RESUMO
The literature recognizes six measures of retention in care, an integral component of the HIV Continuum of Care. Given prior research showing that different retention measures are differentially associated with HIV health outcomes (e.g., CD4 count and viral suppression), we hypothesized that different groups of people living with HIV (PLWH) would also have differential retention outcomes based on the retention measure applied. We conducted a cross-sectional analysis of multisite patient-level medical record data (n = 10,053) from six academically-affiliated HIV clinics using six different measures of retention. Principal component analysis indicated two distinct retention constructs: kept-visit-measures and missed-visit measures. Although black (compared to white) PLWH had significantly poorer retention on the three missed-visit measures, race was not significantly associated with any of the three kept-visit measures. Males performed significantly worse than females on all kept-visit measures, but sex differences were not observed for any missed-visit retention measures. IDU risk transmission group and younger age were associated with poorer retention on both missed- and kept-visit retention measures. Missed- and kept-visit measures may capture different aspects of retention, as indicated in the observed differential associations among race, sex, age, and risk transmission group. Multiple measures are needed to effectively assess retention across patient subgroups.
Assuntos
Infecções por HIV/terapia , Visita a Consultório Médico , Atenção Primária à Saúde/organização & administração , Adulto , Negro ou Afro-Americano , Contagem de Linfócito CD4 , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
We sought to integrate a brief computer and counseling support intervention into the routine practices of HIV clinics and evaluate effects on patients' viral loads. The project targeted HIV patients in care whose viral loads exceeded 1000 copies/ml at the time of recruitment. Three HIV clinics initiated the intervention immediately, and three other HIV clinics delayed onset for 16 months and served as concurrent controls for evaluating outcomes. The intervention components included a brief computer-based intervention (CBI) focused on antiretroviral therapy adherence; health coaching from project counselors for participants whose viral loads did not improve after doing the CBI; and behavioral screening and palm cards with empowering messages available to all patients at intervention clinics regardless of viral load level. The analytic cohort included 982 patients at intervention clinics and 946 patients at control clinics. Viral loads were assessed at 270 days before recruitment, at time of recruitment, and +270 days later. Results indicated that both the control and intervention groups had significant reductions in viral load, ending with approximately the same viral level at +270 days. There was no evidence that the CBI or the targeted health coaching was responsible for the viral reduction in the intervention group. Results may stem partially from statistical regression to the mean in both groups. Also, clinical providers at control and intervention clinics may have taken action (e.g., conversations with patients, referrals to case managers, adherence counselors, mental health, substance use specialists) to help their patients reduce their viral loads. In conclusion, neither a brief computer-based nor targeted health coaching intervention reduced patients' viral loads beyond levels achieved with standard of care services available to patients at well-resourced HIV clinics.
Assuntos
Aconselhamento , Infecções por HIV/virologia , Carga Viral , Adulto , Fármacos Anti-HIV/uso terapêutico , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/psicologia , Humanos , Masculino , Adesão à Medicação , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: We explored the contribution of missed primary HIV care visits ("no-show") to observed disparities in virological failure (VF) among Black persons and persons with injection drug use (IDU) history. METHODS: We used patient-level data from 6 academic clinics, before the Centers for Disease Control and Prevention and Health Resources and Services Administration Retention in Care intervention. We employed staged multivariable logistic regression and multivariable models stratified by no-show visit frequency to evaluate the association of sociodemographic factors with VF. We used multiple imputations to assign missing viral load values. RESULTS: Among 10 053 patients (mean age = 46 years; 35% female; 64% Black; 15% with IDU history), 31% experienced VF. Although Black patients and patients with IDU history were significantly more likely to experience VF in initial analyses, race and IDU parameter estimates were attenuated after sequential addition of no-show frequency. In stratified models, race and IDU were not statistically significantly associated with VF at any no-show level. CONCLUSIONS: Because missed clinic visits contributed to observed differences in viral load outcomes among Black and IDU patients, achieving an improved understanding of differential visit attendance is imperative to reducing disparities in HIV.
Assuntos
Agendamento de Consultas , Infecções por HIV/tratamento farmacológico , Cooperação do Paciente , Carga Viral , Negro ou Afro-Americano , Feminino , Infecções por HIV/etnologia , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores Socioeconômicos , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The aim of the study was to determine whether enhanced personal contact with human immunodeficiency virus (HIV)-infected patients across time improves retention in care compared with existing standard of care (SOC) practices, and whether brief skills training improves retention beyond enhanced contact. METHODS: The study, conducted at 6 HIV clinics in the United States, included 1838 patients with a recent history of inconsistent clinic attendance, and new patients. Each clinic randomized participants to 1 of 3 arms and continued to provide SOC practices to all enrollees: enhanced contact with interventionist (EC) (brief face-to-face meeting upon returning for care visit, interim visit call, appointment reminder calls, missed visit call); EC + skills (organization, problem solving, and communication skills); or SOC only. The intervention was delivered by project staff for 12 months following randomization. The outcomes during that 12-month period were (1) percentage of participants attending at least 1 primary care visit in 3 consecutive 4-month intervals (visit constancy), and (2) proportion of kept/scheduled primary care visits (visit adherence). RESULTS: Log-binomial risk ratios comparing intervention arms against the SOC arm demonstrated better outcomes in both the EC and EC + skills arms (visit constancy: risk ratio [RR], 1.22 [95% confidence interval {CI}, 1.09-1.36] and 1.22 [95% CI, 1.09-1.36], respectively; visit adherence: RR, 1.08 [95% CI, 1.05-1.11] and 1.06 [95% CI, 1.02-1.09], respectively; all Ps < .01). Intervention effects were observed in numerous patient subgroups, although they were lower in patients reporting unmet needs or illicit drug use. CONCLUSIONS: Enhanced contact with patients improved retention in HIV primary care compared with existing SOC practices. A brief patient skill-building component did not improve retention further. Additional intervention elements may be needed for patients reporting illicit drug use or who have unmet needs. CLINICAL TRIALS REGISTRATION: CDCHRSA9272007.
Assuntos
Instituições de Assistência Ambulatorial , Infecções por HIV , Aceitação pelo Paciente de Cuidados de Saúde , Educação de Pacientes como Assunto , Relações Profissional-Paciente , Adolescente , Adulto , Agendamento de Consultas , Feminino , Infecções por HIV/tratamento farmacológico , Necessidades e Demandas de Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Atenção Primária à Saúde , Padrão de Cuidado , Estados Unidos , Adulto JovemRESUMO
CONTEXT: Reducing HIV incidence in the United States and improving health outcomes for people living with HIV hinge on improving access to highly effective treatment and overcoming barriers to continuous treatment. Using laboratory tests routinely reported for HIV surveillance to monitor individuals' receipt of HIV care and contacting them to facilitate optimal care could help achieve these objectives. Historically, surveillance-based public health intervention with individuals for HIV control has been controversial because of concerns that risks to privacy and autonomy could outweigh benefits. But with the availability of lifesaving, transmission-interrupting treatment for HIV infection, some health departments have begun surveillance-based outreach to facilitate HIV medical care. METHODS: Guided by ethics frameworks, we explored the ethical arguments for changing the uses of HIV surveillance data. To identify ethical, procedural, and strategic considerations, we reviewed the activities of health departments that are using HIV surveillance data to contact persons identified as needing assistance with initiating or returning to care. FINDINGS: Although privacy concerns surrounding the uses of HIV surveillance data still exist, there are ethical concerns associated with not using HIV surveillance to maximize the benefits from HIV medical care and treatment. Early efforts to use surveillance data to facilitate optimal HIV medical care illustrate how the ethical burdens may vary depending on the local context and the specifics of implementation. Health departments laid the foundation for these activities by engaging stakeholders to gain their trust in sharing sensitive information; establishing or strengthening legal, policy and governance infrastructure; and developing communication and follow-up protocols that protect privacy. CONCLUSIONS: We describe a shift toward using HIV surveillance to facilitate optimal HIV care. Health departments should review the considerations outlined before implementing new uses of HIV surveillance data, and they should commit to an ongoing review of activities with the objective of balancing beneficence, respect for persons, and justice.
Assuntos
Confidencialidade/ética , Infecções por HIV/prevenção & controle , Melhoria de Qualidade , Comunicação , Registros Eletrônicos de Saúde/ética , Infecções por HIV/epidemiologia , Infecções por HIV/terapia , Política de Saúde/legislação & jurisprudência , Acessibilidade aos Serviços de Saúde/organização & administração , Humanos , Vigilância da População , Melhoria de Qualidade/ética , Medição de Risco/ética , Responsabilidade Social , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Retention in care for human immunodeficiency virus (HIV)-infected patients is a National HIV/AIDS Strategy priority. We hypothesized that retention could be improved with coordinated messages to encourage patients' clinic attendance. We report here the results of the first phase of the Centers for Disease Control and Prevention/Health Resources and Services Administration Retention in Care project. METHODS: Six HIV-specialty clinics participated in a cross-sectionally sampled pretest-posttest evaluation of brochures, posters, and messages that conveyed the importance of regular clinic attendance. 10,018 patients in 2008-2009 (preintervention period) and 11,039 patients in 2009-2010 (intervention period) were followed up for clinic attendance. Outcome variables were the percentage of patients who kept 2 consecutive primary care visits and the mean proportion of all primary care visits kept. Stratification variables were: new, reengaging, and active patients, HIV RNA viral load, CD4 cell count, age, sex, race or ethnicity, risk group, number of scheduled visits, and clinic site. Data were analyzed by multivariable log-binomial and linear models using generalized estimation equation methods. RESULTS: Clinic attendance for primary care was significantly higher in the intervention versus preintervention year. Overall relative improvement was 7.0% for keeping 2 consecutive visits and 3.0% for the mean proportion of all visits kept (P < .0001). Larger relative improvement for both outcomes was observed for new or reengaging patients, young patients and patients with elevated viral loads. Improved attendance among the new or reengaging patients was consistent across the 6 clinics, and less consistent across clinics for active patients. CONCLUSION: Targeted messages on staying in care, which were delivered at minimal effort and cost, improved clinic attendance, especially for new or reengaging patients, young patients, and those with elevated viral loads.
Assuntos
Agendamento de Consultas , Intervenção Médica Precoce/métodos , Infecções por HIV/terapia , Cooperação do Paciente , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Instituições de Assistência Ambulatorial , Estudos Transversais , Intervenção Médica Precoce/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estados UnidosRESUMO
The role of human leukocyte antigen (HLA) class I supertypes in controlling human immunodeficiency virus type 1 (HIV-1) infection in African Americans has not been established. We examined the effects of the HLA-A and HLA-B alleles and supertypes on the outcomes of HIV-1 clade B infection among 338 African American women and adolescents. HLA-B58 and -B62 supertypes (B58s and B62s) were associated with favorable HIV-1 disease control (proportional odds ratio [POR] of 0.33 and 95% confidence interval [95% CI] of 0.21 to 0.52 for the former and POR of 0.26 and 95% CI of 0.09 to 0.73 for the latter); B7s and B44s were associated with unfavorable disease control (POR of 2.39 and 95% CI of 1.54 to 3.73 for the former and POR of 1.63 and 95% CI of 1.08 to 2.47 for the latter). In general, individual alleles within specific B supertypes exerted relatively homogeneous effects. A notable exception was B27s, whose protective influence (POR, 0.58; 95% CI, 0.35 to 0.94) was masked by the opposing effect of its member allele B*1510. The associations of most B supertypes (e.g., B58s and B7s) were largely explained either by well-known effects of constituent B alleles or by effects of previously unimplicated B alleles aggregated into a particular supertype (e.g., B44s and B62s). A higher frequency of HLA-B genotypic supertypes correlated with a higher mean viral load (VL) and lower mean CD4 count (Pearson's r = 0.63 and 0.62, respectively; P = 0.03). Among the genotypic supertypes, B58s and its member allele B*57 contributed disproportionately to the explainable VL variation. The study demonstrated the dominant role of HLA-B supertypes in HIV-1 clade B-infected African Americans and further dissected the contributions of individual class I alleles and their population frequencies to the supertype effects.
Assuntos
Negro ou Afro-Americano/genética , Infecções por HIV/etnologia , Infecções por HIV/imunologia , Infecções por HIV/prevenção & controle , HIV-1/imunologia , Antígenos de Histocompatibilidade Classe I/imunologia , Adolescente , Adulto , Alelos , Criança , Feminino , Genótipo , Infecções por HIV/genética , Antígenos HLA-A/genética , Antígenos HLA-A/imunologia , Antígenos HLA-B/genética , Antígenos HLA-B/imunologia , Antígenos de Histocompatibilidade Classe I/genética , Humanos , Pessoa de Meia-Idade , Razão de Chances , Carga Viral , Adulto JovemRESUMO
Public health benefits of expanded HIV screening will be adequately realized only if an early diagnosis is followed by prompt linkage to care. We characterized rates and factors associated with failure to enter into medical care within three months of HIV diagnosis and assessed the predictors of time to enter care over a follow-up period of up to 60 months. The study cohort included 3697 South Carolina (SC) residents' ≥13 years who were newly HIV-diagnosed in 2004-2008. Date of first laboratory report of CD4(+) T-cell count or viral load (VL) test after 30 days of confirmatory HIV diagnosis was used to define time to linkage to care. Results showed that of the total 3697 persons, 1768 (48%) entered care within three months, 1115 (30%) in four-12 months after diagnosis, and 814 (22%) failed to initiate care within 12 months of HIV diagnosis. At the end of study follow-up period of up to 60 months from the date of HIV diagnosis, 472/3697 (13%) individuals remained out of care. Multivariable Cox proportional hazards analysis showed that compared with hospitals, time to enter care was shorter in those diagnosed at state mental health/correctional facilities (adjusted hazards ratio [aHR] 1.16; 95% confidence interval [CI] 1.02-1.34) and longer in those diagnosed at county health departments (aHR 0.87; 95% CI 0.80-0.96) and at "Other/unknown" facilities (aHR 0.79; 95% CI 0.70-0.89). Time to entry into care was longer for men (aHR 0.82; 95% CI 0.75-0.89) compared with women, blacks (aHR 0.91; 95% CI 0.83-0.98) compared with whites, and males who have sex with males (MSM) (aHR 0.89; 95% CI 0.80-0.98) compared with heterosexual exposure. Delayed entry into HIV care remains a challenge in controlling HIV transmission in SC. Better integration of testing and care facilities could improve the proportion of newly HIV-diagnosed persons who enter care in a timely manner.
Assuntos
Atenção à Saúde/estatística & dados numéricos , Infecções por HIV/terapia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adolescente , Adulto , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Vigilância da População , Fatores de Risco , South Carolina , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: Because people living with HIV now have greater life expectancy and reduced morbidity, there is a greater need for physicians to discuss HIV transmission risk reduction with these patients. Very limited data are available examining how frequently this discussion is held. OBJECTIVE: We examined the frequency of discussing HIV prevention and HIV care topics, as well as the associations of gender, race/ethnicity, and practice characteristics of physicians caring for persons with HIV. METHODS: In a 4-city (Miami, Atlanta, Baltimore, Los Angeles) survey, 417 licensed physicians who primarily cared for patients with HIV were mailed a 58-item questionnaire about how frequently they discussed HIV transmission risk reduction, adherence to HIV antiretroviral treatment (ART), adherence to opportunistic infection (OI) prophylaxis, and how to take medicines. Multivariate logistic regression analyses were used to examine the association between physician gender, race/ethnicity, and practice characteristics, and the frequency of discussing these topics. RESULTS: A total of 317 physicians responded to the mailed questionnaire. Less than 40% of the physicians reported always discussing HIV transmission risk reduction with patients. In contrast, 83.9% and 65.0% reported always discussing adherence to ART and to OI prophylaxis, respectively. Of these physicians, 65.1% strongly agreed or somewhat agreed that they had sufficient time to provide the care and information needed to their patients. In multivariate analysis, the frequency of discussing HIV transmission risk reduction was higher for physicians who were Hispanic (P = 0.03) or Asian/Pacific Islander (P = 0.001), for physicians who reported they had enough time to provide care and information to patients (P = 0.003), and for physicians who cared for fewer patients (P = 0.05). The frequency of discussing HIV transmission risk reduction was suggestive of a higher rate for female physicians, but did not quite reach statistical significance. CONCLUSIONS: We observed a lower frequency of discussing the topic of HIV prevention compared with that of HIV care among the physicians surveyed. This infrequent discussion with patients with HIV represents a missed opportunity, and physicians should be encouraged to include discussion of prevention as a standard of care.
Assuntos
Infecções por HIV/tratamento farmacológico , Infecções por HIV/prevenção & controle , Cooperação do Paciente , Relações Médico-Paciente , Infecções Oportunistas Relacionadas com a AIDS/prevenção & controle , Adulto , Baltimore , Etnicidade , Feminino , Florida , Georgia , Infecções por HIV/transmissão , Humanos , Los Angeles , Masculino , Pessoa de Meia-Idade , Educação de Pacientes como Assunto , Fatores Sexuais , Inquéritos e QuestionáriosRESUMO
Current guidelines specify that visit intervals with viral monitoring should not exceed 6 months for HIV patients. Yet, gaps in care exceeding 6 months are common. In an observational cohort using US patients, we examined the association between gap length and changes in viral load status and sought to determine the length of the gap at which significant increases in viral load occur. We identified patients with gaps in care greater than 6 months from 6399 patients from six US HIV clinics. Gap strata were >6 to <7, 7 to <8, 8 to <9, 9 to <12, and ≥12 months, with viral load measurements matched to the opening and closing dates for the gaps. We examined visit gap lengths in association with two viral load measurements: continuous (log10 viral load at gap opening and closing) and dichotomous (whether patients initially suppressed but lost viral suppression by close of the care gap). Viral load increases were nonsignificant or modest when gap length was <9 months, corresponding to 10% or fewer patients who lost viral suppression. For gaps ≥12 months, there was a significant increase in viral load as well as a much larger loss of viral suppression (in 23% of patients). Detrimental effects on viral load after a care gap were greater in young patients, black patients, and those without private health insurance. On average, shorter gaps in care were not detrimental to patient viral load status. HIV primary care visit intervals of 6 to 9 months for select patients may be appropriate.
Assuntos
Fármacos Anti-HIV/uso terapêutico , Continuidade da Assistência ao Paciente/estatística & dados numéricos , Infecções por HIV/tratamento farmacológico , Infecções por HIV/virologia , Seguro Saúde/estatística & dados numéricos , Atenção Primária à Saúde , Adulto , Negro ou Afro-Americano , Estudos de Coortes , Feminino , Guias como Assunto , Infecções por HIV/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Testes Sorológicos , Fatores de Tempo , Estados Unidos , Carga Viral , Adulto JovemRESUMO
The present study sought to examine psychological and behavioral variables as predictors of attending an HIV medical care provider among person's recently diagnosed with HIV. The study, carried out between 2001 and 2003, was a two-arm randomized intervention trial with participants recruited from public HIV testing centers, sexually transmitted disease (STD) clinics, hospitals, and community-based organizations in Atlanta, Georgia; Baltimore, Maryland; Miami, Florida; and Los Angeles, California. Eighty-six percent of those enrolled (273) had complete baseline and 12-month follow-up data. Measures of number of months since HIV diagnosis, readiness to enter care (based on stages of change), barriers and facilitators to entering care, drug use, and intervention arm (case managed versus simple referral) were examined as predictors of attending an HIV care provider, defined as being in care at least once in each of two consecutive 6-month follow-up periods. In logistic regression, seeing a care provider was significantly more likely among participants diagnosed with HIV within 6 months of enrollment (odds ratio [OR] = 2.52, 95% confidence interval [CI], 1.25, 5.06), those in the preparation versus precontemplation stages at baseline (OR = 2.87, 95% CI, 1.21, 6.81), those who reported at baseline that someone (friend, family member, social worker, other) was helping them get into care (OR = 2.13, 95% CI, 1.02, 4.44), and those who received a case manager intervention (OR = 2.16, 95% CI, 1.23, 3.78). The findings indicate a need to reach HIV-positive person's soon after diagnosis and assist them in getting into medical care. Knowing a person's stages of readiness to enter care and their support networks can help case managers formulate optimal client plans.
Assuntos
Fármacos Anti-HIV/administração & dosagem , Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/psicologia , Infecções por HIV/terapia , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Educação de Pacientes como Assunto , Adolescente , Adulto , Feminino , Humanos , Entrevistas como Assunto , Masculino , Razão de Chances , Inquéritos e QuestionáriosRESUMO
The significance of a gap in HIV care depends, at least partially, on whether patients continue to fill prescriptions for antiretroviral (ARV) drugs during the gap in care. We used a billing claims database to determine the proportion of persons who filled ≥1 prescription for ARV drugs during a gap in care (no clinic visit in >6 months). Persons were stratified into 3 groups: "never" (prescriptions never filled), "sometimes" (prescriptions filled >0%-<100% of months), and "always" (prescriptions filled monthly). Logistic regression analyses were conducted to determine factors associated with "never" filling ARV drugs. Of 14 308 persons, 69% (n = 9817), 13% (n = 1928), and 18% (n = 2563) "never," "sometimes," and "always" filled ARV drugs during the gap in care. Persons aged 18 to 29 years (odds ratio [OR] = 1.56, 95% confidence interval [CI] 1.39-1.74), women (OR = 1.67, CI 1.52-1.83), and persons from the Northeast region of the United States (OR = 1.86, CI 1.69-2.03) were more likely to never fill ARV drugs than persons aged ≥30 years, men, and persons outside the Northeast, respectively. Efforts should be made to minimize gaps in care, emphasize importance of therapy, and provide adherence support.
Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Adesão à Medicação/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Bases de Dados Factuais , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Fatores Sexuais , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: To determine the rate and predictors of community-acquired bacterial pneumonia and its effect on human immunodeficiency virus (HIV) disease progression in HIV-infected women, we performed a multiple-site, prospective study of HIV-infected women in 4 cities in the United States. METHODS: During the period of 1993-2000, we observed 885 HIV-infected and 425 HIV-uninfected women with a history of injection drug use or high-risk sexual behavior. Participants underwent semiannual interviews, and CD4+ lymphocyte count and viral load were assessed in HIV-infected subjects. Data regarding episodes of bacterial pneumonia were ascertained from medical record reviews. RESULTS: The rate of bacterial pneumonia among 885 HIV-infected women was 8.5 cases per 100 person-years, compared with 0.7 cases per 100 person-years in 425 HIV-uninfected women (P < .001). In analyses limited to follow-up after 1 January 1996, highly active antiretroviral therapy (HAART) and trimethoprim-sulfamethoxazole (TMP-SMX) use were associated with a decreased risk of bacterial pneumonia. Among women who had used TMP-SMX for 12 months, each month of HAART decreased bacterial pneumonia risk by 8% (adjusted hazard ratio [HR(adj)], 0.92; 95% confidence interval [CI], 0.89-0.95). Increments of 50 CD4+ cells/mm3 decreased the risk (HR(adj), 0.88; 95% CI, 0.84-0.93), and smoking doubled the risk (HR(adj), 2.12; 95% CI, 1.26-3.55). Bacterial pneumonia increased mortality risk (HR(adj), 5.02; 95% CI, 2.12-11.87), with adjustment for CD4+ lymphocyte count and duration of HAART and TMP-SMX use. CONCLUSIONS: High rates of bacterial pneumonia persist among HIV-infected women. Although HAART and TMP-SMX treatment decreased the risk, bacterial pneumonia was associated with an accelerated progression to death. Interventions that improve HAART utilization and promote smoking cessation among HIV-infected women are warranted.
Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/epidemiologia , Pneumonia Bacteriana/epidemiologia , Adolescente , Adulto , Anti-Infecciosos/uso terapêutico , Terapia Antirretroviral de Alta Atividade , Linfócitos T CD4-Positivos , Infecções Comunitárias Adquiridas/epidemiologia , Comorbidade , Progressão da Doença , Feminino , Infecções por HIV/tratamento farmacológico , Humanos , Pessoa de Meia-Idade , Pneumonia Bacteriana/tratamento farmacológico , Pneumonia Bacteriana/etiologia , Estudos Prospectivos , Assunção de Riscos , Fumar/efeitos adversos , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Estados Unidos/epidemiologia , Carga ViralRESUMO
Little is known about the perception of system and patient barriers to adequate HIV care by an essential resource in the provision of HIV care, HIV medical care providers. To evaluate such perceptions, between November 2000 and June 2001 a survey was mailed to 526 HIV medical care providers who cared for HIV-infected individuals in Atlanta, Baltimore, Los Angeles, and Miami. Logistic regression analysis of survey results revealed significant differences in perceptions of system barriers between Black and Hispanic providers versus White providers and non-medical doctor providers versus medical doctor providers. Female providers differed significantly from male providers in assessing the importance of certain system and patient barriers. The authors observed that there are seeming disparities in perceptions of system and patient barriers to HIV medical care by providers of different race/ethnic groups, genders, and professions. More research needs to be conducted to determine if these disparities reflect differences in the provision of adequate HIV care for disadvantaged individuals.
Assuntos
Atitude do Pessoal de Saúde , Infecções por HIV/terapia , Acessibilidade aos Serviços de Saúde/organização & administração , Populações Vulneráveis , Adulto , Idoso , Atitude do Pessoal de Saúde/etnologia , Baltimore , Feminino , Florida , Georgia , Infecções por HIV/complicações , Infecções por HIV/psicologia , Necessidades e Demandas de Serviços de Saúde , Humanos , Modelos Logísticos , Los Angeles , Masculino , Transtornos Mentais/complicações , Pessoa de Meia-Idade , Profissionais de Enfermagem/psicologia , Pesquisa Metodológica em Enfermagem , Assistentes Médicos/psicologia , Médicos/psicologia , Grupos Raciais/etnologia , Fatores Sexuais , Transtornos Relacionados ao Uso de Substâncias/complicações , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: We evaluated whether heavy alcohol use, illicit drug use or high levels of anxiety, and depression symptoms were modifiers of the retention through enhanced personal contact intervention. The intervention had previously demonstrated overall efficacy in the parent study. DESIGN: Randomized trial. METHODS: A total of 1838 patients from six US HIV clinics were enrolled into a randomized trial in which intervention patients received an 'enhanced contact' protocol for 12 months. All participants completed an audio computer-assisted self-interview that measured depression and anxiety symptoms from the Brief Symptom Inventory, alcohol use from the Alcohol Use Disorders Identification Test-Consumption instrument, and drug use from the WHO (Alcohol, Smoking and Substance Involvement Screening Test) questions. The 12-month binary outcome was completing an HIV primary care visit in three consecutive 4-month intervals. The outcome was compared between intervention and standard of care patients within subgroups on the effect modifier variables using log-binomial regression models. RESULTS: Persons with high levels of anxiety or depression symptoms and those reporting illicit drug use, or heavy alcohol consumption had no response to the intervention. Patients without these 'higher risk' characteristics responded significantly to the intervention. Further analysis revealed higher risk patients were less likely to have successfully received the telephone contact component of the intervention. Among higher risk patients who did successfully receive this component, the intervention effect was significant. CONCLUSION: Our findings suggest that clinic-based retention-in-care interventions are able to have significant effects on HIV patients with common behavioral health issues, but the design of those interventions should assure successful delivery of intervention components to increase effectiveness.
Assuntos
Alcoolismo/complicações , Ansiedade/complicações , Depressão/complicações , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Adesão à Medicação , Transtornos Relacionados ao Uso de Substâncias/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Comportamental/métodos , Criança , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
OBJECTIVE: We evaluated whether being in drug use treatment improves linkage to HIV medical care for HIV-infected drug users. We assessed whether an evidence-based intervention for linkage to care ['ARTAS'] works better for HIV-infected drug users who had been in drug use treatment than those who had not. DESIGN: Randomized trial. METHODS: 295 Participants in the Antiretroviral Treatment Access Study ['ARTAS'] trial were followed for time to first HIV medical care. Drug use (injected and non-injected drugs) in the last 30days and being in drug treatment in the last 12 months were assessed by audio-CASI. We used a proportional hazards model of time to care in drug users with and without drug treatment, adjusting for barriers to care, AIDS symptoms, and demographic factors. We tested whether drug treatment modified the intervention effect by using a drug use/drug treatment*intervention interaction term. RESULTS: Ninety-nine participants (30%) reported drug use in the 30days before enrollment. Fifty-three (18%) reported being in a drug treatment program in the last 12 months. Drug users reporting methadone maintenance became engaged in care in less than half the time of drug users without a treatment history [HR 2.97 (1.20, 6.21)]. The ARTAS intervention effect was significantly larger for drug users with a treatment history compared to drug users without a treatment history (AHR 5.40, [95% CI, 2.03-14.38]). CONCLUSIONS: Having been in drug treatment programs facilitated earlier entry into care among drug users diagnosed with HIV infection, and improved their response to the ARTAS linkage intervention.
Assuntos
Usuários de Drogas/estatística & dados numéricos , Infecções por HIV/tratamento farmacológico , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/tratamento farmacológico , Adolescente , Adulto , Demografia , Feminino , Infecções por HIV/complicações , Humanos , Masculino , Metadona/uso terapêutico , Tratamento de Substituição de Opiáceos , Modelos de Riscos Proporcionais , Transtornos Relacionados ao Uso de Substâncias/complicações , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: The HIV continuum of care paradigm uses a single viral load test per patient to estimate the prevalence of viral suppression. We compared this single-value approach with approaches that used multiple viral load tests to examine the stability of suppression. METHODS: The retrospective analysis included HIV patients who had at least 2 viral load tests during a 12-month observation period. We assessed the (1) percent with suppressed viral load (<200 copies/mL) based on a single test during observation, (2) percent with suppressed viral loads on all tests during observation, (3) percent who maintained viral suppression among patients whose first observed viral load was suppressed, and (4) change in viral suppression status comparing first with last measurement occasions. Prevalence ratios compared demographic and clinical subgroups. RESULTS: Of 10,942 patients, 78.5% had a suppressed viral load based on a single test, whereas 65.9% were virally suppressed on all tests during observation. Of patients whose first observed viral load was suppressed, 87.5% were suppressed on all subsequent tests in the next 12 months. More patients exhibited improving status (13.3% went from unsuppressed to suppressed) than worsening status (5.6% went from suppressed to unsuppressed). Stable suppression was less likely among women, younger patients, black patients, those recently diagnosed with HIV, and those who missed ≥1 scheduled clinic visits. CONCLUSIONS: Using single viral load measurements overestimated the percent of HIV patients with stable suppressed viral load by 16% (relative difference). Targeted clinical interventions are needed to increase the percent of patients with stable suppression.
Assuntos
Infecções por HIV/virologia , Prática de Saúde Pública , Carga Viral , HumanosRESUMO
OBJECTIVE: The Antiretroviral Treatment Access Study (ARTAS) assessed a case management intervention to improve linkage to care for persons recently receiving an HIV diagnosis. METHODS: Participants were recently diagnosed HIV-infected persons in Atlanta, Baltimore, Los Angeles and Miami. They were randomized to either standard of care (SOC) passive referral or case management (CM) for linkage to nearby HIV clinics. The SOC arm received information about HIV and local care resources; the CM intervention arm included up to five contacts with a case manager over a 90-day period. The outcome measure was self-reported attendance at an HIV care clinic at least twice over a 12-month period. RESULTS: A higher proportion of the 136 case-managed participants than the 137 SOC participants visited an HIV clinician at least once within 6 months [78 versus 60%; adjusted relative risk (RR(adj)), 1.36; P = 0.0005) and at least twice within 12 months (64 versus 49%; RR(adj), 1.41; P = 0.006). Individuals older than 40 years, Hispanic participants, individuals enrolled within 6 months of an HIV-seropositive test result and participants without recent crack cocaine use were all significantly more likely to have made two visits to an HIV care provider. We estimate the cost of such case management to be 600-1200 US dollars per client. CONCLUSION: A brief intervention by a case manager was associated with a significantly higher rate of successful linkage to HIV care. Brief case management is an affordable and effective resource that can be offered to HIV-infected clients soon after their HIV diagnosis.
Assuntos
Administração de Caso/organização & administração , Infecções por HIV/tratamento farmacológico , Adolescente , Adulto , Antirretrovirais/uso terapêutico , Administração de Caso/economia , Feminino , Seguimentos , Infecções por HIV/economia , Infecções por HIV/virologia , HIV-1/isolamento & purificação , Custos de Cuidados de Saúde , Serviços de Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Prontuários Médicos , Pessoa de Meia-Idade , Análise Multivariada , RNA Viral/sangue , Fatores Socioeconômicos , Estados Unidos , Carga ViralRESUMO
OBJECTIVE: We examined HIV transmission potential of patients in care by analyzing the amount of person-time spent above a viral load threshold that increases risk for transmission. DESIGN: Observational cohort and supplemental data. METHODS: The cohort included HIV patients who received care at six HIV clinics in the United States, from 1 April 2009 to 31 March 2013, and had two or more viral load tests during this interval. Person-time (in days) above a viral load of 1500 copies/ml out of the total observation time was determined by inspecting consecutive pairs of viral load results and the time intervals between those pairs. The person-time rate ratios comparing demographic and clinical subgroups were estimated with Poisson regression. RESULTS: The cohort included 14 532 patients observed for a median of 1073 days with a median of nine viral load records. Ninety percent of the patients had been prescribed antiretroviral therapy. On average, viral load exceeded 1500 copies/ml during 23% of the patients' observation time (average of 84 days per year, per patient). Percentage of person-time above the threshold was higher among patients who had more than a fourth of their viral load pairs exceeding a 6-month interval (34% of observation time), patients not on antiretroviral therapy (58% of time), new/re-engaging patients (34% of time), patients 16-39 years of age (32% of time), and patients of black race (26% of time). CONCLUSION: HIV patients in care spent an average of nearly a quarter of their time with viral loads above 1500 copies/ml, higher among some subgroups, placing them at risk for potentially transmitting HIV to others.