Adherence to highly active antiretroviral therapy in the real world: experience of twelve English HIV units

In order to describe how human immunodeficiency virus (HIV) clinics in and around London are trying to optimize their patients' adherence to highly active antiretroviral therapy (HAART), we performed a survey of practice and policy in the clinics using a postal questionnaire. Clinics were also asked to review up to 10 randomly selected case notes of patients receiving HAART and complete a questionnaire on each about how adherence was encouraged and assessed. Twelve clinics took part in the project and surveyed the notes of 89 patients. The results show that several clinics define adequate adherence as taking more than 95% of prescribed doses although there was no uniform definition across the participating units. Adherence was encouraged through simplifying HAART regimens, providing dose-dispensing boxes and alarms, arranging early follow-up for patients starting treatment, and offering continuing support through specific health care workers. Adequate discussion and provision of written information was seen as an important aid to adherence but the case note survey showed evidence of deficiencies in this area in approximately 40% of patients. Assessed levels of adherence were less than 95% in 27% of patients. The main reasons for suboptimal adherence were found to be lack of motivation to take treatment by the patients, high pill burden, and drug side effects although there were several other contributing factors. This study shows that the HIV units take HAART adherence seriously but there are several deficiencies in putting policy into practice.     

A systematic review of patient information leaflets for hypertension

OBJECTIVE: To review patient information leaflets on hypertension to determine the quality of information currently available to patients. DESIGN AND SETTING: A standardised systematic rating of patient information leaflets for hypertension in the UK. MAIN OUTCOME MEASURE: A quality score per leaflet based on a pre-determined rating scale. using recognised criteria with marks allocated for content, writing style, readability and design. RESULTS: Sixty-one leaflets were received, 42 from the Internet and 19 from other sources. Leaflets could achieve a maximum of 84 points. Scores ranged from 30 to 70 for non-Internet leaflets and 28 to 67 for Internet leaflets. Leaflets produced by Boeringer Ingelheim for the British Hypertension Society and Greenlines Publishing (with a medical education grant from Knoll Ltd) scored highest overall. A detailed analysis of the non-Internet leaflets showed that few leaflets contained the full range of information considered important though most should be readable by the majority of the adult population and are written using appropriate language and typeface. CONCLUSION: High quality information is available for patients, though some leaflets fall below an adequate standard. Professionals providing advice to patients should have some knowledge of what constitutes good quality information and be critical of the resources they use. Ideally surgeries and clinics should stock a range of the best information available so that patients can chose the leaflet most appropriate to their needs.     

Effect of information leaflets on knowledge in patients with gastrointestinal diseases.

Twelve patient information leaflets concerning common gastrointestinal diseases were produced by the British Digestive Foundation and evaluated to determine whether patients knew more about their disease if they received a leaflet. Eleven hundred and fifty patients attending gastroenterology clinics in the United Kingdom were assessed by postal questionnaire of whom half had received a leaflet relevant to their diagnosis six weeks before assessment. Seven hundred and fifty one replied (398 leafleted, 353 non-leafleted). Most patients found the leaflets helpful and easy to understand; few found them worrying. They were regarded as a better source of information than doctors, particularly for information about the characteristics of the illness and side effects of treatment. In all diagnostic groups assessed the patients' knowledge of their disease was significantly greater if they had received a leaflet than if they had not. Individual responses by patients without leaflets showed that fundamental misconceptions persisted about digestive diseases. The British Digestive Foundation leaflets are an effective means of imparting disease related information to patients.     

Management of recurrent genital herpes: a survey of UK genitourinary medicine clinics in 2003

We carried out a survey of all UK genitourinary (GU) medicine clinics, via postal questionnaire, in order to evaluate the current management of recurrent genital herpes (RGH) in the GU medicine setting. Respondents were invited to answer questions regarding various aspects of herpes simplex virus (HSV) management. There was a 62% response rate. Analysis of the returned surveys revealed that the vast majority of clinics (96%) provided drug treatment for RGH, with 81% having a clinic policy for the management of genital herpes (GH). A majority (64%) of clinics had access to some type of counselling or psychological therapy and 47% encouraged collaboration with primary care for follow-up prescribing. Of the clinics providing drug therapy for RGH, 80% used aciclovir alone with smaller numbers having access to aciclovir, famciclovir and valaciclovir. While many clinics are meeting the British Association of Sexual Health and HIV (BASHH) guidelines, improvements can be made to increase the availability of psychological support to patients with HSV and improve links with primary care.     

UK National Audit of chlamydial infection management in sexual health clinics. case notes audit: information-giving, partner notification and follow-up

Verbal information-giving is good, but only half of cases were reportedly given written information on chlamydia. Follow-up by 'phoning or texting (43%) was as common as follow-up in clinics (39%). About one-fourth of cases did not have follow up, with no recall for around 60% of these cases. Advice about partner notification (PN) was provided by a health adviser or other suitably trained health professional to 91% of cases, and the method of PN was documented for 92% of these cases. PN outcome was not documented for about 25% of these cases. There was no information on the chlamydial status of sexual contacts of about half of cases, and no information about the treatment status of sexual contacts of about 40% of cases. The average number of contacts screened per index was 0.52 outside London and 0.29 for the London Regions, levels below those suggested in the National Guideline.     

General practitioners' views on the screening for genital Chlamydia trachomatis infection and partner notification

A postal survey of general practitioners (GPs) in the East Riding of Yorkshire was undertaken to find out their views about screening for Chlamydia trachomatis infection, the reasons for their inability to screen the high-risk population, facilities available for screening in the primary care setting, treatment regimen and the views about partner notification. Although all GPs had the facilities for chlamydial testing, their views on chlamydial screening differed widely and very few offered opportunistic screening. Most of the GPs would prefer the sexual health clinics (genitourinary medicine [GUM] clinics) to undertake partner notification. Less than half of the GPs surveyed offered the ideal antimicrobial therapy against chlamydial infection, as recommended by the Central Audit Group in Genito-urinary Medicine. This survey shows the necessity to disseminate proper guidelines for the management of uncomplicated C. trachomatis infection in the community. Sexual health clinics should make adequate provision to deal with additional workload resulting from the increased referrals of partners to the clinics when the opportunistic screening is widely provided by the GPs.     

上海市性病患者对性病咨询服务需求的调查

目的　了解性病患者对性病咨询服务的需求情况。方法　对上海市 4家医院性病门诊的性病患者进行问卷调查。结果　①多数性病患者希望在独立的咨询门诊 (5 2 5 % )和看病过程中 (5 0 8% )获得咨询服务 ;②84 9%的性病患者认为咨询服务应在只有医生和病人的两人诊室中进行 ;③ 6 2 1%的性病患者赞同性病咨询服务收费 ,其态度与收入水平有关 ,收入越高赞同的比例越高 ;④ 6 6 4 %的性病患者希望咨询的医生就是看病时的首诊医生 ;⑤男性和女性性病患者咨询的侧重存在差异 ,男性患者更关心有危险行为时的预防措施 (47 9% ) ,而女性患者更关注性病的预后情况 (6 6 4 % )。结论　咨询人员应从性病患者的需求出发 ,为他们提供最需要的服务     

Structure and function of anticoagulation clinics in the United States: an AC forum membership survey

Many anticoagulation clinics have adapted their services to provide care for patients taking direct oral anticoagulants (DOAC) in addition to traditional warfarin management. Anticoagulation clinic scope of service and operations in this transitional environment have not been well described in the literature. A survey was conducted of United States-based Anticoagulation Forum members to inquire about anticoagulation clinic structure, function, and services provided. Survey responses are reported using summary or non-parametric statistics, when appropriate. Unique clinic survey responses were received from 159 anticoagulation clinics. Clinic structure and staffing are highly variable, with approximately half of clinics (52%) providing DOAC-focused care in addition to traditional warfarin-focused care. Of those clinics managing DOAC patients, this accounts for only 10% of their clinic volume. These clinics commonly have a DOAC follow up protocol (75%). Clinics assign a median of 190.5 (interquartile range 50–300) patients per staff full-time-equivalent, with more patients assigned in phone-based care clinics than in face-to-face based care clinics. Most clinics (68.5%) report receiving reimbursement, which occur either through a combination of patient and insurance provider billing (78.2%), insurance reimbursement only (19.5%) or patient reimbursement only (2.3%). There is wide heterogeneity in anticoagulation clinic structure, function, and services provided. Half of all survey-responding anticoagulation clinics provide care for DOAC-treated patients. Understanding how changes in healthcare policy and reimbursement have impacted these clinics remains to be explored.     

Health advice obtained by tourists travelling to Magnetic Island: a risk area for 'Irukandji' jellyfish in North Queensland, Australia

BACKGROUND: Little is known about the travel health advice obtained by tourists travelling to Magnetic Island, which is a known risk area for the potentially fatal 'Irukandji' jellyfish on the Great Barrier Reef coast of north Queensland, Australia. METHODS: Structured interviews were conducted with 208 ferry passengers (93% response) travelling between Townsville (Latitude 19 degrees S) and Magnetic Island. RESULTS: Less than half of the international tourists (21, 46%) had obtained travel health advice before coming to north Queensland, although they were significantly more likely to have done so than domestic tourists (p<0.001). Travel health advice obtained by international tourists was sourced mainly from their general practitioner (8, 50%) or from a guidebook (6, 38%). Eighty-eight percent of north Queensland residents, 70% of domestic tourists, and 34% of international tourists knew what an Irukandji jellyfish was (p<0.001), although this was not associated with having obtained travel health advice. For those passengers returning from the Island, 8 (44%) domestic tourists and 4 (35%) international tourists recalled seeing some information on the Island that improved their knowledge about Irukandji jellyfish. Most of the international tourists travelled to north Queensland by bus (30, 65%), while most domestic tourists arrived by private car (12, 40%) or plane (10, 33%). CONCLUSIONS: Only a small proportion of international tourists knew about Irukandji jellyfish and most tourists had not received travel health advice. The majority of tourists had not received further information about Irukandji jellyfish risk whilst on the island. All travellers to popular north Queensland tourist areas need travel health advice, which includes advice on avoiding contact with Irukandji and Chironex box jellyfish. Health promotion campaigns directed at providing this advice need to be aware that most tourists to north Queensland arrive by bus or car and the only 'shared' vehicle, at least to Magnetic Island, is the passenger ferry.     

A multi-district audit against national guidelines for the management of uncomplicated genital Chlamydia trachomatis infection

A regional audit group in genitourinary medicine (GUM) developed a method to assess their practice using peripatetic audit workers. An audit using 2 audit proformas recorded information relating to an agreed selection of standards contained within the national guidelines for the management of uncomplicated genital chlamydial infection. An audit worker (ADP) reviewed patient records of a sample of cases. Nine GUM clinics throughout the Yorkshire region participated in the audit; 489 cases out of a total annual workload of 2358 cases positively diagnosed as uncomplicated chlamydial infection were reviewed. Variations in compliance with the standards for confirmation of test results and the time from diagnosis to treatment were seen. Recording of discussions, advice and contact tracing activity were limited or separated from the main patient record, making assessment of practice difficult. Post-audit meetings of the group led to action on these areas and commitment to re-audit with the same standards and methods.     

UK National Audit of chlamydial infection management in sexual health clinics. case notes audit: demography, diagnosis and treatment

The case notes of cases of genital chlamydial infection were audited against the UK National Guideline. This was the first web-based and the largest national audit to date, with 193 clinics in all UK Regions contributing data. About half of all cases had no symptoms, with about one-third attending for routine or asymptomatic screens; suggesting significant provision of screening by clinics that might be managed differently to reduce workload. Nucleic acid amplification tests (NAATs) are now well established for chlamydial detection in UK clinics, with 93% of cases having genital NAATs. Azithromycin is now more commonly used than doxycycline (54% vs. 37%). Of 26 pregnant women, 20 were treated with azithromycin, suggesting that most prescribers treating pregnant women consider that erythromycin is not an adequate alternative to azithromycin. Most women had NAATs obtained from sites recommended by the Guideline, with 93% of women who had genital NAATs having these from the cervix or vulvovaginal area.     

UK National Audit of Early Syphilis Management. Clinics audit: screening for and management of early syphilis

Data were provided by 131 clinics, and 56% of cases were managed in clinics in the London regions in 2003. Three clinics (2%) do not routinely screen new patients for syphilis, and 28 clinics (21%) do not routinely screen 'rebook' patients who have had a new partner. More than 80% of clinics routinely conduct cardiovascular and neurological examinations, although chest radiography is only performed by 50% of clinics and lumbar puncture by 13%. Only 19 (14%) clinics indicated not routinely using the recommended procaine penicillin G (PPG) regimen or one- or two-dose benzathine penicillin G (BPG) regimens for early syphilis, with 57% providing two doses of BPG 2.4 g, 40% providing PPG 750 mg for 10 days, and 15% providing one dose of BPG 2.4 g. Only seven clinics (5%) indicated that they provided treatment for early syphilis with PPG that is inferior to that recommended in the national guidelines. Only 18 clinics specified using the recommended dose and duration (or in excess of this) of PPG for neurosyphilis for cases with HIV infection. Provision for management of severe penicillin reaction is good, although few patients are desensitized. All clinics report that contact tracing for early syphilis is provided, and is mainly the responsibility of health advisers. Compared with auditing outcomes, audit of management policies overestimated performance in contact tracing and provision of dark ground microscopy.     

Dropout from interim methadone and subsequent comprehensive methadone maintenance

BACKGROUND: Methadone maintenance in the U.S. is delivered primarily through specialized clinics that provide psychosocial services together with medication. Interim methadone (IM) is an evidence-based approach to increase access by providing methadone without counseling for individuals waiting for admission to comprehensive treatment. Little is known about the role of patient characteristics in predicting outcomes in the IM service pathway (IM with comprehensive methadone treatment following IM). METHODS: This study examined the relationship between patient motivation and dropout among patients in the IM service pathway (n=183). Participants were assessed with the Addiction Severity Index, the Texas Christian University Motivation Scales, and study-specific instruments at baseline, 4 month follow-up or admission to comprehensive treatment (whichever occurred first), and 6 months thereafter. Multinomial logistic regression was used for the analysis, controlling for demographics, route of administration, cocaine use, criminal justice history, and treatment history. RESULTS: Of the total sample, 62% were retained throughout the IM service pathway, 20% left IM, and 18% left subsequent comprehensive treatment. Motivation did not predict dropout from either IM or comprehensive treatment following IM. Unexpectedly, neither did any of the other explanatory variables included in the model. CONCLUSIONS: Most patients remained in the IM service pathway. The patient characteristics examined are not associated with discontinuation of IM or subsequent comprehensive methadone treatment. SCIENTIFIC SIGNIFICANCE: The findings that most patients were retained in the IM service pathway, and that no subgroup experienced higher probability of dropout, bolster the public health potential of IM as a service strategy.     

A multidistrict audit of the management of chlamydial PID in genitourinary medicine clinics in Yorkshire

In response to recent reviews of practice of pelvic inflammatory disease (PID) management, a multidistrict audit involving eight genitourinary clinics within the Yorkshire region was carried out. This audit reports the referral patterns of patients, physical signs and microscopy findings at the first genitourinary medicine (GUM) clinic attendance, antibiotic treatment and follow-up data as well as health adviser involvement and partner participation for 68 patients diagnosed with chlamydial PID. Twenty-eight (41.2%) patients presented with symptoms of less than or equal to four weeks duration, partner notification was recorded as being carried out for all patients and at least one partner was documented as having been treated in 57 (83.8%) patients. There is, however, a wide variation in the antibiotic regimens used for treatment and their duration.     

A simple screening method for determining knowledge of the appropriate levels of activity and risk behaviour in young people with congenital cardiac conditions

OBJECTIVE: To assess a novel method for assessing risk and providing advice about activity to children and young people with congenital cardiac disease and their parents. DESIGN AND SETTING: Questionnaire survey in outpatient clinics at a tertiary centre dealing with congenital cardiac disease, and 6 peripheral clinics. INTERVENTIONS: Children or their parents completed a brief questionnaire. If this indicated a desire for help, or a serious mismatch between advised and real level of activity, they were telephoned by a physiotherapist. MAIN MEASURES OF OUTCOME: Knowledge about appropriate levels of activity, and identification of the number exercising at an unsafe level, the number seeking help, and the type of help required. RESULTS: 253/258 (98.0%) questionnaires were returned, with 119/253 (47.0%) showing incorrect responses in their belief about their advised level of exercise; 17/253 (6.7%) had potentially dangerous overestimation of exercise. Asked if they wanted advice 93/253 (36.8%) said "yes", 43/253 (17.0%) "maybe", and 117/253 (46.2%) "no". Of those contacted by phone to give advice, 72.7% (56/77) required a single contact and 14.3% (11/77) required an intervention that required more intensive contact lasting from 2 up to 12 weeks. Of the cohort, 3.9% (3/77) were taking part in activities that put them at significant risk. CONCLUSIONS: There is a significant lack of knowledge about appropriate levels of activity, and a desire for further advice, in children and young people with congenital cardiac disease. A few children may be at very significant risk. These needs can be identified, and clinical risk reduced, using a brief self-completed questionnaire combined with telephone follow-up from a suitably knowledgeable physiotherapist.     

Impact of information leaflets on HIV test uptake amongst GUM clinic attendees: an update

In the Sexual Health Strategy, the targets of HIV testing uptake in genitourinary medicine clinics (GUM) are set at 40% by year 2004 and 60% by 2007. We assessed the uptake of HIV test amongst GUM clinic attendees, more than six months after introducing an information leaflet in place of verbal pre-test counselling (PTC). The uptake rate was significantly higher than in a previous audit conducted in the same year, two weeks after introduction of the leaflets (62% vs 50%, P =0.001).     

Dropout from Interim Methadone and Subsequent Comprehensive Methadone Maintenance

Background: Methadone maintenance in the United States is delivered primarily through specialized clinics that provide psychosocial services together with medication. Interim methadone (IM) is an evidence-based approach to increase access by providing methadone without counseling for individuals waiting for admission to comprehensive treatment. Little is known about the role of patient characteristics in predicting outcomes in the IM service pathway (IM with comprehensive methadone treatment following IM). Methods: This study examined the relationship between patient motivation and dropout among patients in the IM service pathway (n = 183). Participants were assessed with the Addiction Severity Index, the Texas Christian University Motivation Scales, and study-specific instruments at baseline, 4-month follow-up or admission to comprehensive treatment (whichever occurred first), and 6 months thereafter. Multinomial logistic regression was used for the analysis, controlling for demographics, route of administration, cocaine use, criminal justice history, and treatment history. Results: Of the total sample, 62% were retained throughout the IM service pathway, 20% left IM, and 18% left subsequent comprehensive treatment. Motivation did not predict dropout from either IM or comprehensive treatment following IM. Unexpectedly, neither did any of the other explanatory variables included in the model. Conclusions: Most patients remained in the IM service pathway. The patient characteristics examined are not associated with discontinuation of IM or subsequent comprehensive methadone treatment. Scientific Significance: The findings that most patients were retained in the IM service pathway, and that no subgroup experienced higher probability of dropout, bolster the public health potential of IM as a service strategy.     

Treatment of bacillary pulmonary tuberculosis at the chest clinics in the private sector in Korea, 1993.

SETTING: Cohort study of bacillary pulmonary tuberculosis patients treated at private sector chest clinics in Korea. OBJECTIVE: To assess the treatment behaviour of physicians in private chest clinics and the treatment outcomes of their patients. DESIGN: 1) A retrospective analysis of a cohort of patients admitted from July through October in 1993, and 2) comparison with results from health centres under the National Tuberculosis Programme (NTP). RESULTS: Nine hundred and sixty bacillary patients (507 newly diagnosed--'new', and 453 retreatment--'old') were admitted to the study. Initial smears and cultures were not performed in 7% and 21%, and follow-up smears and cultures not done in 19% and 28%, respectively. The regimens prescribed were variable: 23 in 'new' and 72 in 'old' patients, 86 in total. Six-month short-course treatment using HRZE was prescribed for 26.2% of 'new' patients. In many instances, the planned treatment duration was excessive. The success rates (cured plus completed) for 'new' and 'old' patients were 74% and 51%, respectively. The failure rates were less than 1% in 'new' and 9% in 'old' patients. CONCLUSION: Prescribed regimens were variable in terms of drug combinations and treatment duration. Overall treatment outcome was inferior to that of the health centres under the NTP.     

Private practitioners and tuberculosis control in the Philippines: strangers when they meet?

OBJECTIVE: To investigate the knowledge, attitudes and perspectives of the Filipino private physicians (PPs) on tuberculosis (TB) control issues in the Philippines and their implications for future governmental public health policies. DESIGN: Cross-sectional telephone survey from June to October 2001. PARTICIPANTS: In each of the 78 provinces of the Philippines we randomly selected 10 PPs from the provincial capital city, five PPs from an urban centre with more than 50,000 population, and one PP from 15 rural villages with <50,000 population, making a total of 30 PPs per province. These data were complemented with information from focus group discussions with health workers and policy makers working in TB control, and through personal interviews with PPs. RESULTS: We interviewed 1355 (57.9%) of 2340 PPs identified. TB was diagnosed mainly through X-ray (87.9%) and usually treated with inappropriate regimens of anti-TB drugs (89.3%). The PPs did not follow-up their TB patients, did not trace the defaulters (97.9%) and did not identify contacts (91.4%). Only 24.2% knew the National Tuberculosis Programme (NTP) policies in depth. They defined the NTP's weakest points as diagnosis through sputum microscopy (59.2%) and the management of smear negative patients (29.7%). Most PPs were willing to collaborate with the NTP (83.3%) provided they were paid (38.4%). More than a half (51.5%) objected to obligatory reporting of new TB cases. The PPs based their success in attracting TB patients to their offices on confidentiality (46.1%) and on the kind treatment and flexibility given (43.7%). CONCLUSIONS: Diagnosis and treatment of TB patients is a daily issue for the PPs in the Philippines, although they did not follow usually the NTP guidelines. The majority of the PPs wished to collaborate with the NTP provided they were paid.