Comparison of HIV Screening Strategies in the Emergency Department: A Randomized Clinical Trial.

Importance: The National HIV Strategic Plan for the US recommends HIV screening in emergency departments (EDs). The most effective approach to ED-based HIV screening remains unknown. Objective: To compare strategies for HIV screening when integrated into usual ED practice. Design, Setting, and Participants: This randomized clinical trial included patients visiting EDs at 4 US urban hospitals between April 2014 and January 2016. Patients included were ages 16 years or older, not critically ill or mentally altered, not known to have an HIV positive status, and with an anticipated length of stay 30 minutes or longer. Data were analyzed through March 2021. Interventions: Consecutive patients underwent concealed randomization to either nontargeted screening, enhanced targeted screening using a quantitative HIV risk prediction tool, or traditional targeted screening as adapted from the Centers for Disease Control and Prevention. Screening was integrated into clinical practice using opt-out consent and fourth-generation antigen-antibody assays. Main Outcomes and Measures: New HIV diagnoses using intention-to-treat analysis, absolute differences, and risk ratios (RRs). Results: A total of 76 561 patient visits were randomized; median (interquartile range) age was 40 (28-54) years, 34 807 patients (51.2%) were women, and 26 776 (39.4%) were Black, 22 131 (32.6%) non-Hispanic White, and 14 542 (21.4%) Hispanic. A total of 25 469 were randomized to nontargeted screening; 25 453, enhanced targeted screening; and 25 639, traditional targeted screening. Of the nontargeted group, 6744 participants (26.5%) completed testing and 10 (0.15%) were newly diagnosed; of the enhanced targeted group, 13 883 participants (54.5%) met risk criteria, 4488 (32.3%) completed testing, and 7 (0.16%) were newly diagnosed; and of the traditional targeted group, 7099 participants (27.7%) met risk criteria, 3173 (44.7%) completed testing, and 7 (0.22%) were newly diagnosed. When compared with nontargeted screening, targeted strategies were not associated with a higher rate of new diagnoses (enhanced targeted and traditional targeted combined: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.7; 95% CI, 0.30 to 1.56; P = .38; and enhanced targeted only: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.70; 95% CI, 0.27 to 1.84; P = .47). Conclusions and Relevance: Targeted HIV screening was not superior to nontargeted HIV screening in the ED. Nontargeted screening resulted in significantly more tests performed, although all strategies identified relatively low numbers of new HIV diagnoses. Trial Registration: ClinicalTrials.gov Identifier: NCT01781949.

Lessons from Initiating the First Veterans Health Administration (VA) Women's Health Practice-based Research Network (WH-PBRN) Study.

BACKGROUND: The Veterans Health Administration (VA) Women's Health Practice-Based Research Network (WH-PBRN) was created to foster innovations for the health care of women veterans. The inaugural study by the WH-PBRN was designed to identify women veterans' own priorities and preferences for mental health services and to inform refinements to WH-PBRN operational procedures. Addressing the latter, this article reports lessons learned from the inaugural study. METHODS: WH-PBRN site coordinators at the 4 participating sites convened weekly with the study coordinator and the WH-PBRN program manager to address logistical issues and identify lessons learned. Findings were categorized into a matrix of challenges and facilitators related to key study elements. RESULTS: Challenges to the conduct of PBRN-based research included tracking of regulatory documents; cross-site variability in some regulatory processes; and troubleshooting logistics of clinic-based recruitment. Facilitators included a central institutional review board, strong relationships between WH-PBRN research teams and women's health clinic teams, and the perception that women want to help other women veterans. CONCLUSION: Our experience with the inaugural WH-PBRN study demonstrated the feasibility of establishing productive relationships between local clinicians and researchers, and of recruiting a special population (women veterans) in diverse sites within an integrated health care system. This identified strengths of a PBRN approach.

Patient-centered mental health care for female veterans.

OBJECTIVE: Mental health services for women vary widely across the Veterans Health Administration (VHA) system, without consensus on the need for, or organization of, specialized services for women. Understanding women's needs and priorities is essential to guide the implementation of patient-centered behavioral health services. METHODS: In a cross-sectional, multisite survey of female veterans using primary care, potential stakeholders were identified for VHA mental health services by assessing perceived or observed need for mental health services. These stakeholders (N=484) ranked priorities for mental health care among a wide range of possible services. The investigators then quantified the importance of having designated women's mental health services for each of the mental health services that emerged as key priorities. RESULTS: Treatment for depression, pain management, coping with chronic general medical conditions, sleep problems, weight management, and posttraumatic stress disorder (PTSD) emerged as women's key priorities. Having mental health services specialized for women was rated as extremely important to substantial proportions of women for each of the six prioritized services. Preference for primary care colocation was strongly associated with higher importance ratings for designated women's mental health services. For specific types of services, race, ethnicity, sexual orientation, PTSD symptoms, and psychiatric comorbidity were also associated with higher importance ratings for designated women's services. CONCLUSIONS: Female veterans are a diverse population whose needs and preferences for mental health services vary along demographic and clinical factors. These stakeholder perspectives can help prioritize structural and clinical aspects of designated women's mental health care in the VHA.

Brief report: Validation of a quantitative HIV risk prediction tool using a national HIV testing cohort.

Routine screening is recommended for HIV detection. HIV risk estimation remains important. Our goal was to validate the Denver HIV Risk Score using a national cohort from the Centers for Disease Control and Prevention. Patients of 13 years and older were included, 4,830,941 HIV tests were performed, and 0.6% newly diagnosed infections were identified. Of all visits, 9% were very low risk (HIV prevalence = 0.20%), 27% low risk (HIV prevalence = 0.17%), 41% moderate risk (HIV prevalence = 0.39%), 17% high risk (HIV prevalence = 1.19%), and 6% very high risk (HIV prevalence = 3.57%). The Denver HIV Risk Score accurately categorized patients into different HIV risk groups.

Cannabis use and HIV antiretroviral therapy adherence and HIV-related symptoms.

Occasional cannabis use has been associated with increased antiretroviral therapy (ART) adherence and relief of HIV symptoms, while heavy use has been associated with low ART adherence and negative psychological symptoms. The purpose of the present study was to investigate differences between non-cannabis use (NC), non-dependent cannabis use (C), and dependent use (CD) in terms of ART adherence and HIV symptoms/ART side effects. A cross-sectional sample of 180 HIV+ individuals (78.3 % male) completed measures of substance use and psychopathology, medication adherence, and HIV symptoms/ART side effects. Adherence was also measured via pill count, viral load, and CD4 count. Results indicated that the CD group reported lower adherence and greater HIV symptoms/ART side effects than the other two groups, with no differences observed between NC and C groups. There is a clinical need to address dependent cannabis use among those prescribed ART. Further examination is needed to ascertain the functions of cannabis use among individuals with HIV.

Self-reported cannabis use characteristics, patterns and helpfulness among medical cannabis users.

OBJECTIVES: Little research has investigated the demographic and symptom profile of medical cannabis users in states in the USA that have legalized cannabis use. METHODS: In the present cross-sectional study, we investigated the demographic profile of 217 adults currently receiving medical cannabis, as well as differences in problematic use and perceived helpfulness in terms of (i) symptoms of psychological disorders and pain, and (ii) motives for use. RESULTS: Findings indicated that medical cannabis users (i) use and perceive cannabis to be beneficial for multiple conditions, some for which cannabis is not specifically prescribed or allowed at the state level; and (ii) report similar rates of disordered use as compared with population estimates among regular users. Furthermore, problematic cannabis use was predicted by several symptoms of psychological disorders (e.g. depression) and a variety of use motives (e.g. coping), while cannabis was reported as particularly helpful among those with several psychological symptoms (e.g. traumatic intrusions), as well as those reporting use for social anxiety reasons. CONCLUSIONS: Results are discussed in terms of future directions for research given the current debates regarding legalization of cannabis for medical purposes and, more generally, the lack of empirical data to inform such debates.

Programmatic cost evaluation of nontargeted opt-out rapid HIV screening in the emergency department.

BACKGROUND: The Centers for Disease Control and Prevention recommends nontargeted opt-out HIV screening in healthcare settings. Cost effectiveness is critical when considering potential screening methods. Our goal was to compare programmatic costs of nontargeted opt-out rapid HIV screening with physician-directed diagnostic rapid HIV testing in an urban emergency department (ED) as part of the Denver ED HIV Opt-Out Trial. METHODS: This was a prospective cohort study nested in a larger quasi-experiment. Over 16 months, nontargeted rapid HIV screening (intervention) and diagnostic rapid HIV testing (control) were alternated in 4-month time blocks. During the intervention phase, patients were offered HIV testing using an opt-out approach during registration; during the control phase, physicians used a diagnostic approach to offer HIV testing to patients. Each method was fully integrated into ED operations. Direct program costs were determined using the perspective of the ED. Time-motion methodology was used to estimate personnel activity costs. Costs per patient newly-diagnosed with HIV infection by intervention phase, and incremental cost effectiveness ratios were calculated. RESULTS: During the intervention phase, 28,043 eligible patients were included, 6,933 (25%) completed testing, and 15 (0.2%, 95% CI: 0.1%-0.4%) were newly-diagnosed with HIV infection. During the control phase, 29,925 eligible patients were included, 243 (0.8%) completed testing, and 4 (1.7%, 95% CI: 0.4%-4.2%) were newly-diagnosed with HIV infection. Total annualized costs for nontargeted screening were $148,997, whereas total annualized costs for diagnostic HIV testing were $31,355. The average costs per HIV diagnosis were $9,932 and $7,839, respectively. Nontargeted HIV screening identified 11 more HIV infections at an incremental cost of $10,693 per additional infection. CONCLUSIONS: Compared to diagnostic testing, nontargeted HIV screening was more costly but identified more HIV infections. More effective and less costly testing strategies may be required to improve the identification of patients with undiagnosed HIV infection in the ED.

The underdiagnosis of cannabis use disorders and other Axis-I disorders among military veterans within VHA.

Recent evidence suggests that rates of cannabis use disorders are significantly lower among military veterans within the Veterans Affairs Health Care System (VA) than the general U.S. population. However, prevalence rates obtained from the VA rely on clinician diagnosis, which have been shown to be underrepresentative of actual disorder rates. The present study utilized structured clinical interviews to assess a sample of 84 military veterans with a cannabis use disorder and compared Axis-I disorder diagnosis rates to those obtained through a retrospective electronic medical record chart review. Findings indicated that cannabis use disorders, as well as posttraumatic stress disorder and other anxiety disorders, were significantly underdiagnosed within this military veteran population. In contrast, rates of other substance use disorders as well as mood disorders were overdiagnosed within this VA population. Findings are discussed in relation to the improvement of screening and repeated structured assessment of military veterans within the VA.

Adulthood animal abuse among women court-referred to batterer intervention programs.

The substantial increase in the enrollment of women in batterer intervention programs (BIPs) over the past 30 years has greatly outpaced research on women who perpetrate intimate partner violence (IPV). As a result, it is unknown whether existing programs, which were originally designed to treat male perpetrators, are effective at preventing recidivism among women. Recent research shows that men who perpetrate IPV may also aggress against nonintimate partners, children, and animals, and that the reach of their aggressive tendencies has implications for treatment. Conducting similar investigations on women who perpetrate IPV may help to inform treatment delivery in BIPs. This study examined the prevalence of adulthood animal abuse perpetration and its association with psychological and physical IPV perpetration in a sample of women arrested for domestic violence (N = 87). Seventeen percent (n = 15) of the women committed at least one act of animal abuse since the age of 18, in contrast to the 0.28% prevalence rate reported in the general population. The overrepresentation of animal abuse in this sample was consistent with that of men arrested for domestic violence. Furthermore, women who reported committing animal abuse as an adult showed moderately higher rates of psychological aggression and physical assault perpetration against their partners, relative to women who did not report animal abuse. Implications for future research are discussed.

Male batterers' alcohol use and gambling behavior.

Little work has examined the interrelations among intimate partner violence (IPV), alcohol use, and gambling behavior, and no studies have examined these relationships among males court-ordered to batterer intervention programs (BIPs). The aim of the current investigation was to explore the associations between IPV, alcohol use, and gambling behavior among 341 males court-mandated to attend BIPs utilizing self-report measures. Voluntary, anonymous questionnaires were administered and completed during regularly scheduled BIP sessions. Compared to the general population, a higher percentage of the sample met criteria for pathological gambling (9%), and problem gambling (17%). Further, males exhibiting pathological gambling were more likely to be hazardous drinkers, and hazardous drinkers were more likely to exhibit pathological gambling. Additionally, pathological gamblers were at an increased risk for the perpetration of both physical and sexual aggression. Finally, gambling behavior uniquely predicted the perpetration of sexual aggression above and beyond alcohol use, impulsivity, and relationship satisfaction. The implications of these results for future research and intervention are discussed.

Examining the interface between substance misuse and intimate partner violence.

There is considerable theoretical and empirical support for a link between substance misuse and perpetration and victimization of intimate partner violence. This review briefly summarizes this literature and highlights current research that addresses the interface between treatment for substance abuse and intimate partner violence. Suggestions for future research and clinical implications are provided.

The role of drug use in a conceptual model of intimate partner violence in men and women arrested for domestic violence.

In a previous study, alcohol problems in perpetrators and their partners contributed directly and indirectly to intimate partner violence (IPV), even after including other correlates of violence in the model (G. L. Stuart et al., 2006). The present study extends these findings by examining the role of illicit drug use. We recruited 271 men and 135 women arrested for IPV and used structural equation modeling to examine the data. Results showed that drug use, as reported by the perpetrators, was a stronger predictor of IPV than were alcohol problems in perpetrators and their partners. Arrested males' marijuana use and stimulant use (i.e., cocaine and amphetamines) were associated with perpetration of IPV, and their report of their female partners' stimulant use was associated with her violence perpetration. In arrested women, specific substances used did not predict violence perpetration beyond other model variables; however, female perpetrators' report of male partners' stimulant use predicted male psychological and physical aggression, after controlling for other variables. These results provide further evidence that drug problems by both partners may be important in the evolution of aggression. Implications for batterer intervention programs are discussed.

Interaction between smoking rate and anxiety sensitivity: relation to anticipatory anxiety and panic-relevant avoidance among daily smokers.

The aim of the present investigation was to evaluate the moderating role of anxiety sensitivity (AS) in the relation between smoking rate and panic vulnerability variables, both concurrently and prospectively (3 months), among a community-based sample of 125 daily smokers (60 females; M(age) =26.02 years, S.D. =10.98). Consistent with prediction, the interaction between AS and smoking rate significantly predicted concurrent agoraphobic avoidance (3.2% of unique variance) and change in levels of anticipatory anxiety during the 3-month follow-up period (4.7% unique variance). Smokers high in AS who also smoked at greater rates reported the highest levels of avoidance and greatest increase in anticipatory anxiety. Overall, these data suggest that AS is an important individual difference factor that, when coupled with higher rates of smoking, is associated with greater levels of avoidance and anticipatory anxiety among daily smokers.