Quality of Care for HIV/AIDS and for Primary Prevention by HIV Specialists and Nonspecialists

Impact of an Interprofessional HIV Quality Improvement Team on Patient Care and Resident Learning Opportunities

Introduction

Although human immunodeficiency virus (HIV) care is a recommended competency for family medicine training, many programs report a lack of HIV expertise among faculty. After the departure of faculty with HIV care experience, an interprofessional HIV quality improvement team (HIV-QIT) of physicians and pharmacists aimed to maintain on-site HIV care and retain learning opportunities for residents, using process improvement and panel reviews with a remote HIV specialist faculty member.

Methods

This study reports on a multicycle quality improvement pilot project with pre- and postintervention chart reviews between December 2019 and May 2021. All patients received primary care and HIV-QIT chart reviews on-site. We compared patients with integrated HIV care on-site to those receiving external HIV specialty care. Primary outcomes included virologic suppression, CD4 count ≥200 cells/mm3, and adherence to guideline-recommended HIV care. In cycle 1 (January-June 2020), the HIV-QIT reviewed patient charts and sent guideline-based recommendations to physicians. In cycle 2 (July 2020-May 2021), the HIV-QIT implemented several HIV-specific processes, including decision support updates, note templates, order sets, and reference materials. Sustained process improvements included HIV panel chart audits every 3 to 6 months and subsequent provider education.

Results

Of 29 patients, more than half (55%, n=16) received integrated HIV care at the primary care site. We found no significant difference in care quality measures between primary and specialty care. Barriers to care completion included missed or canceled follow-up visits, on-site phlebotomy service closures, and declined HIV services.

Conclusions

The HIV-QIT maintained on-site HIV treatment and retained experiential learning opportunities through process improvement and specialist-supported care recommendations to primary care physicians.

Direct and Indirect Effects of a Project ECHO Longitudinal Clinical Tele-Mentoring Program on Viral Suppression for Persons With HIV: A Population-Based Analysis

BACKGROUND

Project Extension for Community Health Outcomes (ECHO) aims to connect community providers to academic specialists, deliver longitudinal clinical mentorship and case consultations, plus encourage dissemination of knowledge and resources. The impact on outcomes for persons with HIV (PWH) is uncertain.

SETTING

PWH in Washington and Oregon outside of the Seattle and Portland metro areas, January 2011 to March 2018.

METHODS

Using viral load (VL) surveillance data, we assessed difference in the percentage of PWH who were virally suppressed among PWH whose providers participated versus did not participate in Project ECHO. Analyses included multiple mixed-effects regression models, adjusting for time and for patient, provider, and clinic characteristics.

RESULTS

Based on 65,623 VL results, Project ECHO participation was associated with an increase in the percentage of patients with VL suppression (13.7 percentage points greater; P < 0.0001), although the effect varied by estimated provider PWH patient volume. The difference was 14.7 percentage points ( P < 0.0001) among patients of providers who order <20 VL's/quarter and 2.3 and -0.6 percentage points among patients of providers who order 20-40 or >40 VL's/quarter, respectively ( P > 0.5). The magnitude of difference in VL suppression was associated with the number of sessions attended. Among patients of lower-volume providers who did not participate, VL suppression was 6.2 percentage points higher if providers worked in a clinic where another provider did participate ( P < 0.0001).

CONCLUSION

Project ECHO is associated with improvement in VL suppression for PWH whose providers participate or work in the same clinic system as a provider who participates, primarily because of benefits for patients of lower-volume providers.

Use of antiretroviral therapy in nursing home residents with HIV

BACKGROUND

Antiretroviral therapies (ARTs) are essential HIV care. As people living with HIV age and their presence in nursing homes (NHs) increases, it is critical to evaluate the quality of HIV care. We determine the rate of ART use and examine individual- and facility-level characteristics associated with no ART use in a nationally representative long-stay NH residents with HIV.

METHODS

This retrospective cohort study included all long-stay Medicare fee-for-service NH residents (2013-2016) with HIV who had a valid Minimum Data Set assessment. Residents were followed from long-stay qualification until death, Part D disenrollment, transfer from long-term care to another healthcare setting, or December 31, 2016. We identified individual and facility characteristics that were associated with non-use of ART using generalized estimating equation logistic regression.

RESULTS

Exactly 4171 eligible HIV+ residents from 2459 NHs were included in our study. Only 36% (1507 of 4171) received any ART regimen during an average of 11.6 months of observation. Older age, females, white race, receipt of Medicare skilled nursing benefits, and some major cardiometabolic comorbidities and mental health conditions were associated with non-ART use. Rates of non-ART use did not vary significantly by residents' end-of-life status (p = 0.21). Residents in facilities with a higher HIV concentration [adjusted odds ratio (adjOR) 3.42; 95% confidence interval (CI) 2.13-5.48] and an AIDS unit (adjOR 2.51; 95% CI 1.92-3.30) had higher odds of using an ART.

CONCLUSIONS AND IMPLICATIONS

The rate of ART use by HIV+ long-stay NH residents was low. Facilities' experience with HIV played an important role in ART receipt. Interventions to improve rates of ART use in NHs are urgently needed to ensure optimal health outcomes.

Adolescents and Young Adults: The Pediatrician's Role in HIV Testing and Pre- and Postexposure HIV Prophylaxis

Most sexually active youth in the United States do not believe that they are at risk for contracting HIV and have never been tested. Creating safe environments that promote confidentiality and respect, obtaining an accurate sexual and reproductive health assessment, and providing nonstigmatizing risk counseling are key components of any youth encounters. Pediatricians can play a key role in preventing and controlling HIV infection by promoting risk-reduction counseling and offering routine HIV testing and prophylaxis to adolescent and young adult (youth) patients. In light of persistently high numbers of people living with HIV in the United States and documented missed opportunities for HIV testing, the Centers for Disease Control and Prevention and the US Preventive Services Task Force recommend universal and routine HIV screening among US populations, including youth. Recent advances in HIV diagnostics, treatment, and prevention help support this recommendation. This clinical report reviews epidemiological data and recommends that routine HIV screening be offered to all youth 15 years or older, at least once, in health care settings. After initial screening, youth at increased risk, including those who are sexually active, should be rescreened at least annually, and potentially as frequently as every 3 to 6 months if at high risk (male youth reporting male sexual contact, active injection drug users, transgender youth; youth having sexual partners who are HIV-infected, of both genders, or injection drug users; youth exchanging sex for drugs or money; or youth who have had a diagnosis of or have requested testing for other sexually transmitted infections). Youth at substantial risk for HIV acquisition should be routinely offered HIV preexposure prophylaxis, and HIV postexposure prophylaxis is also indicated after high-risk exposures. This clinical report also addresses consent, confidentiality, and coverage issues that pediatricians face in promoting routine HIV testing and HIV prophylaxis for their patients.

Differential Role of Psychosocial, Health Care System and Neighborhood Factors on the Retention in HIV Care of Women and Men in the Ryan White Program

We investigated potential differential impact of barriers to HIV care retention among women relative to men. Client intake, health assessment, service, and laboratory information among clients receiving medical case management during 2017 in the Miami-Dade County Ryan White Program (RWP) were obtained and linked to American Community Survey data by ZIP code. Cross-classified multilevel logistic regression analysis was conducted. Among 1609 women and 5330 men, 84.6% and 83.7% were retained in care. While simultaneously controlling for all demographic characteristics, vulnerable/enabling factors, and neighborhood indices in the model, younger age, being US born, not working, and having a medical provider with low volume (<10) of clients remained associated with non-retention in care among women and men; while having ≥3 minors in the household and being perinatally infected were additionally associated with retention only for women. Both gender-specific and gender-non-specific barriers should be considered in efforts to achieve higher retention rates.

Human Immunodeficiency Virus-Experienced Clinician Workforce Capacity: Urban-Rural Disparities in the Southern United States

BACKGROUND

Human immunodeficiency virus (HIV)-experienced clinicians are critical for positive outcomes along the HIV care continuum. However, access to HIV-experienced clinicians may be limited, particularly in nonmetropolitan areas, where HIV is increasing. We examined HIV clinician workforce capacity, focusing on HIV experience and urban-rural differences, in the Southern United States.

METHODS

We used Medicaid claims and clinician characteristics (Medicaid Analytic eXtract [MAX] and MAX Provider Characteristics, 2009-2011), county-level rurality (National Center for Health Statistics, 2013), and diagnosed HIV cases (AIDSVu, 2014) to assess HIV clinician capacity in 14 states. We assumed that clinicians accepting Medicaid approximated the region's HIV workforce, since three-quarters of clinicians accept Medicaid insurance. HIV-experienced clinicians were defined as those providing care to ≥ 10 Medicaid enrollees over 3 years. We assessed HIV workforce capacity with county-level clinician-to-population ratios, using Wilcoxon-Mann-Whitney tests to compare urban-rural differences.

RESULTS

We identified 5012 clinicians providing routine HIV management, of whom 28% were HIV-experienced. HIV-experienced clinicians were more likely to specialize in infectious diseases (48% vs 6%, P < .001) and practice in urban areas (96% vs 83%, P < .001) compared to non-HIV-experienced clinicians. The median clinician-to-population ratio for all HIV clinicians was 13.3 (interquartile range, 38.0), with no significant urban-rural differences. When considering HIV experience, 81% of counties had no HIV-experienced clinicians, and rural counties generally had fewer HIV-experienced clinicians per 1000 diagnosed HIV cases (P < .001).

CONCLUSIONS

Significant urban-rural disparities exist in HIV-experienced workforce capacity for communities in the Southern United States. Policies to improve equity in access to HIV-experienced clinical care for both urban and rural communities are urgently needed.

Sociodemographic, HIV-Related Characteristics, and Health Care Factors as Predictors of Self-Reported Vaccination Coverage in a Nationwide Sample of People Aging with HIV in Germany

Preventing infectious diseases through vaccination becomes more significant among the growing population of people aging with HIV. Coverage rates for vaccinations and factors associated with vaccination utilization among this population in Germany are unknown. We assessed the coverage of eight recommended vaccinations in a certain time frame in our convenience sample of 903 people living with HIV aged 50 years and older. We analysed coverage rates and used bivariate and multiple linear regression analyses to identify factors associated with number of reported vaccinations. Coverage rates in our sample ranged between 51.0% for meningococcus disease and 84.6% for the triple vaccination against tetanus, diphtheria, and pertussis. All rates were higher compared to the German general population. Seven factors were related to the number of vaccinations in multiple regression analysis: sexual orientation, education, relationship status, CD4 count, time since last visit to HIV specialist, type of HIV specialist, and distance to HIV specialist. Vaccination coverage among people aging with HIV in Germany is high, but not optimal. To improve vaccination uptake, strengthened efforts need to be focused on female and heterosexual male patients, socioeconomically disadvantaged patients, and patients with barriers to access regular HIV care.

Patient and provider characteristics associated with retention in HIV medical care and viral suppression among in care patients in Hawaii

The percentages of retention in care and viral suppression among persons living with HIV (PLWH) in the United States from 2015 to 2018 were far below the 2020 national goals. This study aims to examine disparities in retention in care and viral suppression. The study population included PLWH diagnosed through 2016, residing in Hawaii at year-end 2016 and 2017, and who were in care in 2017 defined as having ≥1 CD4/viral load tests in 2017. Care providers were categorized as "very frequent" (≥50 patients), "frequent" (25-49 patients), "occasional" (10-24 patients), and "infrequent" (<10 patients). Among the 1752 patients included, 28.0% were not retained in care in 2017 (i.e., <2 CD4/VL tests performed at least 3 months apart), of whom 89.2% had only a single viral load test. Patients receiving care from the "infrequent" group of providers were less likely to be retained in care (adjusted odds ratio (aOR) = 0.48; 95% CI = 0.33, 0.69) or virally suppressed (aOR = 0.39; 95% CI = 0.24, 0.63), than patients receiving care from the "very frequent" group of providers. Percentages of three-year (2016-2018) in care and viral suppression were lowest among patients receiving care from "infrequent" care providers. Patients <45 years old were less likely to be retained in care (aOR = 0.53; 95% CI = 0.41, 0.68) or be virally suppressed (aOR = 0.59; 95% CI = 0.40, 0.86) than those 45 years or older. Patients of multiple races were less likely to be virally suppressed than whites (aOR = 0.38, 95% CI = 0.23, 0.64). Establishing a long-term relationship with an experienced HIV provider appears beneficial to achieve sustainable viral suppression and provision of uninterrupted HIV medical care.

Virologic Suppression in U.S. Navy Personnel Living with HIV Infection and Serving in Operational Assignments

INTRODUCTION

Current United States Navy policy supports the continuation of duty for active duty (AD) service members living with HIV infection. The creation of this policy is instrumental to prevent exclusion and to promote career expansion and promotional opportunities for AD service members infected with HIV. The established instruction parallels the HIV care continuum, a widely accepted public health model. No studies have been done to determine whether allowing service members to fill operational and Outside the Continental United States (OCONUS) assignments disrupts this continuum of care. This retrospective study aims to evaluate how an operational or OCONUS assignment impacts the ability of an HIV AD service members to receive the standard of care HIV medical treatment and maintain viral suppression.

MATERIALS/METHODS

A retrospective chart review was performed on the health records of 20 United States AD Navy service members with HIV who were placed in OCONUS or large ship assignments per current U.S. Navy policy. Health records were reviewed during the service member's assignment. Viral loads were documented immediately prior and at 6 months after starting their new assignment. Changes to anti-retroviral medications and the medical treatment facility, including the specialty of the treating provider were recorded.

RESULTS

The results demonstrate no significant change in the service member's viral load during the first 6 months in an operational or OCONUS assignment. Members still had access to care including medications and specialty providers based on the locality.

CONCLUSION

All service members within this review were able to maintain viral suppression despite the location of their assignments. This limited study suggests that care is accessible and the standard HIV care continuum is maintained while deployed or stationed overseas.

Physician network connections to specialists and HIV quality of care

OBJECTIVE

To estimate novel measures of generalist physicians' network connectedness to HIV specialists and their associations with two dimensions of HIV quality of care.

DATA SOURCES

Medicare and Medicaid claims and the American Medical Association Masterfile data on people living with HIV (PLWH) and the physicians providing their HIV care in California between 2007 and 2010.

STUDY DESIGN

I construct regional patient-sharing physician networks from the shared treatment of PLWH and calculate (a) measures of network connectedness to all physician types and (b) specialty-weighted measures to describe connectedness to HIV specialists. Two HIV quality of care outcomes are then evaluated: medication quality (prescribing antiretroviral drugs from at least two drug classes) and monitoring quality (at least two annual HIV virus monitoring scans). Linear probability models estimate the associations between network statistics and the two dimensions of HIV quality of care, and a policy simulation demonstrates the importance of these statistical relationships. These analyses include 16 124 PLWH, 3240 generalists, and 1031 HIV specialists.

DATA COLLECTION/EXTRACTION METHODS

PLWH are identified from claims for patients with any indication of HIV using an existing algorithm from the literature.

PRINCIPAL FINDINGS

Generalists' network connectedness to HIV specialists is positively related with their own HIV medication quality; one additional HIV specialist connection is associated with a 1.46 percentage point (SE 0.42, P < .01) increase in generalist's medication quality. Based on the estimated associations, a simulated policy that increases connectedness between generalists and HIV specialists reduces the annual rate of HIV infections by up to 6%, roughly 290 fewer infections per year. Only network connectedness to all physician types is associated with improved monitoring quality.

CONCLUSIONS

Network connectedness to HIV specialists is positively associated with generalists' HIV medication quality, which suggests that specialists provide clinical support through patient-sharing for complex treatment protocol.

Validation of an Optimized Algorithm for Identifying Persons Living With Diagnosed HIV From New York State Medicaid Data, 2006-2014

Algorithms are regularly used to identify persons living with diagnosed human immunodeficiency virus (HIV) (PLWDH) in Medicaid data. To our knowledge, there are no published reports of an HIV algorithm from Medicaid claims codes that have been compared with an HIV surveillance system to assess its sensitivity, specificity, positive predictive value, and negative predictive value in identifying PLWDH. Therefore, our aims in this study were to 1) develop an algorithm that could identify PLWDH in New York State Medicaid data from 2006-2014 and 2) validate this algorithm using the New York State HIV surveillance system. Classification and regression tree analysis identified 16 nodes that we combined to create a case-finding algorithm with 5 criteria. This algorithm identified 86,930 presumed PLWDH, 88.0% of which were verified by matching to the surveillance system. The algorithm yielded a sensitivity of 94.5%, a specificity of 94.4%, a positive predictive value of 88.0%, and a negative predictive value of 97.6%. This validated algorithm has the potential to improve the utility of Medicaid data for assessing health outcomes and programmatic interventions.

Initiating Low-Value Inhaled Corticosteroids in an Inception Cohort with Chronic Obstructive Pulmonary Disease

Rationale: Decreasing medication overuse represents an opportunity to avoid harm and costs in the era of value-based purchasing. Studies of inhaled corticosteroids (ICS) overuse in chronic obstructive pulmonary disease (COPD) have examined prevalent use. Understanding initiation of low-value ICS among complex patients with COPD may help shape deadoption efforts.Objectives: Examine ICS initiation among a cohort with low exacerbation risk COPD and test for associations with markers of patient and health system complexity.Methods: Between 2012 and 2016, we identified veterans with COPD from 21 centers. Our primary outcome was first prescription of ICS. We used the care assessment needs (CAN) score to assess patient-level complexity as the primary exposure. We used a time-to-event model with time-varying exposures over 1-year follow-up. We tested for effect modification using selected measures of health system complexity.Results: We identified 8,497 patients with COPD without an indication for ICS and did not have baseline use (inception cohort). Follow-up time was four quarters. Patient complexity by a continuous CAN score was associated with new dispensing of ICS (hazard ratio = 1.17 per 10-unit change; 95% confidence interval = 1.13-1.21). This association demonstrated a dose-response when examining quartiles of CAN score. Markers of health system complexity did not modify the association between patient complexity and first use of low-value ICS.Conclusions: Patient complexity may represent a symptom burden that clinicians are attempting to mitigate by initiating ICS. Lack of effect modification by health system complexity may reflect the paucity of structural support and low prioritization for COPD care.

Development and Validation of HIV-ASSIST, an Online, Educational, Clinical Decision Support Tool to Guide Patient-Centered ARV Regimen Selection

BACKGROUND

Multiple antiretroviral (ARV) regimens are effective at achieving HIV viral suppression, but differ in pill burden, side effects, barriers to resistance, and impact on comorbidities. Current guidelines advocate for an individualized approach to ARV regimen selection, but synthesizing these modifying factors is complex and time-consuming.

METHODS

We describe the development of HIV-ASSIST (https://www.hivassist.com), a free, online decision support tool for ARV selection and HIV education. HIV-ASSIST ranks potential ARV options for any given patient scenario using a composite objective of achieving viral suppression while maximizing tolerability and adherence. We used a multiple-criteria decision analysis framework to construct mathematical algorithms and synthesize various patient-specific (eg, comorbidities and treatment history) and virus-specific (eg, HIV mutations) attributes. We then conducted a validation study to evaluate HIV-ASSIST with prescribing practices of experienced HIV providers at 4 large academic centers. We report on concordance of provider ARV selections with the 5 top-ranked HIV-ASSIST regimens for 10 diverse hypothetical patient-case scenarios.

RESULTS

In the validation cohort of 17 experienced HIV providers, we found 99% concordance between HIV-ASSIST recommendations and provider ARV selections for 4 case-scenarios of ARV-naive patients. Among 6 cases of ARV-experienced patients (3 with and 3 without viremia), there was 84% and 88% concordance, respectively. Among 3 cases of ARV-experienced patients with viremia, providers reported 20 different ARV selections, suggesting substantial heterogeneity in ARV preferences in clinical practice.

CONCLUSIONS

HIV-ASSIST is a novel patient-centric educational decision support tool that provides ARV recommendations concordant with experienced HIV providers for a diverse set of patient scenarios.

Sustained HIV viral suppression among men who have sex with men in the Miami-Dade County Ryan White Program: the effect of demographic, psychosocial, provider and neighborhood factors

Background

HIV viral suppression is associated with health benefits for people living with HIV and a decreased risk of HIV transmission to others. The objective was to identify demographic, psychosocial, provider and neighborhood factors associated with sustained viral suppression among gay, bisexual, and other men who have sex with men.

Methods

Data from adult men who have sex with men (MSM) enrolled in the Miami-Dade County Ryan White Program (RWP) before 2017 were used. Sustained viral suppression was defined as having an HIV viral load < 200 copies/ml in all viral load tests in 2017. Three-level (individual, medical case management site, and neighborhood) cross-classified mixed-effect models were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for sustained viral suppression.

Results

Of 3386 MSM, 90.8% were racial/ethnic minorities, and 84.4% achieved sustained viral suppression. The odds of achieving sustained viral suppression was lower for 18–24 and 25–34 year-old MSM compared with 35–49 year-old MSM, and for non-Latino Black MSM compared with White MSM. Those not enrolled in the Affordable Care Act, and those with current AIDS symptoms and a history of AIDS had lower odds of achieving sustained viral suppression. Psychosocial factors significantly associated with lower odds of sustained viral suppression included drug/alcohol use, mental health symptoms, homelessness, and transportation to appointment needs. Individuals with an HIV physician who serves a larger volume of RWP clients had greater odds of sustained viral suppression. Neighborhood factors were not associated with sustained viral suppression.

Conclusion

Despite access to treatment, age and racial disparities in sustained viral suppression exist among MSM living with HIV. Addressing substance use, mental health, and social services’ needs may improve the ability of MSM to sustain viral suppression long-term. Furthermore, physician characteristics may be associated with HIV outcomes and should be explored further.

HIV and Aging: Reconsidering the Approach to Management of Comorbidities

Health care for older adults with human immunodeficiency virus can be highly complex, resource intensive, and carry a high administrative burden. Data from aging longitudinal cohorts and feedback from the human immunodeficiency virus community suggest that the current model is not meeting the needs of these older adults. We introduce the 6 Ms approach, which acknowledges the multicomplexity of older adults with human immunodeficiency virus, simplifies geriatric principles for non-geriatrics-trained providers, and minimizes extensive training and specialized screening tests or tools. Implementing novel approaches to care requires support at local/national levels.

The organizational attributes of HIV care delivery models in Canada: A cross-sectional study

HIV treatment in Canada has rapidly progressed with the advent of new drug therapies and approaches to care. With this evolution, there is increasing interest in Canada in understanding the current delivery of HIV care, specifically where care is delivered, how, and by whom, to inform the design of care models required to meet the evolving needs of the population. We conducted a cross-sectional survey of Canadian care settings identified as delivering HIV care between June 2015 and January 2016. Given known potential differences in delivery approaches, we stratified settings as primary care or specialist settings, and described their structure, geographic location, populations served, health human resources, technological resources, and available clinical services. We received responses from 22 of 43 contacted care settings located in seven Canadian provinces (51.2% response rate). The total number of patients and HIV patients served by the participating settings was 38,060 and 17,678, respectively (mean number of HIV patients in primary care settings = 1,005, mean number of HIV patients in specialist care settings = 562). Settings were urban for 20 of the 22 (90.9%) clinics and 14 (63.6%) were entirely HIV focused. Primary care settings were more likely to offer preventative services (e.g., cervical smear, needle exchange, IUD insertion, chronic disease self-management program) than specialist settings. The study illustrates diversity in Canadian HIV care settings. All settings were team based, but primary care settings offered a broader range of preventative services and comprehensive access to mental health services, including addictions and peer support.

Training the next generation of HIV providers: impact of trainees on patient satisfaction in an urban HIV clinic

For persons living with HIV and AIDS (PLWHA), care by an HIV-specialist improves outcomes and satisfaction with one's HIV primary care provider (PCP) promotes engagement with care. In the United States, we are facing a workforce shortage of HIV providers. As we aim to train a new generation of HIV providers, it is unclear how PLWHA perceive their experience when cared for by trainees compared to experienced providers. Therefore we assessed patient satisfaction with HIV providers, both trainees in an HIV Primary Care residency program and HIV-specialists. A secondary objective was to evaluate providers' performance in adhering to standard management guidelines for HIV-associated and non-HIV-associated conditions. We surveyed 75 PLWHA, including 51 (68%) assigned to an HIV-specialist PCP and 24 (32%) to a trainee PCP. Overall patient satisfaction on a 10-point scale was similar (mean 9.6 HIV-specialist vs 9.7 trainee, p = 0.71) and remained similar in multivariate logistic regression analysis when controlling for patient age, gender, race, and recently establishing care (Odds Ratio 1.1, 95% Confidence Interval 0.3-5.0). Participants in the trainee group were more likely to feel their provider "always" spent enough time with them (100% vs 81%, p = 0.03). Adherence to HIV guidelines was similar, though trainees were more likely to document counseling on risk reduction (83% vs 47%, p = 0.005) and adherence to antiretroviral therapy (100% vs 66%, p = 0.001). In conclusion, in a structured HIV-training program, residents can provide subspecialty level care in an HIV continuity clinic with levels of performance and patient satisfaction equivalent to those of experienced specialists.

Underutilization of Statins When Indicated in HIV-Seropositive and Seronegative Women

Increased life expectancy of persons living with HIV infection receiving antiretroviral therapy heightens the importance of preventing and treating chronic comorbidities such as cardiovascular disease. While guidelines have increasingly advocated more aggressive use of statins for low-density lipoprotein (LDL) cholesterol reduction, it is unclear whether people with HIV, especially women, are receiving statins when indicated, and whether their HIV disease is a factor in access. We assessed the cumulative incidence of statin use after an indication in the Women's Interagency HIV Study (WIHS), from 2000 to 2014. Additionally, we used weighted proportional hazards regression to estimate the effect of HIV serostatus on the time to initiation of a statin after an indication. Cumulative incidence of statin use 5 years after an indication was low: 38% in HIV-seropositive women and 30% in HIV-seronegative women. Compared to HIV-seronegative women, the weighted hazard ratio for initiation of a statin for HIV-seropositive women over 5 years was 0.94 [95% confidence interval (CI) 0.62, 1.43]. Applying the American College of Cardiology and the American Heart Association (ACC/AHA) guidelines increased the proportion of HIV-seropositive women with a statin indication from 16% to 45%. Clinicians treating HIV-seropositive women should consider more aggressive management of the dyslipidemia often found in this population.

Fostering a "Feeling of Worth" Among Vulnerable HIV Populations: The Role of Linkage to Care Specialists

To address barriers to adequate engagement in medical care among people living with HIV, Wisconsin's AIDS/HIV Program created a new position, the Linkage to Care (LTC) Specialist. Specialists provide intensive, short-term case management and patient navigation services for small caseloads of individuals at high risk of disengaging with medical care. Clients are eligible if they are newly diagnosed with HIV or new to medical care, recently released from incarceration, recently out of care, nonadherent to scheduled medical care visits, or have detectable viral load while in care. Interviews with 30 clients of Specialists were conducted to understand experiences with the program and medical care. Common themes included the ability of Specialists to navigate complex systems of care and support services, the unique role Specialists played in their clients' lives, and the challenges of transitioning out of the program. Although the primary goal of Specialists is to address barriers to medical care, they often adopted a holistic approach that also included housing, financial assistance, and other social determinants of health. Descriptions of the Specialist's role in implementation manuals focus on their functional roles and the services provided. However, clients often discussed the emotional support they received, especially for clients without strong social support networks. Many clients also desired an ongoing relationship with their Specialists even after discharge, but had been able to establish independence and self-efficacy. The LTC Specialists are resource-intensive considering their small caseloads, but fill an important gap in existing, often overtaxed case management systems.

Young Men's Disclosure of Same Sex Behaviors to Healthcare Providers and the Impact on Health: Results from a US National Sample of Young Men Who Have Sex with Men

Many men who have sex with men (MSM) do not disclose their same sex behaviors to healthcare providers (HCPs). We used a series of logistic regression models to explore a conceptual framework that first identified predictors of disclosure to HCPs among young MSM (YMSM), and subsequently examined young men's disclosure of male-male sexual behaviors to HCPs as a mediator between sociodemographic and behavioral factors and three distinct health outcomes [HIV testing, sexually transmitted infection (STI) testing, and human papillomavirus (HPV) vaccination]. We determined the predictors of disclosure to HCPs among YMSM and examined the relationship between disclosure and the receipt of appropriate healthcare services. Data were collected online through a US national sample of 1750 YMSM (ages 18-29 years) using a social and sexual networking website for MSM. Sexual history, STI/HIV screening history, sexual health, and patient-provider communication were analyzed in the logistic regression models. Participants were predominantly white (75.2%) and gay/homosexual (76.7%) with at least some college education (82.7%). Young men's disclosure of male-male sexual behaviors to HCPs was associated with the receipt of all healthcare outcomes in our model. Disclosure was a stronger mediator in HPV vaccination than in HIV and STI testing. Disclosure to non-HCP friends and family, HCP visit in the past year, and previous STI diagnosis were the strongest predictors of disclosure. Young men's disclosure of male-male sexual behaviors to HCPs is integral to the receipt of appropriate healthcare services among YMSM. HPV vaccination is more dependent on provider-level interaction with patients than HIV/STI testing.

Differing Experiences with Pre-Exposure Prophylaxis in Boston Among Lesbian, Gay, Bisexual, and Transgender Specialists and Generalists in Primary Care: Implications for Scale-Up

The Centers for Disease Control and Prevention estimates that one in four sexually active men who have sex with men (MSM) could decrease their HIV risk by using HIV pre-exposure prophylaxis (PrEP). Because many MSM access healthcare from primary care providers (PCPs), these clinicians could play an important role in providing access to PrEP. Semistructured qualitative interviews were conducted with 31 PCPs in Boston, MA, to explore how they approach decisions about prescribing PrEP to MSM and their experiences with PrEP provision. Purposive sampling included 12 PCPs from an urban community health center specializing in the care of lesbian, gay, bisexual, and transgender persons ("LGBT specialists") and 19 PCPs from a general academic medical center ("generalists"). Analyses utilized an inductive approach to identify emergent themes. Both groups of PCPs approached prescribing decisions about PrEP as a process of informed decision-making with patients. Providers would defer to patients' preferences if they were unsure about the appropriateness of PrEP. LGBT specialists and generalists were at vastly different stages of adopting PrEP into practice. For LGBT specialists, PrEP was a disruptive innovation that rapidly became normative in practice. Generalists had limited experience with PrEP; however, they desired succinct decision-support tools to help them achieve proficiency, because they considered preventive medicine to be central to their professional role. As generalists vastly outnumber LGBT specialists in the United States, interventions to support PrEP provision by generalists could accelerate the scale-up of PrEP for MSM nationally, which could in turn decrease HIV incidence for this priority population.