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Martin TCS, Smith LR, Anderson C, Little SJ. Randomized Controlled Trial of 60 minutes for Health With Rapid Antiretroviral Therapy to Reengage Persons With HIV Who Are Out of Care. J Acquir Immune Defic Syndr 2024; 96:486-493. [PMID: 38985446 PMCID: PMC11239090 DOI: 10.1097/qai.0000000000003460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 04/19/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Many persons with HIV remain out of care (PWH-OOC). We evaluated InstaCare, a complex intervention integrating the brief behavioral intervention 60 minutes for Health with the rapid restart of antiretroviral therapy (rapid ART). SETTING Prospective open-label randomized controlled trial among PWH-OOC in San Diego, USA. METHODS PWH-OOC were randomized 1:1 to InstaCare or a time-and-attention control integrating a diet-and-nutrition behavioral intervention also with rapid ART initiation (restart ≤7 days from enrollment). All participants had access to support services (free transport, HIV peer navigation, adherence counseling, and linkage to care) and primary care services (mental health, case management, social work, medication-assisted treatment, and specialist pharmacy). The primary outcomes were viral suppression (<50 copies/mL) and re-engagement with care (≥2 HIV care visits >90 days apart) by 24 weeks. Outcomes were reported on an intention-to-treat basis. RESULTS Between November 2020 and August 2022, 52 PWH-OOC were enrolled. Baseline substance use in the preceding month (49%), unstable housing (51%), moderate/severe depression (49%), and moderate/severe anxiety (41.7%) were prevalent. Rapid ART was provided for all participants. At week 24, the proportion with HIV viral load <50 copies/mL was 37.3% (19/51) (InstaCare 28.0%, control 46.2%, P = 0.25). Fourteen (27.5%) were engaged with care (InstaCare 7/25 [28.0%], control 7/26 [26.9%], P = 1.00). Most participants (94%) reported low or very low emotional distress associated with rapid ART. Study lost to follow-up by week 24 was high (23/51, 45%). CONCLUSIONS The InstaCare complex intervention did not improve viral suppression or reengagement with care among PWH-OOC. Investigation of high-intensity, individually adapted interventions is needed among PWH-OOC.
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Affiliation(s)
- Thomas C. S. Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA
| | - Laramie R. Smith
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA
| | - Christy Anderson
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA
| | - Susan J. Little
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA
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Garcia EA, Foote MMK, McPherson TD, Lash MK, Bosompem AN, Bouscaren A, Chan J, DiLorenzo MA, Feihel D, Fowler RC, Gandhi V, Jenny-Avital ER, Kopping EJ, Mazo D, McLean J, Mgbako O, Sayegh MN, Shaw RN, Su M, Meissner JS, Wang JC, Wen W, Winters JC, Zeana CB, Zucker J, Wong M. Severe Mpox Among People With Advanced Human Immunodeficiency Virus Receiving Prolonged Tecovirimat in New York City. Open Forum Infect Dis 2024; 11:ofae294. [PMID: 38868307 PMCID: PMC11168585 DOI: 10.1093/ofid/ofae294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/16/2024] [Indexed: 06/14/2024] Open
Abstract
Severe mpox has been observed in people with advanced human immunodeficiency virus (HIV). We describe clinical outcomes of 13 patients with advanced HIV (CD4 <200 cells/μL), severe mpox, and multiorgan involvement. Despite extended tecovirimat courses and additional agents, including vaccinia immune globulin, cidofovir, and brincidofovir, this group experienced prolonged hospitalizations and high mortality.
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Affiliation(s)
- Elizabeth A Garcia
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - Mary M K Foote
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - Tristan D McPherson
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - Maura K Lash
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - Amma N Bosompem
- Human Resources Administration, New York City Department of Social Services, New York, New York, USA
| | - Alyssa Bouscaren
- Department of Homeless Services, New York City Department of Social Services, New York, New York, USA
| | - Justin Chan
- Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York, USA
- Department of Internal Medicine and Infectious Diseases, NYC Health + Hospitals/Bellevue, New York, New York, USA
| | - Madeline A DiLorenzo
- Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York, USA
| | - Dennis Feihel
- Lenox Hill Hospital Department of Medicine, Northwell Health, New York, New York, USA
| | - Randal C Fowler
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - Vani Gandhi
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Erik J Kopping
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - Dana Mazo
- Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York, USA
| | - Jacob McLean
- Division of Infectious Diseases, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Ofole Mgbako
- Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York, USA
- Department of Internal Medicine and Infectious Diseases, NYC Health + Hospitals/Bellevue, New York, New York, USA
- New York University Langone Institute for Excellence in Health Equity, NYU Langone Health, New York, New York, USA
| | - Mark N Sayegh
- Division of Infectious Diseases, NYC Health + Hospitals/Harlem, New York, New York, USA
- Division of Infectious Diseases, Columbia University, New York, New York, USA
| | - Raphael N Shaw
- Division of Infectious Diseases, NYC Health + Hospitals/Harlem, New York, New York, USA
- Division of Infectious Diseases, Columbia University, New York, New York, USA
| | - Michelle Su
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - Jeanne Sullivan Meissner
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - Jade C Wang
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - Wendy Wen
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - John C Winters
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Internal Medicine and Infectious Diseases, NYC Health + Hospitals/Elmhurst, Queens, New York, USA
| | - Cosmina B Zeana
- Division of Infectious Diseases, BronxCare Health System, Bronx, New York, USA
| | - Jason Zucker
- Division of Infectious Diseases, New York Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Marcia Wong
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Queens, New York, USA
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Fujita AW, Ramakrishnan A, Mehta CC, Yusuf OB, Thompson AB, Shoptaw S, Carrico AW, Adimora AA, Eaton E, Cohen MH, Jain JP, Adedimeji A, Plankey M, Jones DL, Chandran A, Colasanti JA, Sheth AN. Co-Utilization of HIV, Substance Use, Mental Health Services Among Women With Current Substance Use: Opportunities for Integrated Care? J Prim Care Community Health 2024; 15:21501319241285531. [PMID: 39327860 PMCID: PMC11437548 DOI: 10.1177/21501319241285531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2024] Open
Abstract
BACKGROUND The syndemic of HIV, substance use (SU), and mental illness has serious implications for HIV disease progression among women. We described co-utilization of HIV care, SU treatment, and mental health treatment among women with or at risk for HIV. METHODS We included data from women with or at risk for HIV (n = 2559) enrolled in all 10 sites of the Women's Interagency HIV Study (WIHS) from 2013 to 2020. Current SU was defined as self-reported, non-medical use of drugs in the past year, excluding use of only marijuana. Tobacco and alcohol were assessed separately. We described co-utilization of SU treatment, tobacco and alcohol use treatment, HIV care, and mental health care in the past year among women who were eligible for each service. We compared service utilization by those who did/did not utilize SU treatment using Wald Chi-square tests. RESULTS Among women with current SU (n = 358), 42% reported utilizing SU treatment. Among those with current SU+HIV (n = 224), 84% saw their HIV provider, and 34% saw a mental health provider. Among women with current SU+heavy alcohol use (n = 95), 18% utilized alcohol use treatment; among current SU+tobacco use (n = 276), 8% utilized tobacco use treatment. Women who utilized SU treatment had higher utilization of alcohol use treatment (59% vs. 5%; P < .001) and tobacco use treatment (12% vs. 5%; P = .028). HIV care engagement was high regardless of SU treatment. CONCLUSIONS We found high engagement in SU and HIV care, but low engagement in alcohol and tobacco use treatment. Integrated SU treatment services for women, including tobacco/alcohol treatment and harm reduction, are needed to optimize treatment engagement and HIV care continuum outcomes.
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Affiliation(s)
| | - Aditi Ramakrishnan
- Emory University School of Medicine, Atlanta, GA, USA
- Washington University in St. Louis, St. Louis, MO, USA
| | | | | | - Azure B Thompson
- State University of New York Downstate Health Sciences University, Brooklyn, NY, USA
| | - Steven Shoptaw
- University of California, Los Angeles, Los Angeles, CA, USA
| | - Adam W Carrico
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Adaora A Adimora
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ellen Eaton
- University of Alabama at Birmingham, School of Medicine, Birmingham, AL, USA
| | | | | | | | | | - Deborah L Jones
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Aruna Chandran
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jonathan A Colasanti
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
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Barry MP, Corcorran MA, Tsui JI, Moreno C, Buskin SE, Guthrie BL, Glick SN. High Seroprevalence of Hepatitis C Virus Among Cisgender Women Who Exchange Sex in the Seattle, Washington Area. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:81-90. [PMID: 38258855 DOI: 10.1177/29767342231208936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Injection drug use (IDU) is a risk factor for hepatitis C virus (HCV) acquisition and occurs disproportionately among women who exchange sex (WES). However, little is known about HCV epidemiology in this population. We estimated HCV seroprevalence, identified correlates of HCV seropositivity, and characterized social networks by HCV serostatus and IDU history among WES in the Seattle, Washington, area. METHODS This was a secondary analysis of data from the 2016 National HIV Behavioral Surveillance survey in the Seattle, Washington area, a cross-sectional survey that used respondent-driven sampling (RDS) to enroll WES for money or drugs (N = 291). All participants were offered rapid HCV-antibody testing. We estimated HCV seropositivity and used log regression methods to estimate crude and adjusted prevalence ratios (PRs) for correlates of HCV seropositivity among WES. Using RDS recruitment chain data, we computed homophily indices to estimate the extent to which participants were likely to recruit another participant with the same HCV serostatus and IDU history. RESULTS In the study sample of WES in the Seattle, Washington area, 79% reported lifetime IDU and 60% were HCV seropositive. HCV seropositivity was strongly associated with ever injecting drugs (PRadj: 7.7 [3.3, 18.0]). The RDS homophily scores for HCV seropositivity (0.07) and ever injecting drugs (0.02) suggested that participants did not tend to recruit others with the same characteristics beyond what would be expected by chance. CONCLUSION Among this sample of WES in Seattle, Washington area, HCV seroprevalence was high and strongly associated with a history of IDU. The high burden of HCV among WES suggests this marginalized group would benefit from additional harm reduction services and targeted HCV treatment campaigns to reduce forward transmission. We saw little evidence of preferential recruitment among WES who were HCV seropositive or reported a history of IDU, suggesting the potential futility of peer-based referrals for HCV treatment.
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Affiliation(s)
- Michael P Barry
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- HIV/STD Program, Public Health-Seattle & King County, Seattle, WA, USA
| | - Maria A Corcorran
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Judith I Tsui
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Courtney Moreno
- HIV/STD Program, Public Health-Seattle & King County, Seattle, WA, USA
| | - Susan E Buskin
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- HIV/STD Program, Public Health-Seattle & King County, Seattle, WA, USA
| | - Brandon L Guthrie
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Sara N Glick
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- HIV/STD Program, Public Health-Seattle & King County, Seattle, WA, USA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
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5
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Altwies EE, Zinsli KA, Chwastiak L, Tsui JI, Bhatraju EP, Ramchandani MS, Golden MR, Dombrowski JC. Substance Use and Mental Health Comorbidities and Receipt of Specialty Care Among Patients Enrolled in a Low-Barrier HIV Clinic. AIDS Behav 2023; 27:3952-3960. [PMID: 37351687 PMCID: PMC11022825 DOI: 10.1007/s10461-023-04110-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 06/24/2023]
Abstract
Low-barrier care is one model of a differentiated service delivery approach for people with HIV (PWH) who are not engaged in conventionally-organized HIV care. Although psychiatric and substance use disorders are common among patients in low-barrier clinics, approaches to behavioral health service delivery within this context have not been well-described. We conducted a descriptive analysis using retrospective review of medical records to evaluate substance use and psychiatric comorbidities and receipt of behavioral health services among patients in the Max Clinic in Seattle, Washington. Among 227 patients enrolled from 2015 to mid-2020, most had a history of hazardous substance use (85%), a psychiatric diagnosis (69%) or unstable housing (69%) documented in the medical record. Less than half of patients referred for depression treatment (33%) or for opioid use disorder treatment (40%) completed even one specialty care visit. More effective approaches are needed to engage patients in behavioral health services within the context of low-barrier HIV care.
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Affiliation(s)
- Eden E Altwies
- School of Medicine, University of Washington, Seattle, WA, USA.
| | - Kaitlin A Zinsli
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Lydia Chwastiak
- Department of Psychiatry, University of Washington, Seattle, WA, USA
| | - Judith I Tsui
- Department of Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Matthew R Golden
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Public Health - Seattle & King County HIV/STD Program, Seattle, WA, USA
| | - Julia C Dombrowski
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Public Health - Seattle & King County HIV/STD Program, Seattle, WA, USA
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6
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Sweitzer S, Giegold M, Chen Y, Farber EW, Sumitani J, Henderson A, Easley K, Armstrong WS, Colasanti JA, Ammirati RJ, Marconi VC. The CARES Program: Improving Viral Suppression and Retention in Care Through a Comprehensive Team-Based Approach to Care for People with HIV and Complex Psychosocial Needs. AIDS Patient Care STDS 2023; 37:416-424. [PMID: 37566532 PMCID: PMC10623061 DOI: 10.1089/apc.2023.0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023] Open
Abstract
Retention in HIV care and viral suppression rates remain suboptimal, especially among people with HIV (PWH) facing complex barriers to care such as mental health conditions, substance use disorders, and housing insecurity. The Center for Adherence, Retention, and Engagement Support (CARES) program utilizes an interdisciplinary team that delivers integrated services in a drop-in setting to provide individualized care to PWH with complex psychosocial needs. We describe the CARES program and evaluate its effectiveness in retaining patients in care to achieve virological suppression. We characterized 119 referrals of PWH experiencing homelessness, mental health conditions, and substance use disorders to CARES between 2011 and 2017, and collected data for a 24-month observation period through 2019. Outcomes of patients who participated in CARES were compared with those who were referred but did not participate. The primary outcome was viral suppression (<200 copies/mL) at least once during 2-year follow-up. Retention in care (≥2 completed medical visits ≥90 days apart in each year post-referral) was a secondary outcome. Of 119 PWH referred to CARES, 59 participated with ≥2 visits. Those who participated in CARES were more likely to achieve viral suppression [adjusted odds ratio (aOR) 3.50, 95% confidence interval (CI) 1.19-10.32] and to be retained in care (aOR 3.73, 95% CI 1.52-9.14) compared with those who were referred but did not participate. This analysis found that the CARES program improved retention in care and viral suppression among PWH with complex psychosocial needs and suggests that it may represent a useful model for future programming.
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Affiliation(s)
- Stephanie Sweitzer
- J. Willis Hurst Internal Medicine Residency Program, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maddie Giegold
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Yunyun Chen
- Biostatistics and Informatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Eugene W. Farber
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
| | - Jeri Sumitani
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
| | | | - Kirk Easley
- Biostatistics and Informatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Wendy S. Armstrong
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jonathan A. Colasanti
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Rachel J. Ammirati
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
| | - Vincent C. Marconi
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Emory Vaccine Center, Atlanta, Georgia, USA
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Dombrowski JC, Ramchandani MS, Golden MR. Implementation of Low-Barrier Human Immunodeficiency Virus Care: Lessons Learned From the Max Clinic in Seattle. Clin Infect Dis 2023; 77:252-257. [PMID: 37021670 PMCID: PMC10371304 DOI: 10.1093/cid/ciad202] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/20/2023] [Accepted: 03/31/2023] [Indexed: 04/07/2023] Open
Abstract
Low-barrier care (LBC) for people with human immunodeficiency virus (HIV) is a differentiated service delivery strategy to engage people in HIV treatment who are not well-engaged in conventionally organized HIV medical care. The LBC approach is flexible, but experience suggests that the intervention has distinct core components. This review summarizes our experience implementing one model of LBC, the Max Clinic in Seattle; describes the core components of the intervention; and presents a framework for implementing low-barrier HIV care with the goal of providing a practical guide for clinical and public health leaders seeking to implement a new LBC program. A systematic approach to addressing key factors during LBC implementation can support practitioners to design an LBC approach that fits the local context while maintaining essential elements of the intervention.
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Affiliation(s)
- Julia C Dombrowski
- Department of Medicine, University of Washington, Seattle, Washington, USA
- HIV/STD Program, Public Health–Seattle & King County, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Meena S Ramchandani
- Department of Medicine, University of Washington, Seattle, Washington, USA
- HIV/STD Program, Public Health–Seattle & King County, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Matthew R Golden
- Department of Medicine, University of Washington, Seattle, Washington, USA
- HIV/STD Program, Public Health–Seattle & King County, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Center for AIDS and STD, University of Washington, Seattle, Washington, USA
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Irvine MK, Abdelqader F, Levin B, Thomas J, Avoundjian T, Peterson M, Zimba R, Braunstein SL, Robertson MM, Nash D. Study protocol for data to suppression (D2S): a cluster-randomised, stepped-wedge effectiveness trial of a reporting and capacity-building intervention to improve HIV viral suppression in housing and behavioural health programmes in New York City. BMJ Open 2023; 13:e076716. [PMID: 37451738 PMCID: PMC10351323 DOI: 10.1136/bmjopen-2023-076716] [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] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION With progress in the 'diagnose', 'link' and 'retain' stages of the HIV care continuum, viral suppression (VS) gains increasingly hinge on antiretroviral adherence among people with HIV (PWH) retained in care. The Centers for Disease Control and Prevention estimate that unsuppressed viral load among PWH in care accounts for 20% of onward transmission. HIV intervention strategies include 'data to care' (D2C)-using surveillance to identify out-of-care PWH for follow-up. However, most D2C efforts target care linkage, not antiretroviral adherence, and limit client-level data sharing to medical (versus support-service) providers. Drawing on lessons learnt in D2C and successful local pilots, we designed a 'data-to-suppression' intervention that offers HIV support-service programmes surveillance-based reports listing their virally unsuppressed clients and capacity-building assistance for quality-improvement activities. We aimed to scale and test the intervention in agencies delivering Ryan White HIV/AIDS Programme-funded behavioural health and housing services. METHODS AND ANALYSIS To estimate intervention effects, this study applies a cross-sectional, stepped-wedge design to the intervention's rollout to 27 agencies randomised within matched pairs to early or delayed implementation. Data from three 12-month periods (pre-implementation, partial implementation and full implementation) will be examined to assess intervention effects on timely VS (within 6 months of a report listing the client as needing follow-up for VS). Based on projected enrolment (n=1619) and a pre-implementation outcome probability of 0.40-0.45, the detectable effect size with 80% power is an OR of 2.12 (relative risk: 1.41-1.46). ETHICS AND DISSEMINATION This study was approved by the New York City Department of Health and Mental Hygiene's institutional review board (protocol: 21-036) with a waiver of informed consent. Findings will be disseminated via publications, conferences and meetings including provider-agency representatives. TRIAL REGISTRATION NUMBER NCT05140421.
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Affiliation(s)
- Mary K Irvine
- Bureau of Hepatitis, HIV, and Sexually Transmitted Infections, New York City Department of Health and Mental Hygiene, New York City, New York, USA
| | - Faisal Abdelqader
- Bureau of Hepatitis, HIV, and Sexually Transmitted Infections, New York City Department of Health and Mental Hygiene, New York City, New York, USA
| | - Bruce Levin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York City, New York, USA
| | - Jacinthe Thomas
- Bureau of Hepatitis, HIV, and Sexually Transmitted Infections, New York City Department of Health and Mental Hygiene, New York City, New York, USA
| | - Tigran Avoundjian
- Bureau of Hepatitis, HIV, and Sexually Transmitted Infections, New York City Department of Health and Mental Hygiene, New York City, New York, USA
| | - Meghan Peterson
- Bureau of Hepatitis, HIV, and Sexually Transmitted Infections, New York City Department of Health and Mental Hygiene, New York City, New York, USA
| | - Rebecca Zimba
- Institute for Implementation Science in Population Health, City University of New York, New York City, New York, USA
| | - Sarah L Braunstein
- Bureau of Hepatitis, HIV, and Sexually Transmitted Infections, New York City Department of Health and Mental Hygiene, New York City, New York, USA
| | - McKaylee M Robertson
- Institute for Implementation Science in Population Health, City University of New York, New York City, New York, USA
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York City, New York, USA
- Department of Epidemiology and Biostatistics, City University of New York, New York City, New York, USA
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9
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Irvine MK, Levin B, Abdelqader F, Carmona J, Avoundjian T, Thomas J, Braunstein SL, Robertson M, Nash D. Evaluation of the Revised Versus Original Ryan White Part A HIV Care Coordination Program in a Cluster-Randomized, Stepped-Wedge Trial. J Acquir Immune Defic Syndr 2023; 92:325-333. [PMID: 36729538 PMCID: PMC9936966 DOI: 10.1097/qai.0000000000003139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND To address challenges with delivery of an evidence-based HIV care coordination program (CCP), the New York City Health Department initiated a CCP redesign. We conducted a site-randomized stepped-wedge trial to evaluate effectiveness of the revised versus the original model. SETTING The CCP is delivered in New York City hospitals, community health centers, and community-based organizations to people experiencing or at risk for poor HIV outcomes. METHODS The outcome, timely viral suppression (TVS), was defined as achievement of viral load <200 copies/mL within 4 months among enrollees with unsuppressed viral load (≥200 copies/mL). Seventeen original-CCP provider agencies were randomized within matched pairs to early (August 2018) or delayed (May 2019) starts of revised-model implementation. Data from 3 periods were examined to compare revised versus original CCP effects on TVS. The primary analysis of the intervention effect applied fully conditional maximum likelihood estimation together with an exact, conditional P -value and an exact test-based 95% CI. We assigned each trial enrollee the implementation level of their site (based on a three-component measure) and tested for association with TVS, adjusting for period and study arm. RESULTS Over 3 nine-month periods, 960 individuals were eligible for trial inclusion (intention to treat). The odds ratio of TVS versus no TVS comparing revised with original CCP was 0.88 (95% CI: 0.45, 1.7). Thus, the revised program yielded slightly lower TVS, although the effect was statistically nonsignificant. TVS was not significantly associated with revised-CCP implementation level. CONCLUSION Program revisions did not increase TVS, irrespective of the implementation level.
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Affiliation(s)
- Mary K. Irvine
- Bureau of Hepatitis, HIV and Sexually Transmitted Infections (BHHS), New York City Department of Health and Mental Hygiene (DOHMH); New York, NY
| | - Bruce Levin
- Department of Biostatistics, Mailman School of Public Health (MSPH), Columbia University (CU); New York, NY; and
| | - Faisal Abdelqader
- Bureau of Hepatitis, HIV and Sexually Transmitted Infections (BHHS), New York City Department of Health and Mental Hygiene (DOHMH); New York, NY
| | - Jennifer Carmona
- Bureau of Hepatitis, HIV and Sexually Transmitted Infections (BHHS), New York City Department of Health and Mental Hygiene (DOHMH); New York, NY
| | - Tigran Avoundjian
- Bureau of Hepatitis, HIV and Sexually Transmitted Infections (BHHS), New York City Department of Health and Mental Hygiene (DOHMH); New York, NY
| | - Jacinthe Thomas
- Bureau of Hepatitis, HIV and Sexually Transmitted Infections (BHHS), New York City Department of Health and Mental Hygiene (DOHMH); New York, NY
| | - Sarah L. Braunstein
- Bureau of Hepatitis, HIV and Sexually Transmitted Infections (BHHS), New York City Department of Health and Mental Hygiene (DOHMH); New York, NY
| | - McKaylee Robertson
- Institute for Implementation Science in Population Health (ISPH), Graduate School of Public Health and Health Policy, City University of New York (CUNY); New York, NY
| | - Denis Nash
- Institute for Implementation Science in Population Health (ISPH), Graduate School of Public Health and Health Policy, City University of New York (CUNY); New York, NY
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10
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Hickey MD, Sergi F, Zhang K, Spinelli MA, Black D, Sola C, Blaz V, Nguyen JQ, Oskarsson J, Gandhi M, Havlir DV. Pragmatic randomized trial of a pre-visit intervention to improve the quality of telemedicine visits for vulnerable patients living with HIV. J Telemed Telecare 2023; 29:187-195. [PMID: 33342328 PMCID: PMC8214632 DOI: 10.1177/1357633x20976036] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The COVID-19 pandemic has required a shift of many routine primary care visits to telemedicine, potentially widening disparities in care access among vulnerable populations. In a publicly-funded HIV clinic, we aimed to evaluate a pre-visit phone-based planning intervention to address anticipated barriers to telemedicine. METHODS We conducted a pragmatic randomized controlled trial of patients scheduled for a phone-based HIV primary care visit at the Ward 86 HIV clinic in San Francisco from 15 April to 15 May 2020. Once reached by phone, patients were randomized to either have a structured pre-visit planning intervention to address barriers to an upcoming telemedicine visit versus a standard reminder call. The primary outcome was telemedicine visit attendance. RESULTS Of 476 scheduled telemedicine visits, 280 patients were reached by a pre-visit call to offer enrollment. Patients were less likely to be reached if virally unsuppressed (odds ratio (OR) 0.11, 95% confidence intervals (CI) 0.03-0.48), CD4 < 200 (OR 0.24, 95% CI 0.07-0.85), or were homeless (OR 0.24, 95% CI 0.07-0.87). There was no difference between intervention and control in scheduled visit attendance (83% v. 78%, OR 1.38, 95% CI 0.67-2.81). CONCLUSIONS A structured phone-based planning call to address barriers to telemedicine in a public HIV clinic was less likely to reach patients with poorly-controlled HIV and patients experiencing homelessness, suggesting additional interventions may be needed in this population to ensure access to telemedicine-based care. Among patients reachable by phone, telemedicine visit attendance was high and not improved with a structured pre-visit intervention, suggesting that standard reminders may be adequate in this population.
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Affiliation(s)
- Matthew D Hickey
- Division of HIV, ID and Global Medicine, University of California, USA
| | | | - Kevin Zhang
- Feinberg School of Medicine, Northwestern University, USA
| | | | - Douglas Black
- Division of HIV, ID and Global Medicine, University of California, USA
| | - Cyril Sola
- Division of HIV, ID and Global Medicine, University of California, USA
| | - Vanessa Blaz
- Division of HIV, ID and Global Medicine, University of California, USA
| | - Janet Q Nguyen
- Division of HIV, ID and Global Medicine, University of California, USA
| | - Jon Oskarsson
- Division of HIV, ID and Global Medicine, University of California, USA
| | - Monica Gandhi
- Division of HIV, ID and Global Medicine, University of California, USA
| | - Diane V Havlir
- Division of HIV, ID and Global Medicine, University of California, USA
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11
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Yang WT, Dombrowski JC, Glick SN, Kim HN, Beieler AM, Lan KF, Dhanireddy S. Partial-Oral Antibiotic Therapy for Bone and Joint Infections in People With Recent Injection Drug Use. Open Forum Infect Dis 2023; 10:ofad005. [PMID: 36726538 PMCID: PMC9887258 DOI: 10.1093/ofid/ofad005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023] Open
Abstract
Background Limited outcome data exist regarding partial-oral antibiotic therapy, defined as oral antibiotics as part of a patient's treatment, for bone and joint infections (BJIs) in people who inject drugs (PWID). Methods We conducted a retrospective study of all PWID reporting drug use within 3 months and BJIs requiring ≥6 weeks of antibiotics in an urban safety-net hospital between February 1, 2019, and February 1, 2021. Treatment outcomes were assessed by chart review. Rates of failure, defined as death, symptoms, or signs concerning for worsening or recurrent infections, were assessed 90 and 180 days after completion of antibiotics. Univariate logistic regression was used to explore the association between covariates and failure. Results Of 705 patients with BJI, 88 (13%) were PWID. Eighty-six patients were included in the final cohort. Forty-four (51%) were homeless, 50 (58%) had spine infection, 68 (79%) had surgery, and 32 of 68 (47%) had postoperatively retained hardware. Twelve (14%) of 86 patients received exclusively intravenous (IV) antibiotics, and 74 (86%) received partial-oral antibiotics. Twelve (14%) of 86 patients had patient-directed discharge. In those who received partial-oral antibiotics, the failure rate was 20% at 90 days and 21% at 180 days after completion of intended treatment. Discharge to a medical respite and follow-up with infectious diseases (ID) or surgery were negatively associated with odds of failure. Conclusions Partial-oral treatment of BJI in PWID was a common practice and often successful when paired with medical respite and follow-up with ID or surgery.
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Affiliation(s)
- Wei-Teng Yang
- Correspondence: Wei-Teng Yang, MD, MPH, Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Department of Medicine, Oregon Health & Science University, 3181 Southwest Samuel Jackson Park Road, Mail Code UNH30, Portland, OR 97239. E-mail:
| | - Julia C Dombrowski
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA,HIV/STD Program, Public Health-Seattle & King County, Seattle, Washington, USA
| | - Sara N Glick
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA,HIV/STD Program, Public Health-Seattle & King County, Seattle, Washington, USA
| | - H Nina Kim
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | | | - Kristine F Lan
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
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12
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Kumbhakar RG, Budak JZ, Tao Y, Beste J, Lake E, Navabi N, Mose E, Barker G, Lee J, Hara K, Khosropour C, Dhanireddy S, Dombrowski JC. The Impact of a Walk-in Human Immunodeficiency Virus Care Model for People Who Are Incompletely Engaged in Care: The Moderate Needs (MOD) Clinic. Open Forum Infect Dis 2023; 10:ofac670. [PMID: 36628059 PMCID: PMC9825197 DOI: 10.1093/ofid/ofac670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Background The Moderate Needs (MOD) Clinic in Seattle, Washington provides walk-in primary care for people with human immunodeficiency virus (HIV) who are incompletely engaged in standard care. Methods We evaluated HIV outcomes among patients enrolled in the MOD Clinic (within group analysis) and, separately, among MOD patients versus patients who were MOD-eligible but did not enroll (comparison group analysis) during January 1, 2018-September 30, 2021. The primary outcome was viral suppression ([VS] viral load <200 copies/mL); secondary outcomes care engagement (≥2 visits ≥60 days apart) and sustained VS (≥2 consecutive suppressed viral loads ≥60 days apart). In the within group analysis, we examined outcomes at time of MOD enrollment versus 12 months postenrollment. In the comparison group analysis, we examined outcomes at the time of MOD eligibility versus 12 months posteligibility. Both analyses used modified Poisson regression. Results Most patients in MOD (N = 213) were unstably housed (52%) and had psychiatric comorbidities (86%) or hazardous substance use (81%). Among patients enrolled ≥12 months (N = 164), VS did not increase significantly from baseline to postenrollment (63% to 71%, P = .11), but care engagement and sustained VS both improved (37% to 86%, P < .001 and 20% to 53%, P < .001, respectively) from pre-enrollment to 12 months postenrollment. In the comparison group analysis, VS worsened in nonenrolled patients (N = 517) from baseline to 12 months posteligibility (82% to 75%, P < .001). Patients in the MOD Clinic who met criteria for the comparison group analysis (N = 68) were more likely than nonenrolled patients to be engaged in care at 12 months posteligibility (relative risk, 1.29; 95% confidence interval, 1.03-1.63). Conclusions The MOD Clinic enrollment was associated with improved engagement in care. This model adds to the spectrum of differentiated HIV care services.
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Affiliation(s)
- Raaka G Kumbhakar
- Correspondence: Raaka G. Kumbhakar, MD, Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, 325 9th Ave., Box 358061, Seattle, WA 98104 (). Julia C. Dombrowski, MD, MPH, 325 9th Ave., Box 359777, Seattle, WA 98104 ()
| | - Jehan Z Budak
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Yuan Tao
- Harborview Medical Center, Seattle, Washington, USA
| | - Jason Beste
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Eve Lake
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Nazlee Navabi
- Present Affiliation: Wise Patient Internal Medicine, Seattle, Washington, USA
| | - Eric Mose
- Harborview Medical Center, Seattle, Washington, USA
| | - Gwen Barker
- Harborview Medical Center, Seattle, Washington, USA
| | - Ji Lee
- Harborview Medical Center, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Katie Hara
- Present Affiliation: Bailey-Boushay House, Seattle, Washington, USA
| | | | - Shireesha Dhanireddy
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Julia C Dombrowski
- Correspondence: Raaka G. Kumbhakar, MD, Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, 325 9th Ave., Box 358061, Seattle, WA 98104 (). Julia C. Dombrowski, MD, MPH, 325 9th Ave., Box 359777, Seattle, WA 98104 ()
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13
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Dombrowski JC, Halliday S, Tsui JI, Rao D, Sherr K, Ramchandani MS, Emerson R, Fleming M, Wood T, Chwastiak L. Adaptation of the collaborative care model to integrate behavioral health care into a low-barrier HIV clinic. IMPLEMENTATION RESEARCH AND PRACTICE 2023; 4:26334895231167105. [PMID: 37790178 PMCID: PMC10123894 DOI: 10.1177/26334895231167105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Background The collaborative care management (CoCM) model is an evidence-based intervention for integrating behavioral health care into nonpsychiatric settings. CoCM has been extensively studied in primary care clinics, but implementation in nonconventional clinics, such as those tailored to provide care for high-need, complex patients, has not been well described. Method We adapted CoCM for a low-barrier HIV clinic that provides walk-in medical care for a patient population with high levels of mental illness, substance use, and housing instability. The Exploration, Preparation, Implementation, and Sustainment model guided implementation activities and support through the phases of implementing CoCM. The Framework for Reporting Adaptations and Modifications to Evidence-Based Interventions guided our documentation of adaptations to process-of-care elements and structural elements of CoCM. We used a multicomponent strategy to implement the adapted CoCM model. In this article, we describe our experience through the first 6 months of implementation. Results The key contextual factors necessitating adaptation of the CoCM model were the clinic team structure, lack of scheduled appointments, high complexity of the patient population, and time constraints with competing priorities for patient care, all of which required substantial flexibility in the model. The process-of-care elements were adapted to improve the fit of the intervention with the context, but the core structural elements of CoCM were maintained. Conclusions The CoCM model can be adapted for a setting that requires more flexibility than the usual primary care clinic while maintaining the core elements of the intervention.
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Affiliation(s)
- Julia C. Dombrowski
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Public Health – Seattle & King County, HIV/STD Program, Seattle, WA, USA
| | - Scott Halliday
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Judith I. Tsui
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Deepa Rao
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Kenneth Sherr
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA, USA
| | - Meena S. Ramchandani
- Department of Medicine, University of Washington, Seattle, WA, USA
- Public Health – Seattle & King County, HIV/STD Program, Seattle, WA, USA
| | - Ramona Emerson
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Mark Fleming
- Public Health – Seattle & King County, HIV/STD Program, Seattle, WA, USA
| | - Teagan Wood
- Department of Social Work, Harborview Medical Center, Seattle, WA, USA
| | - Lydia Chwastiak
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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14
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Barry MP, Austin EJ, Bhatraju EP, Glick SN, Stekler JD, Tung EL, Hansen RN, Williams EC, Gojic AJ, Pickering EI, Tsui JI. Qualitative inquiry into perceptions of HIV pre-exposure prophylaxis among people who inject drugs living with hepatitis C in Seattle, WA, USA. Harm Reduct J 2022; 19:121. [PMID: 36320005 PMCID: PMC9628120 DOI: 10.1186/s12954-022-00706-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 10/07/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The incidence of HIV among persons who inject drugs (PWID) in the USA has been increasing since 2014, signaling the need to identify effective ways to engage PWID in HIV prevention services, namely pre-exposure prophylaxis (PrEP). Yet, the uptake of PrEP in this population is minimal compared to other populations at risk of HIV acquisition. In this work, we sought to explore knowledge, attitudes, and perspectives of PrEP acceptability among PWID. METHODS In the context of a pilot study to explore the acceptability of pharmacy-based hepatitis C virus (HCV) treatment, we conducted semi-structured interviews (n = 24) and focus groups (n = 4, 16 participants) with people who were living with HCV and reported active injection drug use (≤ 90 days since last use). Participants were asked open-ended questions about their familiarity with and motivation to use PrEP. As part of a sub-analysis focused on PrEP, qualitative data were analyzed using a Rapid Assessment Process, where three coders used structured templates to summarize qualitative data and iteratively reviewed coded templates to identify themes. Participants also completed short quantitative questionnaires regarding drug use history and attitudes toward health concerns. RESULTS Forty-seven percent of participants expressed having little or no concern regarding HIV acquisition. Targeted analyses focused on HIV prevention identified three themes, which help characterize behavioral determinants of nonadoption. First, knowledge of PrEP was limited among PWID and influenced by infrequent open community discussions around HIV risk. Second, PWID perceived sexual behaviors-but not injection drug use-as a motivator for HIV risk prevention. Finally, PWID identified many individual and environmental barriers that hinder PrEP uptake. CONCLUSION Among PWID, PrEP is rarely discussed and concerns about the feasibility of using daily PrEP are common. Taken with the prevalent perception that drug use is not a high risk for HIV acquisition, our findings point to opportunities for public health work to target PrEP education to PWID and to leverage other successful interventions for PWID as an opportunity to provide PrEP to this vulnerable population.
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Affiliation(s)
- Michael P Barry
- Department of Epidemiology, Hans Rosling Center, School of Public Health, University of Washington, 3980 15th Ave. NE, 8th Floor, Box 351619, Seattle, WA, 98195, USA
- HIV/STD Program, Public Health - Seattle and King County, 401 5th Ave. Suite 1300, Seattle, WA, 98104, USA
| | - Elizabeth J Austin
- Department of Health Systems and Population Health, Hans Rosling Center, School of Public Health, University of Washington, 3980 15th Ave. NE, 4th Floor, Box 351621, Seattle, WA, 98195, USA
| | - Elenore P Bhatraju
- Division of General Internal Medicine, Department of Medicine, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359780, Seattle, WA, 98104, USA
| | - Sara N Glick
- HIV/STD Program, Public Health - Seattle and King County, 401 5th Ave. Suite 1300, Seattle, WA, 98104, USA
- Division of Allergy and Infectious Diseases, University of Washington, 1959 NE Pacific St., Box 356423, Seattle, WA, 98195, USA
| | - Joanne D Stekler
- Department of Epidemiology, Hans Rosling Center, School of Public Health, University of Washington, 3980 15th Ave. NE, 8th Floor, Box 351619, Seattle, WA, 98195, USA
- Division of Allergy and Infectious Diseases, University of Washington, 1959 NE Pacific St., Box 356423, Seattle, WA, 98195, USA
- Department of Global Health, Hans Rosling Center, School of Public Health, University of Washington, 3980 15th Ave. NE, 7th Floor, Seattle, WA, 98195, USA
| | - Elyse L Tung
- Kelley-Ross Pharmacy Group, Seattle, WA, USA
- Department of Pharmacy, University of Washington, H375 Health Science Building, Box 357630, Seattle, WA, 98195-7630, USA
| | - Ryan N Hansen
- Department of Health Systems and Population Health, Hans Rosling Center, School of Public Health, University of Washington, 3980 15th Ave. NE, 4th Floor, Box 351621, Seattle, WA, 98195, USA
- Kelley-Ross Pharmacy Group, Seattle, WA, USA
- Department of Pharmacy, University of Washington, H375 Health Science Building, Box 357630, Seattle, WA, 98195-7630, USA
| | - Emily C Williams
- Department of Health Systems and Population Health, Hans Rosling Center, School of Public Health, University of Washington, 3980 15th Ave. NE, 4th Floor, Box 351621, Seattle, WA, 98195, USA
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound, 1660 South Columbia Way, Building 101, Room 4E51, Seattle, WA, 98108, USA
| | - Alexander J Gojic
- Division of General Internal Medicine, Department of Medicine, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359780, Seattle, WA, 98104, USA
| | - Eleanor I Pickering
- Division of General Internal Medicine, Department of Medicine, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359780, Seattle, WA, 98104, USA
- Department of Social and Behavioral Sciences, Yale School of Public Health, 60 College Street, Suite 316, New Haven, CT, 06510, USA
| | - Judith I Tsui
- Division of General Internal Medicine, Department of Medicine, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359780, Seattle, WA, 98104, USA.
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Padilla M, Carter B, Gutierrez M, Fagan J. The Boundary of HIV Care: Barriers and Facilitators to Care Engagement Among People with HIV in the United States. AIDS Patient Care STDS 2022; 36:321-331. [PMID: 35951449 PMCID: PMC10123534 DOI: 10.1089/apc.2022.0062] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Treating people with HIV (PWH) quickly and effectively to achieve viral suppression is a key strategy for Ending the HIV Epidemic. Understanding barriers and facilitators to HIV care engagement could improve outcomes among PWH and reduce HIV infections. We sampled PWH who participated in the Medical Monitoring Project from June 2018 to May 2019 and were not engaged in HIV care to participate in 60-min semistructured telephone interviews on barriers and facilitators to HIV care engagement. We used applied thematic analysis and placed codes into themes based on their frequency and salience. Participants reported various intrapersonal, health system, and structural barriers to care. We conceptualize the boundary of care as the space between the stages of the HIV care continuum, where PWH may find themselves when they lack intrapersonal, health system, and structural support. Research and interventions tackling these barriers are needed to improve outcomes among PWH and reduce HIV infections.
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Affiliation(s)
- Mabel Padilla
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Brittani Carter
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee, USA
| | - Mariana Gutierrez
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee, USA
| | - Jennifer Fagan
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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16
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Cannon CA, Ramchandani MS, Golden MR. Feasibility of a novel self-collection method for blood samples and its acceptability for future home-based PrEP monitoring. BMC Infect Dis 2022; 22:459. [PMID: 35562692 PMCID: PMC9100305 DOI: 10.1186/s12879-022-07432-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 04/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most non-clinic based HIV pre-exposure prophylaxis (PrEP) programs require fingersticks to self-collect blood specimens for laboratory monitoring, a technique that often results in inadequate blood volume for quantitative syphilis and HIV serological testing. We evaluated the acceptability and feasibility of using the Tasso OnDemand™ device as a self-sampling method for PrEP monitoring tests and compared results from samples obtained using the Tasso device to clinician-collected blood samples. METHODS We enrolled study subjects online and in a sexual health clinic and HIV clinic in Seattle, WA, USA to assess the acceptability of blood self-sampling and preferences for home-based PrEP monitoring. We compared HIV antigen/antibody, quantitative rapid plasma reagin and creatinine results in paired self-collected and clinical specimens collected from a subset of participants. RESULTS Of 141 participants, 124 (88%) were interested in collecting samples for PrEP monitoring at home. Among 48 who completed blood collections, 94% found the Tasso device easy to use and 95% felt they could perform self-sampling at home. Of 27 participants who used two devices, 100% collected sufficient blood to perform up to two tests while 33% collected sufficient serum for three tests. Agreement in test results between paired samples was high. CONCLUSIONS These pilot data suggest that using the Tasso self-collection device is acceptable and could feasibly be used to obtain serum specimens sufficient for guideline-recommended PrEP monitoring, though use of a larger volume device may be preferable.
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Affiliation(s)
- Chase A Cannon
- Department of Medicine, University of Washington, 325 9th Ave, Box 359777, Seattle, WA, USA.
| | - Meena S Ramchandani
- Department of Medicine, University of Washington, 325 9th Ave, Box 359777, Seattle, WA, USA
| | - Matthew R Golden
- Department of Medicine, University of Washington, 325 9th Ave, Box 359777, Seattle, WA, USA
- HIV/STD Program, Public Health-Seattle & King County, 325 9th Ave, Box 359777, Seattle, WA, USA
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17
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Shook AG, Buskin SE, Golden M, Dombrowski JC, Herbeck J, Lechtenberg RJ, Kerani R. Community and Provider Perspectives on Molecular HIV Surveillance and Cluster Detection and Response for HIV Prevention: Qualitative Findings From King County, Washington. J Assoc Nurses AIDS Care 2022; 33:270-282. [PMID: 35500058 PMCID: PMC9062191 DOI: 10.1097/jnc.0000000000000308] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
ABSTRACT Responding quickly to HIV outbreaks is one of four pillars of the U.S. Ending the HIV Epidemic (EHE) initiative. Inclusion of cluster detection and response in the fourth pillar of EHE has led to public discussion concerning bioethical implications of cluster detection and response and molecular HIV surveillance (MHS) among public health authorities, researchers, and community members. This study reports on findings from a qualitative analysis of interviews with community members and providers regarding their knowledge and perspectives of MHS. We identified five key themes: (a) context matters, (b) making sense of MHS, (c) messaging, equity, and resource prioritization, (d) operationalizing confidentiality, and (e) stigma, vulnerability, and power. Inclusion of community perspectives in generating innovative approaches that address bioethical concerns related to the use of MHS data is integral to ensure that widely accessible information about the use of these data is available to a diversity of community members and providers.
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Affiliation(s)
- Alic G. Shook
- College of Nursing, Seattle University Seattle, Washington, USA
| | - Susan E. Buskin
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Epidemiologist, Public Health – Seattle & King County, Seattle, Washington, USA
| | - Matthew Golden
- Public Health – Seattle King County HIV/STD Program
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Julia C. Dombrowski
- Public Health-Seattle & King County HIV/STD Program
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Joshua Herbeck
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | - Roxanne Kerani
- Department of Medicine, University of Washington, Seattle, Washington, USA
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18
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Benbow ND, Mokotoff ED, Dombrowski JC, Wohl AR, Scheer S. The HIV Treat Pillar: An Update and Summary of Promising Approaches. Am J Prev Med 2021; 61:S39-S46. [PMID: 34686289 PMCID: PMC11107265 DOI: 10.1016/j.amepre.2021.05.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 01/22/2023]
Abstract
The Treat pillar of the Ending the HIV Epidemic in the U.S. plan calls for comprehensive strategies to enhance linkage to, and engagement in, HIV medical care to improve viral suppression among people with HIV and achieve the goal of 95% viral suppression by 2025. The U.S. has seen large increases in the proportion of people with HIV who have a suppressed viral load. Viral suppression has increased 41%, from 46% in 2010 to 65% in 2018. An additional increase of 46% is needed to meet the Ending the HIV Epidemic in the U.S. goal. The rate of viral suppression among those in care increased to 85% in 2018, highlighting the need to ensure sustained care for people with HIV. Greater increases in all steps along the HIV care continuum are needed for those disproportionately impacted by HIV, especially the young, sexual and racial/ethnic minorities, people experiencing homelessness, and people who inject drugs. Informed by systematic reviews and current research findings, this paper describes more recent promising practices that suggest an impact on HIV care outcomes. It highlights rapid linkage and treatment interventions; interventions that identify and re-engage people in HIV care through new collaborations among health departments, providers, and hospital systems; coordinated care and low-barrier clinic models; and telemedicine-delivered HIV care approaches. The interventions presented in this paper provide additional approaches that state and local jurisdictions can use to reach their local HIV elimination plans' goals and the ambitious Ending the HIV Epidemic in the U.S. Treat pillar targets by 2030.
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Affiliation(s)
- Nanette D Benbow
- Department of Psychiatry & Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | | | - Julia C Dombrowski
- Department of Medicine, University of Washington, Seattle, Washington; Public Health - Seattle & King County, Seattle, Washington
| | - Amy R Wohl
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California
| | - Susan Scheer
- HIV Epidemiology Section, San Francisco Department of Public Health, San Francisco, California
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Buskin SE, Erly SJ, Glick SN, Lechtenberg RJ, Kerani RP, Herbeck JT, Dombrowski JC, Bennett AB, Slaughter FA, Barry MP, Neme S, Quinnan-Hostein L, Bryan A, Golden MR. Detection and Response to an HIV Cluster: People Living Homeless and Using Drugs in Seattle, Washington. Am J Prev Med 2021; 61:S160-S169. [PMID: 34686286 DOI: 10.1016/j.amepre.2021.04.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/21/2021] [Accepted: 04/28/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The HIV epidemic in King County, Washington has traditionally been highly concentrated among men who have sex with men, and incidence has gradually declined over 2 decades. In 2018, King County experienced a geographically concentrated outbreak of HIV among heterosexual people who inject drugs. METHODS Data sources to describe the 2018 outbreak and King County's response were partner services interview data, HIV case reports, syringe service program client surveys, hospital data, and data from a rapid needs assessment of homeless individuals and people who inject drugs. In 2020, the authors examined the impact of delays in molecular sequence analyses and cluster member size thresholds, for identifying genetically similar clusters, on the timing of outbreak identification. RESULTS In 2018, the health department identified a North Seattle cluster, growing to 30 people with related HIV infections diagnosed in 2008-2019. In total, 70% of cluster members were female, 77% were people who inject drugs, 87% were homeless, and 27% reported exchanging sex. Intervention activities included a rapid needs assessment, 2,485 HIV screening tests in a jail and other outreach settings, provision of 87,488 clean syringes in the outbreak area, and public communications. A lower cluster size threshold and more rapid receipt and analyses of data would have identified this outbreak 4-16 months earlier. CONCLUSIONS This outbreak shows the vulnerability of people who inject drugs to HIV infection, even in areas with robust syringe service programs and declining HIV epidemics. Although molecular HIV surveillance did not identify this outbreak, it may have done so with a lower threshold for defining clusters and more rapid receipt and analyses of HIV genetic sequences.
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Affiliation(s)
- Susan E Buskin
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington; HIV/STD Program, Prevention Division, Public Health-Seattle & King County, Seattle, Washington.
| | - Steven J Erly
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington; Office of Infectious Disease, Division of Disease Control and Health Statistics, Washington State Department of Health, Tumwater, Washington
| | - Sara N Glick
- HIV/STD Program, Prevention Division, Public Health-Seattle & King County, Seattle, Washington; Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
| | - Richard J Lechtenberg
- HIV/STD Program, Prevention Division, Public Health-Seattle & King County, Seattle, Washington
| | - Roxanne P Kerani
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington; Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
| | - Joshua T Herbeck
- Department of Global Health, University of Washington, Seattle, Washington
| | - Julia C Dombrowski
- HIV/STD Program, Prevention Division, Public Health-Seattle & King County, Seattle, Washington; Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
| | - Amy B Bennett
- HIV/STD Program, Prevention Division, Public Health-Seattle & King County, Seattle, Washington
| | - Francis A Slaughter
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington; HIV/STD Program, Prevention Division, Public Health-Seattle & King County, Seattle, Washington
| | - Michael P Barry
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington; HIV/STD Program, Prevention Division, Public Health-Seattle & King County, Seattle, Washington
| | - Santiago Neme
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington; University of Washington Medical Center - Northwest, Seattle, Washington
| | - Laura Quinnan-Hostein
- University of Washington Medical Center - Northwest, Seattle, Washington; Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Andrew Bryan
- University of Washington Medical Center - Northwest, Seattle, Washington; Department of Laboratory Medicine & Pathology, University of Washington Medicine, University of Washington, Seattle, Washington
| | - Matthew R Golden
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington; HIV/STD Program, Prevention Division, Public Health-Seattle & King County, Seattle, Washington; Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
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20
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Guta A, Newman PA. Virality, desire and health assemblages: mapping (dis)continuities in the response to and management of HIV and COVID-19. CULTURE, HEALTH & SEXUALITY 2021; 23:1516-1531. [PMID: 34657555 DOI: 10.1080/13691058.2021.1981453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 09/13/2021] [Indexed: 06/13/2023]
Abstract
In this paper, we explore the relationship between "viral load" as a virological, immunological, epidemiological and social category and how it links the four decades-long global HIV pandemic to the ongoing response to COVID-19. We argue, metaphorically, that the response to SARS-CoV-2 contains 'genetic' material from HIV, which has (as a result of the digital age which reproduces error-filled data at incredible speed) mutated and is being transmitted into the social and political body. Using sexual health and substance use as focal points, we turn to Deleuzoguattarian theoretical insights about the assemblage of desire, affect and material factors that produce epidemics. Contrasting historical and contemporary scenes and issues, we explore the complex assemblage created by viral loads, medical and public health protocols, conceptions of risk, responsibility and fear that connect both pandemics. Finally, we consider the goal of viral eradication and related militaristic metaphors, alongside the increasing convergence of medicine, public health, the law and corporate interests, and contrast this with community responses that engage with what it means to be living and dying in viral times.
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Affiliation(s)
- Adrian Guta
- School of Social Work, University of Windsor, Windsor, ON, Canada
| | - Peter A Newman
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
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21
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Imbert E, Hickey MD, Clemenzi-Allen A, Lynch E, Friend J, Kelley J, Conte M, Das D, Del Rosario JB, Collins E, Oskarsson J, Hicks ML, Riley ED, Havlir DV, Gandhi M. Evaluation of the POP-UP programme: a multicomponent model of care for people living with HIV with homelessness or unstable housing. AIDS 2021; 35:1241-1246. [PMID: 34076613 PMCID: PMC8186736 DOI: 10.1097/qad.0000000000002843] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Homelessness is the greatest risk factor for HIV viremia in San Francisco. Innovative care models for people with HIV (PWH) with homelessness or unstable housing (HUH) are needed to address this inequity. We developed a novel low-barrier clinic-based program for PWH-HUH in an urban safety-net clinic ('POP-UP') and report outcomes on care engagement and viral suppression. DESIGN A prospective cohort study. SETTING San Francisco General Hospital HIV Clinic (Ward 86). PARTICIPANTS We enrolled PWH who are HUH, viraemic and for whom usual care is not working (at least one missed primary care appointment and at least two drop-in visits at Ward 86 in the last year). INTERVENTION POP-UP provides drop-in comprehensive primary care, housing assistance and case management, financial incentives and patient navigation with frequent contact. MAIN OUTCOME MEASURES We describe uptake of eligible patients into POP-UP, and cumulative incidence of antiretroviral therapy (ART) initiation, return to care and virologic suppression 6 months post-enrolment, estimated via Kaplan--Meier. RESULTS Out of 192 referred patients, 152 were eligible, and 75 enrolled. All 75 were off ART and viraemic; 100% had a substance use disorder; and 77% had a mental health diagnosis. Over three-quarters restarted ART within 7 days of enrolment, and 91% returned for follow-up within 90 days. The cumulative incidence of viral suppression at 6 months was 55% (95% confidence interval 43-68). CONCLUSION A novel care model for PWH-HUH demonstrates early success in engaging viraemic patients in care and improving viral suppression. Low-barrier, high-contact primary care programmes offering comprehensive services and incentives may improve outcomes for this vulnerable population.
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Affiliation(s)
- Elizabeth Imbert
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Matthew D. Hickey
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Angelo Clemenzi-Allen
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
- San Francisco Department of Public Health
| | - Elizabeth Lynch
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - John Friend
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Jackelyn Kelley
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | | | | | - Jan Bing Del Rosario
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Erin Collins
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Jon Oskarsson
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Mary Lawrence Hicks
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Elise D. Riley
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
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22
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Morton T, Chege W, Swann E, Senn TE, Cleland N, Renzullo PO, Stirratt MJ. Advancing long-acting and extended delivery HIV prevention and treatment regimens through behavioural science: NIH workshop directions. AIDS 2021; 35:1313-1317. [PMID: 33710013 DOI: 10.1097/qad.0000000000002863] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Tia Morton
- Division of AIDS, National Institute of Allergy and Infectious Disease (NIAID)
| | - Wairimu Chege
- Division of AIDS, National Institute of Allergy and Infectious Disease (NIAID)
| | - Edith Swann
- Division of AIDS, National Institute of Allergy and Infectious Disease (NIAID)
| | - Theresa E Senn
- Division of AIDS Research, National Institute of Mental Health (NIMH), Bethesda, Maryland, USA
| | - Naana Cleland
- Division of AIDS, National Institute of Allergy and Infectious Disease (NIAID)
| | - Philip O Renzullo
- Division of AIDS, National Institute of Allergy and Infectious Disease (NIAID)
| | - Michael J Stirratt
- Division of AIDS Research, National Institute of Mental Health (NIMH), Bethesda, Maryland, USA
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23
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In Support of the Publicly Funded Sexually Transmitted Infections Specialty Clinic-ASTDA Position Statement. Sex Transm Dis 2021; 47:503-505. [PMID: 32520881 DOI: 10.1097/olq.0000000000001202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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24
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Lyss SB, Buchacz K, McClung RP, Asher A, Oster AM. Responding to Outbreaks of Human Immunodeficiency Virus Among Persons Who Inject Drugs-United States, 2016-2019: Perspectives on Recent Experience and Lessons Learned. J Infect Dis 2021; 222:S239-S249. [PMID: 32877545 DOI: 10.1093/infdis/jiaa112] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
In 2015, a large human immunodeficiency virus (HIV) outbreak occurred among persons who inject drugs (PWID) in Indiana. During 2016-2019, additional outbreaks among PWID occurred across the United States. Based on information disseminated by responding health departments and Centers for Disease Control and Prevention (CDC) involvement, we offer perspectives about characteristics of and public health responses to 6 such outbreaks. Across outbreaks, injection of opioids (including fentanyl) or methamphetamine predominated; many PWID concurrently used opioids and methamphetamine or cocaine. Commonalities included homelessness or unstable housing, previous incarceration, and hepatitis C virus exposure. All outbreaks occurred in metropolitan areas, including some with substantial harm reduction and medical programs targeted to PWID. Health departments experienced challenges locating case patients and contacts, linking and retaining persons in care, building support to strengthen harm-reduction programs, and leveraging resources. Expanding the concept of vulnerability to HIV outbreaks and other lessons learned can be considered for preventing, detecting, and responding to future outbreaks among PWID.
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Affiliation(s)
- Sheryl B Lyss
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,US Public Health Service, Atlanta, Georgia, USA
| | - Kate Buchacz
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - R Paul McClung
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,US Public Health Service, Atlanta, Georgia, USA
| | - Alice Asher
- National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alexandra M Oster
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,US Public Health Service, Atlanta, Georgia, USA
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25
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Motavalli D, Taylor JL, Childs E, Valente PK, Salhaney P, Olson J, Biancarelli DL, Edeza A, Earlywine JJ, Marshall BDL, Drainoni ML, Mimiaga MJ, Biello KB, Bazzi AR. "Health Is on the Back Burner:" Multilevel Barriers and Facilitators to Primary Care Among People Who Inject Drugs. J Gen Intern Med 2021; 36:129-137. [PMID: 32918199 PMCID: PMC7858998 DOI: 10.1007/s11606-020-06201-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/27/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND The estimated 2.2 million people who inject drugs (PWID) in the USA experience significant gaps in preventive healthcare and a high burden of infectious, psychiatric, and other chronic diseases. Many PWID rely on emergency medical services, which are costly and not designed to deliver preventive services, manage chronic conditions, or address social needs. OBJECTIVE The objective of this study was to explore barriers and facilitators to primary care utilization from the perspectives of PWID in New England, a region highly affected by the overdose crisis. DESIGN Participants completed semi-structured qualitative interviews exploring substance use and healthcare utilization patterns. PARTICIPANTS We recruited 78 PWID through community-based organizations (e.g., syringe service programs) in 16 urban and non-urban communities throughout Massachusetts and Rhode Island. APPROACH Thematic analysis identified barriers and facilitators to primary care utilization at the individual, interpersonal, and systemic levels. KEY RESULTS Among 78 PWID, 48 described recent primary care experiences; 33 had positive experiences and 15 described negative experiences involving discrimination or mistrust. Individual-level barriers to primary care utilization included perceived lack of need and competing priorities (e.g., avoiding opioid withdrawal, securing shelter beds). Interpersonal-level barriers included stigma and perceived low quality of care for PWID. Systemic-level barriers included difficulty navigating healthcare systems, inadequate transportation, long wait times, and frequent provider turnover. Participants with positive primary care experiences explained how appointment reminders, flexible hours, addiction medicine-trained providers, case management services, and transportation support facilitated primary care utilization and satisfaction. CONCLUSIONS Findings regarding the multilevel barriers and facilitators to accessing primary care among PWID identify potential targets for programmatic interventions to improve primary care utilization in this population. Based on these findings, we make recommendations for improving the engagement of PWID in primary care as a means to advance individual and public health outcomes.
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Affiliation(s)
| | - Jessica L Taylor
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
| | - Ellen Childs
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
| | - Pablo K Valente
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Peter Salhaney
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
- Center for Health Equity Research, Brown University, Providence, RI, USA
| | - Jennifer Olson
- Center for Health Equity Research, Brown University, Providence, RI, USA
| | - Dea L Biancarelli
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
| | - Alberto Edeza
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
- Center for Health Equity Research, Brown University, Providence, RI, USA
| | - Joel J Earlywine
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Mari-Lynn Drainoni
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, ENRM VA Hospital, Bedford, MA, USA
| | - Matthew J Mimiaga
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
- Center for Health Equity Research, Brown University, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Department of Psychiatry and Human Behavior, Brown University Alpert Medical School, Providence, RI, USA
| | - Katie B Biello
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
- Center for Health Equity Research, Brown University, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Angela R Bazzi
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, 02118, USA.
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26
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Conte M, Eshun-Wilson I, Geng E, Imbert E, Hickey MD, Havlir D, Gandhi M, Clemenzi-Allen A. Brief Report: Understanding Preferences for HIV Care Among Patients Experiencing Homelessness or Unstable Housing: A Discrete Choice Experiment. J Acquir Immune Defic Syndr 2020; 85:444-449. [PMID: 33136742 PMCID: PMC8028840 DOI: 10.1097/qai.0000000000002476] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Homelessness and unstable housing (HUH) negatively impact care outcomes for people living with HIV (PLWH). To inform the design of a clinic program for PLWH experiencing HUH, we quantified patient preferences and trade-offs across multiple HIV-service domains using a discrete choice experiment (DCE). METHODS We sequentially sampled PLWH experiencing HUH presenting at an urban HIV clinic with ≥1 missed primary care visit and viremia in the last year to conduct a DCE. Participants chose between 2 hypothetical clinics varying across 5 service attributes: care team "get to know me as a person" versus not; receiving $10, $15, or $20 gift cards for clinic visits; drop-in versus scheduled visits; direct phone communication to care team versus front-desk staff; and staying 2 versus 20 blocks from the clinic. We estimated attribute relative utility (ie, preference) using mixed-effects logistic regression and calculated the monetary trade-off of preferred options. RESULTS Among 65 individuals interviewed, 61% were >40 years old, 45% White, 77% men, 25% heterosexual, 56% lived outdoors/emergency housing, and 44% in temporary housing. Strongest preferences were for patient-centered care team [β = 3.80; 95% confidence interval (CI): 2.57 to 5.02] and drop-in clinic appointments (β = 1.33; 95% CI: 0.85 to 1.80), with a willingness to trade $32.79 (95% CI: 14.75 to 50.81) and $11.45 (95% CI: 2.95 to 19.95) in gift cards/visit, respectively. CONCLUSIONS In this DCE, PLWH experiencing HUH were willing to trade significant financial gain to have a personal relationship with and drop-in access to their care team rather than more resource-intensive services. These findings informed Ward 86's "POP-UP" program for PLWH-HUH and can inform "ending the HIV epidemic" efforts.
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Affiliation(s)
- Madellena Conte
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
- Institute of Global Health Sciences, University of California, San Francisco, San Francisco, CA
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO; and
| | - Elvin Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO; and
| | - Elizabeth Imbert
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
| | - Matthew D Hickey
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
| | - Diane Havlir
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
| | - Monica Gandhi
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
| | - Angelo Clemenzi-Allen
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
- San Francisco Department of Public Health, San Francisco, CA
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27
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Improving Care Outcomes for PLWH Experiencing Homelessness and Unstable Housing: a Synthetic Review of Clinic-Based Strategies. Curr HIV/AIDS Rep 2020; 17:259-267. [PMID: 32382919 DOI: 10.1007/s11904-020-00488-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Singular interventions targeting vulnerable populations of people living with HIV (PLWH) are necessary for reducing new infections and optimizing individual-level outcomes, but extant literature for PLWH who experience homelessness and unstable housing (HUH) has not been compiled. To inform implementation of clinic-based programs that improve care outcomes in this population, we present a synthetic review of key studies examining clinic-based interventions, specifically case management, patient navigation, financial incentives, and the use of mobile technology. RECENT FINDINGS Results from unimodal interventions are mixed or descriptive, are limited by inability to address related multi-modal barriers to care, and do not address major challenges to implementation. Multi-component interventions are needed, but gaps in our knowledge base may limit widespread uptake of such interventions before further data are compiled. Future research evaluating interventions for PLWH experiencing HUH should include implementation outcomes in order to facilitate adaptation across diverse clinical settings.
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28
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Beima-Sofie K, Ortblad KF, Swanson F, Graham SM, Stekler JD, Simoni JM. "Keep It Going if You Can": HIV Service Provision for Priority Populations During the COVID-19 Pandemic in Seattle, WA. AIDS Behav 2020; 24:2760-2763. [PMID: 32385679 PMCID: PMC7207988 DOI: 10.1007/s10461-020-02902-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
| | - Katrina F Ortblad
- Department of Global Health, University of Washington, Seattle, USA.
- Department of Global Health, International Clinical Research Center, University of Washington, 908 Jefferson St, 12th Floor, Seattle, WA, 98104, USA.
| | | | - Susan M Graham
- Department of Global Health, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Joanne D Stekler
- Department of Global Health, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Jane M Simoni
- Department of Global Health, University of Washington, Seattle, USA
- Department of Psychology, University of Washington, Seattle, USA
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29
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O'Donnell L, Irvine MK, Wilkes AL, Rwan J, Myint-U A, Leow DM, Whittier D, Harriman G, Bessler P, Higa D, Courtenay-Quirk C. STEPS to Care: Translating an Evidence-Informed HIV Care Coordination Program Into a Field-Tested Online Practice Improvement Toolkit. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2020; 32:296-310. [PMID: 32897131 DOI: 10.1521/aeap.2020.32.4.296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Increasing care engagement is essential to meet HIV prevention goals and achieve viral suppression. It is difficult, however, for agencies to establish the systems and practice improvements required to ensure coordinated care, especially for clients with complex health needs. We describe the theory-driven, field-informed transfer process used to translate key components of the evidence-informed Ryan White Part A New York City Care Coordination Program into an online practice improvement toolkit, STEPS to Care (StC), with the potential to support broader dissemination. Informed by analyses of qualitative and quantitative data collected from eight agencies, we describe our four phases: (1) review of StC strategies and key elements, (2) translation into a three-part toolkit: Care Team Coordination, Patient Navigation, and HIV Self-Management, (3) pilot testing, and (4) toolkit refinement for national dissemination. Lessons learned can guide the translation of evidence-informed strategies to online environments, a needed step to achieve wide-scale implemention.
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Affiliation(s)
| | - Mary K Irvine
- Bureau of HIV Prevention and Control, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Aisha L Wilkes
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Julie Rwan
- Bureau of HIV Prevention and Control, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Athi Myint-U
- Education Development Center, Inc., Waltham, Massachusetts
| | | | - David Whittier
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Graham Harriman
- Bureau of HIV Prevention and Control, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Patricia Bessler
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Darrel Higa
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cari Courtenay-Quirk
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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30
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English K, May SB, Davila JA, Cully JA, Dindo L, Amico KR, Kallen MA, Giordano TP. Retention in Care and Viral Load Improvement After Discharge Among Hospitalized Out-of-Care People With HIV Infection: A Post Hoc Analysis of a Randomized Controlled Trial. Open Forum Infect Dis 2020; 7:ofaa193. [PMID: 32550239 PMCID: PMC7291684 DOI: 10.1093/ofid/ofaa193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/21/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Understanding factors influencing retention in care (RIC) and viral load improvement (VLI) in people with HIV (PWH) who are out of care and hospitalized will assist in intervention development for this vulnerable population. METHODS The study was a post hoc analysis of prospectively collected data. Hospitalized participants were enrolled if they were newly diagnosed with HIV during the hospitalization or out of HIV care. Participants completed surveys at baseline and 6 months postenrollment and laboratory studies of viral load (VL). Outcomes were RIC (2 completed visits, 1 within 30 days of discharge) and VLI (VL <400 or at least a 1-log10 decrease) 6 months after discharge. Univariate and multivariate regression analyses were conducted examining the contributions of predisposing, enabling, and need factors to outcomes. RESULTS The study cohort included 417 participants enrolled between 2010 and 2013. The population was 73% male, 67% non-Hispanic black, 19% Hispanic, and 70% uninsured. Sixty-five percent had a baseline CD4 <200 cells/mm3, 79% had a VL >400 copies/mL or missing, and the population was generally poor with low educational attainment. After discharge from the hospital, 60% did not meet the definition for RIC, and 49% did not have VLI. Modifiable factors associated with the outcomes include drug use (including marijuana alone and other drugs), life instability (eg, housing, employment, and life chaos), and using avoidance coping strategies in coping with HIV. CONCLUSIONS Hospitalized out-of-care PWH in the United States are at high risk of poor re-engagement in care after discharge. Interventions for this population should focus on improving socioeconomic stability and coping with HIV and reducing drug use.
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Affiliation(s)
- Kellee English
- School of Health Professions, Baylor College of Medicine, Houston, Texas, USA
| | - Sarah B May
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Jessica A Davila
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Jeffrey A Cully
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Psychiatry, Baylor College of Medicine, Houston, Texas, USA
| | - Lilian Dindo
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | | | - Michael A Kallen
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Thomas P Giordano
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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Beima-Sofie K, Begnel ER, Golden MR, Moore A, Ramchandani M, Dombrowski JC. "It's Me as a Person, Not Me the Disease": Patient Perceptions of an HIV Care Model Designed to Engage Persons with Complex Needs. AIDS Patient Care STDS 2020; 34:267-274. [PMID: 32484744 DOI: 10.1089/apc.2019.0310] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Ending the HIV epidemic will require dedicated efforts to engage the highest need persons living with HIV (PLWH) in treatment. We assessed patient perceptions of a clinic in Seattle, Washington, that is designed for PLWH who do not engage in conventional HIV care. The Max Clinic provides walk-in access to care, incentives for blood draws and achieving viral suppression, and intensive case management. We conducted semistructured individual interviews with 25 patients purposively recruited to obtain diverse viewpoints. Interviews were audio-recorded and transcribed. Analysis used a constant comparative approach to identify major themes related to the components of the program. For many participants, engagement in the Max Clinic was the first time they had success with HIV treatment. Relationships with clinic staff and the ability to receive care on a walk-in basis had the strongest influences on engagement. Participants felt that Max Clinic staff attended to their social circumstances in ways that were distinct from prior care experiences. Walk-in visits removed perceived stigma associated with failure to keep appointments and provided immediate attention to acute concerns. Financial incentives initially motivated participants to attend clinic and take medications, but were less important for supporting ongoing engagement in care. Food incentives motivated patients to seek care and helped them focus on health issues. In summary, patients identified walk-in access to care, monetary and food incentives, and relationships with clinic staff, particularly case managers, as the key elements of an HIV clinic model for high-need PLWH.
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Affiliation(s)
- Kristin Beima-Sofie
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Emily R. Begnel
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Matthew R. Golden
- Department of Medicine, University of Washington, Seattle, Washington, USA
- HIV/STD Program, Public Health–Seattle & King County, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Allison Moore
- HIV/STD Program, Public Health–Seattle & King County, Seattle, Washington, USA
| | - Meena Ramchandani
- Department of Medicine, University of Washington, Seattle, Washington, USA
- HIV/STD Program, Public Health–Seattle & King County, Seattle, Washington, USA
| | - Julia C. Dombrowski
- Department of Medicine, University of Washington, Seattle, Washington, USA
- HIV/STD Program, Public Health–Seattle & King County, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
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Dandachi D, Dang BN, Lucari B, Teti M, Giordano TP. Exploring the Attitude of Patients with HIV About Using Telehealth for HIV Care. AIDS Patient Care STDS 2020; 34:166-172. [PMID: 32324481 DOI: 10.1089/apc.2019.0261] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Telehealth could address many of the factors identified as barriers for retention in HIV care. In this study, we explore people with HIV (PWH)'s attitudes about using telemedicine for HIV care instead of face-to-face clinic visits. We administered a one-time survey to PWH presenting to an outpatient HIV center in Houston, Texas, from February to June 2018. The survey items were used to assess PWH's attitudes toward and concerns for telehealth and explanatory variables; 371 participants completed the survey; median age was 51, 36% and were female, and 63% was African American. Overall 57% of respondents were more likely to use telehealth for their HIV care if available, as compared with one-on-one in-person care, and 37% would use telehealth frequently or always as an alternative to clinic visits. Participants reported many benefits, including ability to fit better their schedule, decreasing travel time, and privacy but expressed concerns about the ability to effective communication and examination and the safety of personal information. Factors associated with likelihood of using telehealth include personal factors (US-born, men who have sex with men, higher educational attainment, higher HIV-related stigma perception), HIV-related factors (long-standing HIV), and structural factors (having difficulty attending clinic visits, not knowing about or not having the necessary technology). There was no association between participants with uncontrolled HIV, medication adherence, and likelihood of using telehealth. Telehealth programs for PWH can improve retention in care. Availability and confidence using various telehealth technologies need to be addressed to increase acceptability and usage of telehealth among PWH.
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Affiliation(s)
- Dima Dandachi
- Division of Infectious Diseases, Department of Medicine, University of Missouri, Columbia, Missouri, USA
- Department of Management, Policy, and Community Health, School of Public Health, The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Bich N. Dang
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- VA Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Brandon Lucari
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Michelle Teti
- Department of Public Health, University of Missouri, Columbia, Missouri, USA
| | - Thomas P. Giordano
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- VA Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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Griffin A, Dempsey A, Cousino W, Avery L, Phillips H, Egwim E, Cheever L. Addressing disparities in the health of persons with HIV attributable to unstable housing in the United States: The role of the Ryan White HIV/AIDS Program. PLoS Med 2020; 17:e1003057. [PMID: 32119661 PMCID: PMC7051042 DOI: 10.1371/journal.pmed.1003057] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Amy Griffin and co-authors discuss unstable housing and the response to HIV/AIDS in the United States.
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Affiliation(s)
- Amy Griffin
- US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Division of Policy and Data, Rockville, Maryland, United States of America
| | - Antigone Dempsey
- US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Division of Policy and Data, Rockville, Maryland, United States of America
| | - Wendy Cousino
- US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Division of Policy and Data, Rockville, Maryland, United States of America
| | - Latham Avery
- US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Division of Policy and Data, Rockville, Maryland, United States of America
| | - Harold Phillips
- US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Division of Policy and Data, Rockville, Maryland, United States of America
| | - Emeka Egwim
- US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Division of Policy and Data, Rockville, Maryland, United States of America
| | - Laura Cheever
- US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Division of Policy and Data, Rockville, Maryland, United States of America
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Flash MJE, Garland WH, Martey EB, Schackman BR, Oksuzyan S, Scott JA, Jeng PJ, Rubio M, Losina E, Freedberg KA, Kulkarni SP, Hyle EP. Cost-effectiveness of a Medical Care Coordination Program for People With HIV in Los Angeles County. Open Forum Infect Dis 2019; 6:ofz537. [PMID: 31909083 PMCID: PMC6935680 DOI: 10.1093/ofid/ofz537] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/13/2019] [Indexed: 11/12/2022] Open
Abstract
Background The Los Angeles County (LAC) Division of HIV and STD Programs implemented a medical care coordination (MCC) program to address the medical and psychosocial service needs of people with HIV (PWH) at risk for poor health outcomes. Methods Our objective was to evaluate the impact and cost-effectiveness of the MCC program. Using the CEPAC-US model populated with clinical characteristics and costs observed from the MCC program, we projected lifetime clinical and economic outcomes for a cohort of high-risk PWH under 2 strategies: (1) No MCC and (2) a 2-year MCC program. The cohort was stratified by acuity using social and clinical characteristics. Baseline viral suppression was 33% in both strategies; 2-year suppression was 33% with No MCC and 57% with MCC. The program cost $2700/person/year. Model outcomes included quality-adjusted life expectancy, lifetime medical costs, and cost-effectiveness. The cost-effectiveness threshold for the incremental cost-effectiveness ratio (ICER) was $100 000/quality-adjusted life-year (QALY). Results With MCC, life expectancy increased from 10.07 to 10.94 QALYs, and costs increased from $311 300 to $335 100 compared with No MCC (ICER, $27 400/QALY). ICERs for high/severe, moderate, and low acuity were $30 500/QALY, $25 200/QALY, and $77 400/QALY. In sensitivity analysis, MCC remained cost-effective if 2-year viral suppression was ≥39% even if MCC costs increased 3-fold. Conclusions The LAC MCC program improved survival and was cost-effective. Similar programs should be considered in other settings to improve outcomes for high-risk PWH.
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Affiliation(s)
- Moses J E Flash
- Divisions of General Internal Medicine and Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wendy H Garland
- Division of HIV and STD Programs, Los Angeles County Department of Public Health, Los Angeles, California, USA
| | - Emily B Martey
- Divisions of General Internal Medicine and Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce R Schackman
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, New York, USA
| | - Sona Oksuzyan
- Division of HIV and STD Programs, Los Angeles County Department of Public Health, Los Angeles, California, USA
| | - Justine A Scott
- Divisions of General Internal Medicine and Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Philip J Jeng
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, New York, USA
| | - Marisol Rubio
- Division of HIV and STD Programs, Los Angeles County Department of Public Health, Los Angeles, California, USA
| | - Elena Losina
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts, USA.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Kenneth A Freedberg
- Divisions of General Internal Medicine and Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts, USA.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Sonali P Kulkarni
- Division of HIV and STD Programs, Los Angeles County Department of Public Health, Los Angeles, California, USA
| | - Emily P Hyle
- Divisions of General Internal Medicine and Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts, USA
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Chang EJ, Fleming M, Nunez A, Dombrowski JC. Predictors of Successful HIV Care Re-engagement Among Persons Poorly Engaged in HIV Care. AIDS Behav 2019; 23:2490-2497. [PMID: 30980279 DOI: 10.1007/s10461-019-02491-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Data to Care (D2C) strategy uses HIV surveillance data to identify persons living with HIV (PLWH) who are poorly engaged in care and offers assistance with care re-engagement. We evaluated HIV care re-engagement among PLWH in Seattle & King County, Washington after participation in a D2C program and determined whether variables available at the time of the D2C interview predicted subsequent re-engagement in care. We defined successful re-engagement as surveillance evidence of either continuous care engagement (≥ 2 CD4 counts or HIV RNA results ≥ 60 days apart) or viral suppression (≥ 1 HIV RNA < 200 copies/mL) in the year following the D2C interview. Predictor variables included client characteristics, beliefs about HIV care, and scores on psychosocial assessment scales. Half of participants successfully re-engaged in care. We did not find any significant predictors of re-engagement except viral suppression at the time of the D2C interview. Close follow-up is needed to identify which D2C participants need additional assistance re-engaging in care.
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Affiliation(s)
| | - Mark Fleming
- Public Health - Seattle & King County HIV/STD Program, Seattle, WA, USA
| | - Angela Nunez
- Public Health - Seattle & King County HIV/STD Program, Seattle, WA, USA
| | - Julia C Dombrowski
- Public Health - Seattle & King County HIV/STD Program, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
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Rietmeijer CA. Improving care for sexually transmitted infections. J Int AIDS Soc 2019; 22 Suppl 6:e25349. [PMID: 31468743 PMCID: PMC6715945 DOI: 10.1002/jia2.25349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 06/21/2019] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Rising rates of reported sexually transmitted infections (STIs) in the US and Europe are a public health priority and require a public health response. The diagnosis and treatment of STIs have been the cornerstone of STI control and prevention for many decades and, historically, publicly funded STI clinics have played a central role in the provision of STI care. Innovations in non-invasive diagnostic techniques, especially nucleic acid amplification tests in the mid-1990s, have facilitated the expansion of STI testing and treatment outside traditional STI clinics, including primary care, family planning, school-based health, outreach, corrections, emergency departments and HIV prevention and care settings. As a result, the continued need for categorical STI clinics has been debated. In this Commentary, we discuss how practice can be improved at each level of STI care. DISCUSSION STI practice improvement plans should be tailored to the strengths of each care setting. Thus, in primary care, the focus should be on improving STI screening rates, the provision of hepatitis B and human papillomavirus vaccines and, in jurisdictions where this is legal, expedited partner therapy for gonorrhoea and chlamydia. Extragenital (pharyngeal and rectal) testing for gonorrhoea and chlamydia should be available in settings serving populations more vulnerable to STI acquisition at these anatomical sites, including men who have sex with men. In family planning settings with a mostly female patient population, there are opportunities to serve male partners with both contraceptive and STI services. STI screening rates can also be improved in other settings serving populations at increased risk for STIs, including school-based clinics, emergency departments, correctional health facilities and providers of HIV care and prevention. These improvements are predominantly logistical in nature and not dependent on extensive STI clinical expertise. While some providers in these settings may have the clinical knowledge and skills to evaluate symptomatic patients, many do not, and STI speciality clinics must be available for consultation and referral and evolve from "safety net" providers of last resort to STI centres of excellence. CONCLUSIONS A tailored practice improvement plan can be envisioned to achieve an optimally functioning STI care continuum.
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Affiliation(s)
- Cornelis A Rietmeijer
- Rietmeijer ConsultingDenverCOUSA
- Colorado School of Public HealthUniversity of ColoradoDenverCOUSA
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Dombrowski JC, Galagan SR, Ramchandani M, Dhanireddy S, Harrington RD, Moore A, Hara K, Eastment M, Golden MR. HIV Care for Patients With Complex Needs: A Controlled Evaluation of a Walk-In, Incentivized Care Model. Open Forum Infect Dis 2019; 6:ofz294. [PMID: 31341930 PMCID: PMC6641789 DOI: 10.1093/ofid/ofz294] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/21/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND New approaches are needed to provide care to persons with HIV who do not engage in conventionally organized HIV clinics. The Max Clinic in Seattle, Washington, is a walk-in, incentivized HIV care model located in a public health STD clinic that provides care in collaboration with a comprehensive HIV primary care clinic (the Madison Clinic). METHODS We compared outcomes in the first 50 patients enrolled in Max Clinic and 100 randomly selected matched Madison Clinic control patients; patients in both groups were virally unsuppressed (viral load [VL] >200 copies/mL) at baseline. The primary outcome was any VL indicating viral suppression (≥1 VL <200 copies/mL) during the 12 months postbaseline. Secondary outcomes were continuous viral suppression (≥2 consecutive suppressed VLs ≥60 days apart) and engagement in care (≥2 medical visits ≥60 days apart). We compared outcomes in the 12 months pre- and postbaseline and used generalized estimating equations to compare changes in Max vs control patients, adjusting for unstable housing, substance use, and psychiatric disorders. RESULTS Viral suppression improved in both groups pre-to-post (20% to 82% Max patients; P < .001; and 51% to 65% controls; P = .04), with a larger improvement in Max patients (adjusted relative risk ratio [aRRR], 3.2; 95% confidence interval [CI], 1.8-5.9). Continuous viral suppression and engagement in care increased in both groups but did not differ significantly (continuous viral suppression: aRRR, 1.5; 95% CI, 0.5-5.2; engagement: aRRR, 1.3; 95% CI, 0.9-1.9). CONCLUSIONS The Max Clinic improved viral suppression among patients with complex medical and social needs.
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Affiliation(s)
- Julia C Dombrowski
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Public Health – Seattle & King County HIV/STD Program, Seattle, Washington
| | - Sean R Galagan
- Department of Global Health, University of Washington, Seattle, Washington
| | - Meena Ramchandani
- Department of Medicine, University of Washington, Seattle, Washington
- Public Health – Seattle & King County HIV/STD Program, Seattle, Washington
| | | | | | - Allison Moore
- Public Health – Seattle & King County HIV/STD Program, Seattle, Washington
| | - Katie Hara
- Social Work, Harborview Medical Center, Seattle, Washington
| | - Mckenna Eastment
- Department of Medicine, University of Washington, Seattle, Washington
| | - Matthew R Golden
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Public Health – Seattle & King County HIV/STD Program, Seattle, Washington
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Dasgupta S, Weiser J, Craw J, Tie Y, Beer L. Systematic monitoring of retention in care in U.S.-based HIV care facilities. AIDS Care 2019; 32:113-118. [PMID: 31129989 DOI: 10.1080/09540121.2019.1619660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
National guidelines recommend that HIV providers systematically monitor retention in care to identify and re-engage persons suboptimally in care. We described (1) U.S.-based outpatient HIV care facilities that systematically monitor retention in care, and (2) characteristics of patients attending facilities that monitored retention in care. We used data collected during 6/2014-5/2015 from the Medical Monitoring Project, an annual, cross-sectional survey that produces nationally representative estimates of characteristics of HIV-positive persons in medical care. We described systematic monitoring of retention in care among facilities and patients attending facilities providing this service using weighted percentages and 95% confidence intervals, and used Rao-Scott chi-square tests (p < .05) to assess differences by selected characteristics. Overall, 67% of facilities systematically monitored retention in care, and 81% of patients attended these facilities. Federally qualified health centers, community-based organizations, health departments, non-private practices, and Ryan White HIV/AIDS Program (RWHAP)-funded facilities were more likely to systematically monitor retention in care. Persons living in poverty, and those who were homeless or incarcerated, or injected drugs were more likely to attend facilities with this service. Although systematic monitoring of retention in care is accessible for many patients, improvements at other, non-RWHAP-funded facilities may help in reaching national prevention goals.
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Affiliation(s)
- Sharoda Dasgupta
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, USA
| | - John Weiser
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, USA
| | - Jason Craw
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, USA
| | - Yunfeng Tie
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, USA
| | - Linda Beer
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, USA
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Golden MR, Lechtenberg R, Glick SN, Dombrowski J, Duchin J, Reuer JR, Dhanireddy S, Neme S, Buskin SE. Outbreak of Human Immunodeficiency Virus Infection Among Heterosexual Persons Who Are Living Homeless and Inject Drugs - Seattle, Washington, 2018. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2019; 68:344-349. [PMID: 30998671 PMCID: PMC6476056 DOI: 10.15585/mmwr.mm6815a2] [Citation(s) in RCA: 137] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Clemenzi-Allen A, Neuhaus J, Geng E, Sachdev D, Buchbinder S, Havlir D, Gandhi M, Christopoulos K. Housing Instability Results in Increased Acute Care Utilization in an Urban HIV Clinic Cohort. Open Forum Infect Dis 2019; 6:ofz148. [PMID: 31139668 PMCID: PMC6534280 DOI: 10.1093/ofid/ofz148] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/24/2019] [Indexed: 11/25/2022] Open
Abstract
Background People living with HIV (PLWH) who experience homelessness and unstable housing (HUH) often have fragmented health care. Research that incorporates granular assessments of housing status and primary care visit adherence to understand patterns of acute care utilization can help pinpoint areas for intervention. Methods We collected self-reported living situation, categorized as stable (rent/own, hotel/single room occupancy), unstable (treatment/transitional program, staying with friends), or homeless (homeless shelter, outdoors/in vehicle) at an urban safety-net HIV clinic between February and August 2017 and abstracted demographic and clinical information from the medical record. Regression models evaluated the association of housing status on the frequency of acute care visits—urgent care (UC) visits, emergency department (ED) visits, and hospitalizations—and whether suboptimal primary care visit adherence (<75%) interacted with housing status on acute care visits. Results Among 1198 patients, 25% experienced HUH. In adjusted models, unstable housing resulted in a statistically significant increase in the incidence rate ratio for UC visits (incidence rate ratio [IRR], 1.35; 95% confidence interval [CI], 1.10 to 1.66; P < .001), ED visits (IRR, 2.12; 95% CI, 1.44 to 3.13; P < .001), and hospitalizations (IRR, 1.75; 95% CI, 1.10 to 2.77; P = 0.018). Homelessness led to even greater increases in UC visits (IRR, 1.75; 95% CI, 1.29 to 2.39; P < .001), ED visits (IRR, 4.18; 95% CI, 2.77 to 6.30; P < .001), and hospitalizations (IRR, 3.18; 95% CI, 2.03 to 4.97; P < .001). Suboptimal visit adherence differentially impacted UC and ED visits by housing status, suggesting interaction. Conclusions Increased acute care visit frequency among HUH-PLWH suggests that interventions at these visits may create opportunities to improve care.
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Affiliation(s)
- Angelo Clemenzi-Allen
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital
| | - John Neuhaus
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Elvin Geng
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital
| | - Darpun Sachdev
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital.,San Francisco Department of Public Health, San Francisco, California
| | - Susan Buchbinder
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California.,San Francisco Department of Public Health, San Francisco, California
| | - Diane Havlir
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital
| | - Katerina Christopoulos
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital
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Evaluating the Impact of Housing Status on Gonorrhea and Chlamydia Screening in an HIV Primary Care Setting. Sex Transm Dis 2019; 46:153-158. [PMID: 30383619 DOI: 10.1097/olq.0000000000000939] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Gonorrhea and chlamydia (GC/CT) testing falls below recommended rates for people living with HIV (PLWH) in routine care. Despite evidence that homelessness and unstable housing (HUH) negatively impacts clinical outcomes for PLWH, little is known about GC/CT screening for HUH-PLWH in routine care. METHODS Using an observational cohort of PLWH establishing care at a large publicly funded HIV clinic in San Francisco between February 2013 and December 2014 and with at least 1 primary care visit (PCV) before February 2016, we assessed GC/CT testing for HUH (staying outdoors, in shelters, in vehicles, or in places not made for habitation in the last year) compared with stably housed patients. We calculated (1) the odds of having GC/CT screening at a PCV using logistic regression with random effects to handle intrasubject correlations and (2) the percent of time enrolled in clinical care in which patients had any GC/CT testing ("time in coverage") based on 180-day periods and using linear regression modeling. RESULTS Of 323 patients, mean age was 43 years, 92% were male, 52% were non-Latino white, and 46% were HUH. Homeless and unstably housed PLWH had 0.66 odds of GC/CT screening at a PCV than did stably housed patients (95% confidence interval, 0.44-0.99; P = 0.043). Time in coverage showed no difference by housing status (regression coefficient, -0.93; 95% confidence interval, -8.02 to 6.16; P = 0.80). CONCLUSIONS Homeless and unstably housed PLWH had 34% lower odds of GC/CT screening at a PCV, demonstrating a disparity in routine care provision, but similar time in coverage. More research is needed to effectively increase GC/CT screening among HUH-PLWH.
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