Complementary and alternative medicine use and substitution for conventional therapy by HIV-infected patients

BACKGROUND: HIV-infected patients commonly use complementary and alternative medicine (CAM), but it is not known how often CAM is used as a complement or as a substitute for conventional HIV therapy. OBJECTIVES: To evaluate the prevalence and factors associated with CAM use with potential for adverse effects and CAM substitution for conventional HIV medication. DESIGN AND PARTICIPANTS: Cross-sectional survey of U.S. national probability sample of HIV-infected patients (2,466 adults) in care from December 1996 to July 1997. MAIN OUTCOME VARIABLES: Any CAM use, CAM use with potential for adverse effects, and use of CAM as a substitute for conventional HIV therapy. Substitution was defined as replacement of some or all conventional HIV medications with CAM. RESULTS: Fifty-three percent of patients had recently used at least one type of CAM. One quarter of patients used CAM with the potential for adverse effects, and one-third had not discussed such use with their health care provider. Patients with a greater desire for medical information and involvement in medical decision making and with a negative attitude toward antiretrovirals were more likely to use CAM. Three percent of patients substituted CAM for conventional HIV therapy. They were more likely to desire involvement in medical decision-making (odds ratio, 1.8; 95% confidence interval, 1.0-3.2) and to have a negative attitude toward antiretrovirals (odds ratio, 7.8; 95% confidence interval, 3.0-19.0). CONCLUSIONS: Physicians should openly ask HIV-infected patients about CAM use to prevent adverse effects and to identify CAM substitution for conventional HIV therapy.     

The STI and HIV testing practices of primary care providers

OBJECTIVES: To examine the sexually transmitted infection (STI) and HIV testing practices of primary care providers (PCPs) practicing in predominantly Hispanic communities. METHODS: This is a cross-sectional study. PCPs were identified by matching ZIP codes of physician directories with ZIP codes of Los Angeles County areas that have a population that is > 50% Hispanic (N = 191). PCPs were mailed a survey that assessed their frequencies for asking patients about sexual history, offering STI and safe sex advice, total number of HIV tests ordered in the past six months and their perceived barriers to STI counseling. The survey response rate was 45% (N = 85). RESULTS: Although 73% of PCPs took sexual histories from patients regularly (daily-to-weekly), only 41% offered STI or safe sex advice regularly. PCPs who were white were less likely than those who were Hispanic/Asian/African American/other to take sexual histories from their patients regularly (OR 0.3, 95% CI 0.1-0.9). The total number of HIV tests ordered for patients by PCPs at their practice locations in the past six months were: none (6%), 1-10 tests (27%), 11-20 tests (24%) and > 20 tests (36%). Thirty-six percent of PCPs reported > or = 1 positive HIV test in the past six months. PCPs' perceived barriers to STI counseling included patient's young age (< 16 years), language and presence of patient's relative/partner in consultation room at time of visit. CONCLUSION: Our findings suggest a need for interventions with PCPs practicing in predominantly Hispanic communities to improve their STI and HIV practice patterns.     

Asthma care in community health centers: a study by the southeast regional clinicians' network

Federally funded community health centers (CHCs) were surveyed to assess their ability to serve low-income asthma patients in the southeastern United States. Data were collected on CHC clinicians, pharmacy services, and patient characteristics. Twenty-six (74%) of 35 participating CHCs provided data on 83 distinct clinic sites in eight states, representing 898,977 billable patient visits to 318,920 people during the one-year study period. Participating CHCs provided 23% of all CHC patient visits in Region IV in 1995. Sixty-two percent of patients had a family income below poverty level. Almost 75% of the patients were uninsured or receiving Medicaid. Asthma was the diagnosis code for 2.04% of all medical encounters. Twenty-nine percent of sites were unable to provide medications for uninsured asthma patients, while 66% could provide drug samples. Thirty-three percent of CHCs had in-house pharmacies and 33% offered pharmacy vouchers. Eighty-two percent could provide beta-agonist inhalers, 54% could provide steroid inhalers, and 17% could provide peak flow meters. Federally funded CHCs provide care to many asthma patients from the highest risk segments of the population, but often do not have the resources needed to follow current clinical guidelines.     

HIV-1 drug resistance evolution among patients on potent combination antiretroviral therapy with detectable viremia

Many patients infected with HIV do not achieve or maintain virologic suppression below levels of detection while on potent combination antiretroviral therapy. The likelihood of emergence of incident mutations conferring reduced antiretroviral drug susceptibility was estimated among patients maintained on a stable regimen with ongoing detectable plasma HIV RNA levels. Ninety-eight HIV-infected patients were identified who had 2 genotypic antiretroviral resistance tests available. Poisson log-linear regression models were used to identify predictors and estimate incidence rates of number of acquired antiretroviral drug resistance mutations per person-year. At the 1st resistance test, 88% of patients had evidence of at least 1 mutation. Sixty percent of patients acquired at least 1 new mutation during a median of 9.3 months between consecutive resistance tests, with an incidence rate of 1.61 acquired mutations per person-year (95% CI: 1.36-1.90). Predictors of resistance evolution included average plasma HIV RNA level, HIV RNA slope, and number of mutations detected at the 1st resistance test. The likelihood of acquiring drug resistance mutations while remaining on potent combination antiretroviral therapy that does not confer complete suppression of HIV replication is relatively low and depends on the level of viral replication and prior resistance.     

Telegenetics in Maine: Successful clinical and educational service delivery model developed from a 3-year pilot project.

PURPOSE: The goal of this 3-year pilot project was to increase accessibility to genetics educational and clinical services in Maine. METHODS: Southern Maine Genetics Services, Foundation for Blood Research in collaboration with Maine Telemedicine Services established telemedicine capacity to link with rural health care centers located in Northern, Central, and Southern Maine and public health nursing statewide for the provision of genetics clinical and educational services. Core partners included a rural family practice residency program, a rural pediatric practice in northern Maine, and public health nurses statewide. The telegenetics model created was based on development and implementation of a preventive and medical management technology solution, conducting a pilot study to collect data, and approaching insurance companies for reimbursement. Evaluation included surveys on the quality, acceptability, and usefulness of genetics services delivered via telemedicine, telephone interviews, and decision-making confidence evaluations. RESULTS: During the project period, 24 rural clinical sites participated. In total, 93 presentations were given, and 125 patients were evaluated. Sixty-four percent of patients evaluated were pediatric. Despite site coordinator efforts to complete satisfaction surveys, the provider and patient response level was low (18% and 25%, respectively). Of those evaluations received, provider and patient response to telegenetics was positive. Decision-making confidence for genetics and neurology consultants was high. Our experience contributes to the development of telegenetics models that can be used in other rural states.     

The value of genetic testing: beyond clinical utility

ObjectiveTo assess the value of genetic testing from the perspective of the Department of Veterans Affairs (VA) clinical leadership.MethodsWe administered an Internet-based survey to VA clinical leaders nationwide. Respondents rated the value (on a 5-point scale) of each of six possible reasons for genetic testing. Bivariate and linear regressions identified associations between value ratings and environmental, organizational, provider, patient, and encounter characteristics.ResultsRespondents (n = 353; 63% response rate) represented 92% of VA medical centers. Tests that inform clinical management had the highest value rating (58.6%), followed by tests that inform disease prevention (56.4%), reproductive options (50.1%), life planning (43.9%), and a suspected (39.9%) or established (32.3%) diagnosis. Factors positively associated with high value included a culture that fosters adoption of genomics, specialist versus primary care provider, genetic tests available on laboratory menus, availability of genetic testing guidelines, clinicians knowing when to request genetics referrals, and availability of genetics professionals.ConclusionOur results demonstrate the varied value of genetic testing from the perspective of clinical leadership within a health-care system. Engaging organizational leadership in understanding the various reasons for genetic testing and its value beyond clinical utility may increase adoption of genetic tests to support patient-centered care.Genet Med advance online publication 15 December 2016     

New Models for Medical Education: Web-Based Conferencing to Support HIV Training in Sub-Saharan Africa

Abstract Background: Healthcare workers in Africa managing human immunodeficiency virus (HIV)-infected patients often receive inadequate HIV-specific medical education. The acceptability and feasibility of Web-based distance learning tools to enhance HIV training in Africa have not been extensively evaluated. Materials and Methods: In this prospective observational study, we assessed the feasibility of Web-conferencing to deliver HIV-specific medical training to clinicians supporting HIV care and treatment across 12 Sub-Saharan African countries over a 10-month period. Webinar attendance, technical quality, and participant satisfaction were measured for each Webinar. Demographic details about participants were recorded. Results: Attendance increased from 40 participants in Month 1 to over 160 in Month 10. Thirty-six percent of participants were physicians, and 21% were in allied health professions. A mean of 95% of respondents found the content to be relevant. Participants reported that the opportunity to interact with HIV clinicians from other countries and expert teaching from leading scientists were major reasons for attendance. Audio quality was variable across countries and over time. Barriers to attendance included lack of information technology (IT) literacy and Internet connectivity. Conclusions: This analysis demonstrates that Webinars are feasible and acceptable to support HIV training. Significant impediments to scale up in use of Web-conferencing for HIV education in resource-limited settings include lack of IT hardware and limited IT literacy. Strengthening IT capacity and Internet infrastructure is necessary to support expanded use of Webinars as a tool for continuing HIV education.     

User acceptability and feasibility of self-testing with HIV rapid tests

OBJECTIVE: Because HIV rapid tests are considered for self-testing, this study aims to determine the user acceptability and feasibility of self-testing. METHODS: A cross-sectional study was performed on 350 systematically sampled participants across 2 Singapore HIV testing centers using the Abbott Determine HIV 1/2 blood sample rapid test (Abbott Laboratories, Abbott Park, IL). Participants were surveyed on knowledge of and attitudes toward rapid testing. To determine interrater agreement between self-testing and trained personnel testing, participants performed self-testing with visual instructions, followed by trained personnel testing. Ability to identify test outcomes was determined through interpretation of sample test results. RESULTS: Eighty-nine percent of participants preferred testing in private, but most indicated that confidential counseling by trained counselors was necessary. Almost 90% found the kit easy to use and instructions easy to understand. Nevertheless, 85% failed to perform all steps correctly, especially blood sampling, and 56% had invalid results because of incorrect test performance. Interrater agreement between results from self-testing and trained personnel testing had a kappa value of 0.28. Twelve percent could not correctly determine results using sample tests, including 2% and 7% who read positive and negative samples, respectively, incorrectly. CONCLUSIONS: A substantial proportion could not perform self-testing or identify outcomes. Self-testing with the Determine HIV 1/2 kit in Singapore should be deferred.     

Homozygous and heterozygous CCR5-Delta32 genotypes are associated with resistance to HIV infection

OBJECTIVE: To investigate evidence for resistance to HIV-1 infection associated with the heterozygous genotype CCR5-+/Delta32 and with the homozygous genotype CCR5-Delta32/Delta32, which results in a nonfunctional CCR5 receptor. DESIGN: Cohort study of initially HIV-seronegative high-risk individuals from eight different cities. Enrollment data were analyzed to investigate the association of demographic factors and risk behaviors with CCR5 genotypes on the assumption that increased genotype prevalence among persons with histories of longer or more intensive exposure to HIV would indicate HIV resistance associated with that genotype. Longitudinal data were analyzed to investigate the association of HIV seroincidence with CCR5 genotypes. The cohort of 2996 individuals included 1892 men who have sex with men (MSM), 474 male injection drug users (IDUs), 347 women at heterosexual risk, and 283 female IDUs. MEASUREMENTS: CCR5 genotype, HIV serostatus, demographic factors, and risk behaviors during the 6 months before enrollment, followed by measurement of HIV seroincidence during the subsequent 18 months (for men) and 24 months (for women). RESULTS: Forty (1.3%) subjects were homozygous CCR5-Delta32/Delta32 and 387 (12.9%) were heterozygous CCR5-+/Delta32. All but 1 CCR5-Delta32/Delta32 individuals and 51 CCR5-+/Delta32 individuals were Caucasian. Among 1531 Caucasian MSM, CCR5-+/Delta32 individuals were present more frequently (22.3%) among those reporting unprotected receptive anal intercourse than among those not reporting this risk (15.9%) (p =.002), suggesting a selective advantage of the heterozygous genotype. CCR5-+/Delta32 individuals also had a significantly reduced relative risk of HIV seroconversion adjusted for unprotected receptive anal intercourse compared with CCR5-/+ individuals (relative risk = 0.30, 95% confidence interval [CI]: 0.08-0.97). CCR5-Delta32/Delta32 prevalence among Caucasian MSM was significantly associated with age among subjects recruited from high HIV seroprevalence cities (New York City and San Francisco) (odds ratio [OR] for each decade increase in age = 2.57, CI: 1.56-4.21) but not among those recruited from lower HIV prevalence sites (Boston, Chicago, Philadelphia, Seattle, and Providence/Pawtucket, Rhode Island) (OR = 1.20, CI: 0.75-1.89). CONCLUSIONS: Cross-sectional and longitudinal analyses indicated that among high-risk HIV seronegative MSM, CCR5-+/Delta32 and CCR5-Delta32/Delta32 are associated with protection against HIV infection. These findings imply that strategies aimed at reducing susceptibility to HIV infection by blocking CCR5 receptor sites need not seek blockage of all receptor sites to achieve an imperfect but substantial degree of protection.     

Acceptability of pharmacy-based bone density measurement by women and primary healthcare providers

OBJECTIVES: To assess women's information sources regarding, and monetary value placed on, pharmacy-based bone density screening. In addition, we evaluated clinicians' response to peripheral bone mass measurements. DESIGN: We recruited 197 women 50 years of age or older in four rural Midwestern community pharmacies. Each woman completed a questionnaire and underwent calcaneal bone density testing. Results were sent to participants' primary care providers. These providers, and others practicing within a 50-mile radius, were surveyed anonymously to evaluate usefulness of bone density data provided by this program or pharmacy-based osteoporosis screening in general. In addition, clinicians were asked how they would manage a woman with a calcaneal T-score of -1.3. RESULTS: Fifty-six percent of participants [95% CI, 49%-63%] became interested in screening through the media, and only 6% (CI, 3%-9%) became interested through contact with their primary care provider. Women were willing to pay a median of $25 for screening. Of 18 responding clinicians with patients in this study, 72% (CI, 47%-90%) found the results useful. Of the 67 responding clinicians, 51% (CI, 39%-63%) supported pharmacy-based bone mass measurement. For a case scenario of a woman with a calcaneal T-score of -1.3, 57% (CI, 46%-68%) of clinicians indicated that they would have ordered central dual-energy x-ray absorptiometry, and 20% (CI, 11%-29%) would have prescribed antiresorptive therapy. CONCLUSIONS: This study suggests that (1) women are an important force in obtaining bone density testing outside the clinic setting, both by self-education and willingness to pay, and (2) primary care clinicians receiving such results find them useful and indicate willingness to use them in decision-making.     

Patient perceptions of access to care and referrals to specialists: a comparison of African-American and white older patients with knee and hip osteoarthritis

BACKGROUND: There is a marked racial difference in the use of knee and hip replacement for osteoarthritis (OA). The reasons for this disparity remain unclear. We examined how African-American and white patients with symptomatic OA of the knee and/or hip compare with respect to their perceptions of care for knee and hip OA. METHODS: Survey of 596 male patients with OA of the knee and/or hip in primary care clinics at Cleveland VAMC. RESULTS: African-American (44%) and white (56%) study participants were comparable with respect to age and clinical factors. African Americans were more likely to have VA insurance only [OR=1.93 (1.13-3.28)]. African Americans were less likely to report difficulty getting medical care when needed [OR=0.54 (0.34-0.88)]. Differences in the two groups regarding satisfaction with and confidence in the primary physician were not significant. The proportions of participants who received specialty care referrals were similar. CONCLUSION: African-American patients reported having only VA insurance more often than white patients. Other aspects of perceived system and provider-based factors were similar between groups.     

Prevalence of the human immunodeficiency virus among university students

BACKGROUND AND METHODS. To estimate the magnitude of the human immunodeficiency virus (HIV) epidemic among university students, we conducted a blinded HIV-seroprevalence survey at 19 universities throughout the United States. HIV-antibody testing was performed on blood collected for routine medical purposes at the student health centers of the participating institutions. At each campus, from 250 to 1000 blood specimens were collected consecutively and tested for HIV antibodies by enzyme-linked immunosorbent assay and Western blot analysis. Nonidentifying demographic data were linked with the test results. RESULTS. Of 16,863 specimens in the sample, 30 (0.2 percent) were positive for antibodies to HIV. Positive specimens were found at 9 of the 19 schools. All were from students over 18 years old; 19 (63 percent) were from students over 24. All but 2 of the 30 infected students were men. The seroprevalence rate for men was 0.5 percent (95 percent confidence interval, 0.3 to 0.7), and for women it was 0.02 percent (95 percent confidence interval, 0.002 to 0.066). Seroprevalence increased with age--from 0.08 percent (95 percent confidence interval, 0.04 to 0.15) for students 18 to 24 years old to 1.0 percent (95 percent confidence interval, 0.2 to 2.9) for those 40 or older. CONCLUSIONS. HIV infection is present on U.S. university campuses, although the rate appears to be far lower than that of populations known to be at high risk. The potential clearly exists, however, for the further spread of HIV infection in this population, and preventive measures are needed.     

The use of viral culture and p24 antigen testing to diagnose human immunodeficiency virus infection in neonates. The HIV Infection in Newborns French Collaborative Study Group.

BACKGROUND. Early diagnosis of human immunodeficiency virus (HIV) infection in infants born to infected mothers is important for the infants' medical care, but the presence of maternal antibodies makes serologic tests uninformative. METHODS. In a cohort study of 181 infants born to HIV-infected mothers, we assessed the diagnostic value of HIV viral culture and testing for the presence of p24 antigen. The infants were tested at birth, again during the first 3 months, then followed and tested at the age of at least 18 months. RESULTS. Of the 181 infants, 3 died of HIV infection and 37 were seropositive after the age of 18 months. Viral cultures at birth were positive in 19 of the 40 infected infants and in none of the uninfected infants, yielding a sensitivity of 48 percent (95 percent confidence interval, 32 to 63 percent) and a specificity of 100 percent (95 percent confidence interval, 97 to 100 percent). By the age of three months, 30 of the 40 infants (75 percent) had positive cultures; again, there were no false positive results among the infants who were tested a second time, of the 141 who remained uninfected. The sensitivity of testing for p24 antigen at birth was only 18 percent, with a specificity of 100 percent. The presence of p24 antigen at birth was associated with the development of early and severe HIV-related disease (P less than 0.04). CONCLUSIONS. Viral culture at birth can correctly identify about half of newborns with HIV infection. The fact that this usually sensitive technique fails to identify about half the ultimately infected neonates suggests that vertical transmission of HIV may occur late in pregnancy or during delivery.     

Prevalence estimates of alcohol problems in a veterans administration outpatient population: Audit vs. Mast

Prior reports have indicated that the prevalence of alcohol-related problems in VA patients is significantly higher than that found in the general population. Prevalence rates, however, are likely to be affected by the screening instrument employed. A sample of 722 VA outpatients awaiting general medical and urgent care treatment was asked to complete two screening questionnaires: the World Health Organization's AUDIT and the brief MAST. Of 508 completed AUDITs, 55 (11%) scored above the cut-offs of 11 for harmful consumption, and 85 (17%) above the more liberal cut-off score of 8; whereas of 501 completed MASTs, 104 (21%) scored above the cutoff. Differences in identification rates are discussed.     

The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests

We studied the effect of informing physicians of the charges for outpatient diagnostic tests on their ordering of such tests in an academic primary care medical practice. All tests were ordered at microcomputer workstations by 121 physicians. For half (the intervention group), the charge for the test being ordered and the total charge for tests for that patient on that day were displayed on the computer screen. The remaining physicians (control group) also used the computers but received no message about charges. The primary outcomes measured were the number of tests ordered and the charges for tests per patient visit. In the 14 weeks before the study, the number of tests ordered and the average charge for tests per patient visit were similar for the intervention and control groups. During the 26-week intervention period, the physicians in the intervention group ordered 14 percent fewer tests per patient visit than did those in the control group (P less than 0.005), and the charges for tests were 13 percent ($6.68 per visit) lower (P less than 0.05). The differences were greater for scheduled visits (17 percent fewer tests and 15 percent lower charges for the intervention group; P less than 0.01) than for unscheduled (urgent) visits (11 percent fewer tests and 10 percent lower charges; P greater than 0.3). During the 19 weeks after the intervention ended, the number of tests ordered by the physicians in the intervention group was only 7.7 percent lower than the number ordered by the physicians in the control group, and the charges for tests were only 3.5 percent lower (P greater than 0.3). Three measures of possible adverse outcomes--number of hospitalizations, emergency room visits, and outpatient visits during the study period and the following six months--were similar for the patients seen by the physicians in both groups. We conclude that displaying the charges for diagnostic tests significantly reduced the number and cost of tests ordered, especially for patients with scheduled visits. The effects of this intervention did not persist after it was discontinued.     

An international study of the relation between somatic symptoms and depression.

BACKGROUND AND METHODS: Patients with depression, particularly those seen by primary care physicians, may report somatic symptoms, such as headache, constipation, weakness, or back pain. Some previous studies have suggested that patients in non-Western countries are more likely to report somatic symptoms than are patients in Western countries. We used data from the World Health Organization's study of psychological problems in general health care to examine the relation between somatic symptoms and depression. The study, conducted in 1991 and 1992, screened 25,916 patients at 15 primary care centers in 14 countries on 5 continents. Of the patients in the original sample, 5447 underwent a structured assessment of depressive and somatoform disorders. RESULTS: A total of 1146 patients (weighted prevalence, 10.1 percent) met the criteria for major depression. The range of patients with depression who reported only somatic symptoms was 45 to 95 percent (overall prevalence, 69 percent; P=0.002 for the comparison among centers). A somatic presentation was more common at centers where patients lacked an ongoing relationship with a primary care physician than at centers where most patients had a personal physician (odds ratio, 1.8; 95 percent confidence interval, 1.2 to 2.7). Half the depressed patients reported multiple unexplained somatic symptoms, and 11 percent denied psychological symptoms of depression on direct questioning. Neither of these proportions varied significantly among the centers. Although the overall prevalence of depressive symptoms varied markedly among the centers, the frequencies of psychological and physical symptoms were similar. CONCLUSIONS: Somatic symptoms of depression are common in many countries, but their frequency varies depending on how somatization is defined. There is substantial variation in how frequently patients with depression present with strictly somatic symptoms. In part, this variation may reflect characteristics of physicians and health care systems, as well as cultural differences among patients.     

Brief strengths-based case management promotes entry into HIV medical care: results of the antiretroviral treatment access study-II

OBJECTIVE: The Antiretroviral Treatment Access Study-II (ARTAS-II) evaluated a brief case management intervention delivered in health departments and community-based organizations (CBOs) to link recently diagnosed HIV-infected persons to medical care rapidly. METHODS: Recently diagnosed HIV-infected persons were recruited from 10 study sites across the United States during 2005 to 2006. The intervention consisted of up to 5 sessions with an ARTAS linkage case manager over a 90-day period. The outcome measure was whether or not the participant had seen an HIV medical care provider at least once within 6 months of enrollment. Multivariate logistic regression was used to identify significant predictors of receiving HIV medical care. RESULTS: Seventy-nine percent (497 of 626) of participants visited an HIV clinician at least once within the first 6 months. Participants who were older than 25 years of age, Hispanic, and stably housed; had not recently used noninjection drugs; had attended 2 or more sessions with the case manager; and were recruited at a study site that had HIV medical care colocated on its premises were all significantly more likely to have received HIV care. CONCLUSIONS: The ARTAS linkage case management intervention provides a model that health departments and CBOs can use to ensure that recently diagnosed HIV-infected persons attend an initial HIV care encounter.     

The care of HIV-infected adults in rural areas of the United States.

OBJECTIVE: This study describes the population of HIV-infected adults receiving care in rural areas of the United States and compares HIV care received in rural and urban areas. METHODS: Interviews were conducted with a nationally representative sample of 367 HIV-infected adults receiving health care in rural areas and 2806 HIV-infected adults receiving health care in urban areas of the contiguous United States. RESULTS: We estimate that 4800 HIV-infected persons received medical care in rural areas during the first half of 1996. Patients in rural HIV care were more likely than patients in urban HIV care to receive care from providers seeing few (<10) HIV-infected patients (38% vs. 3%; p <.001). Rural care patients were less likely than urban care patients to have taken highly active antiretroviral agents (57% vs. 73%; p <.001) or Pneumocystis carinii pneumonia prophylactic medication when indicated (60% vs. 75%; p =.006). CONCLUSIONS: Few American adults received HIV care in rural areas of the United States. Our findings suggest ongoing disparities between urban and rural areas in access to high-quality HIV care.