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McCann NC, Davenport MJ, Mandavia AD, Stein MD, Livingston NA. HIV Prevalence and HIV Screening History Among a Veterans Association Cohort of People with Opioid and Alcohol Use Disorders. J Gen Intern Med 2024; 39:403-410. [PMID: 37848765 PMCID: PMC10897116 DOI: 10.1007/s11606-023-08452-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/28/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Veterans face high risk for HIV and substance use, and thus could be disproportionately impacted by the HIV and substance use disorder (SUD) "syndemic." HIV prevalence among veterans with SUD is unknown. OBJECTIVE To project HIV prevalence and lifetime HIV screening history among US veterans with alcohol use disorder (AUD), opioid use disorder (OUD), or both. DESIGN We conducted a retrospective cohort analysis using national Veterans Health Administration (VHA) data. PARTICIPANTS We selected three cohorts of veterans with SUD: (1) AUD, (2) OUD, and (3) AUD/OUD. Included veterans had ICD codes for AUD/OUD from 2016 to 2022 recorded in VHA electronic medical records, sourced from the VA Corporate Data Warehouse (CDW). MAIN MEASURES We estimated HIV prevalence by dividing the number of veterans who met two out of three criteria (codes for HIV diagnosis, antiretroviral therapy, or HIV screening/monitoring) by the total number of veterans in each cohort. We also estimated lifetime HIV screening history (as documented in VHA data) by cohort. We reported HIV prevalence and screening history by cohort and across demographic/clinical subgroups. KEY RESULTS Our sample included 669,595 veterans with AUD, 63,787 with OUD, and 57,015 with AUD/OUD. HIV prevalence was highest in the AUD/OUD cohort (3.9%), followed by the OUD (2.1%) and AUD (1.1%) cohorts. Veterans of Black race and Hispanic/Latinx ethnicity, with HCV diagnoses, and aged 50-64 had the highest HIV prevalence in all cohorts. Overall, 12.8%, 29.1%, and 33.1% of the AUD/OUD, OUD, and AUD cohorts did not have history of HIV screening, respectively. CONCLUSIONS HIV prevalence was high in all SUD cohorts, and was highest among veterans with AUD/OUD, with disparities by race/ethnicity and age. A substantial portion of veterans had not received HIV screening in the VHA. Findings highlight room for improvement in HIV prevention and screening services for veterans with SUD.
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Affiliation(s)
- Nicole C McCann
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Michael J Davenport
- Data Science Core, Boston CSPCC, VA Boston Healthcare System, Boston, MA, USA
| | - Amar D Mandavia
- Medical Informatics, VA Boston Healthcare System, Boston, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Michael D Stein
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA
| | - Nicholas A Livingston
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
- National Center for PTSD, Behavioral Science Division, VA Boston Health Care System, Boston, MA, USA.
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Justice AC, Goetz MB, Stewart CN, Hogan BC, Humes E, Luz PM, Castilho JL, Nash D, Brazier E, Musick B, Yiannoutsos C, Malateste K, Jaquet A, Cornell M, Shamu T, Rajasuriar R, Jiamsakul A, Althoff KN. Delayed presentation of HIV among older individuals: a growing problem. Lancet HIV 2022; 9:e269-e280. [PMID: 35218732 PMCID: PMC9128643 DOI: 10.1016/s2352-3018(22)00003-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/30/2021] [Accepted: 01/05/2022] [Indexed: 12/31/2022]
Abstract
Late presentation for care is a major impediment to the prevention and effective treatment of HIV infection. Older individuals are at increased risk of late presentation, represent a growing proportion of people with late presentation, and might require interventions tailored to their age group. We provide a summary of the literature published globally between 2016-21 (reporting data from 1984-2018) and quantify the association of age with delayed presentation. Using the most common definitions of late presentation and older age from these earlier studies, we update this work with data from the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium, focusing on data from 2000-19, encompassing four continents. Finally, we consider how late presentation among older individuals might be more effectively addressed as electronic medical records become widely adopted.
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Affiliation(s)
- Amy C Justice
- VA Connecticut Healthcare System, Yale Schools of Medicine and Public Health, Yale University, West Haven, CT, USA.
| | - Matthew B Goetz
- VA Greater Los Angeles Healthcare System, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Cameron N Stewart
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Brenna C Hogan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth Humes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Paula M Luz
- Affiliation Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Jessica L Castilho
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Denis Nash
- City University of New York Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - Ellen Brazier
- Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - Beverly Musick
- Department of Biostatistics and Health Data Science, School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Constantin Yiannoutsos
- Department of Biostatistics, Richard M Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA
| | - Karen Malateste
- Inserm, French National Research Institute for Sustainable Development, Universite de Bordeaux, Bordeaux, France
| | - Antoine Jaquet
- Inserm, French National Research Institute for Sustainable Development, Universite de Bordeaux, Bordeaux, France
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Tinei Shamu
- Graduate School of Health Sciences, Institute of Social and Preventative Medicine, University of Bern, Bern, Switzerland
| | - Reena Rajasuriar
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Awachana Jiamsakul
- Biostatistics and Databases Program, The Kirby Institute, UNSW, Sydney, NSW, Australia
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Implementing HIV Testing in Substance Use Treatment Programs: A Systematic Review. J Assoc Nurses AIDS Care 2015; 28:199-215. [PMID: 26825458 DOI: 10.1016/j.jana.2015.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 11/16/2015] [Indexed: 11/22/2022]
Abstract
People who use drugs are at increased risk for HIV acquisition, poor engagement in health care, and late screening for HIV with advanced HIV at diagnosis and increased HIV-related morbidity, mortality, and health care costs. This systematic review evaluates current evidence about the effectiveness and feasibility of implementing HIV testing in U.S. substance use treatment programs. The literature search identified 535 articles. Full text review was limited to articles that explicitly addressed strategies to implement HIV testing in substance use programs: 17 met criteria and were included in the review; nine used quantitative, qualitative, or mixed-method designs to describe or quantify HIV testing rates, acceptance by clients and staff, and cost-effectiveness; eight organization surveys described barriers and facilitators to testing implementation. The evidence supported the effectiveness and feasibility of rapid, routine, and streamlined HIV testing in substance use treatment programs. Primary challenges included organizational support and sustainable funding.
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Conners EE, Hagedorn HJ, Butler JN, Felmet K, Hoang T, Wilson P, Klima G, Sudzina E, Anaya HD. Evaluating the implementation of nurse-initiated HIV rapid testing in three Veterans Health Administration substance use disorder clinics. Int J STD AIDS 2013; 23:799-805. [PMID: 23155100 DOI: 10.1258/ijsa.2012.012050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Individuals with substance use disorders (SUDs) are at higher risk of HIV infection, yet recent studies show rates of HIV testing are low among this population. We implemented and evaluated a nurse-initiated HIV oral rapid testing (NRT) strategy at three Veterans Health Administration SUD clinics. Implementation of NRT includes streamlined nurse training and a computerized clinical reminder. The evaluation employed qualitative interviews with staff and a quantitative evaluation of HIV testing rates. Barriers to testing included lack of laboratory support and SUD nursing resistance to performing medical procedures. Facilitators included the ease of NRT integration into workflow, engaged management and an existing culture of disease prevention. Six-months post intervention, rapid testing rates at SUD clinics in sites 1, 2, and 3 were 5.0%, 1.1% and 24.0%, respectively. Findings indicate that NRT can be successfully incorporated into some types of SUD subclinics with minimal perceived impact on workflow and time.
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Affiliation(s)
- E E Conners
- Veterans Affairs Quality Enhancement Research Initiative (QUERI) for HIV and Hepatitis, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
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Abstract
BACKGROUND Despite the Centers for Disease Control and Prevention recommendations for annual HIV testing of at-risk populations, including those with substance use disorders, there are no data on the human immunodeficiency virus (HIV) testing practices of buprenorphine-prescribing physicians. OBJECTIVE To describe HIV testing practices among buprenorphine-prescribing physicians. METHODS We conducted a cross-sectional survey of physicians enrolled in a national system to support buprenorphine prescribing between July and August 2008. The electronic survey included questions on demographics; clinical training and experience; clinical practice; patient characteristics; and physician screening practices, including HIV testing. RESULTS Only 46% of 382 respondent physicians conducted HIV testing. On univariate analysis, physicians who conducted HIV testing were more likely to report addiction specialty training (33% vs 19%, P = 0.001), practicing in addiction settings (28% vs 16%, P = 0.006), and having treated more than 50 patients with buprenorphine (50% vs 31%, P < 0.0001) than those who did not. Compared with physicians who did not conduct HIV testing, physicians who conducted HIV testing had a lower proportion of buprenorphine patients who were white (75% vs 82%, P = 0.01) or dependent upon prescription opioids (57% vs 70%, P < 0.0001). In multivariate analysis, physicians who conducted HIV testing were more likely to have treated more than 50 patients with buprenorphine (odds ratio = 1.777, 95% CI 1.011-3.124) and had fewer patients dependent upon prescription opioids (odds ratio = 0.986 95% CI 0.975-0.998) than physicians who did not. CONCLUSIONS Interventions to increase HIV testing among physicians prescribing buprenorphine are needed.
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McInnes DK, Solomon JL, Bokhour BG, Asch SM, Ross D, Nazi KM, Gifford AL. Use of electronic personal health record systems to encourage HIV screening: an exploratory study of patient and provider perspectives. BMC Res Notes 2011; 4:295. [PMID: 21843313 PMCID: PMC3173346 DOI: 10.1186/1756-0500-4-295] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Accepted: 08/15/2011] [Indexed: 12/12/2022] Open
Abstract
Background When detected, HIV can be effectively treated with antiretroviral therapy. Nevertheless in the U.S. approximately 25% of those who are HIV-infected do not know it. Much remains unknown about how to increase HIV testing rates. New Internet outreach methods have the potential to increase disease awareness and screening among patients, especially as electronic personal health records (PHRs) become more widely available. In the US Department of Veterans' Affairs medical care system, 900,000 veterans have indicated an interest in receiving electronic health-related communications through the PHR. Therefore we sought to evaluate the optimal circumstances and conditions for outreach about HIV screening. In an exploratory, qualitative research study we examined patient and provider perceptions of Internet-based outreach to increase HIV screening among veterans who use the Veterans Health Administration (VHA) health care system. Findings We conducted two rounds of focus groups with veterans and healthcare providers at VHA medical centers. The study's first phase elicited general perceptions of an electronic outreach program to increase screening for HIV, diabetes, and high cholesterol. Using phase 1 results, outreach message texts were drafted and then presented to participants in the second phase. Analysis followed modified grounded theory. Patients and providers indicated that electronic outreach through a PHR would provide useful information and would motivate patients to be screened for HIV. Patients believed that electronic information would be more convenient and understandable than information provided verbally. Patients saw little difference between messages about HIV versus about diabetes and cholesterol. Providers, however, felt patients would disapprove of HIV-related messages due to stigma. Providers expected increased workload from the electronic outreach, and thus suggested adding primary care resources and devising methods to smooth the flow of patients getting screened. When provided a choice between unsecured emails versus PHRs as the delivery mechanism for disease screening messages, both patients and providers preferred PHRs. Conclusions There is considerable potential to use PHR systems for electronic outreach and social marketing to communicate to patients about, and increase rates of, disease screening, including for HIV. Planning for direct-to-patient communications through PHRs should include providers and address provider reservations, especially about workload increases.
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Affiliation(s)
- D Keith McInnes
- Center for Health Quality, Outcomes & Economic Research, ENRM VA Medical Center, Bedford, MA, USA.
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