Emergency Provider Attitudes and Barriers to Universal HIV Testing in the Emergency Department

Background: The Centers for Disease Control and Prevention (CDC) recently published recommendations for routine, voluntary human immunodeficiency virus (HIV) testing of adults in all health care settings, including the emergency department (ED). Study Objective: The objective of this study was to examine the willingness of ED providers to offer HIV testing, as well as their perceived barriers to implementation of these guidelines. Methods: Before the establishment of a routine HIV testing program in the ED, a 21-item survey was used to assess ED providers' knowledge, attitudes, and perceived challenges to HIV testing. Six months after program initiation, the identical survey was re-administered to determine whether HIV testing program experience altered providers' perceptions. Results: There were 108 of 146 (74%) providers who completed both the pre- and post-implementation surveys. Although the majority of emergency providers at 6 months were supportive of an ED-based HIV testing program (59/108 [55%]), only 38% (41/108) were willing to offer the HIV test most or all of the time. At 6 months, the most frequently cited barriers to offering a test were: inadequate time (67/108 [62%]), inadequate resources (65/108 [60%]), and concerns regarding provision of follow-up care (64/108 [59%]). Conclusions: After the implementation of a large-scale HIV testing program in an ED, the majority of emergency providers were supportive of routine HIV testing. Nevertheless, 6 months after program initiation, providers were still reluctant to offer the test due to persistent barriers. Further studies are needed to identify feasible implementation strategies that minimize barriers to routine HIV testing in the ED.     

Georgia prenatal care providers' perceptions of barriers to sexually transmitted disease screening

BACKGROUND: Evidence suggests that sexually transmitted disease (STD) screening during pregnancy is not optimal. No published studies have systematically examined barriers that hinder routine STD screening. This study examines prenatal care providers' perceptions about barriers to routine STD screening of pregnant women. METHODS: Using a conceptual framework, four a priori barrier categories were developed: provider, patient, organizational, and structural. Responses to a question on barriers to STD screening in a 1998 mail survey of Georgia prenatal care providers were qualitatively classified into one of these categories. RESULTS: Of the 293 providers who responded, 71% identified structural barriers, with 52% citing inadequate reimbursement. These respondents were most likely to name barriers categorized as structural, not patient, provider, or organization issues. CONCLUSION: Efforts to improve STD screening of pregnant women should include a focus on structural level interventions, such as instituting health care policies that provide adequate reimbursement for routine STD screening during pregnancy.     

A structured interview approach to evaluate HIV training for medical care providers.

HIV/AIDS education trainings and self-reported changes in provider behavior resulting from the trainings were evaluated in a structured interview with 24 health care providers. The participants were asked to provide concrete examples of behavior changes related to eight specific areas in the provision of HIV/AIDS medical care. The structured interview process also served as an effective needs assessment of future training topics and of the modalities desired by the providers. The authors' results suggest that by carrying out a structured interview of training attendees, training programs can be more precisely evaluated, and strengths and gaps in overall HIV/AIDS provider education can be better identified and addressed.     

Coming full circle: mentorship in HIV/AIDS care.

The role of the mentor has been found to be crucial for learning, yet mentorship in HIV/AIDS nursing care has not been well documented. The purpose of this study was to (a) examine the characteristics of a nurse mentor in HIV care as perceived by nursing and medical students and HIV staff, and (b) explore an HIV nurse mentor's perceptions of her role and responsibilities in the professional development of students and staff. Mentorship, as a process of "coming full circle," was highlighted by the mentor's accounts of early influences in her career as well as students' and staff members' intents to facilitate the professional development of the next generation. The legacy of excellent HIV nursing care can be continued if expert HIV nurse mentors are identified and encouraged to work with students, inexperienced nurses, and health care providers. Health care institutions have a responsibility to foster mentorship in HIV/AIDS care to assure quality health care for clients and the professional development of expert nurses in HIV/AIDS care.     

Cultural competence and health care: Japanese, Korean, and Indian patients in the United States

Cultural competence requires sensitivity to the diverse ethnic, religious, and cultural expectations of patients in our health care system. In the increasingly multicultural world of the city hospital, patients will benefit from increased cultural competency on the part of health care providers. This study interviews Japanese, Korean, and Indian immigrants to the United States, showing that these individuals hold vastly different expectations concerning: 1) when to seek medical assistance; 2) the role of the doctor in the community; 3) the role of the patient and the patient's family in conversations with the medical specialist; 4) the roles of doctors versus nurses; 5) issues of privacy and disclosure to patient and family; 6) organ donation; and 7) end-of-life care. The paper concludes with immigrants' views on what would make their medical experience in the United States more comfortable, and hence, potentially more beneficial to their mental and physical health.     

Assessment of palliative care needs for people living with HIV/AIDS in Rwanda

Abstract

The rising number of people living with HIV/AIDS (PLWHA) world-wide has made healthcare professionals and policy makers search for accessible healthcare that will meet the needs of people who are suffering from the disease and enhance their quality of life (QoL). This study investigated met and unmet palliative care needs of PLWHA in selected areas in Rwanda. The study sample included 306 participants: PLWHA, healthcare professionals and co-ordinators of HIV/AIDS units. Quantitative and qualitative methodologies were used. The data were analysed separately and then triangulated. In the findings, over 50% of PLWHA had symptoms related to HIV/AIDS most of the time, with the most common symptom being pain. Participation in activities of daily living was associated with the health status of PLWHA (P < 0.001). The most common perceived palliative care needs of PLWHA were: (i) medical needs, psychosocial needs and the need for financial assistance (77%); (ii) home-based care (47%); (iii) nutritional support (44%); and (iv) pain relief and management of other symptoms (43%). Most PLWHA indicated these palliative care needs were unmet, in particular, the need for pain relief, symptom management, financial assistance and nutritional support. Over 50% of healthcare professionals reported they were not trained in palliative care. They indicated that inadequate policy and resources were the main obstacles to the provision of optimal palliative care. Addressing unmet palliative care needs would enhance the QoL of PLWHA. In addition, developing policy related to the provision of palliative care and building the capacity of healthcare providers is essential for the provision of adequate palliative care services in Rwanda.     

Pharmaceutical care for HIV patients on directly observed therapy

BACKGROUND: Inner-city patients infected with HIV can be a challenging group to treat. Homelessness, mental illness, substance abuse, and hepatitis C infection may serve as barriers to effective treatment. A multidisciplinary team including the pharmacist can impact upon the delivery of care to the inner-city HIV patient population. OBJECTIVE: To describe the implementation and provision of pharmaceutical care to inner-city patients taking directly observed therapy (DOT), as well as drug-related problems (DRPs) and their respective outcomes. METHODS: Pharmaceutical care, including the prospective identification and management of DRPs, was provided by a clinical pharmacist. RESULTS: Fifty-seven patients were followed over a 14-month period. Overall, 149 DRPs were identified and >95% were resolved. Those included (1) adverse effects (n = 56; gastrointestinal, central nervous system effects, allergies, laboratory abnormalities), (2) drug interactions (n = 32), (3) drugs indicated for comorbidities (n = 24; safety in pregnancy, tuberculosis, Pneumocystis carinii pneumonia prophylaxis, oral candidiasis, herpes zoster, nutritional supplements), (4) adherence issues (n = 20; altering timing of medication, changing formulation, decreasing pill burden), (5) drugs no longer indicated (n = 10; opportunistic infection prophylaxis, treatment of primary infection), and (6) dosage adjustment (n = 7) for weight and renal insufficiency. CONCLUSIONS: In the provision of pharmaceutical care to HIV-infected patients on DOT, an HIV pharmacist significantly contributed to antiretroviral selection, monitoring of drug therapy, and managing DRPs. An HIV pharmacist can assist in promoting patient adherence and improved outcomes in this setting.     

Older adults and HIV and STI screening: the patient perspective

To explore patient provider interactions regarding human immunodeficiency virus (HIV) and sexually transmitted infection (STI) screening of older adults in Connecticut through a focus group approach. Older adults were defined as individuals over 64 years old. Two focus groups convened. The data analysis revealed that the majority of participants had not been screened for HIV or STIs and had not talked with their health care providers about sexual health in recent years. The lack of conversation about sexual health and sexual health screening was the major barrier to sexual health screening. Instigation of the conversation of sexual health and a positive relationship with the health care provider were suggested to overcome these barriers. Health care providers have an important role in initiating conversation about and screening patients for STIs, including HIV. The media, specifically television, was identified as a potential avenue for successful health education.     

Jail Transitions and Rural Communities: Implications for Practice and Policy

Individuals who experience mental illness and are transitioning from jail into rural communities have high rates of health disparities and face unique challenges when attempting to access health care, which is further complicated in the context of rurality. Continuation of justice system requirements often presents further barriers, including lack of continuity between health care providers, lack of bridge medications from jail to community, transportation barriers, and competing requirements between justice system obligations and health care system needs. Health care providers can identify barriers within these patient populations; yet, interventions are limited when unidirectional. Advocacy for policy change is needed.     

Barriers to Culturally Competent Human Immunodeficiency Virus Care Among the Black,Indigenous, and People of Color Community

Black, Indigenous, and people of color (BIPOC) are at a higher risk for human immunodeficiency virus (HIV) infection and face unique challenges in the United States health care system. Health care providers can understand the barriers to care for at-risk groups and identify interventions to improve health outcomes. Demographic, social, and economic factors all play a role in the health disparities regarding the HIV infection rate in these at-risk populations. There are many challenges in establishing early diagnosis of HIV infection and linking newly diagnosed people living with HIV (PLWH) to evidence-based care. Systemic barriers include a lack of access to testing resources, a lack of primary care provider training in HIV testing and counseling, and a delay of linkage to care of newly diagnosed PLWH to treatment. Delayed initiation of HIV treatment can increase morbidity and mortality and perpetuate HIV transmission. Consistent use of pre-exposure prophylaxis (PrEP) has proven to decrease the incidence of HIV transmission while maintaining a low side effect profile; however, PrEP usage among the BIPOC population is low, increasing the risk of HIV seroconversion. Increased testing, PrEP utilization, and linkage to care for PLWH promote viral suppression, reducing HIV transmission. Specific population-based interventions for prevention, testing, and treatment can encourage providers to empower patients to seek and remain in care. By decreasing racial disparities in the delivery of care, providers can help achieve viral suppression, improving the overall health outcomes among BIPOC communities.     

Promoting healthy behaviors in HIV primary care

Recent treatment advances have prolonged the life expectancy of persons with human immunodeficiency virus (HIV). HIV care providers must now promote healthy behaviors, such as smoking cessation, exercise, and screening for general medical problems, such as diabetes and hyperlipidemia. This report describes recently published evidence and recommendations for providing HIV primary care.     

An overview of patients' preference for, and satisfaction with, care provided by general practitioners and nurse practitioners

Aim and objectives. To assess patients’ views on the care provided by nurse practitioners compared with that provided by general practitioners and to determine factors influencing these views. Background. Many countries have sought to shift aspects of primary care provision from doctors to nurses. It is unclear how patients view these skill mix changes. Design. Cross‐sectional survey. Method. Patients (n = 235) who received care from both nurse and doctor were sent a self‐administered questionnaire. The main outcome measures were patient preferences, satisfaction with the nurses and doctors and factors influencing patients’ preference and satisfaction. Results. Patients preferred the doctor for medical aspects of care, whereas for educational and routine aspects of care half of the patients preferred the nurse or had no preference for either the nurse or doctor. Patients were generally very satisfied with both nurse and doctor. Patients were significantly more satisfied with the nurse for those aspects of care related to the support provided to patients and families and to the time made available to patients. However, variations in preference and satisfaction were mostly attributable to variation in individual patient characteristics, not doctor, nurse or practice characteristics. Conclusion. Patient preference for nurse or doctor and patient satisfaction both vary with the type of care required and reflect usual work demarcations between nurses and doctors. In general, patients are very satisfied with the care they receive. Relevance to clinical practice. In many countries, different aspects of primary care provision have shifted from doctors to nurses. Our study suggests that these skill mix changes meet the needs of patients and that patients are very satisfied with the care they receive. However, to implement skill mix change in general practice it is important to consider usual work demarcations between nurses and doctors.     

Enroling and retaining human immunodeficiency virus (HIV) patients in their care: A metasynthesis of qualitative studies

ObjectivesTo report the findings of a metasynthesis review of qualitative studies on patient and provider experiences and perspectives on linkage and retention in HIV care.DesignThe review is an extraction, aggregation, interpretation and synthesis of qualitative findings based on the Sandelowski and Barroso method.Data sourcesA search of the literature was conducted in the databases Cumulative Index to Nursing and Allied Health, PubMed and PsycInfo for articles published from 2008 to 2013. Inclusion criteria were qualitative research articles published in English from across the world and in peer-reviewed journals. Literature reviews, conference abstracts and grey literature were excluded from this metasynthesis.Review methodsThe review consisted of a) comprehensive search, b) study classification, c) abstraction of findings, d) synthesis. Of the 4640 citations screened, 69 articles were included for this metasynthesis.Results69 unique articles from 44 countries were included. This metasynthesis takes into account the perspectives of at least 2263 HIV-positive participants (740 men, 1008 women, 78 transgender individuals and 437 unspecified sex) and 994 healthcare providers, family members and community members. The most salient barriers and facilitators to HIV linkage and retention in HIV care affirm ecological factors that are mostly beyond individual patients’ control. Triadic streams of influence concurrently affect care engagement that include a person’s psychological state upon diagnosis and their informational challenges (intrapersonal stream); one-on-one interactions with providers and their immediate community (social stream); and life demands, overall quality of care experiences and other structural barriers (cultural-attitudinal stream). Each stream’s influence on HIV care engagement varies at any given point to reflect an individual’s evolving and unique experiences with HIV infection throughout the illness trajectory.ConclusionThere is sufficient evidence that detail how to best link and retain patients in HIV care. Themes identified indicate going beyond individual-level factors and towards shifting attention and resources to systems that patients navigate. Forceful structural-level actions are needed to correct these long-identified barriers and enhance care engagement facilitators.     

Access and equity in HIV/AIDS palliative care: a review of the evidence and responses

The high prevalence of pain and other symptoms throughout the HIV disease trajectory, the need for management of side effects related to antiretroviral therapy, the continuing incidence of cancers and new emerging co-morbidities as a result of extended life expectancy under new therapeutic regimes, and the ongoing need for terminal care all prove the curative versus palliative dichotomy to be inappropriate. Although there is evidence for both need and effectiveness of palliative care in HIV patient care, access is often poor and care less than optimal. This review aimed to identify evidence of barriers and inequalities in HIV palliative care in order to inform policy and service development. Biomedical databases were searched using a specific strategy, and evidence extracted into the barrier and inequity categories of patient, clinician, service and disease factors. A model of the barriers and inequalities is presented from the evidence. Recommendations are made from the evidence for promoting access and outcomes through integrated palliative care from diagnosis to end-of-life, alongside antiretroviral therapy when initiated. Service responses that have attempted to increase access to palliative care are presented.     

Primary care intervention and management for adults with early HIV infection.

Recent clinical drug trials have demonstrated that early intervention with zidovudine will delay disease progression in asymptomatic or minimally symptomatic HIV-infected individuals. These trials will encourage larger numbers of seropositive persons to seek access to primary care, overloading specialized clinics for AIDS and HIV care. The care of early HIV-infected individuals will need to be delivered by mainstream primary care providers. This article discusses the initiation and management of zidovudine, and chemoprophylaxis against Pneumocystis carinii pneumonia in early HIV infection.     

Ancillary services for individuals living with HIV/AIDS

Providing comprehensive care to those living with HIV/AIDS remains a daunting task. Access to early HIV medical care helps to delay an AIDS diagnosis, and ancillary services can help meet the non-medical needs of HIV-positive individuals, which can ultimately impact their ability to access medical care. Some research has been done measuring ancillary service provision and primary care entry and retention; however, due to the lack of a comprehensive system of care, it has been difficult to determine the true impact of ancillary service usage and health outcomes. Additional qualitative research examining ancillary service usage, health outcomes, and quality of life needs to be done to develop a standard model of appropriate and comprehensive HIV care.     

Nurse practitioner, nurse midwife and physician assistant attitudes and care practices related to persons with HIV/AIDS

Although multiple studies of nurses' attitudes toward people living with HIV/AIDS (PLWAs) can be found in the literature, little is known about the attitudes, beliefs and practices of nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs). A survey including a 21-item AIDS Attitude Scale measuring the constructs of Avoidance and Empathy was sent to 1,291 NPs, CNMs and PAs in Louisiana, Arkansas and Mississippi to describe their attitudes and care practices related to PLWAs. Respondents who were more comfortable treating PLWAs had significantly lower avoidance scores and significantly higher empathy scores than respondents with lower comfort levels in providing care. Greater than 80% of respondents indicated that they would provide health care to HIV-infected individuals. Respondents who referred HIV/AIDS patients for all care did so primarily due to lack of experience with HIV and the availability of more experienced providers. Avoidance and empathy scores were not found to be significantly associated with referral for care. This study suggests that this group of providers has relatively low avoidance and high empathy toward PLWAs and is willing to care for HIV-infected individuals.     

Beyond the end of exceptionalism: integrating HIV testing into routine medical care and HIV prevention

In September 2006, the US CDC issued new guidelines for HIV testing. These guidelines were designed not only to simplify and expand HIV testing but also to integrate testing into routine medical care in the USA. The nationwide implementation of these guidelines is currently facing several political and legal barriers. In this article, we examine the origins of current patient-driven and risk-based HIV testing in the USA and highlight shortcomings of this strategy. We then demonstrate how the changing HIV epidemic in the USA requires routine HIV screening at all points of contact in the medical system in order to control the HIV epidemic and how novel testing strategies could increase the yield of testing in these settings.