Strategies to improve outcomes of youth experiencing healthcare transition from pediatric to adult HIV care in a large U.S. city.

BACKGROUND: The healthcare transition (HCT) from pediatric to adult HIV care can be disruptive to HIV care engagement and viral suppression for youth living with HIV (YLH). METHODS: We performed qualitative interviews with 20 YLH who experienced HCT and with 20 multidisciplinary pediatric and adult HIV clinicians to assess and rank barriers and facilitators to HCT and obtain their perspectives on strategies to improve the HCT process. We used the Exploration Preparation Implementation Sustainment Framework to guide this qualitative inquiry. RESULTS: The most impactful barriers identified by YLH and clinicians focused on issues affecting the patient-clinician relationship, including building trust, and accessibility of clinicians. Both groups reported that having to leave the pediatric team was a significant barrier (ranked #1 for clinicians and #2 for YLH). The most impactful facilitator included having a social worker or case manager to navigate the HCT (listed #1 by clinicians and #2 by YLH); case managers were also identified as the individual most suited to support HCT. While YLH reported difficulty building trust with their new clinician as their #1 barrier, they also ranked the trust they ultimately built with a new clinician as their #1 facilitator. Factors reported to bridge pediatric and adult care included providing a warm handoff, medical record transfer, developing relationships between pediatric clinics and a network of youth-friendly adult clinics, and having the pediatric case manager attend the first adult appointment. Longer new patient visits, increased health communication between YLH and clinicians and sharing vetted clinician profiles with YLH were identified as innovative strategies. CONCLUSION: In this multi-disciplinary contextual inquiry, we have identified several determinants that may be targeted to improve HCT for YLH.

HIV and Hodgkin Lymphoma Survival: A Prospective Study in Botswana.

PURPOSE: People living with HIV (PLWH) experience increased risk of Hodgkin lymphoma (HL) despite effective initiation of antiretroviral therapy (ART). In high-income countries, outcomes following HIV HL have been reported to be non-differential, or inferior for PLWH. We sought to assess the effect of HIV on HL survival in Botswana, an African country with a generalized HIV epidemic and high ART coverage, to describe a context more reflective of global HIV populations. PATIENTS AND METHODS: In the Thabatse Cancer Cohort, consenting participants initiating treatment for HL at one of four cancer centers in Botswana were enrolled from 2010 to 2020. Patients were followed quarterly for up to 5 years. The impact of HIV on survival following treatment initiation was assessed using an inverse probability-weighted Cox marginal structural model adjusted for age, performance status, and disease stage. RESULTS: Seventy-eight new HL cases were enrolled, 47 (60%) were PLWH and 31 (40%) were HIV-uninfected. Baseline characteristics were similar between groups. The majority (61%) of patients presented with regional disease (stage I or II) with no statistically significant difference by HIV status (P = .38). Nearly all (87%) PLWH participants were on ART before their HL diagnosis (median ART duration 42 months), and median CD4 count was 413 cells/µL (interquartile range 253-691). Survival, in unadjusted analyses, was lower among patients without HIV compared with PLWH (log rank P = .021). In adjusted analysis, HIV infection was not significantly associated with survival in inverse probability-weighted Cox model (hazard ratio 0.43; 95% CI, 0.16 to 1.16; P = .094). CONCLUSION: In this cohort of patients treated for HL in Botswana, survival in PLWH (87% on long-standing ART) was at least as good as in individuals without HIV.

Hypothyroidism-induced Acute Kidney Injury and Hyponatremia.

Thyroid hormones affect every organ system in the body including renal development and physiology, and electrolyte and water homeostasis. These effects happen as a consequence of the combination of direct effects of thyroid hormones on renal tubules and hemodynamic effects of thyroid hormones. As a consequence, both hypothyroidism and hyperthyroidism significantly affect renal function. This case describes a patient with hypothyroidism-related acute kidney injury without rhabdomyolysis, and no additional precipitating factor. While there are many case reports describing hypothyroidism-related rhabdomyolysis leading to acute kidney injury, there are only a handful of case reports on hypothyroidism-related acute kidney injury without rhabdomyolysis.