Improvements in Depression and Changes in Fatigue: Results from the SLAM DUNC Depression Treatment Trial.

Fatigue and depression are common co-morbid conditions among people with HIV infection. We analyzed a population of HIV-infected adults with depression, who were enrolled in a depression treatment trial, to examine the extent to which improvements in depression over time were associated with improvements in HIV-related fatigue. Data for this analysis come from a randomized controlled trial to evaluate the effectiveness of improved depression treatment on antiretroviral adherence. Fatigue was measured using the HIV-Related Fatigue Scale, and depressive symptoms were measured with the Hamilton Depression Rating Scale. Participants (n = 234) were on average nearly 44 years of age and predominantly male, black or African American, and unemployed. Individuals who experienced stronger depression response (i.e., greater improvement in depression score) had larger decreases in fatigue. However, even among those who demonstrated a full depression response, nearly three-quarters continued to have either moderate or severe fatigue at 6 and 12 months.

Balancing Contamination and Referral Bias in a Randomized Clinical Trial: An Application of Pseudo-Cluster Randomization.

In randomized trials of provider-focused clinical interventions, treatment allocation often cannot be blinded to participants, study staff, or providers. The choice of unit of randomization (patient, provider, or clinic) entails tradeoffs in cost, power, and bias. Provider- or clinic-level randomization can minimize contamination, but it incurs the equally problematic potential for referral bias; that is, because arm assignment of future participants generally cannot be concealed, differences between arms may arise in the types of patients enrolled. Pseudo-cluster randomization is a novel study design that balances these competing validity threats. Providers are randomly assigned to an imbalanced proportion of intervention-arm participants (e.g., 80% or 20%). Providers can be masked to the imbalance, avoiding referral bias. Contamination is reduced because only a minority of control-arm participants are treated by majority-intervention providers. Pseudo-cluster randomization was implemented in a randomized trial of a decision support intervention to manage depression among patients receiving human immunodeficiency virus care in the southern United States in 2010-2014. The design appears successful in avoiding referral bias (participants were comparable between arms on important characteristics) and contamination (key depression treatment indicators were comparable between usual care participants managed by majority-intervention and majority-usual care providers and were markedly different compared with intervention participants).

The North Carolina HIV Bridge Counselor Program: Outcomes From a Statewide Level Intervention to Link and Reengage HIV-Infected Persons in Care in the South.

BACKGROUND: To improve the HIV continuum of care, a team of field service interventionists (State Bridge Counselors, SBC) was developed through a state public health system and provided brief (1-2) contacts for linkage of newly diagnosed persons with HIV and reengagement of persons living with HIV (PLWH) who were not in care. SETTING: North Carolina, United States. METHODS: Service data from January 2013 to June 2015 were analyzed to determine characteristics of clients referred to SBCs, proportions linked or reengaged in care, and/or achieved viral load suppression (VLs). We evaluated associations between client characteristics and outcomes using multivariable analyses and estimated odds ratios (OR) with 95% confidence intervals (CI). RESULTS: SBCs provided linkage services to 299 newly diagnosed individuals and reengagement services to 606 PLWH throughout North Carolina. Among persons who received linkage services, 189 (63%) had evidence of care within 90 days of referral and 205 (69%) had VLs within a year. Among PLWH who received reengagement services, 278 (46%) had care within 90 days and 308 (51%) had VLs within a year. Persons aged 30-39 years (OR, 2.1; 95% CI, 1.1 to 3.9) and 40-49 years had an increased likelihood (OR, 2.4; 95% CI, 1.1 to 5.2) of linkage within 90 days compared with persons aged 18-29 years. Non-white PLWH had an increased OR of 1.7; (95% CI, 1.2 to 2.5) of reengagement compared with whites. CONCLUSIONS: Our SBC program successfully implemented a "low-touch" approach to provision of linkage and reengagement services, demonstrating that public health resources can be used to address the HIV care continuum on a statewide level.

Missed opportunities for concurrent HIV-STD testing in an academic emergency department.

OBJECTIVES: We evaluated emergency department (ED) provider adherence to guidelines for concurrent HIV-sexually transmitted disease (STD) testing within an expanded HIV testing program and assessed demographic and clinical factors associated with concurrent HIV-STD testing. METHODS: We examined concurrent HIV-STD testing in a suburban academic ED with a targeted, expanded HIV testing program. Patients aged 18-64 years who were tested for syphilis, gonorrhea, or chlamydia in 2009 were evaluated for concurrent HIV testing. We analyzed demographic and clinical factors associated with concurrent HIV-STD testing using multivariate logistic regression with a robust variance estimator or, where applicable, exact logistic regression. RESULTS: Only 28.3% of patients tested for syphilis, 3.8% tested for gonorrhea, and 3.8% tested for chlamydia were concurrently tested for HIV during an ED visit. Concurrent HIV-syphilis testing was more likely among younger patients aged 25-34 years (adjusted odds ratio [AOR] = 0.36, 95% confidence interval [CI] 0.78, 2.10) and patients with STD-related chief complaints at triage (AOR=11.47, 95% CI 5.49, 25.06). Concurrent HIV-gonorrhea/chlamydia testing was more likely among men (gonorrhea: AOR=3.98, 95% CI 2.25, 7.02; chlamydia: AOR=3.25, 95% CI 1.80, 5.86) and less likely among patients with STD-related chief complaints at triage (gonorrhea: AOR=0.31, 95% CI 0.13, 0.82; chlamydia: AOR=0.21, 95% CI 0.09, 0.50). CONCLUSIONS: Concurrent HIV-STD testing in an academic ED remains low. Systematic interventions that remove the decision-making burden of ordering an HIV test from providers may increase HIV testing in this high-risk population of suspected STD patients.