HIV,Hepatitis C,and Other Sexually Transmitted Infections Among Male Sex Workers in Ho Chi Minh City,Vietnam

There is little data on the burden of HIV and other infections that affect male sex workers (MSW) in Vietnam. We conducted behavioral and biological sexual health surveys with 300 MSW in Ho Chi Minh City. Generalized estimating equation models were built to assess factors associated with HIV, hepatitis C, and other sexually transmitted infections (STI). Of 300 MSW, 19 (6.3 %) were diagnosed seropositive for HIV, 11 (3.7 %) had hepatitis C, and 26 (8.7 %) had at least one prevalent STI. In a multivariable model, opiate use was significantly associated with HIV infection (aOR 6.46, 95 % CI 1.28–32.7) and hepatitis C (aOR = 19.6, 95 % CI 2.35–163.6). Alcohol dependency was associated with increased odds of hepatitis C (aOR = 4.79, 95 % CI 1.02–22.5) and decreased odds of other STI (aOR = 0.30, 95 % CI 0.10–0.97). These findings suggest that MSW in Vietnam would benefit from regular HIV and STI testing, as well as linkage to care and substance use rehabilitation services.     

What Prevents Central Asian Migrant Workers from Accessing HIV Testing? Implications for Increasing HIV Testing Uptake in Kazakhstan

Several barriers prevent key populations, such as migrant workers, from accessing HIV testing. Using data from a cross-sectional study among Central Asian migrant workers (n = 623) in Kazakhstan, we examined factors associated with HIV testing. Overall, 48% of participants had ever received an HIV test. Having temporary registration (AOR 1.69; (95% CI [1.12–2.56]), having an employment contract (AOR 2.59; (95% CI [1.58–4.23]), being able to afford health care services (AOR 3.61; (95% CI [1.86–7.03]) having a medical check-up in the past 12 months (AOR 1.85; 95% CI [1.18–2.89]), and having a regular doctor (AOR 2.37; 95% CI [1.20–4.70]) were associated with having an HIV test. HIV testing uptake among migrants in Kazakhstan falls far short of UNAIDS 90-90-90 goals. Intervention strategies to increase HIV testing among this population may include initiatives that focus on improving outreach to undocumented migrants, making health care services more affordable, and linking migrants to health care.     

Does Integrating Family Planning into HIV Services Improve Gender Equitable Attitudes? Results from a Cluster Randomized Trial in Nyanza,Kenya

This study investigated whether integrating family planning (FP) services into HIV care was associated with gender equitable attitudes among HIV-positive adults in western Kenya. Surveys were conducted with 480 women and 480 men obtaining HIV services from 18 clinics 1 year after the sites were randomized to integrated FP/HIV services (N = 12) or standard referral for FP (N = 6). We used multivariable regression, with generalized estimating equations to account for clustering, to assess whether gender attitudes (range 0–12) were associated with integrated care and with contraceptive use. Men at intervention sites had stronger gender equitable attitudes than those at control sites (adjusted mean difference in scores = 0.89, 95 % CI 0.03–1.74). Among women, attitudes did not differ by study arm. Gender equitable attitudes were not associated with contraceptive use among men (AOR = 1.06, 95 % CI 0.93–1.21) or women (AOR = 1.03, 95 % CI 0.94–1.13). Further work is needed to understand how integrating FP into HIV care affects gender relations, and how improved gender equity among men might be leveraged to improve contraceptive use and other reproductive health outcomes.     

Rural Residence and Adoption of a Novel HIV Therapy in a National, Equal-Access Healthcare System

Rural persons with HIV face barriers to care that may influence adoption of advances in therapy. We performed a retrospective cohort study to determine rural–urban variation in adoption of raltegravir—the first HIV integrase inhibitor—in national Veterans Afffairs (VA) healthcare. There were 1,222 veterans with clinical indication for raltegravir therapy at time of its FDA approval in October 2007, of whom 223 (19.1%) resided in rural areas. Urban persons were more likely than rural to initiate raltegravir within 180 days (17.3% vs. 11.2%, P = 0.02) and 360 days (27.5% vs. 19.7%, P = 0.02), but this gap narrowed slightly at 720 days (36.3% vs. 31.8%, P = 0.19). In multivariable analysis adjusting for patient characteristics, urban residence predicted raltegravir adoption within 180 days (odds ratio 1.72, 95% CI 1.09–2.70) and 360 days (OR 1.63, 95% CI 1.13–2.34), but not 720 days (OR 1.26, 95% CI 0.84–1.87). Efforts are needed to reduce geographic variation in adoption of advances in HIV therapy.     

Laparoscopic lavage versus surgical resection for acute diverticulitis with generalised peritonitis: a systematic review and meta-analysis

This systematic review and meta-analysis investigates current evidence on the therapeutic role of laparoscopic lavage in the management of diverticular peritonitis. A systematic review of the literature was performed on PubMed until June 2016, according to preferred reporting items for systematic reviews and meta-analyses guidelines. All randomised controlled trials comparing laparoscopic lavage with surgical resection, irrespective of anastomosis or stoma formation, were analysed. After assessment of titles and full text, 3 randomised trials fulfilled the inclusion criteria. Overall the quality of evidence was low because of serious concerns regarding the risk of bias and imprecision. In the laparoscopic lavage group, there was a statistically significant higher rate of postoperative intra-abdominal abscess (RR 2.54, 95% CI 1.34–4.83), a lower rate of postoperative wound infection (RR 0.10, 95% CI 0.02–0.51), and a shorter length of postoperative hospital stay during index admission (WMD = ?2.03, 95% CI ?2.59 to ?1.47). There were no statistically significant differences in terms of postoperative mortality at index admission or within 30 days from intervention in all Hinchey stages and in Hinchey stage III, postoperative mortality at 12 months, surgical reintervention at index admission or within 30–90 days from index intervention, stoma rate at 12 months, or adverse events within 90 days of any Clavien–Dindo grade. The surgical reintervention rate at 12 months from index intervention was significantly lower in the laparoscopic lavage group (RR 0.57, 95% CI 0.38–0.86), but these data included emergency reintervention and planned intervention (stoma reversal). This systematic review and meta-analysis did not demonstrate any significant difference between laparoscopic peritoneal lavage and traditional surgical resection in patients with peritonitis from perforated diverticular disease, in terms of postoperative mortality and early reoperation rate. Laparoscopic lavage was associated with a lower rate of stoma formation. However, the finding of a significantly higher rate of postoperative intra-abdominal abscess in patients who underwent laparoscopic lavage compared to those who underwent surgical resection is of concern. Since the aim of surgery in patients with peritonitis is to treat the sepsis, if one technique is associated with more postoperative abscesses, then the technique is ineffective. Even so, laparoscopic lavage does not appear fundamentally inferior to traditional surgical resection and this technique may achieve reasonable outcomes with minimal invasiveness.     

Late Diagnosis Due to Missed Opportunities and Inadequate Screening Strategies in HIV Infected Mexican Women

Late diagnosis of HIV remains a public health issue in Mexico. Most national programs target high-risk groups, not including women. More data on factors associated with late diagnosis and access to care in women are needed. In 2012–2013, Mexican women recently diagnosed with HIV were interviewed. Socio-cultural background, household-dynamics and clinical data were collected. Of 301 women, 49 % had <200 CD4 cells/mm³, 8 % were illiterate, 31 % had only primary school. Physical/sexual violence was reported by 47/30 %; 75 % acquired HIV from their stable partners. Prenatal HIV screening was not offered in 61 %; 40 % attended consultation for HIV-related symptoms without being tested for HIV. Seeking medical care ≥3 times before diagnosis was associated with baseline CD4 <200 cells/mm³ (adjusted OR 3.74, 95 % CI 1.88–7.45, p < 0.001). There were missed opportunities during prenatal screening and when symptomatic women seeked medical care. Primary care needs to be improved and new strategies implemented for early diagnosis in women.     

Heavy alcohol use as a risk factor for severe outcomes among adults hospitalized with laboratory-confirmed influenza, 2005–2012

We examined heavy alcohol use as a risk factor for severe influenza (intensive care admission or death) among hospitalized adults. In <65- and ≥65-year-olds, heavy alcohol use increased disease severity [relative risk (RR) 1.34; 95 % confidence interval (CI): 1.04–1.74, and RR 2.47; 95 % CI: 1.69–3.60, respectively]. Influenza vaccination and early, empiric antiviral treatment should be emphasized in this population.     

Health care costs associated with hospital acquired complications in patients with chronic kidney disease

Background

Patients with CKD are at increased risk of potentially preventable hospital acquired complications (HACs). Understanding the economic consequences of preventable HACs, may define the scope and investment of initiatives aimed at prevention.

Methods

Adult patients hospitalized from April, 2003 to March, 2008 in Alberta, Canada comprised the study cohort. Healthcare costs were determined and categorized into ‘index hospitalization’ including hospital cost and in-hospital physician claims, and ‘post discharge’ including ambulatory care cost, physician claims, and readmission costs from discharge to 90 days. Multivariable regression was used to estimate the incremental healthcare costs associated with potentially preventable HACs.

Results

In fully adjusted models, the median incremental index hospitalization cost was CAN-$6169 (95% CI; 6003–6336) in CKD patients with ≥1 potentially preventable HACs, compared with those without. Post-discharge incremental costs were 1471(95% CI; 844–2099) in those patients with CKD who developed potentially preventable HACs within 90 days after discharge compared with patients without potentially preventable HACs. Additionally, the incremental costs associated with ≥1 potentially preventable HACs within 90 days from admission in patients with CKD were $7522 (95% CI; 7219–7824). A graded relation of the incremental costs was noted with the increasing number of complications. In patients without CKD but with ≥1 preventable HACs incremental costs within 90 days from hospital admission was $6688 (95% CI: 6612–6723).

Conclusions

Potentially preventable HACs are associated with substantial increases in healthcare costs in people with CKD. Investment in implementing targeted strategies to reduce HACs may have a significant benefit for patient and health system outcomes.

     

Specialty,Political Affiliation,and Perceived Social Responsibility Are Associated with U.S. Physician Reactions to Health Care Reform Legislation

BACKGROUND

Little is known about how U.S. physicians’ political affiliations, specialties, or sense of social responsibility relate to their reactions to health care reform legislation.

OBJECTIVE

To assess U.S. physicians’ impressions about the direction of U.S. health care under the Affordable Care Act (ACA), whether that legislation will make reimbursement more or less fair, and examine how those judgments relate to political affiliation and perceived social responsibility.

DESIGN

A cross-sectional, mailed, self-reported survey.

PARTICIPANTS

Simple random sample of 3,897 U.S. physicians.

MAIN MEASURES

Views on the ACA in general, reimbursement under the ACA in particular, and perceived social responsibility.

KEY RESULTS

Among 2,556 physicians who responded (RR2: 65 %), approximately two out of five (41 %) believed that the ACA will turn U.S. health care in the right direction and make physician reimbursement less fair (44 %). Seventy-two percent of physicians endorsed a general professional obligation to address societal health policy issues, 65 % agreed that every physician is professionally obligated to care for the uninsured or underinsured, and half (55 %) were willing to accept limits on coverage for expensive drugs and procedures for the sake of expanding access to basic health care. In multivariable analyses, liberals and independents were both substantially more likely to endorse the ACA (OR 33.0 [95 % CI, 23.6–46.2]; OR 5.0 [95 % CI, 3.7–6.8], respectively), as were physicians reporting a salary (OR 1.7 [95 % CI, 1.2–2.5]) or salary plus bonus (OR 1.4 [95 % CI, 1.1–1.9) compensation type. In the same multivariate models, those who agreed that addressing societal health policy issues are within the scope of their professional obligations (OR 1.5 [95 % CI, 1.0–2.0]), who believe physicians are professionally obligated to care for the uninsured / under-insured (OR 1.7 [95 % CI, 1.3–2.4]), and who agreed with limiting coverage for expensive drugs and procedures to expand insurance coverage (OR 2.3 [95 % CI, 1.8–3.0]), were all significantly more likely to endorse the ACA. Surgeons and procedural specialists were less likely to endorse it (OR 0.5 [95 % CI, 0.4–0.7], OR 0.6 [95 % CI, 0.5–0.9], respectively).

CONCLUSIONS

Significant subsets of U.S. physicians express concerns about the direction of U.S. health care under recent health care reform legislation. Those opinions appear intertwined with political affiliation, type of medical specialty, as well as perceived social responsibility.     

HIV-Positive and in Jail: Race,Risk Factors,and Prior Access to Care

Black individuals represent 13 % of the US population but 46 % of HIV positive persons and 40 % of incarcerated persons. The national EnhanceLink project evaluated characteristics of HIV-positive jail entrants at ten sites and explored associations between race and HIV disease state. Between 1/2008 and 10/2011, 1,270 study participants provided demographic and clinical data. Adjusted odds ratios (aORs) were calculated for advanced HIV disease (CD4 < 200 cells/mm³) and uncontrolled viremia (viral load > 400 copies/ml) for Black (n = 807) versus non-Black (n = 426) participants. Sixty-five percent of HIV-positive jail participants self-identified as Black. Among all participants, fewer than half had a high school diploma or GED, the median number of lifetime arrests was 15, and major mental illness and substance abuse were common. Black participants were more likely to be older than non-Black participants, and less likely to have health insurance (70 vs 83 %) or an HIV provider (73 vs 81 %) in the prior 30 days. Among all male study participants (n = 870), 20 % self-identified as homosexual or bisexual. Black male participants were more likely to be homosexual or bisexual (22 vs 16 %) and less likely to have a history of injection drug use (20 vs 50 %) than non-Black male participants. Advanced HIV disease was associated with self-identification as Black (aOR = 1.84, 95 % CI 1.16–2.93) and time since HIV diagnosis of more than two years (aOR = 3.55, 95 % CI 1.52–8.31); advanced disease was inversely associated with age of less than 38 years (aOR = 0.41, 95 % CI 0.24–0.70). Uncontrolled viremia was inversely associated with use of antiretroviral therapy (ART) in the prior 7 days (aOR = 0.25, 95 % CI 0.15–0.43) and insurance coverage in the prior 30 days (aOR = 0.46, 95 % CI 0.26–0.81). Conclusions: The racial disparities of HIV and incarceration among Black individuals in the US are underscored by the finding that 65 % of HIV-positive jail participants self-identified as Black in this ten-site study. Our study also found that 22 % of Black male participants self-identified as men who have sex with men (MSM). We believe these findings support jails as strategic venues to reach heterosexual, bisexual, and homosexual HIV-positive Black men who may have been overlooked in the community. Among HIV-positive jail entrants, Black individuals had more advanced HIV disease. Self-identification as Black was associated with a lower likelihood of having health insurance or an HIV provider prior to incarceration. HIV care and linkage interventions are needed within jails to better treat HIV and to address these racial disparities.     

Correlates of Unstructured Antiretroviral Treatment Interruption in a Cohort of HIV-Positive Individuals in British Columbia

Treatment interruptions (TIs) limit the therapeutic success of combination antiretroviral therapy and are associated with higher morbidity and mortality. HIV-positive individuals dealing with concurrent health issues, access challenges and competing life demands are hypothesized to be more likely to interrupt treatment. Individuals were included if they initiated cART ≥1 year prior to interview date and had a CD4 cell count and initial regimen recorded at initiation. Using pharmacy recording, a TI was defined as a patient-initiated gap in treatment ≥90 consecutive days during the 12 months preceding or following the study interview. 117 (15.2 %) of 768 participants included in this study had a TI during the study window. 76.0 % of participants were male, 27.5 % were of Aboriginal ancestry and the median age was 46 (interquartile range 40–52). In multivariable logistic regression, TIs were significantly associated with current illicit drug use (adjusted odds ratio [aOR] 1.68, 95 % confidence interval [CI] 1.05–2.68); <95 % adherence in the first year of treatment (aOR 2.68, 95 % CI 1.67–4.12); living with at least one person (aOR 1.95; 95 % CI 1.22–3.14) or living on the street (aOR 5.08, 95 % CI 1.72–14.99) compared to living alone; poor perception of overall health (aOR 1.64 95 % CI 1.05–2.55); being unemployed (aOR: 2.22, 95 % CI 1.16–4.23); and younger age at interview (aOR 0.57, 95 % CI 0.44–0.75, per 10 year increase). Addressing socioeconomic barriers to treatment retention is vital for supporting the continuous engagement of patients in care.     

National Study of Health Insurance Type and Reasons for Emergency Department Use

BACKGROUND

The rates of emergency department (ED) utilization vary substantially by type of health insurance, but the association between health insurance type and patient-reported reasons for seeking ED care is unknown.

OBJECTIVE

We evaluated the association between health insurance type and self-perceived acuity or access issues among individuals discharged from the ED.

DESIGN, PATIENTS

This was a cross-sectional analysis of the 2011 National Health Interview Survey. Adults whose last ED visit did not result in hospitalization (n?=?4,606) were asked structured questions about reasons for seeking ED care. We classified responses as 1) perceived need for immediate evaluation (acuity issues), or 2) barriers to accessing outpatient services (access issues).

MAIN MEASURES

We analyzed survey-weighted data using multivariable logistic regression models to test the association between health insurance type and reasons for ED visits, while adjusting for sociodemographic characteristics.

KEY RESULTS

Overall, 65.0 % (95 % CI 63.0–66.9) of adults reported ≥ 1 acuity issue and 78.9 % (95 % CI 77.3–80.5) reported ≥ 1 access issue. Among those who reported no acuity issue leading to the most recent ED visit, 84.2 % reported ≥ 1 access issue. Relative to those with private insurance, adults with Medicaid (OR 1.05; 95 % CI 0.79–1.40) and those with Medicare (OR 0.98; 95 % CI 0.66–1.47) were similarly likely to seek ED care due to an acuity issue. Adults with Medicaid (OR 1.50; 95 % CI 1.06–2.13) and Medicaid + Medicare (dual eligible) (OR 1.94; 95 % CI 1.18–3.19) were more likely than those with private insurance to seek ED care for access issues.

CONCLUSION

Variability in reasons for seeking ED care among discharged patients by health insurance type may be driven more by lack of access to alternate care, rather than by differences in patient-perceived acuity. Policymakers should focus on increasing access to alternate sites of care, particularly for Medicaid beneficiaries, as well as strategies to increase care coordination that involve ED patients and providers.     

Outcomes of HIV-Infected Patients Receiving Care at Multiple Clinics

Receiving care at multiple clinics may compromise the therapeutic patient-provider alliance and adversely affect the treatment of people living with HIV. We evaluated 12,759 HIV-infected adults in Philadelphia, PA between 2008 and 2010 to determine the effects of using multiple clinics for primary HIV care. Using generalized estimating equations with logistic regression, we examined the relationship between receiving care at multiple clinics (≥1 visit to two or more clinics during a calendar year) and two outcomes: (1) use of ART and (2) HIV viral load ≤200 copies/mL for patients on ART. Overall, 986 patients (8 %) received care at multiple clinics. The likelihood of attending multiple clinics was greater for younger patients, women, blacks, persons with public insurance, and for individuals in their first year of care. Adjusting for sociodemographic factors, patients receiving care at multiple clinics were less likely to use ART (AOR = 0.62, 95 % CI 0.55–0.71) and achieve HIV viral suppression (AOR = 0.78, 95 % CI 0.66–0.94) than individuals using one clinic. Qualitative data are needed to understand the reasons for visiting multiple clinics.     

The Role of Internalized Stigma in the Disclosure of Injecting Drug Use Among People Who Inject Drugs and Self-Report as HIV-Positive in Kohtla-Järve,Estonia

Disclosure of injecting drug use and its associations with stigma have received very little research attention. This cross-sectional study examined the role of internalized HIV and drug stigma (i.e., self-stigmatization) in the disclosure of injecting drug use among people who inject drugs (PWID) self-reporting as HIV-positive (n = 312) in Kohtla-Järve, Estonia. The internalization of both stigmas was relatively high. On average, PWID disclosed to three disclosure targets out of seven. Disclosure was highest to close friends and health care workers and lowest to employers and casual sex partners. Internalized drug stigma was negatively associated with disclosure to other family members (AOR = 0.48; 95% CI 0.30–0.77) and health care workers (AOR = 0.46; 95% CI 0.25–0.87). Internalized HIV stigma was positively associated with disclosure to health care workers (AOR = 2.26; 95% CI 1.27–4.00). No interaction effect of internalized stigmas on disclosures emerged. We concluded that effects of internalized stigmas on disclosures are few and not uniform.     

Advanced Disease, Diuretic Use, and Marital Status Predict Hospital Admissions in an Ambulatory Cirrhosis Cohort

Background and Aims

Hospital admissions in cirrhotic patients are a source of significant health care expenditure. Most studies to date have focused on readmissions in patients with decompensated cirrhosis. We sought to describe predictors of hospital admissions in an ambulatory cirrhosis cohort consisting of both compensated and decompensated patients to identify patients who could benefit from intensified outpatient chronic disease management.

Methods

We performed a retrospective cohort study of 395 cirrhotic patients followed at an academic medical center liver clinic. Inclusion criteria were documented cirrhosis and longitudinal care at our center during 2006–2008. Patients were followed until December 2011, death, or liver transplantation. The primary outcomes were non-elective cirrhosis-related hospital admissions within 1 year and time to admission. The secondary outcome was 2-year cirrhosis-related mortality. The study was approved by the Partners Human Research Committee (protocol 2012P001912).

Results

Seventy-eight patients (19.7 %) had at least one cirrhosis-related hospital admission within 1 year. The following were significant predictors in the multivariable model: model for end-stage liver disease score ≥15 [OR 2.22, 95 % CI (1.21–4.07), p = 0.01], diagnosis of hepatocellular carcinoma [3.64 (1.42–9.35), 0.007], diuretic use [2.27 (1.23–4.17), 0.008], at least one cirrhosis-related admission during the baseline year [2.17 (1.21–3.89), 0.01], and being unmarried [1.92 (1.10–3.35), 0.02].

Conclusions

Advanced disease, diuretic use, and marital status were associated with cirrhosis-related hospital admissions in patients followed at an academic medical center liver clinic. Our findings suggest that patients with inadequately or overzealously treated ascites, as well as those with limited social supports, could benefit from intensified outpatient management.     

Maternal Influences on Access to and Use of Infant ARVs and HIV Health Services in Uganda

Vertical transmission of HIV is responsible for about 14 % of new HIV cases reported each year in sub-Saharan Africa. Barriers that prevent women from accessing and using antiretroviral medications (ARVs) for themselves and their infants perpetuate the epidemic. To identify influences on access to and use of infant HIV health services, specifically nevirapine administration, we conducted a mixed methods study among HIV-positive women in Uganda. This included a cross-sectional survey (n = 384) and focus group discussions (n = 6, 5–9 participants each). Of the 384 women, 80 % gave nevirapine to their infants within 72 h of birth. Factors independently associated with nevirapine administration were lack of maternal adherence to ARVs (AOR 3.55, 95 % CI 1.36–9.26) and attending a support group (AOR 2.50, 95 % CI 1.06–5.83). Non-health facility births were inversely related to nevirapine use (AOR 0.02, 95 % CI 0.003–0.09). Focus group discussions identified four themes impacting access and use: attending a support group, health care worker attitudes, lack of partner support, and poor health messaging regarding ARVs. Improving health care worker messaging regarding ARVs and providing women with needed support to access and use infant ARV prophylaxis is critical to overcoming access barriers. Eliminating these barriers may prevent numerous HIV infections each year saving the lives of many HIV-exposed infants.     

Temporal trend of diabetes in pregnant women and its association with birth outcomes, 2011 to 2017

AimTo assess changes in the prevalence of diabetes in pregnant women, and its association with selected birth outcomes (including caesarean section, episiotomy, admission to the special care nursery/neonatal intensive care unit, postpartum haemorrhage and neonatal birth weight) from 2011 to 2017.MethodsIn a single-centre, retrospective cohort study, we examined records of pregnant women who attended an Australian tertiary hospital between 2011 and 2017, identifying women with gestational diabetes mellitus and pre-existing diabetes mellitus, and examined trends associated with diabetes and their effects on birth outcomes.ResultsThe average incidence of women with diabetes increased by 9% annually (RR = 0.09, 95% CI = 1.08–1.11), which was 6% greater in women who received antenatal doctor-led care (RR = 1.06, 95% CI = 1.01–1.13), 42% greater in women who had other endocrine diseases (including thyroid, adrenal or pituitary diseases) (RR = 1.42, 95% CI = 1.31–1.53), and 61% greater in women with hypertension during pregnancy (RR = 1.61, 95% CI = 1.47–1.78). The presence of diabetes did not affect the relative risks of caesarean section, episiotomy, postpartum haemorrhage, decreased neonatal birth weight or special care nursery/neonatal intensive care unit admission, after adjustment for demographics and health and care status and behaviours.ConclusionsThe rate of diabetes during pregnancy increased from 2011 to 2017. Diabetes did not affect the relative risk of untoward birth outcomes.     

Factors associated with time to diagnosis in early rheumatoid arthritis

Early diagnosis and treatment yield optimal outcomes in rheumatoid arthritis (RA); thus, barriers to disease recognition must be identified and addressed. We determined the impact of sociodemographic factors, medical comorbidities, family history, and disease severity at onset on the time to diagnosis in early RA. The Canadian early ArThritis CoHort study data on 1,142 early RA patients were analyzed for predictors of time to diagnosis using regression analysis. Sociodemographic factors (age, sex, income strata, education, ethnicity), measures of disease activity (joint counts, DAS28 score, acute-phase reactants, patient global evaluation, function), family history, serology, chronic musculoskeletal and mental health conditions, and obesity at diagnosis were considered. In multivariate linear regression analysis, more swollen joints (β = ?0.047 per joint, 95 % CI ?0.085, ?0.010, p = 0.014), higher erythrocyte sedimentation rate (ESR) (β = ?0.012 per 1 mm/h, 95 % CI ?0.022, ?0.002, p = 0.0018), and worse patient global scores (β = ?0.082 per 1 unit on a visual analogue scale, 95 % CI ?0.158, ?0.006, p = 0.034) at baseline predicted a shorter time to diagnosis. Anti-cyclic citrullinated peptide (anti-CCP) antibody positivity (β = 0.688, 95 % CI 0.261, 1.115, p = 0.002) and low income (annual <$20,000 β = 1.185, 95 % CI 0.227, 2.143, p = 0.015; annual $20,000–50,000 β = 0.933, 95 % CI 0.069, 1.798, p = 0.034) increased time to diagnosis. In the logistic regression models, the odds of being diagnosed within 6 months of symptom onset were increased for each swollen joint present [odds ratio (OR) 1.04, 95 % CI 1.02–1.06 per joint], each 1 mm/h elevation in the ESR (OR 1.01, 95 % CI 1.00–1.02), and decreased for patients who were either rheumatoid factor or anti-CCP positive compared to both factors being negative (OR 0.68, 95 % CI 0.51–0.91). Higher disease activity results in a more rapid diagnosis for Canadian patients with early RA, but those with lower income have delays in diagnosis. Strategies to identify patients with a less severe disease presentation and in lower socioeconomic strata are needed to ensure equal opportunity for optimal management.     

Multiple Dimensions of Stigma and Health Related Factors Among Young Black Men Who Have Sex with Men

This study is among the first to examine the association between multiple domains of HIV-related stigma and health-related correlates including viral load and medication adherence among young Black men who have sex with men (N = 92). Individual logistic regressions were done to examine the hypothesized relationships between HIV-related stigma and various health and psychosocial outcomes. In addition to examining total stigma, we also examined four domains of HIV stigma. Findings revealed the various domains of stigma had differential effects on health-related outcomes. Individuals who reported higher levels of total stigma and personalized stigma were less likely to be virally suppressed (OR 0.96, 95 % CI 0.91–1.00 and OR 0.50, 95 % CI 0.25–1.02, respectively). Concerns about public attitudes toward HIV were positively related to medication adherence (OR 2.18, 95 % CI 1.20–3.94) and psychological distress (OR 5.02, 95 % CI 1.54–16.34). The various domains of HIV stigma differentially affected health and psychosocial outcomes, and our findings suggest that some forms of HIV stigma may significantly affect viral load and medication adherence among this population. Stigma-informed approaches to care and treatment are needed, along with incorporated psychological and social supports.     

Young Transgender Women of Color: Homelessness,Poverty, Childhood Sexual Abuse and Implications for HIV Care

This study describes a sample of HIV+ young transgender women of color aged 18–24 and their experience with homelessness as part of a demonstration project of engagement and retention in HIV medical care funded by Health Resources and Services Administration. The study engaged transgender women of color in HIV care in nine sites across the US between 2012 and 2017. This analysis describes and compares transwomen who had been homeless in the last 6 months to those not homeless. We hypothesized that homelessness would compete with HIV care, food, shelter, and be associated with poverty. Variable domains included sociodemographic, mental health and substance use, HIV care, sexual risk behavior, social support from transgender and other friends, and childhood sexual abuse. There were 102 youth enrolled, 77 (75.5%) who had been homeless, and 25 (24.5%) who had not been homeless. Bivariate analyses showed that low income, sex work as source of income, inability to afford food, lack of viral load (VL) suppression, childhood sexual abuse, lower levels of social support, and higher levels of depression were associated with homelessness. A logistic regression model showed that being unable to afford food (AOR = 9.24, 95% CI 2.13–40.16), lack of VL suppression in last 6 months (AOR = 0.10, 95% CI .02–.57), and lack of transgender friend support (AOR = 0.09, 95% CI .02–.53) was associated with homelessness. Programs that place basic needs first—food and shelter—may be able to engage and assist young transgender women of color with HIV to survive and live healthier lives.