrimination, calibration, and clinical utility across all eight NHS regions. In held-out data from London (n=8239), the model showed a similarly consistent performance (C-statistic 0·77 [95% CI 0·76 to 0·78]; calibration-in-the-large 0·00 [-0·05 to 0·05]); calibration slope 0·96 [0·91 to 1·01]), and greater net benefit than any other reproducible prognostic model. INTERPRETATION: The 4C Deterioration model has strong potential for clinical utility and generalisability to predict clinical deterioration and inform decision making among adults hospitalised with COVID-19. FUNDING: National Institute for Health Research (NIHR), UK Medical Research Council, Wellcome Trust, Department for International Development, Bill & Melinda Gates Foundation, EU Platform for European Preparedness Against (Re-)emerging Epidemics, NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, NIHR HPRU in Respiratory Infections at Imperial College London.

Risk stratification of patients admitted to hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: development and validation of the 4C Mortality Score.

OBJECTIVE: To develop and validate a pragmatic risk score to predict mortality in patients admitted to hospital with coronavirus disease 2019 (covid-19). DESIGN: Prospective observational cohort study. SETTING: International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) World Health Organization (WHO) Clinical Characterisation Protocol UK (CCP-UK) study (performed by the ISARIC Coronavirus Clinical Characterisation Consortium-ISARIC-4C) in 260 hospitals across England, Scotland, and Wales. Model training was performed on a cohort of patients recruited between 6 February and 20 May 2020, with validation conducted on a second cohort of patients recruited after model development between 21 May and 29 June 2020. PARTICIPANTS: Adults (age ≥18 years) admitted to hospital with covid-19 at least four weeks before final data extraction. MAIN OUTCOME MEASURE: In-hospital mortality. RESULTS: 35 463 patients were included in the derivation dataset (mortality rate 32.2%) and 22 361 in the validation dataset (mortality rate 30.1%). The final 4C Mortality Score included eight variables readily available at initial hospital assessment: age, sex, number of comorbidities, respiratory rate, peripheral oxygen saturation, level of consciousness, urea level, and C reactive protein (score range 0-21 points). The 4C Score showed high discrimination for mortality (derivation cohort: area under the receiver operating characteristic curve 0.79, 95% confidence interval 0.78 to 0.79; validation cohort: 0.77, 0.76 to 0.77) with excellent calibration (validation: calibration-in-the-large=0, slope=1.0). Patients with a score of at least 15 (n=4158, 19%) had a 62% mortality (positive predictive value 62%) compared with 1% mortality for those with a score of 3 or less (n=1650, 7%; negative predictive value 99%). Discriminatory performance was higher than 15 pre-existing risk stratification scores (area under the receiver operating characteristic curve range 0.61-0.76), with scores developed in other covid-19 cohorts often performing poorly (range 0.63-0.73). CONCLUSIONS: An easy-to-use risk stratification score has been developed and validated based on commonly available parameters at hospital presentation. The 4C Mortality Score outperformed existing scores, showed utility to directly inform clinical decision making, and can be used to stratify patients admitted to hospital with covid-19 into different management groups. The score should be further validated to determine its applicability in other populations. STUDY REGISTRATION: ISRCTN66726260.

Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study.

OBJECTIVE: To characterise the clinical features of patients admitted to hospital with coronavirus disease 2019 (covid-19) in the United Kingdom during the growth phase of the first wave of this outbreak who were enrolled in the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) World Health Organization (WHO) Clinical Characterisation Protocol UK (CCP-UK) study, and to explore risk factors associated with mortality in hospital. DESIGN: Prospective observational cohort study with rapid data gathering and near real time analysis. SETTING: 208 acute care hospitals in England, Wales, and Scotland between 6 February and 19 April 2020. A case report form developed by ISARIC and WHO was used to collect clinical data. A minimal follow-up time of two weeks (to 3 May 2020) allowed most patients to complete their hospital admission. PARTICIPANTS: 20 133 hospital inpatients with covid-19. MAIN OUTCOME MEASURES: Admission to critical care (high dependency unit or intensive care unit) and mortality in hospital. RESULTS: The median age of patients admitted to hospital with covid-19, or with a diagnosis of covid-19 made in hospital, was 73 years (interquartile range 58-82, range 0-104). More men were admitted than women (men 60%, n=12 068; women 40%, n=8065). The median duration of symptoms before admission was 4 days (interquartile range 1-8). The commonest comorbidities were chronic cardiac disease (31%, 5469/17 702), uncomplicated diabetes (21%, 3650/17 599), non-asthmatic chronic pulmonary disease (18%, 3128/17 634), and chronic kidney disease (16%, 2830/17 506); 23% (4161/18 525) had no reported major comorbidity. Overall, 41% (8199/20 133) of patients were discharged alive, 26% (5165/20 133) died, and 34% (6769/20 133) continued to receive care at the reporting date. 17% (3001/18 183) required admission to high dependency or intensive care units; of these, 28% (826/3001) were discharged alive, 32% (958/3001) died, and 41% (1217/3001) continued to receive care at the reporting date. Of those receiving mechanical ventilation, 17% (276/1658) were discharged alive, 37% (618/1658) died, and 46% (764/1658) remained in hospital. Increasing age, male sex, and comorbidities including chronic cardiac disease, non-asthmatic chronic pulmonary disease, chronic kidney disease, liver disease and obesity were associated with higher mortality in hospital. CONCLUSIONS: ISARIC WHO CCP-UK is a large prospective cohort study of patients in hospital with covid-19. The study continues to enrol at the time of this report. In study participants, mortality was high, independent risk factors were increasing age, male sex, and chronic comorbidity, including obesity. This study has shown the importance of pandemic preparedness and the need to maintain readiness to launch research studies in response to outbreaks. STUDY REGISTRATION: ISRCTN66726260.

Characterizing Adverse Events Reported Immediately After Osteopathic Manipulative Treatment.

CONTEXT: Although adverse events in various types of manual therapy have been previously investigated, little is known about the incidence and types of adverse events that occur after osteopathic manipulative treatment (OMT). OBJECTIVE: To estimate the incidence and characterize the types of adverse events that patients report after OMT and prior to leaving the office to increase the likelihood of identifying adverse events caused by OMT. METHODS: As part of a prospective study evaluating the use and effectiveness of OMT, patients assessed how they felt immediately after OMT compared with before OMT using a 5-point ordinal rating scale (much better, better, about the same, worse, much worse). For patients who indicated they felt their condition had changed, a follow-up, open-ended question asked them to describe how it had changed. Patients who felt worse or much worse were considered to have experienced an adverse event. Two reviewers independently coded the types of adverse events based on the descriptions provided by the patients. Generalized logistic regression models were used to calculate incidence rates and 95% CIs for the types of adverse events. These models were also used to calculate the ORs and 95% CIs for associations of adverse events with demographic characteristics and with individual OMT techniques after accounting for demographic characteristics. RESULTS: Immediately after OMT, 884 patients provided data at 1847 office visits (663 [76%] women; 794 [92%] identified as white; mean [SD] age, 51.8 [15.8] years). Patients reported they felt worse or much worse immediately after OMT at 45 office visits; the incidence rate for adverse events was 2.5% (95% CI, 1.3%-4.7%). Pain/discomfort was the most commonly identified type of adverse event (16 [0.9%]; 95% CI, 0.5%-1.6%). Insufficient information was provided to determine the type of adverse event at 20 office visits. Women reported adverse events more frequently than men (OR, 13.9; 95% CI, 1.7-115.6; P=.01). CONCLUSION: The incidence of adverse events immediately after OMT, most commonly pain/discomfort, was lower than previous reports from other manual medicine disciplines. Larger studies are needed to determine the incidence of serious adverse events and to assess adverse events that occur in the days following OMT.

The educational impact of web-based and face-to-face patient deterioration simulation programs: An interventional trial.

BACKGROUND: There are international concerns relating to the management of patient deterioration. The "failure to rescue" literature identifies that nursing staff miss cues of deterioration and often fail to call for assistance. Simulation-based educational approaches may improve nurses' recognition and management of patient deterioration. OBJECTIVES: To investigate the educational impact of the First2Act web-based (WB) and face-to-face (F2F) simulation programs. DESIGN & SETTING: A mixed methods interventional cohort trial with nursing staff from four Australian hospitals. PARTICIPANTS: Nursing staff working in four public and private hospital medical wards in the State of Victoria. METHODS: In 2016, ward nursing staff (n = 74) from a public and private hospital completed three F2F laboratory-based team simulations with a patient actor in teams of three. 56 nursing staff from another public and private hospital individually completed a three-scenario WB simulation program (First2ActWeb) [A 91% participation rate]. Validated tools were used to measure knowledge (multi-choice questionnaire), competence (check-list of actions) and confidence (self-rated) before and after the intervention. RESULTS: Both WB and F2F participants' knowledge, competence and confidence increased significantly after training (p ≤0.001). Skill performance for the WB group increased significantly from 61% to 74% (p ≤ 0.05) and correlated significantly with post-test knowledge (p = 0.014). No change was seen in the F2F groups' performance scores. Course evaluations were positive with median ratings of 4/5 (WB) and 5/5 (F2F). The F2F program received significantly more positive evaluations than the WB program (p < 0.05), particularly with regard to quality of feedback. CONCLUSION: WB and F2F simulation are effective education strategies with both programs demonstrating positive learning outcomes. WB programs increase ease of access to training whilst F2F enable the development of tactile hands on skills and teamwork. A combined blended learning education strategy is recommended to enhance competence and patient safety.

An Update of the Review of Neuropsychological Consequences of HIV and Substance Abuse: A Literature Review and Implications for Treatment and Future Research.

Neuropyschological dysfunction, ranging from mild cerebral indicators to dementia has been a consistent part of the medical picture of HIV/AIDS. However, advances in medical supervision, particularly as a result of antiretroviral (ARV) treatment, have resulted in some mitigation of the neuropsychological effects of HIV and necessitate re-evaluation of the pattern and nature of HIV-related cognitive or mental deficits. The associated enhancements in morbidity and mortality that have occurred as a result of ARV medication have led to a need for interventions and programs that maintain behaviors that are healthy and stop the resurgence of the risk of HIV transmission. Risk factors such as mental illness and substance use that may have contributed to the initial infection with HIV still need consideration. These risk factors may also increase neuropsychological dysfunction and impact observance of prevention for treatment and recommendations. Explicitly, a better comprehension of the role of substance use on the progression of HIV-related mental decline can enlighten management and evaluation of persons living with HIV with concurrent disorders of substance use. This review provides a summary of the neurophyschology of substance use and HIV and the existing research that has looked at the effects of both substance use and HIV disease on neurophyscological function and suggestions for future research and treatment.

HIV-Risk Related Attitudes and Behaviors Among Older Impoverished Women Living in Puerto Rico.

HIV has increasingly impacted older adults regarding sero-prevalence and sero-incidence as long-term survivors of HIV/AIDS are living longer. This study examines the relationship between age and HIV-related attitudes and risk behaviors among female public housing residents in Puerto Rico. Using a self-administered survey instrument, 1,138 female public housing residents were surveyed between April and August 2006. Bivariate results showed that older women (aged 50+ years) were significantly less likely to report HIV testing and to discuss safer sex with their most recent "steady" sex partner than women under the age of 50 years. Older women were also more likely to express anxiety associated with condoms and more barriers to using condoms. The older versus younger groups did not significantly differ regarding condom use, which was extremely low across the groups. In the past three and 12 months, older women were less likely than younger women to report having (a) multiple sex partners and; (b) oral and anal sex with their most recent steady sex partner; (c) oral sex with their most recent non-steady sex partner and, (d) engaging in sexual activity in the previous three and 12 months. Age-specific messages concerning their increased risk of HIV among other interventions would likely curtail the increase in the number of new HIV cases being reported among members of this sub-population.

Condom-use patterns among women who live in public housing developments in Ponce, Puerto Rico.

Abstract:Background. Understanding condom-use patterns and the reasons that women have for choosing not to use condoms with their sexual partners, (both steady and non-steady), is important to the development and implementation of targeted, culturally appropriate interventions that can promote condom use in low-income and impoverished women. Methods. A total of 386 women from four public housing developments in Ponce, Puerto Rico, underwent HIV/STI testing and completed a self-administered questionnaire. Data were collected from August 2008 to October 2010. Results. Reported levels of condom use were low with both steady and non-steady sexual partners. Reasons given for not using condoms with both partner types included the respondent claiming to know her partner well, a general dislike for condoms, not having condoms available, and perceiving no need for them. Conclusions. These findings provide a foundation on which to build an intervention to promote condom use among impoverished women who live in public housing in Puerto Rico in addition to other disadvantaged or impoverished women. It is imperative that health practitioners consider the reasons that these women have for not using condoms in order to inform the development and implementation of effective HIV-prevention interventions.

HIV-Testing Practices and a History of Substance Use among Women Living in Public Housing in Puerto Rico.

The objective of this study was to examine the relationship between HIV testing practices and history of substance use among a large sample of women living in public housing in Puerto Rico and the relationships among HIV testing and history of substance abuse. A total of 1138 women were surveyed between April and August 2006 using a self-administered survey instrument. A total of 82% of the women in the sample group reported a history of HIV testing. Logistic regression analysis revealed that those with a history of alcohol use, marijuana use, and other illicit drug use were more likely to report a history of HIV testing (P < .05). These findings suggest the possibility that women who engage in riskier behaviors may be aware of these risks and therefore make more of an effort to determine their status. Future studies should, however, further examine the risks among women from subpopulations who may be at high risk for HIV.

The viability of outercourse for HIV prevention within the Puerto Rican context.

BACKGROUND: As the number of HIV/AIDS cases continues to increase in Puerto Rico, outercourse, or non-penetrative sexual activities, may be one alternative for healthy sexual living for persons living with or at risk for HIV/AIDS. METHODS: Between April and August 2006, we surveyed 1138 women living in low-income housing in Ponce, PR on their attitudes toward and participation in outercourse activities. RESULTS: The majority of the sample were aged >25 years (80.2%), with a mean sample age of 36.77 (SD = 12.31). Approximately one half (49.8%) of the women in the sample were legally married or involved in a common-law relationship. Mutual masturbation and the use of sex toys were viewed as "real sex" by only 33% and 16%, respectively, of the women surveyed. A slight majority had at least a high school education (57.5%). Of those with a steady sex partner in the previous 12 months, 47% engaged in mutual masturbation, and 17% used sex toys. Of those with a non-steady sex partner in the previous 12 months, 41% engaged in mutual masturbation, and 14% used sex toys. Logistic regressions indicated that persons who perceived mutual masturbation and the use of sex toys as real sex were more likely than those who did not perceive them to be so to engage in either or both behaviors with their most recent steady sex partner (OR = 4.5, CI =3.3-6.2 and OR=18.11, CI = 11.5-28.6, respectively); the same relationship emerged with their most recent non-steady sex partner (OR = 4.0, CI = 1.9-8.3 and OR = 15.9, CI = 5.3-47.4). CONCLUSIONS: The levels of participation in outercourse were low across the sample; also low was the perception of outercourse as being real sex. Outercourse appears to be, primarily, a precursor to penetrative sex, especially with steady sex partners. If culturally sensitive prevention messages were to promote outercourse as real sex and as an ultimate sexual goal, couples might be able to maintain an intimate, yet safe, sexual relationship. Outercourse should not be promoted as the only option for safer sex relationships but instead in the context of a comprehensive prevention message, which would also include protected sexual intercourse for those who choose to engage in penetrative activities.

Neuropsychological consequences of HIV and substance abuse: a literature review and implications for treatment and future research.

Neuropsychological dysfunction, ranging from mild cognitive symptoms to dementia has been a consistent part of the clinical picture of HIV/AIDS. However, advances in clinical management, particularly antiretroviral (ARV) treatment, have mitigated the neuropsychological effects of HIV and revised the pattern and nature of cognitive deficits, which are observed in HIV-infected individuals. The attendant improvements in mortality and morbidity have led to a need for programs and interventions that sustain healthy behavior and prevent a resurgence of HIV transmission risk. Psychiatric risk factors, particularly substance use, which often contribute to initial acquisition of HIV, still require attention. These risk factors may also exacerbate neuropsychological dysfunction and compromise adherence to prevention recommendations and treatment. Specifically, a more complete understanding of the effects of substance abuse on the progression of HIV related cognitive decline can inform evaluation and management of HIV seropositives with concurrent substance use disorders. This review provides an overview of the neuropsychology of HIV and substance abuse and the extant research that has examined the effects of both HIV disease and substance use on neuropsychological functioning and implications for treatment and future research.

The effect of sympathy on discriminatory attitudes toward persons living with HIV/AIDS in Puerto Rico: a hierarchical analysis of women living in public housing.

As the number of persons living with HIV/AIDS (PLWHA) continues to increase in Puerto Rico, it becomes increasingly important to address the issues of stigma and other discriminatory attitudes. Therefore, the objective of the present study is to examine the attitudes toward PLWHA of a large sample of women living in public housing in Puerto Rico, including sympathy and support for PLWHA in the workplace and in school. A total of 1138 women completed a self-administered 218-item survey made up of questions that measured HIV-related knowledge, attitudes and behaviors. Levels of sympathy varied depending upon the target group, with HIV-infected drug users receiving the least sympathy. Most women reported that HIV-positive teachers should be allowed to teach and that HIV-positive children should be allowed to attend school. However, a significantly lower percentage reported that HIV-infected nurses should be allowed to continue working. Women who were more sympathetic toward PLWHA were more tolerant of PLWHA in the workplace and school, while those with inaccurate knowledge concerning HIV transmission were less tolerant. Also, those who knew a PLWHA were more tolerant. Levels of discriminatory attitudes in Puerto Rico are high and warrant both individual- and societal-level interventions.

HIV testing practices among women living in public housing in Puerto Rico.

OBJECTIVE: The objective of our study was to examine HIV testing practices among a large sample of women living in public housing in Puerto Rico and the relationships among HIV testing, sociodemographic variables, and HIV-related behaviors. METHODS: A total of 1138 women were surveyed between April and August 2006 using a self-administered survey instrument. RESULTS: Eighty-two percent of the women in the sample group reported a history of HIV testing. Hierarchical logistic regression analyses revealed that those adults who were at least 25 years of age and those who perceived some risk of HIV were more likely to report previous HIV testing. Also, those who had attended an HIV/AIDS education workshop or discussion and those who reported knowing persons living with HIV/AIDS were more likely to report previous testing. CONCLUSIONS: A large percentage of the women in our study have been tested for HIV; it is imperative, however, that appropriate HIV education and prevention messages be given to them when they receive their results. Client-initiated HIV testing to learn HIV status provided through counseling and testing remains critical to the effectiveness of HIV prevention. It is unwise to underestimate the importance of being tested. One of the first steps in self-protection from HIV is to be informed of one's HIV status, which allows one to make appropriate and responsible sexual decisions. Future success in decreasing the number of new infections among women will result from targeting women who may be at high risk, although not because of sex work or drug use. Increasing knowledge of HIV serostatus and the implications of these results, especially among those who are infected, can serve as a gateway to sustained behavioral risk reduction intervention, as well as to care and treatment. Considering the fact that both the actual and estimated numbers of HIV/AIDS cases among women in Puerto Rico continue to increase, it is clear that effective, targeted, and aggressive strategies are urgently needed to prevent both primary and secondary HIV transmission.

Trends in HIV risk perception, condom use and sexual history among Jamaican youth, 1996-2004.

As the number of HIV/AIDS cases continues to increase among youth, aged 15-24 years, it becomes critically important to identify the factors that are contributing to this increase. Trends in perceived risk and risk behaviours were examined among youth by sex and age in an attempt to address this concern. National-level cross-sectional data across three time periods (1996, 2000, 2004) gathered from youths, aged 15-24 years in Jamaica for six outcomes were examined (perceived risk, ever had sex, initiation of sex before age 14, multiple sexual partnerships, condom use at last sex with regular and non-regular partners). Trend analyses were employed for each outcome for the total sample and separately by sex and age. A significant positive increase in condom use emerged; males reported higher levels of condom use at last sex with most recent regular partner (55.7% in 1996, 67.9% in 2004, p < 0.01). Condom use by females with regular and non-regular partners did not increase. There was no significant change in the percent of youths reporting multiple partnerships, the percent initiating sex or age at first sex. Youths did perceive themselves to be at greater risk for HIV in 2004 than in 1996 (40.0% vs. 17.6%, p < 0.001). These analyses revealed inadequate protective behaviour adoption by Jamaican youths. Prevention programs targeting youths need to be expanded significantly, be culturally relevant, and also address social vulnerability.