Linking HIV-infected persons of color and injection drug users to HIV medical and other services: the California Bridge Project

Our objectives were to describe the strategies and successes in linking out-of-treatment HIV-infected persons of color and injection drug users (IDUs) to a comprehensive HIV care, treatment, and prevention program and other community services. Peer-based outreach staff at 21 sites throughout California provided assessments and referrals to 1453 persons living with HIV but without routine care. A linkage was defined as the receipt of a referred service. Half (49.7%) of persons of color and 41.6% of IDUs received services at a California Early Intervention Program (EIP) site after the date of first contact with peer staff; 58.1% of clients referred to EIP were linked to the program. IDUs were less likely to link to EIP. However, IDU clients were less likely to be referred to EIP, and more likely to be referred and linked to other community programs. Interventions such as the California Bridge Project can effectively link HIV-infected persons from marginalized populations to care, treatment, and prevention services. Programs that address immediate needs such as housing are more appealing to IDUs than programs offering HIV medical care.     

Neurological examination findings to predict limitations in mobility and falls in older persons without a history of neurological disease

PURPOSE: To estimate the prevalence of neurological signs and their association with limitations in mobility and falls in a sample of older persons without known neurological disease. METHODS: A neurologist examined 818 participants from the InCHIANTI study who were aged > or =65 years and who did not have cognitive impairment, treatment with neuroleptics, and a history of neurological disease. Mobility was assessed as walking speed and self-reported ability to walk at least 1 km without difficulty. Participants were asked to report falls that had occurred in the previous 12 months. RESULTS: Less than 20% (160/818) of participants had no neurological signs. Neurological signs were more prevalent in older participants and those with impaired mobility. When all neurological signs were included in sex-and age-adjusted multivariate models, 10 were mutually independent correlates of poor mobility. After adjusting for age and sex, the number of neurological signs was associated with progressively slower walking speed (P <0.001), a higher probability of reported inability to walk 1 km (P <0.001), and a history of falls (P <0.05). CONCLUSION: Neurological signs are independent correlates of limitations in mobility and falls in older persons who have no clear history of neurological disease.     

Burden of medical illness in drug- and alcohol-dependent persons without primary care

Little is known about the frequency, severity, and risk factors for disease in drug- and alcohol-dependent persons without primary medical care. Our aims are to assess the burden of medical illness, identify patient and substance dependence characteristics associated with worse physical health, and compare measures of illness burden in this population. This was accomplished through a cross-sectional study among alcohol-, heroin- or cocaine-dependent persons without primary medical care who were admitted to an urban inpatient detoxification unit. The mean age of these patients was 35.7 (SD 7.8) years; 76% were male and 46% were Black. Forty-five percent reported being diagnosed with a chronic illness, and 80% had prior medical hospitalizations. The mean age-adjusted SF-36 Physical Component Summary (PCS) score was lower than the general U.S. population norm (44.1 vs 50.1; p<0.001). In multivariable analysis, female gender (adjusted mean change in PCS score: -3.71 points, p=.002), problem use of hallucinogens (-3.51, p=0.013), heroin (-2.94, p=0.008), other opiates (-3.20, p=.045), living alone (-3.15, p=.023), having medical insurance (-2.26, p=0.014) and older age (-.22 points per year, p=0.001) were associated with worse health. From these data, it seems that alcohol- and drug-dependent persons without primary medical care have a substantial burden of medical illness compared to age- and gender-matched U.S. population controls. While the optimal measure of medical illness burden in this population is unclear, a variety of health measures document this medical illness burden in addicted persons.     

Alcoholism treatment and medical care costs from Project MATCH

Aims. This paper examines the costs of medical care prior to and following initiation of alcoholism treatment as part of a study of patient matching to treatment modality. Design Longitudinal study with pre- and post-treatment initiation. Measurements. The total medical care costs for inpatient and outpatient treatment for patients participating over a span of 3 years post-treatment. Setting. Three treatment sites at two of the nine Project MATCH locations (Milwaukee, WI and Providence, RI). Participants. Two hundred and seventy-nine patients. Intervention. Patients were randomly assigned to one of three treatment modalities: a 12-session cognitive behavioral therapy (CBT), a four-session motivational enhancement therapy (MET) or a 12-session Twelve-Step facilitation (TSF) treatment over 12 weeks. Findings. Total medical care costs declined from pre- to post-treatment overall and for each modality. Matching effects independent of clinical prognosis showed that MET has potential for medical-care cost-savings. However, patients with poor prognostic characteristics (alcohol dependence, psychiatric severity and/or social network support for drinking) have better cost-savings potential with CBT and/or TSF., Conclusions. Matching variables have significant importance in increasing the potential for medical-care cost-reductions following alcoholism treatment.     

Rural HIV-infected women's access to medical care: ongoing needs in California

HIV-infected women living in rural areas often have considerably less access to care than their urban and suburban counterparts. In much of the USA, little is known about HIV care among rural populations. This study elucidated barriers to care for rural women in California. Methods included retrospective structured interviews conducted with 64 women living in rural areas and receiving HIV care at 11 California healthcare facilities. Facilities were randomly sampled and all HIV-infected female patients seeking care at those facilities during a specified time period were eligible. The most commonly cited barriers to accessing care included physical health problems that prevented travel to care (32.8%), lack of transportation (31.2%), and lack of ability to navigate the healthcare system (25.0%). Being divorced/separated/widowed (compared to being either married or single) was associated with reporting physical health as a barrier to care (p=0.03); being unemployed (p=0.003) or having to travel 31-90 minutes (p=0.007, compared to less than 31 or greater than 90) were both associated with transportation as a barrier; and speaking English rather than Spanish was associated with reporting "difficulty navigating the system" (p=0.04). Twenty-nine women (45.3%) reported difficulty in traveling to appointments. Overall, 24 (37.5%) women missed an HIV medical appointment in the previous 12-month period, primarily due to their physical health and transportation limitations. Physical health and transportation problems were both the major barriers to accessing health services and the primary reasons for missing HIV care appointments among this population of HIV-infected women living in rural areas. Providing transportation programs and/or mobile clinics, as well as providing support for patients with physical limitations, may be essential to improving access to HIV care in rural areas.     

Living with HIV but without medical care: barriers to engagement

This cross-sectional study examined factors associated with the receipt of HIV medical care among people who know their HIV status and are not newly diagnosed with HIV. Interviews were conducted with 1133 HIV-positive individuals between October 2003 and July 2005 who enrolled in 1 of 10 outreach programs across the country. The sample was predominantly non-white (86%), male (59%), and unstably housed (61%), with a past history of cocaine use (68%). Twelve percent had received no HIV medical care in the 6 months prior to the interview. Those with no care were similar to those who received some HIV care in sociodemographic characteristics, but in multivariate analysis were less likely to have a case manager (p < 0.001) or use mental health services (p < .001), had lower mental health status scores (p < 0.05), were more likely to be active drug users (p < 0.01), had greater unmet support service needs (p < 0.05) and reported that health beliefs were a barrier to care (p < 0.001). Interventions to engage people in HIV medical care need to address barriers to care through linkages with mental health, substance abuse treatment and support services, and address the health beliefs that deter people from seeking care.     

Health and wellbeing of HIV-positive Australians: findings from the third national HIV Futures Survey

The aim of this paper is to characterize the health and well being of people living with HIV/AIDS (PLWHA) in Australia. The HIV Futures 3 Survey was a self-complete anonymous questionnaire distributed through multiple sites. Data were collected on health, clinical and social variables. There were 894 responses, 6% of the known HIV-positive population. Respondents were aged between 20 and 77; 79% were homosexual men. In all, 58% reported a viral load of <500 copies/mL, and 81% a CD4 count of over 250 cells/microL. In all, 38% reported another major health condition, and 26% a mental health condition. A total of 72% were using antiretroviral therapy. About 48% were in a regular relationship, and 42% of regular partners were HIV-positive. In all, 55% had stopped working because of HIV and 31% were living in poverty. While the overall picture for PLWHA in Australia is optimistic, there remain clear patterns of health and social disadvantage that require ongoing policy vigilance and service provision.     

Individual and structural factors influencing HIV care linkage and engagement: Perceived barriers and solutions among HIV-positive persons

ABSTRACT

To meet the National HIV/AIDS Strategy’s goals of reducing and preventing HIV transmission, understanding factors that shape HIV-positive persons’ care-seeking behaviors is critical. Accordingly, this study examined factors that affect HIV care linkage and engagement. Six focus groups were conducted with 33 HIV-positive persons living in North Carolina. A variety of factors influenced care behaviors, including: structural and policy factors, relationship with HIV care systems, and individuals’ personal characteristics. Participants also provided solutions for addressing specific factors to care. Improving clinical services and utilizing context-specific strategies can help facilitate greater care linkage and engagement.     

Psychopathology of first-episode psychosis in HIV-positive persons in comparison to first-episode schizophrenia: a neglected issue

This study aims to detect different psychopathological dimensions in first-episode psychoses with different underlying causes. We evaluated 22 subjects with first-episode psychosis, who differed in biological variables (HIV-positive versus HIV-negative) and who were compared by using the Structured Clinical Interview for DSM-III-Reviewer, the 18-item Brief Psychiatric Rating Scale (BPRS), the 17-item Hamilton Depression Rating Scale, the 14-item Hamilton Anxiety Rating Scale and the Mini-Mental State Examination. HIV-positive subjects had higher mean scores on the global BPRS and on the paranoid Positive and Negative Syndrome Scale subscale compared with HIV-negative subjects. Conversely, higher prevalence of affective and anxious symptoms was found in the HIV-negative patients in comparison to HIV-positives. HIV-positives had significantly greater attention/concentration impairment than HIV-negative persons. In conclusion, taking into account psychopathological dimensions may help psychiatrists in clinical decision-making regarding the differential diagnosis of psychotic symptoms. The psychopathological pattern of first-episode psychosis in HIV-positive patients may represent an 'elementary model' of acute psychosis characterized by paranoid delusions in the absence of the usual affective symptoms.     

The effect of perceived stigma from a health care provider on access to care among a low-income HIV-positive population

Perceived stigma in clinical settings may discourage HIV-infected individuals from accessing needed health care services. Having good access to care is imperative for maintaining the health, well being, and quality of life of persons living with HIV/AIDS (PLWHAs). The purpose of this prospective study, which took place from January 2004 through June 2006, was to evaluate the relationship between perceived stigma from a health care provider and access to care among 223 low income, HIV-infected individuals in Los Angeles County. Approximately one fourth of the sample reported perceived stigma from a health care provider at baseline, and about one fifth reported provider stigma at follow up. We also found that access to care among this population was low, as more than half of the respondents reported difficulty accessing care at baseline and follow up. Perceived stigma was found to be associated with low access to care both at baseline (odds ratio [OR] = 3.29; 95% confidence interval [CI] = 1.55, 7.01) and 6-month follow up (2.85; 95% CI = 1.06, 7.65), even after controlling for sociodemographic characteristics and most recent CD4 count. These findings are of particular importance because lack of access or delayed access to care may result in clinical presentation at more advanced stages of HIV disease. Interventions are needed to reduce perceived stigma in the health care setting. Educational programs and modeling of nonstigmatizing behavior can teach health care providers to provide unbiased care.     

Receipt of recommended medical care in HIV-infected and at-risk persons

The authors evaluated receipt of recommended medical care for 133 HIV-infected and 101 at-risk San Francisco public health clinic patients. Fewer than half the patients received syphilis and tuberculosis screening, hepatitis B immunity testing or vaccination, and tetanus boosters. The HIV-infected persons were significantly (p≤0.01) more likely than the at-risk persons to receive preventive care, except for interventions specific to women. More than 80% of the HIV-infected persons received CD4 testing, zidovudine andPneumocystis carinii pneumonia prophylaxis, and pneumococcal vaccine. Only 40% of the at-risk persons reported having HIV-antibody testing recommended. Interventions to increase care delivery to HIV-infected and at-risk persons are needed.     

Health department-HIV clinic integration of data and human resources to re-engage out of care HIV-positive persons into clinical care in a New York City locale

ABSTRACT

We describe an enhanced data to care (eD2C) initiative combining New York City (NYC) Department of Health and Mental Hygiene (DOHMH) HIV surveillance data and a collaborating HIV clinic records to identify and re-engage into care persons living with HIV (PLWH), and presumed to be out of care (OOC). DOHMH identified presumed-OOC persons who lacked recent HIV-related laboratory test reports (e.g., viral load, CD4) in the NYC surveillance registry, and whose last laboratory reports were from the collaborating clinic. The clinic then obtained the current care status of the presumed-OOC persons per their medical record system. The final list of persons deemed to be OOC by DOHMH and clinic were given to a clinic patient navigator and DOHMH disease intervention specialist (DIS) for re-engagement in care efforts. The initiative was a pilot effort aimed at reducing the inefficiencies (e.g., persons current with care, but deemed to be OOC) inherent in routine data to care (rD2C), using surveillance data or clinic medical records alone. Significantly, fewer PLWH, presumed to be OOC in eD2C than DOHMH rD2C were found to be current with care (2% vs. 16%, P?=?<.001). After adjusting for significant characteristics, time since OOC and years since HIV diagnosis, the odds of re-engaging in HIV care were significantly higher among eD2C (aOR: 2172.31; 95% CI: 1171.23–4044.36) than the rD2C group. We demonstrated the feasibility of leveraging DOHMH and HIV clinic data and human resources to potentially gain efficiencies in efforts to re-engage and retain PLWH in HIV care.     

Examining barriers to care: provider and client perspectives on the stigmatization of HIV-positive Asian Americans with and without viral hepatitis co-infection

Between 1999 and 2003, Asian Americans and Pacific Islanders (APIs) in the US experienced more rapid growth in the number of AIDS cases than any other racial or ethnic group. In addition, the prevalence of HBV and HIV co-infection is estimated to be significantly higher among APIs in the US than in other racial/ethnic groups. High rates of HIV and hepatitis B or C (HBV and/or HCV) co-infection, in concert with language and cultural barriers, create significant challenges to effective coordination of treatment. The purpose of this study is to identify barriers to care and treatment in APIs with HIV with and without hepatitis co-infection. Specifically, we analyze results from semi-structured interviews with health care providers (N=23) and Asian Americans who are HIV and hepatitis (HBV and/or HCV) co-infected (N =17) in order to clarify how stigma in particular may impede/limit access to coordinated health care provision. Providers and clients recognize the need for integrated, culturally and linguistically appropriate access to care while simultaneously acknowledging that stigma is a severe barrier to access to care. This article sheds light on the complexities of the stigma experienced by HIV and hepatitis co-infected Asian Americans and suggests a need for further research and renewed efforts by caregivers to reduce stigma in these communities.     

Cascade of care and factors associated with virological suppression among HIV-positive persons linked to care in the Test and Keep in Care (TAK) project

Introduction

Early treatment remains the most effective HIV prevention strategy; poor linkage to care after HIV diagnosis may compromise this benefit. We sought to better understand patient characteristics and their association with virological suppression (VS) following cART initiation.

Methods

The TAK project collects pre-linkage to care and clinical data on patients diagnosed with HIV in voluntary testing facilities in central Poland. Data collected for persons diagnosed in 2010–2013 were linked with HIV clinic records. Individuals linked to care who commenced cART were followed from until the earliest of first VS (HIV RNA <?50 copies/ml), last visit, death or 6 January 2016. Cox-proportional hazard models were used to identify factors associated with first viral suppression.

Results

232 persons were HIV positive, 144 (62%, 95% CI 55, 68%) linked to care, 116 (81% of those linked to care, 95% CI 73, 87%) started cART during follow up, of which 113 (97%, 95% CI 93, 99%) achieved VS. Non-PI based regimen (for integrase inhibitors aHR: 5.03: 1.90, 13.32) and HLA B5701-positive (aHR: 3.97: 1.33, 11.85) were associated with higher chance of VS. Unknown syphilis status (aHR: 0.27: 0.13, 0.57) and higher HIV RNA (aHR a tenfold increase: 0.56: 0.42, 0.75) remained associated with lower chance of VS.

Conclusions

Although a low proportion of persons were linked to care, almost all those linked to care started cART and achieved rapid VS. The high rates of VS were irrespective of prior HIV-associated risk behaviours. Linkage to care remains the highest priority in prevention strategies in central Poland.

     

Associations between HIV-positive individuals' receipt of ancillary services and medical care receipt and retention

This study examines associations between HIV-positive individuals' receipt of ancillary services and their receipt of and retention in primary medical care. Ancillary care services examined include case management, mental health and substance abuse treatment/counseling, advocacy, respite and buddy/companion services, as well as food, housing, emergency financial assistance, and transportation. The selection criterion used was the receipt of care from January-June 1997 at selected facilities receiving funding under the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, a federally funded safety net programme in the USA. The receipt of each ancillary service was associated with the receipt of any primary medical care from a safety net provider. All ancillary services were more strongly associated with primary care receipt than with retention in care or the mean number of primary care visits per year. Mental health and substance abuse treatment/counselling, client advocacy, respite care and buddy/companion services all had significant associations with all primary medical care measures. This is the first time in one study that the primary medical and ancillary services received by all clients at safety net-funded providers from multiple cities and states have been examined. All types of safety net providers, from the largest medical centre to the smallest community-based organization, are represented in this study. The patterns seen here are similar to the findings from the other, geographically more restricted, studies reported on in this volume.     

Aneurysms from the viewpoint of medical history

The history of arterial aneurysms dates back to the old Egypts, Byzantines and Greeks. Vesal 1557 and Harvey 1628 introduced the disease into modern medicine. They diagnosed a pulsating tumor intra vitam and confirmed the aneurysm at autopsy. Further corner stones during the 18th and beginning of the 19th century were the monographs of Lancisi and Scarpa, the latter beautifully illustrated. The first effectful therapy was external compression, the second ligature of the artery proximal to the aneurysm, which was pioneered by John Hunter in 1785. Endoaneurysmoraphy (Matas) and wrapping by cellophane were performed, before diagnostic ultrasound and bypass surgery became routine procedures and improved dramatically the survival of the patients. The diagnostic and therapeutic problems in the middle of the 20th century are illustrated by the fate of two prominent patients, Albert Einstein and Thomas Mann, who died both of a ruptured aneurysm in 1955.     

End-of-life care: findings from a national survey of informal caregivers

BACKGROUND: Family and friends are thought to be the predominant providers of end-of-life care, although nationally representative data on this topic have been lacking. METHODS: This study draws from the 1999 National Long-Term Care Survey and its Informal Caregivers Survey to characterize primary informal caregivers' experiences providing end-of-life care to chronically disabled community-dwelling older adults. Study participants were 1149 primary informal caregivers, stratified by care recipients' survival or death during the following 12 months. RESULTS: An estimated 11.2% of the chronically disabled community-dwelling older adults died within 1 year of being interviewed. Among persons who died, 72.3% were receiving help from an informal caregiver at the time of the interview. End-of-life primary informal caregivers helped an average of 43 hours per week, 84.4% provided daily assistance, and caregiver support services were infrequently used (ie, respite care and support groups were used by less than 5% of caregivers). While end-of-life caregivers reported significant emotional (28.9%), physical (18.4%), and financial (14.0%) strains, more than two thirds endorsed personal rewards related to their helping role. Compared with primary informal caregivers of persons who survived the following 12 months, end-of-life caregivers provided significantly higher levels of assistance and reported more challenges and strains, but they were no less likely to endorse rewards related to their helping role. CONCLUSIONS: End-of-life caregivers provide frequent and intense assistance with few supportive services. These data underscore the relevance of families to end-of-life care, and the potential benefit of better integrating families in patient care.     

Models of adult day care: findings from a national survey

We examined a nationally representative sample of 60 adult day care centers to describe the state of this evolving care modality after a decade's growth. Results indicate that day care centers can be categorized into three models of care, each of which serves a distinctive subpopulation. Model appropriateness was tested with analysis of variance of differences in participant characteristics. Services, staffing, costs, and other program features are contrasted among the three models.