Impact of harm reduction care in HIV clinical settings on stigma and health outcomes for people with HIV who use drugs: study protocol for a mixed-methods, multisite, observational study.

INTRODUCTION: Our previous pilot work suggests relational harm reduction strengthens relationships between people with HIV (PWH) who use drugs and their healthcare providers and improves HIV health outcomes. However, there is limited research examining ways that structural (eg, strategies like syringe service programmes) and/or relational (patient-provider relationship) harm reduction approaches in HIV clinical settings can mitigate experiences of stigma, affect patient-provider relationships and improve outcomes for PWH who use drugs. Our mixed methods, multisite, observational study aims to fill this knowledge gap and develop an intervention to operationalise harm reduction care for PWH who use drugs in HIV clinical settings. METHODS AND ANALYSIS: Aim 1 will explore the relationship between healthcare providers' stigmatising attitudes towards working with PWH who use drugs and providers' acceptance and practice of structural and relational harm reduction through surveys (n=125) and interviews (n=20) with providers. Aim 2 will explore the interplay between patient-perceived harm reduction, intersectional stigma and clinical outcomes related to HIV, hepatitis C (if applicable) and substance use-related outcomes through surveys (n=500) and focus groups (k=6, total n=36) with PWH who use drugs. We will also psychometrically evaluate a 25-item scale we previously developed to assess relational harm reduction, the Patient Assessment of Provider Harm Reduction Scale. Aim 3 will use human-centred design approaches to develop and pretest an intervention to operationalise harm reduction care for PWH who use drugs in HIV clinical settings. ETHICS AND DISSEMINATION: This study was approved via expedited review by the University of Pittsburgh Institutional Review Board (STUDY21090002). Study findings will be presented in peer-reviewed journals and public health conferences as well as shared with patient participants, community advisory boards and harm reduction organisations. TRIAL REGISTRATION NUMBER: NCT05404750.

A scoping review of US insurers' use of patient-reported outcomes.

OBJECTIVES: To complete a scoping review of US health insurers' use of health-related quality of life (HRQOL) patient-reported outcome measures (PROMs). STUDY DESIGN: Literature review. METHODS: A literature search was constructed for articles that contained an insurer-related term and an HRQOL-related term between 1999 and 2019 using the MEDLINE, Embase, Web of Science, Cochrane Database of Systematic Reviews, EconLit, and Business Source Complete databases. RESULTS: The search identified 14,253 unduplicated records, of which 2340 passed abstract screening and 350 were included in the review. The populations addressed in these studies included both populations with specific health conditions (eg, diabetes) and an entire member population. The most common purpose of the article was to evaluate a policy or program (n = 255; 72.9%); the range of interventions evaluated included federal policy, subgroup management strategies, and identification of individual patients. The most common insurance mechanism was Medicare (n = 205; 58.6%). The most common source of data was collected specifically for a research project (n = 172; 49.1%), and the least common source of data was collected by providers at the point of care (n = 34; 9.7%). The most commonly addressed age group was 65 years and older (n = 262; 74.9%), and the least commonly addressed was younger than 18 years (n = 36; 10.3%). The most commonly used PROMs were single-item self-rated health (n = 138; 47.1%) and activities of daily living (n = 88; 30.0%), with validated depression questionnaires (n = 56; 19.1%) being the most common disease-focused questionnaire. CONCLUSIONS: This review found a wide variety of articles across insurance providers, health conditions, and uses of PROMs. There is a noted paucity of data in pediatric populations and little information about the use of data collected within health care settings that is transmitted to health insurers.

Professional agency vs consumer directed care workers: Outcomes in managed care.

Direct care workers are a major part of the long-term services and supports (LTSS) needed to address the health of individuals and accounted for $112 billion in United States spending in 2015. Direct care workers are hired within professional agency models (PAMs) or consumer-directed models (CDMs) where workers (including family) are contracted by the individual to obtain services. We sought to identify differences in cost and utilisation outcomes between PAM and CDM participants. Data were obtained from the University of Pittsburgh Medical Center (UPMC) Insurance Services Division from the participants enrolled in UPMC Community HealthChoices in Pennsylvania during 2018. A retrospective, observational cohort study design was performed using claims data. Utilisation outcomes were assessed using multivariate logistic regression and cost outcomes by linear regression. The 3,232 participants met the inclusion criteria. Of these, 69% (N = 2,217) were in a PAM, 23% (N = 752) were in a CDM, and 8% (N = 263) used a combination of services. PAM groups were older (mean 62.4 years vs 54.1 years), more likely to be women (69.0% vs 62.8%), and had more healthcare needs. Hospital utilisation was the same among groups. However, total cost was lower in CDM groups due to differences in LTSS costs between CDM and PAM services. Among dually eligible Medicare and Medicaid beneficiaries receiving LTSS, there are significant differences in age, gender, race and health needs. While hospital utilisation was not different between groups, CDM groups had lower total costs of care compared to PAM. These findings have implications for families, policymakers and insurers in helping to govern community LTSS while supporting member autonomy.

Predicting Unplanned Health Care Utilization and Cost: Comparing Patient-reported Outcomes Measurement Information System and Claims.

OBJECTIVES: There is little literature describing if and how payers are utilizing patient-reported outcomes to predict future costs. This study assessed if Patient-reported Outcomes Measurement Information System (PROMIS) domain scores, collected in routine practice at neurology clinics, improved payer predictive models for unplanned care utilization and cost. STUDY DESIGN: Retrospective cohort analysis of private Health Plan-insured patients with visits at 18 Health Plan-affiliated neurology clinics. METHODS: PROMIS domains (Anxiety v1.0, Cognitive Function Abilities v2.0, Depression v1.0, Fatigue v1.0, Pain Interference v1.0, Physical Function v2.0, Sleep Disturbance v1.0, and Ability to Participate in Social Roles and Activities v2.0) are collected as part of routine care. Data from patients' first PROMIS measures between June 27, 2018 and April 16, 2019 were extracted and combined with claims data. Using (1) claims data alone and (2) PROMIS and claims data, we examined the association of covariates to utilization (using a logit model) and cost (using a generalized linear model). We evaluated model fit using area under the receiver operating characteristic curve (for unplanned care utilization), akaike information criterion (for unplanned care costs), and sensitivity and specificity in predicting top 15% of unplanned care costs. RESULTS: Area under the receiver operating curve values were slightly higher, and akaike information criterion values were similar, for PROMIS plus claims covariates compared with claims alone. The PROMIS plus claims model had slightly higher sensitivity and equivalent specificity compared with claims-only models. CONCLUSION: One-time PROMIS measure data combined with claims data slightly improved predictive model performance compared with claims alone, but likely not to an extent that indicates improved practical utility for payers.

Disparities in Chronic Health Outcomes and Health Behaviors Between Lesbian and Heterosexual Adult Women in Pittsburgh: A Longitudinal Study.

Background: Compared to heterosexual women, lesbian women experience higher rates of many chronic diseases, including depression, obesity, hypertension, and diabetes. Lesbian women report higher rates of risky health behaviors such as hazardous drinking and cigarette smoking. However, little longitudinal research has been done to examine changes in disparities between lesbian and heterosexual adult women. Methods: A total of 1,084 women were initially recruited from Pittsburgh, PA to participate in the Epidemiologic Study of HEalth Risk in Women (ESTHER) study and completed a baseline survey between 2003 and 2006. In 2015 or 2016, N = 483 women, 270 of whom were lesbian, completed a follow-up survey. Participants completed a questionnaire at both baseline and follow-up and completed a clinic visit for the baseline study to provide biometric data. Results: At baseline, lesbian participants reported higher rates of obesity (p = 0.03), depression (p = 0.02), and smoking (p = 0.04). Lesbian participants had elevated measured C-reactive protein levels (p = 0.05). By the time of the follow-up survey 10 years later, lesbian women continued to have higher rates of smoking (p = 0.04), but the disparity in depression (p = 0.53) and obesity (p = 0.24) rates had resolved. We found no differences in any other outcomes of interest. Conclusions: To our knowledge, this is the first study to report a resolution in obesity or depression disparities between lesbian and heterosexual women. Future research is necessary to determine if other disparities, such as respiratory conditions, appear over time and how lesbian women's health may continue to improve relative to heterosexual women and stem this public health inequity.

Mental Health, Drug, and Violence Interventions for Sexual/Gender Minorities: A Systematic Review.

CONTEXT: Compared with cisgender (nontransgender), heterosexual youth, sexual and gender minority youth (SGMY) experience great inequities in substance use, mental health problems, and violence victimization, thereby making them a priority population for interventions. OBJECTIVE: To systematically review interventions and their effectiveness in preventing or reducing substance use, mental health problems, and violence victimization among SGMY. DATA SOURCES: PubMed, PsycINFO, and Education Resources Information Center. STUDY SELECTION: Selected studies were published from January 2000 to 2019, included randomized and nonrandomized designs with pretest and posttest data, and assessed substance use, mental health problems, or violence victimization outcomes among SGMY. DATA EXTRACTION: Data extracted were intervention descriptions, sample details, measurements, results, and methodologic rigor. RESULTS: With this review, we identified 9 interventions for mental health, 2 for substance use, and 1 for violence victimization. One SGMY-inclusive intervention examined coordinated mental health services. Five sexual minority-specific interventions included multiple state-level policy interventions, a therapist-administered family-based intervention, a computer-based intervention, and an online intervention. Three gender minority-specific interventions included transition-related gender-affirming care interventions. All interventions improved mental health outcomes, 2 reduced substance use, and 1 reduced bullying victimization. One study had strong methodologic quality, but the remaining studies' results must be interpreted cautiously because of suboptimal methodologic quality. LIMITATIONS: There exists a small collection of diverse interventions for reducing substance use, mental health problems, and violence victimization among SGMY. CONCLUSIONS: The dearth of interventions identified in this review is likely insufficient to mitigate the substantial inequities in substance use, mental health problems, and violence among SGMY.

A comparison of adherence, outcomes, and costs among opioid use disorder Medicaid patients treated with buprenorphine and methadone: A view from the payer perspective.

Medication-assisted treatment (MAT) with methadone or buprenorphine has been shown to be more effective at reducing the use of illicit opioids, the risk of drug-related overdose, and overall healthcare costs, on average, compared to abstinence-based addiction treatments for individuals with an opioid use disorder (OUD). Individuals who are adherent to MAT are more likely to experience positive outcomes. We used physical and behavioral Medicaid claims data of individuals newly treated with methadone (n = 212) and buprenorphine (n = 972) to examine the overall predictors of adherence, differences in adherence to each medication, the relationship between adherence and ED nonfatal drug-related overdose, and differences in total cost of care between the two medications. We found that older individuals and women had significantly lower risk of non-adherence. At six months, only 3.6% of individuals who were adherent to either treatment experienced a nonfatal drug-related overdose in the ED, compared to 13.2% of individuals who were non-adherent. We found no significant difference between methadone and buprenorphine on nonfatal drug-related overdose. Non-adherence to methadone was associated with a significant increase in total cost of care. Implications for how these results could be used to improve the overall impact of MAT are discussed.

A Systematic Review of Health Outcomes Associated With Provision of Representative Payee Services.

OBJECTIVE: The Social Security Administration's Representative Payment Program appoints payees as financial managers for individuals determined incapable of managing their funds. The aim is to afford stability and increase clients' ability to meet health and behavioral priorities. This systematic review examined literature on the effect of representative payee services on identified outcomes. METHODS: A search of academic databases and gray literature was conducted in November 2015 and repeated in December 2017. Included studies had a comparison group; excluded studies examined services other than representative payee. Primary outcomes included substance use, symptoms of mental illness, housing stability, quality of life, and other health-specific outcomes. Secondary outcomes included the client-payee relationship and client satisfaction with services. RESULTS: Eighteen articles met inclusion criteria. Studies assessing primary outcomes found several positive and few negative effects of representative payee services. Studies examining secondary outcomes indicated that receipt of such services may affect the client-provider relationship, increase conflict and violence, and increase clients' perceptions of financial leverage (i.e., a payee's use of control over funds to encourage, incentivize, or otherwise coerce certain behaviors). Most studies were of poor or moderate quality. Studies spanned nearly two decades, and results may have been confounded by the evolution of service delivery modalities. CONCLUSIONS: Representative payee services are largely beneficial or neutral in terms of health and behavior outcomes. Negative findings mainly involved the client-payee relationship. Given that more than five million individuals have a representative payee, assessing the impact of these services with more rigorous research designs is worthwhile.

HIV Treatment Cascade by Housing Status at Enrollment: Results from a Retention in Care Cohort.

Though housing instability is linked to poor HIV health outcomes, studies that assess the HIV treatment cascade by housing status are limited. Using data from a multi-site Retention in Care initiative we constructed HIV treatment cascades for participants (n = 463) of five grantee sites. We found no significant differences in viral suppression at follow-up among participants who were unstably housed at enrollment (49%) as compared to those who were stably housed at enrollment (54%). Among participants with available data at 6- or 12-month follow-up, 94% were engaged in care, 90% were retained in, 94% were on ART, and 71% had suppressed viral load. Some site-level differences were noted; at two of the sites participants who were stably housed were more likely to be retained in care and on ART. Overall, findings demonstrated that participants moved successfully through the HIV treatment cascade regardless of housing status at enrollment, suggesting that evidence-based support and services to help people living with HIV/AIDS can help mitigate barriers to engagement in care associated with lack of stable housing.

Exploring the Healthcare Environment and Associations with Clinical Outcomes of People Living with HIV/AIDS.

Despite three decades of dramatic treatment breakthroughs in antiretroviral regimens, clinical outcomes for people living with HIV vary greatly. The HIV treatment cascade models the stages of care that people living with HIV go through toward the goal of viral suppression and demonstrates that <30% of those living with HIV/AIDS in the United States have met this goal. Although some research has focused on the ways that patient characteristics and patient-provider relationships contribute to clinical adherence and treatment success, few studies to date have examined the ways that contextual factors of care and the healthcare environment contribute to patient outcomes. Here, we present qualitative findings from a mixed-methods study to describe contextual and healthcare environment factors in a Ryan White Part C clinic that are associated with patients' abilities to achieve viral suppression. We propose a modification of Andersen's Behavioral Model of Health Services Utilization, and its more recent adaptation developed by Ulett et al., to describe the ways that clinic, system, and provider factors merge to create a system of care in which more than 86% of the patient population is virally suppressed.

Harm reduction principles for healthcare settings.

BACKGROUND: Harm reduction refers to interventions aimed at reducing the negative effects of health behaviors without necessarily extinguishing the problematic health behaviors completely. The vast majority of the harm reduction literature focuses on the harms of drug use and on specific harm reduction strategies, such as syringe exchange, rather than on the harm reduction philosophy as a whole. Given that a harm reduction approach can address other risk behaviors that often occur alongside drug use and that harm reduction principles have been applied to harms such as sex work, eating disorders, and tobacco use, a natural evolution of the harm reduction philosophy is to extend it to other health risk behaviors and to a broader healthcare audience. METHODS: Building on the extant literature, we used data from in-depth qualitative interviews with 23 patients and 17 staff members from an HIV clinic in the USA to describe harm reduction principles for use in healthcare settings. RESULTS: We defined six principles of harm reduction and generalized them for use in healthcare settings with patients beyond those who use illicit substances. The principles include humanism, pragmatism, individualism, autonomy, incrementalism, and accountability without termination. For each of these principles, we present a definition, a description of how healthcare providers can deliver interventions informed by the principle, and examples of how each principle may be applied in the healthcare setting. CONCLUSION: This paper is one of the firsts to provide a comprehensive set of principles for universal harm reduction as a conceptual approach for healthcare provision. Applying harm reduction principles in healthcare settings may improve clinical care outcomes given that the quality of the provider-patient relationship is known to impact health outcomes and treatment adherence. Harm reduction can be a universal precaution applied to all individuals regardless of their disclosure of negative health behaviors, given that health behaviors are not binary or linear but operate along a continuum based on a variety of individual and social determinants.

Exploring Changes in Interagency Collaboration Following AIDS United's Positive Charge: A Five-Site HIV Linkage and Retention in Care Program.

BACKGROUND: Many out-of-care people living with HIV have unmet basic needs and are served by loosely connected agencies. Prior research suggests that increasing agencies' coordination may lead to higher quality and better coordinated care. This study examines four U.S. interagency networks in AIDS United's HIV linkage and retention in care program. This study explores changes in the networks of implementing agencies. METHODS: Each network included a lead agency and collaborators. One administrator and service provider per agency completed an online survey about collaboration prior to and during Positive Charge. We measured how many organizations were connected to one another through density, or the proportion of reported connections out of all possible connections between organizations. Network centralization was measured to investigate whether this network connectivity was due to one or more highly connected organizations or not. To compare collaboration by type, density and centralization were calculated for any collaboration and specific collaboration types: technical assistance, shared resources, information exchange, and boosting access. To characterize the frequency of collaboration, we examined how often organizations interacted by "monthly or greater" versus "less than monthly." RESULTS: Density increased in all networks. Density was highest for information exchange and referring clients. When results were restricted to "monthly or greater," the densities of all networks were lower. CONCLUSIONS: This study suggests that a targeted linkage to care initiative may increase some collaboration types among organizations serving people living with HIV. It also provides insights to policy makers about how such networks may evolve.

Overview of the University of Pittsburgh/amfAR Training Program in HIV Prevention Research for MSM and Male-to-Female Transgender Populations in Low- and Middle-Income Countries.

Gay men, other men who have sex with men and transgender (GMT) populations suffer a disproportionate burden of HIV disease around the globe, which is directly attributable to the virulently homophobic environments in which many GMT people live. In addition to the direct effects of homophobia on GMT individuals, the ongoing marginalization of GMT people has meant that there is limited social capital on which effective HIV prevention and care programs can be built in many low- and middle-income countries (LMIC). Thus, meaningful responses meant to address the dire situation of GMT populations in LMIC settings must include a combination of bold and innovative approaches if efforts to end the epidemic are to have any chance of making a real difference. The HIV Scholars Program at the University of Pittsburgh's Center for LGBT Health Research is a prime example of a creative and dynamic approach to raising the expertise needed within GMT populations to respond to the global HIV/AIDS pandemic.

Risk of the Metabolic Syndrome in Sexual Minority Women: Results from the ESTHER Study.

OBJECTIVE: Compared to heterosexuals, sexual minority women (SMW) have higher rates of the metabolic syndrome risk factors (e.g., obesity, smoking, heavy drinking, and depression). Yet, no published research has examined whether SMW have higher rates of the metabolic syndrome. The aim of this study is to describe the prevalence of the metabolic syndrome and its individual factors in a sample of heterosexuals and SMW, and identify whether SMW are at greater risk of having the metabolic syndrome. MATERIALS AND METHODS: Data are from the Epidemiologic STudy of HEalth Risk in Women (ESTHER), a cross-sectional convenience sample of 479 SMW and 400 heterosexual women from Pittsburgh, Pennsylvania. Participants provided self-report questionnaire data, clinical data, and blood work. RESULTS: Compared to heterosexuals, SMW had higher mean waist circumference, fasting glucose, and systolic and diastolic blood pressure. Nearly one-quarter (24.3%) of SMW had the metabolic syndrome compared to 15.6% of heterosexual women (p = 0.002). After controlling for demographic and risk factors, SMW had a 44% higher risk of having the metabolic syndrome than heterosexuals (p = 0.031). CONCLUSIONS: To our knowledge, this is the first study to identify this health disparity in SMW. Future studies should explore differential risk of mortality and metabolic health between SMW and heterosexuals.

Connected Care: improving outcomes for adults with serious mental illness.

OBJECTIVES: To evaluate the effectiveness of Connected Care-a care coordination effort of physical and behavioral health managed care partners in Pennsylvania-on acute service use among adult Medicaid beneficiaries with serious mental illness (SMI). STUDY DESIGN: We examined changes in service utilization using a difference-in-differences model, comparing study group with a comparison group, and conducted key informant interviews to better understand aspects of program implementation. METHODS: We compared the difference in service use rates between baseline year and 2-year intervention period for the Connected Care group (n = 8633) with the difference in rates for the comparison group (n = 10,514), confirming results using a regression adjustment. RESULTS: Mental health hospitalizations (per 1000 members per month) decreased for the Connected Care group from 41.1 to 39.6, while increasing for the comparison group from 33.8 to 37.2 (P = .04). All-cause readmissions within 30 days decreased nearly 10% for Connected Care while increasing slightly for the comparison group (P < .01), with a similar pattern observed for 60- and 90-day all-cause readmissions. No differences were observed in physical health hospitalizations, drug and alcohol admissions, or ED use. Data from qualitative stakeholder interviews illuminated facilitators and barriers of implementing Connected Care. CONCLUSIONS: Payer-level healthcare information sharing can help identify members who could benefit from care coordination services, inform care management activities, and assist with pharmacy management. Results can inform state, health plan, and provider efforts around integration of care for individuals with SMI and improve care efficiencies and quality, which is especially important in this time of Medicaid expansion.

Unpacking Linkage and Reengagement in HIV Care: A Day in the Life of a Positive Charge Care Coordinator.

UNLABELLED: AIDS United's Positive Charge (PC) was a multiorganizational HIV linkage to care program implemented in five U.S. LOCATIONS: To better understand the process of linkage and reengagement in care, we conducted interviews with care coordinators and program supervisors at 20 PC implementing agencies. Though linkage to care is often considered a single column in the HIV continuum of care, we found that it contains several underlying and often complex steps. The steps described are: identifying individuals in need of services; contacting those individuals through a variety of means; assessing and addressing needs and barriers to care; initial engagement (or reengagement) in HIV primary care; and provision of ongoing support to promote retention. We highlight strategies used to complete these steps. These findings will be of utility to other HIV interventions that aim to improve linkage and engagement in HIV care.

Barriers and Facilitators to Implementing Access to HIV Care Interventions: A Qualitative Analysis of the Positive Charge Initiative.

Research indicates that less than half of people living with HIV (PLWH) have undetectable levels of virus, despite recent findings that viral load suppression dramatically reduces the transmissibility of HIV. Linkage to HIV care is a crucial initial step, yet we know relatively little about how to effectively implement linkage interventions to reach PLWH who are not in care. AIDS United's initiative, Positive Charge (PC), funded five U.S. sites to develop and implement comprehensive linkage interventions. Evaluation of the initiative included qualitative interviews with management and service staff from each intervention site. Sites experienced barriers and facilitators to implementation on multiple environmental, organization, and personnel levels. Successful strategies included developing early relationships with collaborating partners, finding ways to share key information among agencies, and using evaluation data to build support among leadership staff. Lessons learned will be useful for organizations that develop and implement future interventions targeting hard-to-reach, out-of-care PLWH.