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Villegas AC, Saylor D, Kvalsund M, Atadzhanov M, Chiluba C, Chishimba L, Zimba S, Chomba M, Siddiqi OK. Task-shifting to optimize outpatient neurological care in Zambia. HUMAN RESOURCES FOR HEALTH 2021; 19:88. [PMID: 34271924 PMCID: PMC8283831 DOI: 10.1186/s12960-021-00619-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 06/10/2021] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To investigate opportunities for task shifting to decongest an outpatient neurology clinic in Zambia by describing current patient flow through the clinic and potential nodes for intervention using process mapping. BACKGROUND Zambia has a population of approximately 18 million people with 4 full-time adult neurologists, as of 2018, who all practice at the University Teaching Hospital (UTH), the main tertiary care center in the country. As a result of this provider-to-patient ratio, the outpatient neurology clinic is overcrowded and overbooked. Task-shifting programs have shown to improve efficiency, access and quality of care through the use of less specialized healthcare workers in low- and middle-income countries (LMIC). METHODS We evaluated patient flow in the UTH neurology outpatient clinic through the development and analysis of a process map. The characteristics of the clinic population between 2014 and 2018 were retrospectively reviewed from the clinic register. Between July and August 2018, we prospectively collected appointment lag times and time each patient spent waiting at various points in the clinic process. We conducted interviews with clinic staff and neurologists to generate a detailed process map of current pathways to care within the clinic. We then devised task-shifting strategies to help reduce patient wait times based on the overview of clinic process mapping and patient demographics. RESULTS From 2014 to 2018, there were 4701 outpatients seen in the neurology clinic. The most common neurological diagnoses were epilepsy (39.2%), headache (21.5%) and cerebrovascular disease (16.7%). During prospective data collection, patients waited an average of 57.8 (SD 73.4) days to be seen by a neurologist. The average wait time from arrival in the clinic to departure was 4.0 (SD 2.5) h. The process map and interviews with clinic staff revealed long waiting times due to a paucity of providers. Nurses and clerks represent an influential stakeholder group, but are not actively involved in any activity to reduce wait times. A large proportion of follow-up patients were stable and seen solely to obtain medication refills. CONCLUSIONS Epilepsy, headache, and stroke make up the largest percentage of outpatient neurological illness in Zambia. Targeting stable patients in these diagnostic categories for a task-shifting intervention may lead to substantially decreased patient wait times. Potential interventions include shifting clinical follow-ups and medication refills to less specialized healthcare workers.
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Affiliation(s)
- Ana C Villegas
- School of Public Health, Boston University, Boston, MA, USA
| | - Deanna Saylor
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michelle Kvalsund
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
- International Neurologic & Psychiatric Epidemiology Program, Department of Neurology & Ophthalmology, Michigan State University, East Lansing, MI, USA
| | - Masharip Atadzhanov
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | - Clarence Chiluba
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | - Lorraine Chishimba
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | - Stanley Zimba
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | - Mashina Chomba
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | - Omar K Siddiqi
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia.
- Global Neurology Program, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA.
- Center for Virology and Vaccine Research, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Bensley KM, Fortney J, Chan G, Dombrowski JC, Ornelas I, Rubinsky AD, Lapham GT, Glass JE, Williams EC. Differences in Receipt of Alcohol-Related Care Across Rurality Among VA Patients Living With HIV With Unhealthy Alcohol Use. J Rural Health 2019; 35:341-353. [PMID: 30703856 PMCID: PMC6639081 DOI: 10.1111/jrh.12345] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE It is unknown whether receipt of evidence-based alcohol-related care varies by rurality among people living with HIV (PLWH) with unhealthy alcohol use-a population for whom such care is particularly important. METHODS All positive screens for unhealthy alcohol use (AUDIT-C ≥ 5) among PLWH were identified using Veterans Health Administration electronic health record data (10/1/09-5/30/13). Three domains of alcohol-related care were assessed: brief intervention (BI) within 14 days, and specialty addictions treatment or alcohol use disorder (AUD) medications (filled prescription for naltrexone, disulfiram, acamprosate, or topiramate) within 1 year of positive screen. Adjusted Poisson models and recycled predictions were used to estimate predicted prevalence of outcomes across rurality (urban, large rural, small rural), clustered on facility. Secondary analyses assessed outcomes in the subsample with documented AUD. FINDINGS 4,581 positive screens representing 3,458 PLWH (3,112 urban, 130 large rural, and 216 small rural) were included; 49.1% had diagnosed AUD. PLWH in large rural areas had highest receipt of BI (urban 56.6%, 95% CI: 55.0-58.2; large rural 66.0%, CI: 58.6-73.5; small rural 60.7%, CI: 54.6-67.0). PLWH in urban areas had highest receipt of specialty addictions treatment (urban 28.2%, CI: 26.7-29.8; large rural 19.7%, CI: 13.1-26.2; small rural 19.6%, CI: 14.1-25.0). There was no difference in receipt of AUD medications, although overall receipt was low (3%-4%). Results were similar in the subsample with AUD. CONCLUSION Among PLWH with unhealthy alcohol use, those in rural areas may be vulnerable to under-receipt of specialty addictions treatment. Targeted interventions may help ensure PLWH receive recommended care regardless of rurality.
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Affiliation(s)
- Kara M Bensley
- VA Health Services Research & Development, Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
- Alcohol Research Group, Public Health Institute, Emeryville, California
| | - John Fortney
- VA Health Services Research & Development, Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington
| | - Gary Chan
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington
| | - Julia C Dombrowski
- Department of Medicine and Allergy & Infectious Diseases, University of Washington School of Medicine, Seattle, Washington
| | - India Ornelas
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | - Anna D Rubinsky
- Kidney Health Research Collaborative, University of California San Francisco, and VA San Francisco Healthcare System, San Francisco, California
| | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Emily C Williams
- VA Health Services Research & Development, Denver Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
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3
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Bensley KM, McGinnis KA, Fortney J, Chan KCG, Dombrowski JC, Ornelas I, Edelman EJ, Goulet JL, Satre DD, Justice AC, Fiellin DA, Williams EC. Patterns of Alcohol Use Among Patients Living With HIV in Urban, Large Rural, and Small Rural Areas. J Rural Health 2018; 35:330-340. [PMID: 30339740 DOI: 10.1111/jrh.12326] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND For people living with HIV (PLWH), alcohol use is harmful and may be influenced by unique challenges faced by PLWH living in rural areas. We describe patterns of alcohol use across rurality among PLWH. METHODS Veterans Aging Cohort Study electronic health record data were used to identify patients with HIV (ICD-9 codes for HIV or AIDS) who completed AUDIT-C alcohol screening between February 1, 2008, and September 30, 2014. Regression models estimated and compared 4 alcohol use outcomes (any use [AUDIT-C > 0] and alcohol use disorder [AUD; ICD-9 codes for abuse or dependence] diagnoses among all PLWH, and AUDIT-C risk categories: lower- [1-3 men/1-2 women], moderate- [4-5 men/3-5 women], higher- 6-7]), and severe-risk [8-12], and heavy episodic drinking (HED; ≥1 past-year occasion) among PLWH reporting use) across rurality (urban, large rural, small rural) and census-defined region. FINDINGS Among 32,699 PLWH (29,540 urban, 1,301 large rural, and 1,828 small rural), both any alcohol use and AUD were highest in urban areas, although this varied across region. Predicted prevalence of any alcohol use was 54.1% (53.5%-54.7%) in urban, 49.6% (46.9%-52.3%) in large rural, and 50.6% (48.3%-52.9%) in small rural areas (P < .01). Predicted prevalence of AUD was 14.4% (14.0%-14.8%) in urban, 11.8% (10.0%-13.5%) in large rural, and 12.3% (10.8%-13.8%) in small rural areas (P < .01). Approximately 12% and 25% had higher- or severe-risk drinking and HED, respectively, but neither differed across rurality. CONCLUSION Though some variation across rurality and region was observed, alcohol-related interventions are needed for PLWH across all geographic locations.
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Affiliation(s)
- Kara M Bensley
- VA Health Services Research & Development, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington.,University of Washington School of Public Health, Department of Health Services, Seattle, Washington.,Alcohol Research Group, Public Health Institute, Emeryville, California
| | | | - John Fortney
- VA Health Services Research & Development, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington.,University of Washington School of Public Health, Department of Health Services, Seattle, Washington.,University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences, Seattle, Washington
| | - K C Gary Chan
- University of Washington School of Public Health, Department of Health Services, Seattle, Washington.,University of Washington School of Public Health, Department of Biostatistics, Seattle, Washington
| | - Julia C Dombrowski
- University of Washington School of Medicine, Department of Medicine and Allergy & Infectious Diseases, Seattle, Washington
| | - India Ornelas
- University of Washington School of Public Health, Department of Health Services, Seattle, Washington
| | - E Jennifer Edelman
- Yale University School of Medicine, New Haven, Connecticut.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
| | - Joseph L Goulet
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - Derek D Satre
- University of California, Department of Psychiatry, San Francisco, California.,Kaiser Permanente Northern California, Division of Research, Oakland, California
| | - Amy C Justice
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - David A Fiellin
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
| | - Emily C Williams
- VA Health Services Research & Development, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington.,University of Washington School of Public Health, Department of Health Services, Seattle, Washington
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4
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Margusino-Framiñán L, Cid-Silva P, Castro-Iglesias Á, Mena-de-Cea Á, Rodríguez-Osorio I, Pernas-Souto B, Vázquez-Rodríguez P, López-Calvo S, Martín-Herranz I. Teleconsultation for the Pharmaceutical Care of HIV Outpatients in Receipt of Home Antiretrovirals Delivery: Clinical, Economic, and Patient-Perceived Quality Analysis. Telemed J E Health 2018; 25:399-406. [PMID: 30036159 DOI: 10.1089/tmj.2018.0041] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background/Introduction: Pharmacist teleconsultations, combined with home drug delivery or mail-order pharmacy (MOP), can help hospital outpatients with difficulties accessing treatment. The objectives of this study are to describe a teleconsultation protocol and to evaluate clinical, economic, and patient-perceived quality results. Materials and Methods: A cohort observational study was carried out for 3 years on HIV outpatients. Clinical variables were adherence, plasma HIV-RNA, and CD4+ levels. A pharmacoeconomic analysis was carried out through a cost-minimization study. Patient-perceived quality was assessed through a satisfaction survey. Simple random sampling was performed for 95% safety, accuracy ±1%, and losses ±20%. Results: The 38 participants (sample size) consisted of 82% male patients, aged 44.7 ± 8.4 years. There were 854 teleconsultations and 100% treatment adherence. All HIV outpatients kept virally suppressed (p = 1.00) and maintained a controlled immunological level (p = 0.87). The economic evaluation revealed 137 ± 23 € patient/year costs-saved and 18.5 ± 7.2 h/patient/year working time gained. Patient-perceived quality average score was >9.4 out of 10 in all items; the most valued factors were the saving of direct costs and reconciliation with work commitments (45%) and the least valued attributes were making the payment for the shipment and having to adjust to a telephone appointment (41%). Discussion/Conclusions: A teleconsultation protocol associated with home antiretrovirals delivery or MOP obtains a high degree of satisfaction from the HIV hospital outpatients receiving treatment, without repercussions on the therapeutic objectives and with the saving of important direct costs for the patient and indirect costs in relation to labor productivity.
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Affiliation(s)
- Luis Margusino-Framiñán
- 1 Pharmacy Service, A Coruña University Hospital, A Coruña, Spain.,2 Division of Clinical Virology, A Coruña Biomedical Research Institute (INIBIC), A Coruña University Hospital, SERGAS, A Coruña University (UDC), A Coruña, Spain
| | - Purificación Cid-Silva
- 1 Pharmacy Service, A Coruña University Hospital, A Coruña, Spain.,2 Division of Clinical Virology, A Coruña Biomedical Research Institute (INIBIC), A Coruña University Hospital, SERGAS, A Coruña University (UDC), A Coruña, Spain
| | - Ángeles Castro-Iglesias
- 2 Division of Clinical Virology, A Coruña Biomedical Research Institute (INIBIC), A Coruña University Hospital, SERGAS, A Coruña University (UDC), A Coruña, Spain.,3 Infectious Diseases Unit, Internal Medicine Service, A Coruña University Hospital, A Coruña, Spain
| | - Álvaro Mena-de-Cea
- 2 Division of Clinical Virology, A Coruña Biomedical Research Institute (INIBIC), A Coruña University Hospital, SERGAS, A Coruña University (UDC), A Coruña, Spain.,3 Infectious Diseases Unit, Internal Medicine Service, A Coruña University Hospital, A Coruña, Spain
| | - Iria Rodríguez-Osorio
- 2 Division of Clinical Virology, A Coruña Biomedical Research Institute (INIBIC), A Coruña University Hospital, SERGAS, A Coruña University (UDC), A Coruña, Spain.,3 Infectious Diseases Unit, Internal Medicine Service, A Coruña University Hospital, A Coruña, Spain
| | - Berta Pernas-Souto
- 2 Division of Clinical Virology, A Coruña Biomedical Research Institute (INIBIC), A Coruña University Hospital, SERGAS, A Coruña University (UDC), A Coruña, Spain.,3 Infectious Diseases Unit, Internal Medicine Service, A Coruña University Hospital, A Coruña, Spain
| | - Pilar Vázquez-Rodríguez
- 2 Division of Clinical Virology, A Coruña Biomedical Research Institute (INIBIC), A Coruña University Hospital, SERGAS, A Coruña University (UDC), A Coruña, Spain.,3 Infectious Diseases Unit, Internal Medicine Service, A Coruña University Hospital, A Coruña, Spain
| | - Soledad López-Calvo
- 2 Division of Clinical Virology, A Coruña Biomedical Research Institute (INIBIC), A Coruña University Hospital, SERGAS, A Coruña University (UDC), A Coruña, Spain.,3 Infectious Diseases Unit, Internal Medicine Service, A Coruña University Hospital, A Coruña, Spain
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5
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Anoje C, Agu KA, Oladele EA, Badru T, Adedokun O, Oqua D, Khamofu H, Adebayo O, Torpey K, Chabikuli ON. Adherence to On-Time ART Drug Pick-Up and Its Association with CD4 Changes and Clinical Outcomes Amongst HIV Infected Adults on First-Line Antiretroviral Therapy in Nigerian Hospitals. AIDS Behav 2017; 21:386-392. [PMID: 27388161 DOI: 10.1007/s10461-016-1473-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Medication adherence is a major determinant of antiretroviral treatment (ART) success. Promptness in medication refill pick-ups may give an indication of medication adherence. This study determined medication refill adherence among HIV positive patients on ART and its association with treatment outcomes in HIV treatment centers in Nigeria. This retrospective multi-center cohort study involved a review of ART refill records for 3534 HIV-positive patients aged 18-60 years who initiated first-line ART between January 2008 and December 2009 and were on therapy for ≥18 months after ART initiation. Drug refill records of these patients for 10 consecutive refill visits after ART initiation were analyzed. The first ten consecutive refill appointment-keeping rates after ART initiation ranged from 64.3 % to 76.1 % which decreased with successive visits. Altogether, 743 (21.1 %) patients were deemed adherent, meaning they picked up their drugs within 7 days of the drug refill appointment date on at least nine out of ten refill visits. The adherent group of patients had a mean CD4 cells increase of 206 ± 6.1 cells/dl after 12 months of ART compared to 186 ± 7.1 cells/dl reported among the nonadherent group (p = 0.0145). The proportion of patients in the adherent category who showed no OIs after 12 months on ART (81 %) was significantly higher when compared to the proportion in the non-adherent category (23.5 %), (p = 0.008). The multivariate analysis showed that the odds of being adherent was 2-3 times more in patients who had a baseline CD4 count of less than 200 cells/dl compared to those with a baseline CD4 of >350 cells/dl. (AOR 2.43, 95 % CI 1.62-3.66). In addition, for patients with baseline CD4 cell count of 201-350 cells/dl, the odds of being adherent was found to be 1.9 compared to those with baseline CD4 of greater than 350 cells/dl (AOR 1.93, 95 % CI 1.27-2.94). Pharmacy refill data can serve as an adherence measure. Adherence to on-time drug pickup on ≥90 % of refill appointments was associated with a better CD4 count response and a reduction in the presence of opportunistic infections in ART patients after 12 months of treatment.
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Affiliation(s)
- Chukwuemeka Anoje
- FHI 360, Plot 1073 J.S Tarka Street, Area 3 Garki Abuja, Abuja, Nigeria.
| | - Kenneth Anene Agu
- Howard University Pharmacists and Continuing Education Center, Abuja, Nigeria
| | - Edward A Oladele
- FHI 360, Plot 1073 J.S Tarka Street, Area 3 Garki Abuja, Abuja, Nigeria
| | - Titilope Badru
- FHI 360, Plot 1073 J.S Tarka Street, Area 3 Garki Abuja, Abuja, Nigeria
| | | | - Dorothy Oqua
- Howard University Pharmacists and Continuing Education Center, Abuja, Nigeria
| | - Hadiza Khamofu
- FHI 360, Plot 1073 J.S Tarka Street, Area 3 Garki Abuja, Abuja, Nigeria
| | - Olufunso Adebayo
- FHI 360, Plot 1073 J.S Tarka Street, Area 3 Garki Abuja, Abuja, Nigeria
| | - Kwasi Torpey
- FHI 360, Plot 1073 J.S Tarka Street, Area 3 Garki Abuja, Abuja, Nigeria
| | - Otto Nzapfurundi Chabikuli
- Department of Family Medicine, Medical University of Southern Africa, Pretoria, South Africa
- FHI 360 South Africa, Hatfield, Pretoria, South Africa
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6
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Malhotra A, Whitley-Williams PN, Gaur S, Petrova A. Treatment Response in Association with Adherence Patterns to Highly Active Antiretroviral Therapy in Pediatric Patients with Perinatally Acquired HIV Infection. ACTA ACUST UNITED AC 2014; 13:461-5. [DOI: 10.1177/2325957414521498] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background: Assessment of longitudinal adherence patterns on virologic and immunologic responses to HAART in perinatally acquired HIV patients has not been studied. Methods: Perinatally infected pediatric HIV patients with adherence documented at least twice and corresponding viral load and T-cell (%) data measured during 2008-2009 were studied. Multiple adherence measures were utilized to identify patients with persistent adherence, nonadherence, or alteration of adherence. Virologic and immunologic outcomes were assessed. Results: Persistent adherence, nonadherence, and alteration of adherence to HAART were recorded in 41.9%, 8.1%, and 50.0% of 62 studied patients. Persistent adherence was associated with higher likelihood for persistent virologic suppression and lower risk for persistent virologic failure. Conclusion: Alteration of adherence to HAART is a significant predictor of persistent virologic failure and high viremia in perinatally infected HIV patients. Implementation of longitudinal adherence assessments may target patients with nonsustained adherence patterns and help decrease the risk for virologic failure and disease progression.
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Affiliation(s)
- Amisha Malhotra
- Department of Pediatrics, Division of Infectious Disease, Rutgers University–Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Patricia N. Whitley-Williams
- Department of Pediatrics, Division of Infectious Disease, Rutgers University–Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Sunanda Gaur
- Department of Pediatrics, Division of Infectious Disease, Rutgers University–Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Anna Petrova
- Department of Pediatrics, Division of Infectious Disease, Rutgers University–Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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7
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Evans D, Menezes C, Mahomed K, Macdonald P, Untiedt S, Levin L, Jaffray I, Bhana N, Firnhaber C, Maskew M. Treatment outcomes of HIV-infected adolescents attending public-sector HIV clinics across Gauteng and Mpumalanga, South Africa. AIDS Res Hum Retroviruses 2013; 29:892-900. [PMID: 23373540 DOI: 10.1089/aid.2012.0215] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
There is little evidence comparing treatment outcomes between adolescents and other age groups, particularly in resource-limited settings. A retrospective analysis of data from seven HIV clinics across urban Gauteng (n=5) and rural Mpumalanga (n=2), South Africa was conducted. The analysis compared HIV-positive antiretroviral treatment (ART)-naive young adolescents (10-14 years), older adolescents (15-19), and young adults (20-24 years) to adults (≥25 years) initiated onto standard first-line ART between April 2004 and August 2010. Log-binomial regression was used to estimate relative risk (RR) of failure to suppress viral load (≥400 copies/ml) or failure to achieve an adequate CD4 response at 6 or 12 months. The effect of age group on virological failure, mortality, and loss to follow-up (LTFU; ≥90 days since scheduled visit date) was estimated using Cox proportional hazards models. Of 42,427 patients initiating ART, 310 (0.7%) were young adolescents, 342 (0.8%) were older adolescents, and 1599 (3.8%) were young adults. Adolescents were similar to adults in terms of proportion male, baseline CD4 count, hemoglobin, and TB. Compared to adults, both older adolescents (6 months RR 1.75 95% CI 1.25-2.47) and young adults (6 months RR 1.33 95% CI 1.10-1.60 and 12 months RR 1.64 95% CI 1.23-2.19) were more likely to have an unsuppressed viral load and were more likely to fail virologically (HR 2.90 95% CI 1.74-4.86; HR 2.94 95% CI 1.63-5.31). Among those that died or were LTFU, the median time from ART initiation until death or LTFU was 4.7 months (IQR 1.5-13.2) and 10.9 months (IQR 5.0-22.7), respectively. There was no difference in risk of mortality by age category, compared to adults. Young adolescents were less likely to be LTFU at any time period after ART initiation (HR 0.43 95% CI 0.26-0.69) whereas older adolescents and young adults were more likely to be LTFU after ART initiation (HR 1.78 95% CI 1.34-2.36; HR 1.63 95% CI 1.41-1.89) compared to adults. HIV-infected adolescents and young adults between 15 and 24 years have poorer ART treatment outcomes in terms of virological response, LTFU, and virological failure than adults receiving ART. Interventions are needed to help improve outcomes and retention in care in this unique population.
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Affiliation(s)
- Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Colin Menezes
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Leon Levin
- Right to Care, Johannesburg, South Africa
| | | | | | - Cindy Firnhaber
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Right to Care, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
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8
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Antiretroviral adherence among rural compared to urban veterans with HIV infection in the United States. AIDS Behav 2013; 17:174-80. [PMID: 23080359 DOI: 10.1007/s10461-012-0325-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Rural-dwelling persons with HIV infection face barriers to maintaining high levels of antiretroviral adherence. We compared adherence among 1,782 rural and 18,519 urban veterans initiating antiretroviral therapy in the Veterans Affairs (VA) healthcare system in the United States between 1998 and 2007. Residence was determined using rural urban commuting area codes and adherence using pharmacy-based refill measures. The median proportion of days covered (PDC) by combination antiretroviral therapy in the first year of treatment ranged from 0.72 among urban residents to 0.79 among rural-small town/remote residents (p < 0.0001). In multivariable logistic regression, predictors of high adherence (PDC greater than 0.90) were residence in a rural-small town/remote setting (odds ratio 1.24, 95 % CI 1.09-1.56, relative to urban), increasing age, white race, absence of an alcohol or substance use disorder, and absence of hepatitis C infection. Results may differ outside VA healthcare, where there may be fewer resources to support adherence among rural-dwelling persons with HIV.
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9
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Saberi P, Dong BJ, Johnson MO, Greenblatt RM, Cocohoba JM. The impact of HIV clinical pharmacists on HIV treatment outcomes: a systematic review. Patient Prefer Adherence 2012; 6:297-322. [PMID: 22536064 PMCID: PMC3333818 DOI: 10.2147/ppa.s30244] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Due to the rapid proliferation of human immunodeficiency virus (HIV) treatment options, there is a need for health care providers with knowledge of antiretroviral therapy intricacies. In a HIV multidisciplinary care team, the HIV pharmacist is well-equipped to provide this expertise. We conducted a systematic review to assess the impact of HIV pharmacists on HIV clinical outcomes. METHODS We searched six electronic databases from January 1, 1980 to June 1, 2011 and included all quantitative studies that examined pharmacist's roles in the clinical care of HIV-positive adults. Primary outcomes were antiretroviral adherence, viral load, and CD(4) (+) cell count and secondary outcomes included health care utilization parameters, antiretroviral modifications, and other descriptive variables. RESULTS Thirty-two publications were included. Despite methodological limitation, the involvement of HIV pharmacists was associated with statistically significant adherence improvements and positive impact on viral suppression in the majority of studies. CONCLUSION This systematic review provides evidence of the beneficial impact of HIV pharmacists on HIV treatment outcomes and offers suggestions for future research.
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Affiliation(s)
- Parya Saberi
- Department of Medicine, University of California, San Francisco, CA, USA
- Correspondence: Parya Saberi, Center for AIDS Prevention Studies, UCSF Box 0886, San Francisco, CA 94105, USA, Email
| | - Betty J Dong
- Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
| | - Mallory O Johnson
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Ruth M Greenblatt
- Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
| | - Jennifer M Cocohoba
- Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
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Acri T, TenHave TR, Chapman JC, Bogner HR, Gross R. Lack of association between retrospectively collected pharmacy refill data and electronic drug monitoring of antiretroviral adherence. AIDS Behav 2010; 14:748-54. [PMID: 19089608 DOI: 10.1007/s10461-008-9502-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Accepted: 11/28/2008] [Indexed: 10/21/2022]
Abstract
Antiretroviral medication refill adherence has not been compared directly to electronic drug monitoring (EDM) in any identifiable published study. We retrospectively studied adults with undetectable HIV titers on highly active antiretroviral therapy. We used Pearson correlation coefficients and receiver operating characteristic curves to relate the two adherence measures, and we used the Wilcoxon rank-sum test to assess the relation between adherence and viral load. In sixty-five subjects, the majority of whom were African American and male with median age of 44 years, pharmacy refill adherence was difficult to collect retrospectively, was not significantly correlated with EDM adherence, and was not significantly related to viral load. Ninety-day supply pharmacy refill adherence correctly classified 95% EDM adherence maximally at 94 days between refills, and the measure was most sensitive for non-adherence at <90 days. Reassessment of the relation between pharmacy refill data and EDM would be warranted when pharmacy refill data is collected as soon as feasible from sources with complete data capture.
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Rickles NM, Brown TA, Mcgivney MS, Snyder ME, White KA. Adherence: a review of education, research, practice, and policy in the United States. Pharm Pract (Granada) 2010; 8:1-17. [PMID: 25152788 PMCID: PMC4140572 DOI: 10.4321/s1886-36552010000100001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Accepted: 03/01/2010] [Indexed: 12/01/2022] Open
Abstract
Objective To describe the education, research, practice, and policy related to pharmacist interventions to improve medication adherence in community settings in the United States. Methods Authors used MEDLINE and International Pharmaceutical Abstracts (since 1990) to identify community and ambulatory pharmacy intervention studies which aimed to improve medication adherence. The authors also searched the primary literature using Ovid to identify studies related to the pharmacy teaching of medication adherence. The bibliographies of relevant studies were reviewed in order to identify additional literature. We searched the tables of content of three US pharmacy education journals and reviewed the American Association of Colleges of Pharmacy website for materials on teaching adherence principles. Policies related to medication adherence were identified based on what was commonly known to the authors from professional experience, attendance at professional meetings, and pharmacy journals. Results Research and Practice: 29 studies were identified: 18 randomized controlled trials; 3 prospective cohort studies; 2 retrospective cohort studies; 5 case-controlled studies; and one other study. There was considerable variability in types of interventions and use of adherence measures. Many of the interventions were completed by pharmacists with advanced clinical backgrounds and not typical of pharmacists in community settings. The positive intervention effects had either decreased or not been sustained after interventions were removed. Although not formally assessed, in general, the average community pharmacy did not routinely assess and/or intervene on medication adherence. Education National pharmacy education groups support the need for pharmacists to learn and use adherence-related skills. Educational efforts involving adherence have focused on students’ awareness of adherence barriers and communication skills needed to engage patients in behavioral change. Policy Several changes in pharmacy practice and national legislation have provided pharmacists opportunities to intervene and monitor medication adherence. Some of these changes have involved the use of technologies and provision of specialized services to improve adherence. Conclusions Researchers and practitioners need to evaluate feasible and sustainable models for pharmacists in community settings to consistently and efficiently help patients better use their medications and improve their health outcomes.
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Affiliation(s)
- Nathaniel M Rickles
- Department of Pharmacy Practice, Northeastern University School of Pharmacy. Boston, MA ( United States )
| | - Todd A Brown
- Department of Pharmacy Practice. Northeastern University School of Pharmacy. Boston, MA ( United States )
| | - Melissa S Mcgivney
- Director, Community Practice Residency Program, University of Pittsburgh School of Pharmacy. Pittsburgh, PA ( United States )
| | - Margie E Snyder
- School of Pharmacy & Pharmaceutical Sciences, Purdue University . Indianapolis, IN ( United States )
| | - Kelsey A White
- School of Pharmacy & Pharmaceutical Sciences, Purdue University . Indianapolis, IN ( United States )
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Devine S, Vlahiotis A, Sundar H. A comparison of diabetes medication adherence and healthcare costs in patients using mail order pharmacy and retail pharmacy. J Med Econ 2010; 13:203-11. [PMID: 20345227 DOI: 10.3111/13696991003741801] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare long-term diabetes medication adherence and healthcare costs in patients using mail order pharmacy versus retail pharmacy. METHODS The MarketScan database was used to identify patients who filled prescriptions for oral anti-diabetes medications in a retail pharmacy for at least 6 months before switching to mail order pharmacy for at least 12 months. These patients were matched to others who used retail pharmacy continuously for at least 18 months. A propensity score was used to create matched groups of patients comparable on probability of switching to mail order, weighted Poisson regression was used to analyze differences in medication adherence, and Tobit regression was used to compare costs. RESULTS A total of 14,600 patients who switched to mail order were matched to 43,800 patients who used retail pharmacy continuously. The average adjusted adherence in retail pharmacy was 63.4% compared to 84.8% after switching to mail order. Per-member-per-month total healthcare and total medical costs were on average $34.32 and $37.54 lower in the mail order group, respectively. Diabetes-related medical costs were on average $19.14 lower in the mail order group, while pharmacy costs were $14.13 higher. LIMITATIONS Limitations include a patient population under the age of 65, no information on pharmacy benefit design, and limited follow-up time relative to that necessary to identify long-term diabetes complications. CONCLUSIONS After adjusting for measured confounders of medication adherence and disease severity, individuals who switched to mail order pharmacy had higher medication possession ratios and trended toward lower total and diabetes-related medical costs over time.
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Jordan MR, La H, Nguyen HD, Sheehan H, Lien TTM, Duong DV, Hellinger J, Wanke C, Tang AM. Correlates of HIV-1 viral suppression in a cohort of HIV-positive drug users receiving antiretroviral therapy in Hanoi, Vietnam. Int J STD AIDS 2009; 20:418-22. [PMID: 19451329 DOI: 10.1258/ijsa.2008.008389] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Injection drug users bear the burden of HIV in Vietnam and are a focus of national treatment programmes. To date, determinants of successful therapy in this population are unknown. Substance use and clinical correlates of viral suppression were studied in 100 HIV-1-infected drug users receiving antiretroviral therapy (ART) for at least six months in Hanoi, Vietnam. The mean age of the cohort was 29.9 + 4.9 years; all were men. A majority of patients (73%) achieved viral suppression (HIV-RNA <1000 copies/mL). Correlates of viral suppression include self-reported > or = 95% adherence (P < 0.01) and current use of trimethoprim/sulphamethoxazole (P < 0.01); current or ever diagnosed with tuberculosis was associated with viral non-suppression (P = 0.006). Tobacco use was prevalent (84%), and surprisingly 48% of patients reported active drug use; neither was associated with viral non-suppression. This is the first study to document successful ART treatment in a population of Vietnamese drug users; rates of viral suppression are comparable to other international populations. The 28% of patients without HIV-1 suppression highlight the need for adherence promotion, risk reduction programmes, and population-based surveillance strategies for assessing the emergence of HIV drug resistance in settings where access to viral load and drug resistance testing is limited.
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Affiliation(s)
- M R Jordan
- Tufts Medical Center, Division of Geographic Medicine and Infectious Disease, Boston, MA 02111, USA.
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Sleath B, Ballinger R, Covert D, Robin AL, Byrd JE, Tudor G. Self-reported prevalence and factors associated with nonadherence with glaucoma medications in veteran outpatients. ACTA ACUST UNITED AC 2009; 7:67-73. [PMID: 19447359 DOI: 10.1016/j.amjopharm.2009.04.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of the current study was to determine the self-reported prevalence of and factors associated with nonadherence with glaucoma medications in veteran outpatients. METHODS This survey study was conducted at a Veterans Affairs (VA) clinic. A survey was administered to patients with glaucoma. We calculated the percentage of self-reported adherence with glaucoma medications in each patient. Logistic regression was used to assess whether patient characteristics and difficulties with using glaucoma medications were related to patients' reporting that they were <100% adherent with their glaucoma medications in the previous week. RESULTS The survey was completed by 141 patients (men, 91.5%; mean [SD] age, 70.22 [11.60] years [range, 37-93 years]; black race, 45.4%; white race, 44.0%; "other" or data unavailable, 10.6%). Nonwhite patients were significantly less adherent in the previous week than were white patients (27.0% vs 11.3%; P < 0.05). A total of 67.4% patients reported > or =1 difficulty in using their glaucoma medications. The 3 most commonly reported difficulties were "drops fall on cheek" (29.1%), "too many drops come out" (20.6%), and "hard to read print" (17.0%). A total of 19.1% of patients self-reported using <100% of their glaucoma medications in the previous week. The number of difficulties reported was significantly associated with reporting being <100% adherent in the previous week (P<0.05). CONCLUSION In this small sample of VA patients with glaucoma, adherence to glaucoma medications could be improved, especially among those who reported difficulties using their medications and those who were nonwhite.
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Affiliation(s)
- Betsy Sleath
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina School of Pharmacy, Chapel Hill, North Carolina, USA.
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Abstract
BACKGROUND Despite the proven effectiveness of many medications for chronic diseases, many patients do not refill their prescriptions in the required timeframe. OBJECTIVE Compare the effectiveness of 3 pharmacist strategies to decrease time to refill of prescriptions for common chronic diseases. RESEARCH DESIGN/SUBJECTS: A randomized, controlled clinical trial with patients as the unit of randomization. Nine pharmacies within a medium-sized grocery store chain in South Carolina were included, representing urban, suburban, and rural areas and patients from a variety of socioeconomic backgrounds. Patients (n = 3048) overdue for refills for selected medications were randomized into 1 of 3 treatment arms: (1) pharmacist contact with the patient via telephone, (2) pharmacist contact with the patient's prescribing physician via facsimile, and (3) usual care. MEASURES The primary outcome was the number of days from their recommended refill date until the patient filled a prescription for any medication relevant to his/her chronic disease. Prescription refill data were obtained routinely from the pharmacy district office's centralized database. Patient disposition codes were obtained by pharmacy employees. An intent-to-treat approach was used for all analyses. RESULTS There were no significant differences by treatment arm in the study outcomes. CONCLUSIONS Neither of the interventions is more effective than usual care at improving persistence of prescription refills for chronic diseases in overdue patients.
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Bangsberg D. Preventing HIV Antiretroviral Resistance through Better Monitoring of Treatment Adherence. J Infect Dis 2008; 197 Suppl 3:S272-8. [DOI: 10.1086/533415] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Jordan MR, Bennett DE, Bertagnolio S, Gilks CF, Sutherland D. World Health Organization surveys to monitor HIV drug resistance prevention and associated factors in sentinel antiretroviral treatment sites. Antivir Ther 2008. [DOI: 10.1177/135965350801302s07] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The World Health Organization (WHO) estimates that >2 million people will have started antiretroviral therapy (ART) by the end of 2006. As the development of some HIV drug resistance (HIVDR) is inevitable in populations taking ART, the emergence of HIVDR must be balanced against the benefits of providing ART, including improved health outcomes and decreased HIV/AIDS-associated morbidity and mortality. ART programmes should operate to minimize the emergence of HIVDR in populations receiving therapy and HIVDR itself must be monitored to ensure ongoing regimen efficacy. ART regimens in resource-limited settings are usually selected at the national level following a public health approach: generally only one first-line regimen with alternate regimen(s) incorporating within-class drug substitutions are available in the public sector. The WHO has developed a population-based HIVDR assessment and prevention strategy, which includes standardized HIVDR monitoring surveys in populations receiving first-line ART at sentinel sites. The WHO surveys monitor HIVDR prevention in sentinel sites by utilizing a standardized, minimum-resource prospective survey methodology to assess the success of adult and paediatric ART sites in preventing HIVDR emergence during the first year of ART. The surveys also identify associated factors that can be addressed at the level of the ART site or programme. WHO HIVDR monitoring surveys are designed to be integrated easily into a country's ongoing, routine HIV-related evaluation activities. Performed regularly at representative sites, the data generated will inform evidence-based decision making regarding national and global ART regimen selection and minimize the emergence of HIVDR at a population level.
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Wood E, Hogg RS, Yip B, Moore D, Harrigan PR, Montaner JSG. Superior virological response to boosted protease inhibitor-based highly active antiretroviral therapy in an observational treatment programme. HIV Med 2007; 8:80-5. [PMID: 17352763 DOI: 10.1111/j.1468-1293.2007.00430.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The use of boosted protease inhibitor (PI)-based antiretroviral therapy has become increasingly recommended in international HIV treatment consensus guidelines based on the results of randomized clinical trials. However, the impact of this new treatment strategy has not yet been evaluated in community-treated cohorts. METHODS We evaluated baseline characteristics and plasma HIV RNA responses to unboosted and boosted PI-based highly active antiretroviral therapy (HAART) among antiretroviral-naïve HIV-infected patients in British Columbia, Canada who initiated HAART between August 1997 and September 2003 and who were followed until September 2004. We evaluated time to HIV-1 RNA suppression (<500 HIV-1 RNA copies/mL) and HIV-1 RNA rebound (>or=500 copies/mL), while stratifying patients into those that received boosted and unboosted PI-based HAART as the initial regimen, using Kaplan-Meier methods and Cox proportional hazards regression. RESULTS During the study period, 682 patients initiated therapy with unboosted PI and 320 individuals initiated HAART with a boosted PI. Those who initiated therapy with a boosted PI were more likely to have a CD4 cell count <200 cells/muL and to have a plasma HIV RNA>100 000 copies/mL, and to have AIDS at baseline (all P<0.001). However, when we examined virological response rates, those who initiated HAART with a boosted PI achieved more rapid virological suppression [relative hazard 1.26, 95% confidence interval (CI) 1.06-1.51, P=0.010]. CONCLUSIONS Patients prescribed boosted PIs achieved superior virological response rates despite baseline factors that have been associated with inferior virological responses to HAART. Despite the inherent limitations of observational studies which require this study be interpreted with caution, these findings support the use of boosted PIs for initial HAART therapy.
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Affiliation(s)
- E Wood
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada
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Shrank WH, Stedman M, Ettner SL, DeLapp D, Dirstine J, Brookhart MA, Fischer MA, Avorn J, Asch SM. Patient, physician, pharmacy, and pharmacy benefit design factors related to generic medication use. J Gen Intern Med 2007; 22:1298-304. [PMID: 17647066 PMCID: PMC2219782 DOI: 10.1007/s11606-007-0284-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Revised: 05/23/2007] [Accepted: 06/21/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND Increased use of generic medications conserves insurer and patient financial resources and may increase patient adherence. OBJECTIVE The objective of the study is to evaluate whether physician, patient, pharmacy benefit design, or pharmacy characteristics influence the likelihood that patients will use generic drugs DESIGN, SETTING, AND PARTICIPANTS Observational analysis of 2001-2003 pharmacy claims from a large health plan in the Western United States. We evaluated claims for 5,399 patients who filled a new prescription in at least 1 of 5 classes of chronic medications with generic alternatives. We identified patients initiated on generic drugs and those started on branded medications who switched to generic drugs in the subsequent year. We used generalized estimating equations to perform separate analyses assessing the relationship between independent variables and the probability that patients were initiated on or switched to generic drugs. RESULTS Of the 5,399 new prescriptions filled, 1,262 (23.4%) were generics. Of those initiated on branded medications, 606 (14.9%) switched to a generic drug in the same class in the subsequent year. After regression adjustment, patients residing in high-income zip codes were more likely to initiate treatment with a generic than patients in low-income regions (RR = 1.29; 95% C.I. 1.04-1.60); medical subspecialists (RR = 0.82; 0.69-0.95) and obstetrician/gynecologists (RR = 0.81; 0.69-0.98) were less likely than generalist physicians to initiate generics. Pharmacy benefit design and pharmacy type were not associated with initiation of generic medications. However, patients were over 2.5 times more likely to switch from branded to generic medications if they were enrolled in 3-tier pharmacy plans (95% C.I. 1.12-6.09), and patients who used mail-order pharmacies were 60% more likely to switch to a generic (95% C.I. 1.18-2.30) after initiating treatment with a branded drug. CONCLUSIONS Physician and patient factors have an important influence on generic drug initiation, with the patients who live in the poorest zip codes paradoxically receiving generic drugs least often. While tiered pharmacy benefit designs and mail-order pharmacies helped steer patients towards generic medications once the first prescription has been filled, they had little effect on initial prescriptions. Providing patients and physicians with information about generic alternatives may reduce costs and lead to more equitable care.
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Affiliation(s)
- William H Shrank
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont St, Suite 3030, Boston, MA 02120, USA.
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Berg CJ, Michelson SE, Safren SA. Behavioral aspects of HIV care: adherence, depression, substance use, and HIV-transmission behaviors. Infect Dis Clin North Am 2007; 21:181-200, x. [PMID: 17502235 DOI: 10.1016/j.idc.2007.01.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A variety of psychosocial stressors are involved in living with HIV, maintaining a regimen of highly active antiretroviral therapy, and negotiating necessary self-care behaviors. Because health care providers are in regular contact with HIV-infected individuals in care, these contacts allow for the opportunity to assess and intervene on important variables related to quality of life and HIV outcomes. This article reviews information about four important behavioral aspects of HIV care: treatment adherence, depression, high-risk sex, and substance abuse. Efforts by health care providers to address these factors may result in better treatment outcomes, enhanced quality of life among HIV patients, and decreased HIV transmission.
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Affiliation(s)
- Carla J Berg
- Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
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Dieckhaus KD, Odesina V. Outcomes of a multifaceted medication adherence intervention for HIV-positive patients. AIDS Patient Care STDS 2007; 21:81-91. [PMID: 17328657 DOI: 10.1089/apc.2006.0044] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Treatment of HIV infection with highly active antiretroviral therapy (HAART) requires high levels of adherence in order to obtain maximum benefit and minimize the development of antiviral resistance. Many patients in community clinical settings have imperfect adherence that may lead to poor clinical outcomes. The Connecticut HIV Medication Project (CHaMP) is a multidisciplinary program designed to evaluate patients receiving antiviral therapy. Based on results of a multifaceted assessment, a variety of targeted interventions and follow-up are offered. A retrospective analysis was performed on patients who were referred to the program over a 35-month period from March 2002 through January 2005. Two hundred forty-nine patients who were referred for adherence services had baseline and follow-up data available for analysis. Participants who maintained an unchanged antiretroviral regimen experienced a significant increase in self-reported adherence (89.1% to 96.9%, p < 0.001) and likelihood of reporting more than 95% adherence (36.6% to 73.1%, p < 0.001) by 7-day recall. Improvements in plasma HIV viremia (3.10 +/- 1.21 log copies to 2.78 +/- 0.98, p < 0.01) were also demonstrated. Limitations to this study included the unusually high level of baseline adherence, the large fraction of patients (28.6%) who were lost to follow-up, and follow-up that was limited to one time point at 12-16 weeks such that attrition of the intervention effect could not be assessed. The CHaMP experience demonstrates that the development of a multifaceted clinical program can have significant impact on medication adherence and viral burden in HIV infection.
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Affiliation(s)
- Kevin D Dieckhaus
- Division of Infectious Diseases , University of Connecticut Health Center, Farmington, Connecticut 06030-3212, USA.
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Wood E, Hogg RS, Yip B, Moore D, Harrigan PR, Montaner JSG. Impact of baseline viral load and adherence on survival of HIV-infected adults with baseline CD4 cell counts > or = 200 cells/microl. AIDS 2006; 20:1117-23. [PMID: 16691062 DOI: 10.1097/01.aids.0000226951.49353.ed] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Baseline plasma HIV RNA levels > 100 000 copies/ml have been associated with elevated mortality rates after the initiation of HAART. There is uncertainty regarding the optimal strategy for patients with high plasma HIV RNA but CD4 cell count > or = 200 cells/microl. OBJECTIVE To evaluate the impact of baseline plasma HIV RNA on survival among patients with CD4 cell counts > or = 200 cells/microl. METHODS Patients were stratified by plasma HIV RNA, CD4 cell count and adherence level. Mortality rates were evaluated using Kaplan-Meier methods and Cox regression. RESULTS Among 1166 patients initiating HAART with a CD4 cell count > or = 200 cells/microl, a baseline HIV RNA > or = 100 000 copies/ml was statistically associated with elevated mortality among non-adherent patients (log-rank P = 0.032), but not for adherent patients (log-rank P = 0.690). In a multivariate Cox model comparing patients with a baseline CD4 cell count > or = 200 cells/microl and a baseline plasma HIV RNA < 100 000 copies/ml, the mortality rate was statistically similar among patients with a baseline CD4 cell count > or = 200 cells/microl and a baseline plasma HIV RNA > or = 100 000 copies/ml (relative hazard, 1.21; 95% confidence interval, 0.89-1.65; P = 0.232). CONCLUSION HIV RNA > or = 100 000 copies/ml was only associated with mortality among HIV-infected patients initiating HAART with CD4 cell counts > or= 200 cells/microl if the patients were non-adherent.
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Affiliation(s)
- Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, 667-1081 Burrard Street, Vancouver, BC, Canada
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Bangsberg DR. Monitoring adherence to HIV antiretroviral therapy in routine clinical practice: The past, the present, and the future. AIDS Behav 2006; 10:249-51. [PMID: 16783537 DOI: 10.1007/s10461-006-9121-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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