Efficacy of 25-OH Vitamin D3 prophylactic administration for reducing lameness in broilers grown on wire flooring.

Bacterial chondronecrosis with osteomyelitis (BCO) is the most common cause of lameness in commercial broilers. Growing broilers on wire flooring provides an excellent experimental model for reproducibly triggering significant levels of lameness attributable to BCO. In the present study we evaluated the efficacy of adding HyD (25-OH vitamin D3) to the drinking water as a preventative/prophylactic treatment for lameness. Broiler chicks were reared on 5 x 10 ft flat wire floor panels within 6 environmental chambers. Three chambers were supplied with tap water (Control group) and the remaining chambers were supplied with HyD (HyD group: 0.06 mL HyD solution/L water; dosing based on the HyD Solution label to provide 33.9 µg 25-OHD3/L) from d 1 through 56. Feed was provided ad libitum and was formulated to meet or exceed minimum standards for all ingredients, including 5,500 IU vitamin D3/kg. Lameness initially was detected on d 28, and the cumulative incidence of lameness on d 56 was higher in the Control group than in the HyD group (34.7 vs. 22.7%, respectively; P = 0.03; Z-test of proportions; chambers pooled). The most prevalent diagnoses for lame birds were osteochondrosis and osteomyelitis (BCO) of the proximal femora (52%) and tibiae (79%), accompanied by minor incidences of tibial dyschondroplasia (0.33%), spondylolisthesis, or kinky back (0.67%), and twisted legs (1%). Broilers that survived to d 56 without developing lameness did not differ in BW when compared by group within a gender. The wire flooring model imposes a rigorous, sustained challenge that undoubtedly is much more severe than typically would be experienced by broilers under normal commercial conditions. Therefore the encouraging response to HyD supplementation in the present study supports the potential for 25-OH vitamin D3 to attenuate outbreaks of lameness caused by BCO in commercial broiler flocks.

A cryptic lineage within the pupfish Cyprinodon dearborni suggests multiple colonizations of South America.

The coastal South American species Cyprinodon dearborni contains two lineages distinct at both mitochondrial and nuclear loci. One appears to be a long-term South American endemic, whereas the other is a more recent colonizer related to the widespread Cyprinodon variegatus.

Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States.

BACKGROUND: There have been no previous nationally representative estimates of the prevalence of mental disorders and drug use among adults receiving care for human immunodeficiency virus (HIV) disease in the United States. It is also not known which clinical and sociodemographic factors are associated with these disorders. SUBJECTS AND METHODS: We enrolled a nationally representative probability sample of 2864 adults receiving care for HIV in the United States in 1996. Participants were administered a brief structured psychiatric instrument that screened for psychiatric disorders (major depression, dysthymia, generalized anxiety disorders, and panic attacks) and drug use during the previous 12 months. Sociodemographic and clinical factors associated with screening positive for any psychiatric disorder and drug dependence were examined in multivariate logistic regression analyses. RESULTS: Nearly half of the sample screened positive for a psychiatric disorder, nearly 40% reported using an illicit drug other than marijuana, and more than 12% screened positive for drug dependence during the previous 12 months. Factors independently associated with screening positive for a psychiatric disorder included number of HIV-related symptoms, illicit drug use, drug dependence, heavy alcohol use, and being unemployed or disabled. Factors independently associated with screening positive for drug dependence included having many HIV-related symptoms, being younger, being heterosexual, having frequent heavy alcohol use, and screening positive for a psychiatric disorder. CONCLUSIONS: Many people infected with HIV may also have psychiatric and/or drug dependence disorders. Clinicians may need to actively identify those at risk and work with policymakers to ensure the availability of appropriate care for these treatable disorders.

Implications of generalists' slow adoption of zidovudine in clinical practice.

BACKGROUND: The lag time for adoption of new acquired immunodeficiency syndrome (AIDS) therapies into the clinical practices of different types of ambulatory care providers can be estimated from patient use of zidovudine therapy during the first few years after approval by the Food and Drug Administration. METHODS: We analyzed receipt of zidovudine therapy from April 1987 through March 1990 by 3643 patients with a diagnosis of AIDS. The study group was continuously enrolled in the New York State Medicaid program for at least 6 months after diagnosis. For each patient, the dominant providers of ambulatory care, receipt of zidovudine therapy, and consultation with a human immunodeficiency virus-AIDS specialist within 6 months after diagnosis were determined from Medicaid claims. AIDS specialists included physicians or clinics specializing in infectious disease or hematology/oncology or specific clinics within designated AIDS centers. RESULTS: In 1987, 55% of those who had an AIDS specialist as their dominant care provider received zidovudine therapy, compared with only 36% of patients with a primary care clinic as their dominant care provider. It was not until 1990, 3 years after approval by the Food and Drug Administration, that the percentage of patients receiving zidovudine therapy (77% to 78%) was comparable for patients of primary care clinics and AIDS specialists. In logistic regression analysis, zidovudine use did not differ between patients of AIDS specialists and patients with other types of dominant providers when the latter group had consulted with an AIDS specialist (adjusted odds ratio, 1.38; 95% confidence interval, 0.99 to 1.95). CONCLUSIONS: In our AIDS study population, there was at least a 3-year lag before patients of primary care clinics received zidovudine therapy at the same rate as patients of AIDS specialists. Conditions such as AIDS with rapid changes in treatment options may require a close relationship between generalists and specialists to increase access to new therapies.

CD4+ T-lymphocyte measures in the treatment of individuals infected with human immunodeficiency virus type 1. A review for clinical practitioners.

The CD4+ lymphocyte is a major target of the human immunodeficiency virus type 1 (HIV-1). CD4+ T-lymphocyte measures have been used to predict the risk of HIV-1-related complications in diverse populations, to guide management decisions, and to define cases of the acquired immunodeficiency syndrome (AIDS). To examine the role of CD4+ measures in the management and epidemiologic monitoring of HIV-1 infection, we evaluated current literature regarding the accuracy and precision of CD4+ measures and the use of these and other prognostic measures in the care of HIV-1-infected persons. Several studies have reported wide intraindividual and interindividual variability in the absolute CD4+ count, which can detract from its clinical usefulness. Approaches to address this variability include the following: drawing specimens at a similar time of the day; monitoring CD4+ percent that has less variability; following a meticulous laboratory technique; using serial tests to guide management decisions; and retesting after efforts to eliminate transient treatment and clinical factors that can affect the CD4+ count. The expense and limited availability of CD4+ measures also present barriers to widespread use. Other laboratory and clinical factors offer additional prognostic information and have an evolving role in management decisions. CD4+ measures have an important role in HIV-1 clinical care, research, and disease surveillance, but strategies are required to address problems with variability, expense, and availability.

Delayed medical care after diagnosis in a US national probability sample of persons infected with human immunodeficiency virus.

OBJECTIVE: To identify health care and patient factors associated with delayed initial medical care for human immunodeficiency virus (HIV) infection. DESIGN: Survey of a national probability sample of persons with HIV in care. SETTING: Medical practices in the contiguous United States. PATIENTS: Cohort A (N = 1540) was diagnosed by February 1993 and was in care within 3 years; cohort B (N = 1960) was diagnosed by February 1995 and was in care within 1 year of diagnosis. MAIN OUTCOME MEASURE: More than 3- or 6-month delay. RESULTS: Delay of more than 3 months occurred for 29% of cohort A (median, 1 year) and 17% of cohort B. Having a usual source of care at diagnosis reduced delay, with adjusted odds ratios (ORs) of 0.61 (95% confidence interval [CI], 0.48-0.77) in cohort A and 0. 70 (95% CI, 0.50-0.99) in cohort B. Medicaid coverage at diagnosis showed lower adjusted ORs of delay compared with private insurance (cohort A: adjusted OR, 0.52; 95% CI, 0.30-0.92; cohort B: adjusted OR, 0.48; 95% CI, 0.27-0.85). Compared with whites, Latinos had 53% and 95% higher adjusted ORs of delay (P<.05) in cohorts A and B, respectively, and African Americans had a higher adjusted OR in cohort A (1.56; 95% CI, 1.19-2.04). The health care factors showed similar effects on delay of greater than 6 months. CONCLUSIONS: Medicaid insurance and a usual source of care were protective against delay after HIV diagnosis. After full adjustment, delay was still greater for Latinos and, to a lesser extent, African Americans compared with whites.

The Hippo pathway effector YAP is a critical regulator of skeletal muscle fibre size.

The Yes-associated protein (YAP) is a core effector of the Hippo pathway, which regulates proliferation and apoptosis in organ development. YAP function has been extensively characterized in epithelial cells and tissues, but its function in adult skeletal muscle remains poorly defined. Here we show that YAP positively regulates basal skeletal muscle mass and protein synthesis. Mechanistically, we show that YAP regulates muscle mass via interaction with TEAD transcription factors. Furthermore, YAP abundance and activity in muscles is increased following injury or degeneration of motor nerves, as a process to mitigate neurogenic muscle atrophy. Our findings highlight an essential role for YAP as a positive regulator of skeletal muscle size. Further investigation of interventions that promote YAP activity in skeletal muscle might aid the development of therapeutics to combat muscle wasting and neuromuscular disorders.

A population-based comparison of the clinical course of children and adults with AIDS.

OBJECTIVE: To examine the association of clinical complications and age at diagnosis with survival for a cohort of children and adults with AIDS. DESIGN: A population-based analysis of 734 children and 5584 adults diagnosed with AIDS from 1985 to 1990 in New York State. RESULTS: The initial AIDS-defining diagnoses for 68% of children were lymphoid interstitial pneumonitis or infections specified in the Centers for Disease Control and Prevention's (CDC) pediatric AIDS case definition but not the CDC's 1987 adult AIDS case definition. Of opportunistic infections in both case definitions, Pneumocystis carinii pneumonia (PCP) was the most common initial AIDS diagnosis, occurring in 53% of adults, 47% of children aged < 6 months at diagnosis (n = 122) and 14% aged > or = 6 months at diagnosis (n = 612). Median survival after AIDS diagnosis was 62 months for all children compared with 11 months for adults. For children initially diagnosed with conditions only in the pediatric case definition, median survival ranged from 27 to 62 months compared with less than 12 months for children and adults with PCP. Compared with children aged 6-54 months, the estimated hazards of death for younger and older children were 2.06 [95% confidence interval (CI), 1.48-2.86] and 1.54 (95% CI, 1.10-2.16), respectively. CONCLUSION: Children survived significantly longer than adults after AIDS diagnosis, but their survival varied by age at diagnosis. Differences in the types of common initial AIDS-defining diagnoses appear to contribute to the observed differences in survival.

The relationship of clinic experience with advanced HIV and survival of women with AIDS.

OBJECTIVE: Hospital and physician experience have been linked to improved outcomes for persons with HIV. Because many HIV-infected patients receive care in clinics, we studied clinic HIV experience and survival for women with AIDS. DESIGN: Retrospective cohort study of women with AIDS whose dominant sources of care were clinics. Clinic HIV experience was estimated as the cumulative number of Medicaid enrollees with advanced HIV who used a particular clinic as their dominant provider up to the year of the patient's AIDS diagnosis: low experience (< 20 patients), medium (20-99 patients), high (> or = 100 patients). Proportional hazards models examined relationships between experience and survival. SETTING: A total of 117 New York State clinics. PATIENTS: A total of 887 New York State Medicaid-enrolled women diagnosed with AIDS in 1989-1992. MAIN OUTCOME MEASURE: Survival after AIDS diagnosis. RESULTS: In later study years (1991-1992), patients in high experience clinics had an approximately 50% reduction in the relative hazard of death (0.53; 95% confidence interval, 0.35-0.82) compared with patients in low experience clinics. Adjusting for demographic and clinical variables, 71% of patients in high experience clinics were alive 21 months after diagnosis compared with 53% in low experience clinics. Experience and survival were not significantly associated in the early study years (1989-1990). CONCLUSIONS: In more recent years, women with AIDS receiving care in high experience clinics survived longer after AIDS diagnosis than those in low experience clinics, providing further evidence of a relationship between provider HIV experience and outcomes.

What do physicians in practice do to prevent osteoporosis?

Osteoporosis-associated fractures are a major public health problem in the United States. Although clinicians and policy groups have advocated estrogen replacement therapy and other clinical measures to prevent osteoporosis, few studies have assessed whether these measures are being adopted by physicians in practice. The purpose of this study is to evaluate physicians' use of osteoporosis prevention measures and to assess the impact of physician specialty and practice setting on osteoporosis prevention performance. A survey of nearly 300 physicians was carried out in a large metropolitan area. Gynecologists, general internists, and cardiopulmonary specialists were included from one of three practice settings: fee-for-service private practice, full-time academic medicine, or a large health maintenance organization. Most physicians, regardless of clinical specialty or practice setting, report that they advocate exercise and calcium supplementation. Few physicians prescribe estrogen replacement therapy (ERT) for the majority of their postmenopausal patients. Although there are minimal differences among the three types of practice settings examined, ERT varies markedly by clinical specialty. Of the gynecologists surveyed, 37% report prescribing ERT for the majority of their postmenopausal patients to prevent osteoporosis compared to only 7 and 5% of general internists and cardiopulmonary specialists, respectively (chi 2 = 45.3, p less than 0.0001). Although the efficacy of exercise and calcium supplementation to prevent osteoporotic fractures has not been well established, these measures are commonly advocated by both generalists and subspecialists. Although gynecologists are significantly more likely to prescribe ERT to prevent osteoporosis than the other clinical specialists, in general very few physicians prescribe ERT for most postmenopausal patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Variations in inpatient mortality for AIDS in a national sample of hospitals.

In this project, we examined the spectrum of AIDS-related conditions and variations in associated inpatient mortality for AIDS patients treated in a national sample of hospitals. We identified 10,538 adult discharges with a diagnosis indicating AIDS from 258 hospitals from a national sample of 438 acute-care hospitals with 6 million discharges in 1986-1987. Opportunistic and other infections occurred in 55.9 and 37.9%, respectively, of AIDS discharges, and inpatient fatality rates varied considerably depending on complication type(s) and comorbidities. Clinical conditions were more important predictors of inpatient death than demographic or treatment site characteristics. Among opportunistic infections, odds of inpatient death were significantly increased for progressive multifocal leukoencephalopathy (odds ratio [OR] = 2.8), Pneumocystis carinii pneumonia (OR = 2.4), cryptococcosis (OR = 1.6), atypical mycobacterial infections (OR = 1.6), and toxoplasmosis (OR = 1.3). Odds of inpatient death were also significantly increased by non-AIDS-defining infections causing septicemia (OR = 3.1) or CNS involvement (OR = 1.6) or pulmonary involvement (OR = 1.5). After controlling for clinical conditions, significant differences in odds of death persisted across regions, age, and ethnic groups. Increases in hospitals' AIDS treatment experience were associated with a significant decrease in odds of inpatient death. These analyses provide a national perspective on the diversity of AIDS-related clinical conditions and their relative effects on inpatient mortality.

The AIDS-defining diagnosis and subsequent complications: a survival-based severity index.

To define a survival-based severity measure for AIDS, we convened a panel of AIDS experts who identified factors influencing AIDS prognosis and estimated the impact of prognostic factors on survival time. The resulting conceptual model included 19 AIDS-defining conditions and 80 subsequent AIDS-related complications. This model was tested on longitudinal disease histories of 3,937 AIDS patients in the New York State Medicaid Program diagnosed between 1983 and 1986 and followed through 1988. The initial AIDS diagnosis and complications within 3 months of AIDS onset were identified from coded diagnoses recorded on inpatient and outpatient claims. Three AIDS-defining diagnosis groups were created; survival times from least to most severe group were 25, 10, and 7 months. To determine the influence of subsequent complications on risk of death, the survival times associated with combinations of defining diagnosis groups and four severity levels of subsequent complications were determined. Median survival ranged from 43 months for the least severe defining diagnosis group without early complications to 12 months for the group with severe defining diagnoses and serious complications. The matrix of AIDS-defining diagnoses and complications was divided into four severity categories with significantly different survival curves. This severity measure uses longitudinal data commonly available to clinicians and researchers to create distinct AIDS prognostic categories.

Health care delivery, zidovudine use, and survival of women and men with AIDS.

The aim of this study was to define predictors of survival for women and men after AIDS diagnosis. We examined health care delivery and drug therapy in the year before AIDS diagnosis for continuously enrolled New York State Medicaid beneficiaries with AIDS in 1988-1990. We examined the association of these factors with survival after AIDS diagnosis. Of 1,077 women and 1,871 men, 60% of both gender groups were drug users. In both risk groups, women had more outpatient visits than men but were equally likely to visit an AIDS specialist. In those who were not drug users, men were twice as likely as women to receive either zidovudine or Pneumocystis carinii pneumonia prophylaxis. No difference appeared among drug users. Survival after AIDS diagnosis was similar by gender for those who were not drug users (RR = 1.09; 95% CI = 0.90-1.33). In drug users, women had a slightly lower risk of death than men (RR = 0.84; 95% CI = 0.72-0.98). Risk of death after AIDS diagnosis was higher for persons starting zidovudine earlier in both risk groups. Among drug users, women received more ambulatory care and survived slightly longer than men. Among those who were not drug users, survival was similar by gender even after adjusting for differences in care.

Physician intention to recommend complete diagnostic evaluation in colorectal cancer screening.

Primary care physicians (PCPs) often do not recommend complete diagnostic evaluation (CDE; i.e., diagnostic colonoscopy or the combination of flexible sigmoidoscopy and barium enema X-ray procedures) for patients with an abnormal screening fecal occult blood test (FOBT+) result. Information is needed to understand why PCPs do not recommend CDE. In the spring of 1994, a telephone survey was carried out using a random sample of 520 PCPs in Pennsylvania or New Jersey who had patients that were targeted for an FOBT screening program. Survey data were obtained from 363 (70%) PCPs on physician practice characteristics; personal background; perceptions concerning FOBT screening, CDE performance, and patient behavior; social influence related to CDE; and intention to recommend CDE for FOBT+ patients. Physician CDE intention scores were distributed as follows: low (22%), moderate (51%), and high (27%). Multivariate analyses demonstrate that physician board certification status, time in practice, belief in CDE efficacy, and belief that CDE is standard practice were positively associated with CDE intention, whereas concern about CDE-related costs was negatively associated with CDE intention. Among physicians in larger practices, perceived FOBT screening efficacy was negatively associated with CDE intention, and belief in the benefit of CDE was positively associated with outcome. There is substantial variability in CDE intention among PCPs. Physician perceptions about FOBT screening and follow-up are associated with CDE intention, are likely to influence CDE performance, and may be amenable to educational intervention. Additional research is needed to evaluate the impact of educational interventions on CDE intention and performance.

Estimation of survival after AIDS diagnosis: CD4 T lymphocyte count versus clinical severity.

We compared the relative contribution to estimating survival after AIDS diagnosis of a clinical severity measure, the Severity Index for Adults with AIDS (SIAA), and laboratory values at AIDS diagnosis that are often used prognostically. Three SIAA categories were defined from the first AIDS-defining condition and the most severe complication within 3 months. We studied 421 Italian patients surviving > or = 3 months after AIDS diagnosis. Survival curves for laboratory measures grouped by quartile showed poorest survival for CD4 count <100/microliter, hemoglobin <8 g/dl, total lymphocyte count <400/microliter, and albumin <3 g/dl. Adjusting for demographics and zidovudine therapy, the estimated hazard of death was 2.4 (95% CI, 1.6-3.5) for CD4 counts <100/microliter versus higher counts and 4.9 (95% CI, 3.0- 7.8) for the most versus the least severe SIAA category. SIAA offered greater prognostic discrimination than CD4 count at AIDS diagnosis.

The role of functional status in predicting inpatient mortality with AIDS: a comparison with current predictors.

To assess the independent prognostic role of functional status, as reflected by a measure of an inpatient's global requirement for nursing assistance with basic activities of daily living (Global ADL), we compared Global ADL with three validated AIDS mortality predictors: the Clinical AIDS Prognostic Staging (CAPS); the Severity Classification System for AIDS Hospitalization--version 2 (SCAH-2); and CD4 cell count. Our study sample consisted of 1392 patients with AIDS and a hospital stay of 3 or more days at one of 20 hospitals in 11 U.S. cities with high AIDS incidence. Data were collected from September 1990 through December 1991. Two percent of patients refused participation, and 26% were eliminated due to incomplete data collection, leaving an analytic sample of 1003 patients. Only 30% of patients had a CD4 count measured at any time during hospitalization. Cox regression was used to measure the hazard of inpatient mortality adjusted for length of stay. Overall mortality was 12%. Mortality rates for patients in Global ADL stages I-IV were 3%, 8%, 19%, and 51%, respectively (p < 0.0001). Global ADL more effectively discriminated mortality than CAPS (p < 0.001), SCAH-2 (p < 0.001), or CD4 count (p < 0.001). Global ADL also added independent information in analyses adjusted for both CAPS and SCAH-2: a single stage increase of Global ADL demonstrated a 1.9-fold increased hazard of death (CI: 1.6, 2.3). SCAH-2, assigned at discharge, was not strongly correlated with admission predictors (Global ADL: r = 0.17; CI: 0.11, 0.23 or CAPS: r = 0.03, CI: 0.02, 0.17). We conclude that Global ADL, alone or in tandem with other severity systems, provides an excellent severity adjustment for inpatient mortality with AIDS. Finally, CD4 cell counts were not routinely available and were not as predictive as Global ADL in the patients for whom both were available.

Survival experience of 789 children with the acquired immunodeficiency syndrome.

To define predictors of survival we studied longitudinal histories of 789 New York State Medicaid-enrolled children diagnosed with acquired immunodeficiency syndrome (AIDS) from 1983 to 1989 and followed through 1990. Median survival times for 3 severity groups of AIDS-defining conditions were 66, 48 and 9 months. In a proportional hazards model, the relative risk of death for the most vs. least severe group was 3.33 (95% confidence interval, 2.53, 4.37) and the relative risk for children < 6 months old at diagnosis vs. older children was 1.81 (95% confidence interval, 1.41, 2.34). We increased our ability to predict death by using a 4-category severity index that assesses both the AIDS-defining diagnosis and clinical complications within 3 months of diagnosis (relative risk, 5.27; 95% confidence interval, 3.16, 8.78 for most vs. least severe). These analyses offer new clinical severity measures and reveal that, regardless of the AIDS-defining diagnosis, children with AIDS who are < 6 months old have a poor prognosis.

Health care of children and adults with acquired immunodeficiency syndrome. A population-based analysis.

OBJECTIVES: To compare the use of medical services by pediatric and adult patients with acquired immunodeficiency syndrome (AIDS) in the 6 months before and after the diagnosis of AIDS when demand for care is often high and to study the influence of human immunodeficiency virus specialty care on survival of pediatric patients. DESIGN: Retrospective analysis of Medicaid files. SETTING: New York State Medicaid Program. PATIENTS: A cohort identified as having AIDS from 1985 through 1990 and enrolled on Medicaid from birth or 1 year or more before diagnosis. Because of differing prognoses, 3 groups were studied by age at the time that AIDS was diagnosed: infants younger than 6 months, children aged 6 months to 12 years, and adults aged 13 to 60 years. MAIN OUTCOME MEASURES: Frequencies of any service use and, among users, monthly rates of services. From Cox proportional hazards models, the adjusted hazard of death for human immunodeficiency virus specialty ambulatory care. RESULTS: Nearly all infants (n = 122) were hospitalized before and after the diagnosis of AIDS was made--the most of all groups. After diagnosis, only 81% of older children (n = 612) were hospitalized vs 93% of infants and 90% of adults (n = 5602). Hospitalized children had a median of only 3.3 inpatient days per month vs 12.3 and 7.8 inpatient days for infants and adults, respectively. Of older children, 45% used the emergency department vs 33% of adults. Human immunodeficiency virus specialty care for infants and children was associated with a 40% lower risk of death after the diagnosis of AIDS. CONCLUSIONS: In this AIDS cohort, infants had the greatest use of inpatient care, and older children used the emergency department more than adults. The finding of improved survival for infants and children with human immunodeficiency virus specialty care warrants further study in more recent years.

Adherence to antiretroviral therapy by pregnant women infected with human immunodeficiency virus: a pharmacy claims-based analysis.

OBJECTIVE: To assess adherence to antiretroviral therapy with the use of Medicaid pharmacy claims data for human immunodeficiency virus (HIV)-infected pregnant women and to identify associated maternal and health care factors. METHODS: We retrospectively studied a cohort of 2714 HIV-infected women in New York State who delivered live infants from 1993-96. Among 682 women prescribed antiretroviral therapy in the last two trimesters, we studied 549 who started therapy more than 2 months before delivery. Adherence was defined as adequate if the supplied drug covered at least 80% of the days from the first prescription in the last two trimesters until delivery. Multivariable analyses were used to examine associations between maternal and health care factors and adherence. RESULTS: Only 34.2% of 549 subjects had at least 80% adherence based on pharmacy data, a rate that remained stable over time. The adjusted odds ratios (ORs) of adherence for black (OR 0.47, 95% confidence interval [CI] 0.30, 0.75) and Hispanic (OR 0.49, 95% CI 0.29, 0.82) women were nearly 50% lower than for white women. The OR of adherence was 0.32 (95% CI 0.12, 0.90) for teenagers compared with women aged 25-29 years and 0.56 (95% CI 0.34, 0.92) for women in New York City versus those residing elsewhere. Women on antiretroviral therapy before pregnancy were more likely to adhere (OR 1.55, 95% CI 1.02, 2.35). CONCLUSION: Teenagers, women of minority groups, and women living in New York City had greater risks of poor antiretroviral adherence, whereas women already prescribed antiretrovirals before pregnancy had better adherence. Our conservative pharmacy data-based measure showed that most HIV-infected women adhered poorly and adherence did not improve over the 4-year study.

Improved birth outcomes associated with enhanced Medicaid prenatal care in drug-using women infected with the human immunodeficiency virus.

OBJECTIVE: To evaluate the effectiveness of an intervention designed to enhance Medicaid prenatal care in improving birth outcomes of drug-using women infected with the human immunodeficiency virus (HIV). METHODS: Medicaid and vital statistics records were linked for 353 HIV-infected drug-using women delivering in 1993 and 1994 while enrolled in New York State Medicaid. Of these, 68% were treated by providers participating in the Prenatal Care Assistance Program, designed to provide case management, improved continuity, referral services, and behavioral risk reduction counseling. In a series of logistic models, we estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of low birth weight (less than 2500 g) and preterm delivery (before 37 weeks), comparing women using and not using the program. RESULTS: Women using the Prenatal Care Assistance Program were significantly less likely, after adjustments were made for maternal characteristics, to have low birth weight infants and preterm deliveries (OR 0.52, 95% CI 0.31, 0.89; and OR 0.57, 95% CI 0.34, 0.97, respectively). Adding measures of greater adequacy and continuity of prenatal care to the models explained just over 20% of the Prenatal Care Assistance Program's protective effect. The addition of maternal high-risk behavior, HIV-focused care, and drug use treatment variables altered program effect estimates less profoundly (together accounting for 4 and 9% of the program's protection against low birth weight and preterm delivery, respectively). CONCLUSION: The Prenatal Care Assistance Program appeared to be successful in reducing the incidence of low birth weight and preterm delivery in this high-risk population. The program's success can be attributed, in part, to increased adequacy and continuity of prenatal care and, to a lesser extent, to more frequent receipt of special services and reduced maternal high-risk behaviors.