Examining the Impact of State-Level Factors on HIV Testing for Medicaid Enrollees With Schizophrenia.

BACKGROUND: People with schizophrenia experience unique barriers to routine HIV testing, despite increased risk of HIV compared with the general US population. Little is known about how health care delivery system factors affect testing rates or whether there are testing differences for people with schizophrenia. SETTING: Nationally representative sample of Medicaid enrollees with and without schizophrenia. METHODS: Using retrospective longitudinal data, we examined whether state-level factors were associated with differences in HIV testing among Medicaid enrollees with schizophrenia compared with frequency-matched controls during 2002-2012. Multivariable logistic regression estimated testing rate differences between and within cohorts. RESULTS: Higher HIV testing rates for enrollees with schizophrenia were associated with higher state-level Medicaid spending per enrollee, efforts to reduce Medicaid fragmentation, and higher federal prevention funding. State-level AIDS epidemiology predicted more frequent HIV testing for enrollees with schizophrenia versus controls. Living in rural settings predicted lower HIV testing, especially for people with schizophrenia. CONCLUSION: Overall, state-level predictors of HIV testing rates varied among Medicaid enrollees, although rates were generally higher for those with schizophrenia than controls. Increased HIV testing for people with schizophrenia was associated with coverage of HIV testing when medically necessary, higher Centers for Disease Control and Prevention prevention funding, and higher AIDS incidence, prevalence, and mortality when compared with controls. This analysis suggests that state policymaking has an important role to play in advancing that effort. Overcoming fragmented care systems, sustaining robust prevention funding, and consolidating funding streams in innovative and flexible ways to support more comprehensive systems of care delivery deserve attention.

Characteristics and Trends in HIV Testing Among Medicaid Enrollees Diagnosed as Having Schizophrenia.

OBJECTIVE: People with schizophrenia have more HIV risk factors and higher rates of HIV infection than the general U.S. population. The authors aimed to examine HIV testing patterns in this population nationally and by demographic characteristics and presence of high-risk comorbid conditions. METHODS: This retrospective longitudinal study compared HIV testing between Medicaid-only enrollees with schizophrenia and without schizophrenia during 2002-2012 (N=6,849,351). Interrupted time series were used to analyze the impacts of the 2006 federal policy change recommending expanded HIV testing. Among enrollees with schizophrenia, multivariable logistic regression was used to estimate associations between testing and both demographic characteristics and comorbid conditions. Sensitivity analyses were also conducted. RESULTS: Enrollees diagnosed as having schizophrenia had consistently higher HIV testing rates than those without schizophrenia. When those with comorbid substance use disorders or sexually transmitted infections were excluded, testing was higher for individuals without schizophrenia (p<0.001). The federal policy change likely increased testing for both groups (p<0.001), but the net change was greater for those without schizophrenia (3.1 vs. 2.2 percentage points). Among enrollees with schizophrenia, testing rates doubled during 2002-2012 (3.9% to 7.2%), varied across states (range 17 percentage points), and tripled for those with at least one annual nonpsychiatric medical visit (vs. no visit; adjusted OR=3.10, 95% CI=2.99-3.22). CONCLUSIONS: Nationally, <10% of enrollees with schizophrenia had annual HIV testing. Increases appear to be driven by high-risk comorbid conditions and nonpsychiatric encounters, rather than by efforts to target people with schizophrenia. Psychiatric guidelines for schizophrenia care should consider HIV testing alongside annual metabolic screening.

Breast Cancer Screening Rates Among Medicaid Beneficiaries With Schizophrenia.

OBJECTIVE: Women with serious mental illness are more likely to be diagnosed as having late-stage breast cancer than women without serious mental illness, suggesting a disparity in screening mammography. This study aimed to compare screening mammography rates in a nationally representative sample of Medicaid beneficiaries with and without schizophrenia. METHODS: Medicaid Analytic eXtract files, 2007-2012, were used to identify a cohort of women ages 40-64 with schizophrenia who were eligible for Medicaid but not Medicare (N=87,572 in 2007 and N=114,341 in 2012) and a cohort without schizophrenia, frequency-matched by age, race-ethnicity, and state (N=97,003 in 2007 and N=126,461 in 2012). Annual screening mammography rates were calculated and adjusted for demographic characteristics and comorbid conditions. Multivariable logistic regression was used to estimate the association between beneficiary characteristics and screening mammography rates. RESULTS: In 2012, 27.2% of women with schizophrenia completed screening mammography, compared with 26.8% of the control cohort. In the schizophrenia cohort, American Indian/Alaskan Native women had significantly lower odds of receiving mammography (OR=0.82, p=0.02) than White women, whereas Hispanic/Latina women had higher odds (OR=1.16, p<0.001). Women with schizophrenia and a nonalcohol-related substance use disorder had lower odds of receiving mammography (OR=0.74, p<0.001) than women without a substance use disorder. Having at least one medical visit in the past year (vs. no visits) increased the odds of receiving screening mammography (OR=5.08, p<0.001). CONCLUSIONS: Screening mammography rates were similar between Medicaid-insured women with and those without schizophrenia. Interventions to increase uptake may need to focus on improving socioeconomic conditions and primary care engagement for vulnerable populations, regardless of psychiatric condition.

Hepatitis C Screening Among Medicaid Patients With Schizophrenia, 2002-2012.

OBJECTIVE: Although people with schizophrenia are disproportionately affected by Hepatitis C virus (HCV) compared to the general population, HCV screening among US Medicaid recipients with schizophrenia has not been characterized. Following 1998 CDC recommendations for screening in high-risk populations, we estimated the proportion of Medicaid recipients with and without schizophrenia screened for HCV across states and over time. Examining patterns of screening will inform the current public health imperative to test all adults for HCV now that safer and more effective treatments are available. METHODS: Data are drawn from 1 353 424 Medicaid recipients aged 15-64 years with schizophrenia and frequency-matched controls from 2002 to 2012. Participants with known HCV infection one year prior and those dual-eligible for Medicare were excluded. Multivariable logistic regression estimated associations between predictor variables and HCV screening. RESULTS: HCV screening was low (<4%) but increased over time. Individuals with schizophrenia consistently showed higher screening compared to controls across years and states. Several demographic and clinical characteristics predicted higher screening, especially comorbid HIV (OR = 6.5; 95% CI = 6.0-7.0). Outpatient medical care utilization increased screening by nearly double in 2002 (OR = 1.8; CI = 1.7-1.9) and almost triple in 2012 (OR = 2.7; CI = 2.6-2.9). CONCLUSIONS: Low screening was a missed opportunity to improve HCV prevention efforts and reduce liver-related mortality among people with schizophrenia. Greater COVID-19 disease severity in HCV patients and the availability of effective HCV treatments increase the urgency to improve HCV screening. Eliminating Medicaid restrictions and expanding statewide HIV policies to include HCV would have multiple public health benefits, particularly for people with schizophrenia.

HIV Testing and Counseling at U.S. Substance Use Treatment Facilities: A Missed Opportunity for Early Identification.

OBJECTIVE: The objective of this study was to determine the availability and national distribution of HIV testing and counseling at substance use treatment facilities in the United States. METHODS: Analyses of data from the 2018 National Survey of Substance Abuse Treatment Services assessed HIV testing and counseling availability in U.S. substance use treatment facilities (excluding those in U.S. territories). Facilities were subcategorized by availability of mental health services and medication for opioid use disorders and compared by using logistic models. Descriptive statistics were calculated to characterize the availability of HIV testing and counseling by state, state HIV incidence, and facility characteristics. RESULTS: Among U.S. substance use treatment facilities (N=14,691), 29% offered HIV testing, 53% offered HIV counseling, 23% offered both, and 41% offered neither. Across states, the proportions of facilities offering HIV testing ranged from 9.0% to 62.8%, and the proportion offering counseling ranged from 19.2% to 83.3%. In only three states was HIV testing offered by at least 50% of facilities. HIV testing was significantly more likely to be offered in facilities that offered medication for opioid use disorder (48.0% versus 16.0% in those not offering such medication) or mental health services (31.2% versus 24.1% in those not offering such services). Higher state-level HIV incidence was related to an increased proportion of facilities offering HIV testing. CONCLUSIONS: Only three in 10 substance use treatment facilities offered HIV testing in 2018. This finding represents a missed opportunity for early identification of HIV among people receiving treatment for substance use disorders.

Cancer Type and Risk of Newly Diagnosed Depression Among Elderly Medicare Beneficiaries With Incident Breast, Colorectal, and Prostate Cancers.

BACKGROUND: Elderly individuals (age >65 years) with cancer are at high risk for newly diagnosed depression after a cancer diagnosis. It is not known whether the risk of newly diagnosed depression varies by cancer type. PURPOSE: To examine the variations in the risk of newly diagnosed depression by cancer type among elderly individuals with cancer. METHODS: This study used a retrospective cohort study design and data from the linked SEER-Medicare files. Elderly individuals (age >65 years) with incident breast, colorectal (CRC), and prostate cancers diagnosed between 2007 and 2011 (N=53,821) were followed for 12 months after cancer diagnosis. Depression diagnosis was identified during the 12-month follow-up period after cancer diagnosis using the ICD-9-Clinical Modification. Complementary log-log regression was used to examine the association between cancer type and risk of newly diagnosed depression after adjusting for other risk factors for depression. RESULTS: We found a significantly higher percentage of newly diagnosed depression among women with CRC compared with those with breast cancer (5.8% vs 3.9%), and among men with CRC compared with those with prostate cancer (3.4% vs 1.6%). In the adjusted analysis, women with CRC had a 28.0% higher risk of newly diagnosed depression compared with women with breast cancer (adjusted risk ratio [ARR], 1.28; 95% CI, 1.12-1.46) and men with CRC had a 104.0% higher risk of newly diagnosed depression compared with those with prostate cancer (ARR, 2.04; 95% CI, 1.65-2.51). CONCLUSIONS: Our findings identified cancer types associated with a high risk of newly diagnosed depression after cancer diagnosis, who might benefit from routine depression screening to help in its early detection and treatment.

Depression treatment and healthcare expenditures among elderly Medicare beneficiaries with newly diagnosed depression and incident breast, colorectal, or prostate cancer.

OBJECTIVES: Depression is associated with high healthcare expenditures, and depression treatment may reduce healthcare expenditures. However, to date, there have not been any studies on the effect of depression treatment on healthcare expenditures among cancer survivors. Therefore, this study examined the association between depression treatment and healthcare expenditures among elderly with depression and incident cancer. METHODS: The current study used a retrospective longitudinal study design, the linked Surveillance, Epidemiology, and End Results-Medicare database. Elderly (≥66 years) fee-for-service Medicare beneficiaries with newly diagnosed depression and incident breast, colorectal, or prostate cancer (N = 1502) were followed for a period of 12 months after depression diagnosis. Healthcare expenditures were measured every month for a period of 12-month follow-up period. Depression treatment was identified during the 6-month follow-up period. The adjusted associations between depression treatment and healthcare expenditures were analyzed with generalized linear mixed model regressions with gamma distribution and log link after controlling for other factors. RESULTS: The average 1-year total healthcare expenditures after depression diagnosis were $38 219 for those who did not receive depression treatment; $42 090 for those treated with antidepressants only; $46 913 for those treated with psychotherapy only; and $51 008 for those treated with a combination of antidepressants and psychotherapy. As compared to no depression treatment, those who received antidepressants only, psychotherapy only, or a combination of antidepressants and psychotherapy had higher healthcare expenditures. However, second-year expenditures did not significantly differ among depression treatment categories. CONCLUSIONS: Among cancer survivors with newly diagnosed depression, depression treatment did not have a significant effect on expenditures in the long term.

Treatment considerations for HIV-infected individuals with severe mental illness.

There has been a general recognition of a syndemic that includes HIV/AIDS and serve mental illnesses including schizophrenia, major depression, bipolar disorder, post-traumatic stress disorder, and others. The pathophysiology and direction of effects between severe mental illness and HIV infection is less clear however, and relatively little work has been done on prevention and treatment for people with these complex, co-occurring conditions. Here we present the most recent work that has been published on HIV and mental illness. Further, we describe the need for better treatments for "triply diagnosed persons"; those with HIV, mental illness, and substance abuse and dependence. Finally, we describe the potential drug-drug interactions between psychotropic medications and anti-retrovirals, and the need for better treatment guidelines in this area. We describe one example of an individually tailored intervention for persons with serious mental illness and HIV (PATH+) that shows that integrated community-based treatments using advanced practice nurses (APNs) as health navigators can be successful in improving health-related quality of life and reducing the burden of disease in these persons.

Serious mental illness and risk of new HIV/AIDS diagnoses: an analysis of Medicaid beneficiaries in eight states.

OBJECTIVE: A longitudinal analysis was used to explore the relationship between diagnosis of serious mental illness and subsequent new diagnoses of HIV. METHODS: Logistic regression was used to predict HIV/AIDS diagnoses in 2002­2004 among Medicaid beneficiaries in eight states (N=6,417,676) who were without HIV in 2001. Results for beneficiaries with and without serious mental illness, a substance use disorder, and psychiatric comorbidities in 2001 were compared. RESULTS: After controlling for substance abuse or dependence and other factors, the analyses indicated that the odds of new HIV/AIDS diagnoses among beneficiaries with or without serious mental illness did not differ significantly. Compared with beneficiaries without a substance use disorder or serious mental illness, individuals with a substance use disorder but without serious mental illness were 3.1 times (OR=3.13, p<.001) more likely, and those with both substance abuse or dependence and serious mental illness were 2.1 times (OR=2.09, p<.001) more likely, to receive a new HIV diagnosis in 2002­2004. However, people with serious mental illness but without a substance use disorder in 2001 were 23% less likely (OR=.77, p<.001) than people without serious mental illness or a substance use disorder in 2001 to receive a new HIV diagnosis. CONCLUSIONS: After substance abuse or dependence was controlled for longitudinally, little independent association between serious mental illness and the risk of new HIV diagnoses was found. HIV-prevention services for low-income individuals should be delivered to all persons with serious mental illness, but especially those with comorbid substance use disorders.

Racial and ethnic disparities in depression care in community-dwelling elderly in the United States.

OBJECTIVES: We investigated racial/ethnic disparities in the diagnosis and treatment of depression among community-dwelling elderly. METHODS: We performed a secondary analysis of Medicare Current Beneficiary Survey data (n = 33,708) for 2001 through 2005. We estimated logistic regression models to assess the association of race/ethnicity with the probability of being diagnosed and treated for depression with either antidepressant medication or psychotherapy. RESULTS: Depression diagnosis rates were 6.4% for non-Hispanic Whites, 4.2% for African Americans, 7.2% for Hispanics, and 3.8% for others. After we adjusted for a range of covariates including a 2-item depression screener, we found that African Americans were significantly less likely to receive a depression diagnosis from a health care provider (adjusted odds ratio [AOR] = 0.53; 95% confidence interval [CI] = 0.41, 0.69) than were non-Hispanic Whites; those diagnosed were less likely to be treated for depression (AOR = 0.45; 95% CI = 0.30, 0.66). CONCLUSIONS: Among elderly Medicare beneficiaries, significant racial/ethnic differences exist in the diagnosis and treatment of depression. Vigorous clinical and public health initiatives are needed to address this persisting disparity in care.

A systematic review of validated methods for identifying suicide or suicidal ideation using administrative or claims data.

PURPOSE: As part of the Mini-Sentinel pilot program, under contract with the Food and Drug Administration, an effort has been made to evaluate the validity of algorithms useful for identifying health outcomes of interest, including suicide and suicide attempt. METHOD: Literature was reviewed to evaluate how well medical episodes associated with these events could be identified in administrative or claims data sets from the USA or Canada. RESULTS: Six studies were found to include sufficient detail to assess performance characteristics of an algorithm on the basis of International Classification of Diseases, Ninth Revision, E-codes (950-959) for intentional self-injury. Medical records and death registry information were used to validate classification. Sensitivity ranged from 13.8% to 65%, and positive predictive value range from 4.0% to 100%. Study comparisons are difficult to interpret, however, as the studies differed substantially in many important elements, including design, sample, setting, and methods. Although algorithm performance varied widely, two studies located in prepaid medical plans reported that comparisons of database codes to medical charts could achieve good agreement. CONCLUSIONS: Insufficient data exist to support specific recommendations regarding a preferred algorithm, and caution should be exercised in interpreting clinical and pharmacological epidemiological surveillance and research that rely on these codes as measures of suicide-related outcomes.

Use of Medicaid data to explore community characteristics associated with HIV prevalence among beneficiaries with schizophrenia.

OBJECTIVES: People with severe mental illness (SMI) may be at increased risk for several adverse health conditions, including HIV/AIDS. This disproportionate disease burden has been studied primarily at the individual rather than community level, in part due to the rarity of data sources linking individual information on medical and mental health characteristics with community-level data. We demonstrated the potential of Medicaid data to address this gap. METHODS: We analyzed data on Medicaid beneficiaries with schizophrenia from eight states that account for 66% of cumulative AIDS cases nationally. RESULTS: Across 44 metropolitan statistical areas (MSAs), the treated prevalence of HIV among adult Medicaid beneficiaries diagnosed with schizophrenia was 1.56% (standard deviation = 1.31%). To explore possible causes of variation, we linked claims files with a range of MSA social and contextual variables including local AIDS prevalence rates, area-based economic measures, crime rates, substance abuse treatment resources, and estimates of injection drug users (IDUs) and HIV infection among IDUs, which strongly predicted community infection rates among people with schizophrenia. CONCLUSIONS: Effective strategies for HIV prevention among people with SMI may include targeting prevention efforts to areas where risk is greatest; examining social network links between IDU and SMI groups; and implementing harm reduction, drug treatment, and other interventions to reduce HIV spread among IDUs. Our findings also suggest the need for research on HIV among people with SMI that examines geographical variation and demonstrates the potential use of health-care claims data to provide epidemiologic insights into small-area variations and trends in physical health among those with SMI.

Diagnosis and treatment of depression in older community-dwelling adults: 1992-2005.

OBJECTIVE: To examine evolving patterns of depression diagnosis and treatment in older U.S. adults in the era of newer-generation antidepressants. DESIGN: Trend analysis using data from the Medicare Current Beneficiary Survey, a nationally representative survey of Medicare enrollees, from 1992 to 2005. SETTING: Community, usual care. PARTICIPANTS: Older Medicare fee-for-service beneficiaries. MEASUREMENTS: Depression diagnoses and psychotherapy use identified from Medicare claims; antidepressant use identified from detailed medication inventories conducted by interviewers. RESULTS: The proportion of older adults who received a depression diagnosis doubled, from 3.2% to 6.3%, with rates increasing substantially across all demographic subgroups. Of those diagnosed, the proportion receiving antidepressants increased from 53.7% to 67.1%, whereas the proportion receiving psychotherapy declined from 26.1% to 14.8%. Adjusting for other characteristics, odds of antidepressant treatment in older adults diagnosed with depression were 86% greater for women, 53% greater for men, 89% greater for whites, 13% greater for African Americans, 84% greater for metropolitan-area residents, and 55% greater for nonmetropolitan-area residents. Odds of antidepressant treatment were 54% greater for those diagnosed with major depressive disorder (MDD) and 83% greater for those with other depression diagnoses, whereas the odds of receiving psychotherapy was 29% lower in those with MDD diagnoses and 74% lower in those with other depression diagnoses. CONCLUSION: Overall diagnosis and treatment rates increased over time. Antidepressants are assuming a more-prominent and psychotherapy a less-prominent role. These shifts are most pronounced in groups with less-severe depression, in whom evidence of efficacy of treatment with antidepressants alone is less clear.

Antidepressant treatment and adherence to antiretroviral medications among privately insured persons with HIV/AIDS.

In order to examine relationships between depression treatments (antidepressant and/or psychotherapy utilization) and adherence to antiretroviral therapy (ART), we conducted a retrospective analysis of medical and pharmacy insurance claims for privately insured persons living with HIV/AIDS (PLWHA) diagnosed with depression (n = 1,150). Participants were enrolled in 80 insurance plans from all 50 states. Adherence was suboptimal. Depression treatment initiators were significantly more likely to be adherent to ART than the untreated. We did not observe an association between psychotherapy utilization and ART adherence, yet given the limitations of the data (e.g., there is no information on types of psychological treatment and its targets), the lack of association should not be interpreted as lack of efficacy.

Bipolar medication use and adherence to antiretroviral therapy among patients with HIV-AIDS and bipolar disorder.

OBJECTIVE: The study examined relationships between adherence to bipolar medication and to antiretroviral therapy, measured by medication fills, among patients with diagnoses of bipolar disorder and HIV infection. METHODS: A retrospective study was conducted of Medicaid claims data (2001-2004) from eight states, focusing on antiretroviral adherence. The unit of analysis was person-month (N=53,971). The average observation period for the 1,687 patients was 32 months. Analyses controlled for several patient characteristics. RESULTS: Patients possessed antiretroviral drugs in 72% of the person-months. When a bipolar medication prescription was filled in the prior month, the rate of antiretroviral possession in the subsequent month was 78%, compared with 65% when bipolar medication was not filled in the prior month (p<.001). Odds of antiretroviral possession were 66% higher in months when patients had a prior-month supply of bipolar medication. CONCLUSIONS: Bipolar medication adherence may improve antiretroviral adherence among patients with bipolar disorder and HIV infection.

Patterns and correlates of tic disorder diagnoses in privately and publicly insured youth.

OBJECTIVE: This study examined the prevalence and demographic and clinical correlates of children diagnosed with Tourette disorder, chronic motor or vocal tic disorder, and other tic disorders in public and private insurance plans over the course of a 1-year period. METHOD: Claims were reviewed of Medicaid (n = 10,247,827) and privately (n = 16,128,828) insured youth (4-18 years old) focusing on tic disorder diagnoses during a 1-year period. Rates are presented for children with each tic disorder diagnosis overall and stratified by demographic characteristics and co-identified mental disorders. Mental health service use, including medications prescribed, and co-existing psychiatric disorders were also examined. RESULTS: In Medicaid-insured children, rates of diagnosis per 1,000 were 0.53 (95% confidence interval [CI] 0.51-0.55) for Tourette disorder, 0.08 (95% CI 0.07-0.08) for chronic motor or vocal tic disorder, and 0.43 (95% CI 0.41-0.44) for other tic disorders. In privately insured children, comparable rates were 0.50 (95% CI 0.49-0.52), 0.10 (95% CI 0.10-0.11), and 0.59 (95% CI 0.58-0.61). In 1 year, children diagnosed with tic disorders also frequently received other psychiatric disorder diagnoses. Compared with privately insured youth, children under Medicaid diagnosed with Tourette disorder had higher rates of attention-deficit/hyperactivity disorder (50.2% versus 25.9%), other disruptive behavior (20.6% versus 5.6%), and depression (14.6% versus 9.8%) diagnoses and higher rates of antipsychotic medication use (53.6% versus 33.2%). CONCLUSIONS: Despite similarities in annual rates of tic disorder diagnoses in publicly and privately insured children, important differences exist in patient characteristics and service use of publicly and privately insured youth who are diagnosed with tic disorders.

Prevalence of diagnosed HIV disease among medicaid beneficiaries with schizophrenia in U.S. metropolitan areas.

Numerous reports suggest HIV may be elevated among those with severe mental illnesses such as schizophrenia or bipolar illness, but this has been studied in only a limited number of sites. Medicaid claim's files from 2002 to 2003 were examined for metropolitan statistical areas (MSAs) in 8 states, focusing on schizophrenia. Across 102 MSAs, 1.81% of beneficiaries with schizophrenia had received diagnoses of HIV/AIDS. MSA rates ranged widely, from 5.2% in Newark, NJ, to no cases in 16 of the MSAs.

HIV patients with psychiatric disorders are less likely to discontinue HAART.

OBJECTIVE: We examined whether having a psychiatric disorder among HIV-infected individuals is associated with differential rates of discontinuation of HAART and whether the number of mental health visits impact these rates. DESIGN: This longitudinal study (fiscal year: 2000-2005) used discrete time survival analysis to evaluate time to discontinuation of HAART. The predictor variable was presence of a psychiatric diagnosis (serious mental illness versus depressive disorders versus none). SETTING: Five United States outpatient HIV sites affiliated with the HIV Research Network. PATIENTS: The sample consisted of 4989 patients. The majority was nonwhite (74.0%) and men (71.3%); 24.8% were diagnosed with a depressive disorder, and 9% were diagnosed with serious mental illness. MAIN OUTCOME MEASURES: Time to discontinuation of HAART adjusting for demographic factors, injection drug use history, and nadir CD4 cell count. RESULTS: Relative to those with no psychiatric disorders, the hazard probability for discontinuation of HAART was significantly lower in the first and second years among those with SMI [adjusted odds ratio: first year, 0.57 (0.47-0.69); second year, 0.68 (0.52-0.89)] and in the first year among those with depressive disorders [adjusted odds ratio: first year, 0.61 (0.54-0.69)]. The hazard probabilities did not significantly differ among diagnostic groups in subsequent years. Among those with psychiatric diagnoses, those with six or more mental health visits in a year were significantly less likely to discontinue HAART compared with patients with no mental health visits. CONCLUSION: Individuals with psychiatric disorders were significantly less likely to discontinue HAART in the first and second years of treatment. Mental health visits are associated with decreased risk of discontinuing HAART.

What do prospective research participants want to know? What do they assume they know already?

USING A FRAMEWORK BASED ON conversational pragmatics, data were collected on spontaneous information requests by people who were invited to participate in a simple research study. Subjects requested information on some standard elements of consent (e.g., scientific purpose, time required, investigator), but not others (e.g., voluntariness, freedom to quit, data maintenance, risks). Using post hoc fixed response queries, we investigated factors responsible for absence of queries on elements of consent. We found that participants sometimes did not ask because they assumed they already knew the answer; other times they did not care about the answer. This small pilot study suggests that inclusion of elements considered inappropriate by respondents may be redundant and, in at least some circumstances, potentially confusing.