Insurance coverage, usual source of care, and receipt of clinically indicated care for comorbid conditions among adults living with human immunodeficiency virus

People who living with HIV/AIDS also have a high prevalence of anxiety disorders: a systematic review and meta-analysis

Background

An estimated 301 million people worldwide suffer from anxiety disorders. People living with HIV/AIDS (PLWHA) are particularly prone to anxiety disorders that could interfere with the important developmental process in an individual's development and ultimately result in a wide range of negative mental, physical, and psychosocial consequences, as well as poor quality of life in those population groups. Early intervention for anxiety disorders can reverse some of the physical damage caused by anxiety. However, based on systematic reviews and meta-analyses, the specific prevalence of anxiety disorders in PLWHA remains unknown.

Method

We conducted a literature search on PubMed, Embase, and Web of Science up to 22 October 2022. A random-effects meta-analysis was used to pool prevalence rates from the included studies. Sensitivity and subgroup analyses were performed to identify the possible sources of heterogeneity and to compare the prevalence estimates across groups. The Joanna Briggs Institute's Quality Assessment Checklist was used to assess the quality of the included studies. Cochran's Q and I2 tests were used to assess the between-study heterogeneity.

Results

Ten studies with a total of 238,570 cases were included for the final analysis. Results showed that 15.5% of HIV/AIDS patients had anxiety disorders. The prevalence was higher in females (20.8%) than males (20.7%). The mean age of PLWHA with anxiety disorders was 46.58 ± 11.15 years in these included studies. The subgroup analyses showed significant higher prevalence in non-heterosexual (32.1%).

Conclusion

We attempted to quantify literature that could allow for stronger inferences to be made regarding the significantly higher prevalence of anxiety disorders in PLWHA, a finding that suggests the imperativeness of intervention strategies to alleviate suffering and reduce the probable negative ramifications.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023442219, identifier CRD42023442219.

Usual source of care and experiences with primary care among community health service centre patients in Changchun, China: A cross-sectional survey

Under China's healthcare reforms, community health service centres (CHCs) have been established as the preferred primary care providers. Even with this change, there is still little attention paid to patients' usual source of care (USC) from CHCs in Northeastern China. The main purposes of this study were to explore the determinants of usual source of community health service and to examine the association between usual source of community health service and patients' experiences with primary care. A cross-sectional survey with 515 adult patients at CHCs in Jilin Province, China, was conducted between July 2016 and November 2016. The patients' experiences with primary care were assessed with the Primary Care Assessment Tool (PCAT). Patients with self-perceived poor health status (odds ratio = 1.984, 95% confidence interval = 1.145-3.437) and chronic disease (odds ratio = 2.207, 95% confidence interval = 1.203-4.051) were more likely to have a usual source of community health service than patients with self-perceived good health status or without chronic disease. Patients scored the highest on comprehensiveness of services available (Mean = 2.87) and the lowest on community orientation (Mean = 1.83) in all domains of the PCAT, with values ranging from 1 to 4. A multiple linear regression analysis revealed that patients with a usual source of community health service had significantly higher overall scores than those without (B = 0.205, p < .001). This study demonstrated the important role of CHCs in providing affordable health services for patients with chronic disease or poor health status. Moreover, patients who chose a CHC as a USC had better experiences with primary care compared with patients who did not choose a CHC as a USC. However, community-oriented services need to be improved, and efforts to improve patients' experiences should include policies that incentivise patients to adopt a CHC as their USC.

Symptoms of generalized anxiety disorder as a risk factor for substance use among adults living with HIV

This study examined the association between symptoms of generalized anxiety disorder (GAD) and substance use among 932 people living with HIV (PLWH) in Florida. PLWH completed a 45-minute questionnaire assessing demographics, symptoms of GAD and depression, and use of substances including alcohol, cigarettes, marijuana, crack/cocaine, and injection drugs. The GAD-7 measured symptoms of anxiety and participants were categorized as experiencing none/mild anxiety (score 0-9) or moderate/severe symptoms (score ≥10). Adjusted binary logistic regressions assessed the association between moderate-severe GAD symptoms and substance use while controlling for covariates, including depressive symptoms. Approximately one-third (31.4%) of the sample reported experiencing moderate/severe symptoms of GAD. After controlling for covariates, PLWH with moderate/severe symptoms of GAD had greater odds of reporting current cigarette use (AOR = 1.70, 95% CI = 1.18-2.45 p = 0.004), past 30-day hazardous alcohol consumption (AOR = 1.50, 95% CI = 1.04-2.16, p = 0.028), and past 12-month non-injection crack/cocaine use (AOR = 1.75, 95% CI = 1.13-2.69, p = 0.011) compared to PLWH reporting none/mild symptoms. Findings demonstrate that moderate/severe GAD symptoms were common among this sample of PLWH in Florida and were associated with use of cigarettes, crack/cocaine, and hazardous alcohol consumption. Future studies should explore interventions to reduce comorbid anxiety and substance use.

Effects of social health insurance on access and utilization of obstetric health services: results from HIV+ pregnant women in Kenya

BACKGROUND

Reducing maternal morbidity and mortality remains a top global health agenda especially in high HIV/AIDS endemic locations where there is increased likelihood of mother to child transmission (MTCT) of HIV. Social health insurance (SHI) has emerged as a viable option to improve population access to health services, while improving outcomes for disenfranchised populations, particularly HIV+ women. However, the effect of SHI on healthcare access for HIV+ persons in limited resource settings is yet to undergo rigorous empirical evaluation. This study analyzes the effect of health insurance on obstetric healthcare access including institutional delivery and skilled birth attendants for HIV+ pregnant women in Kenya.

METHODS

We analyzed cross-sectional data from HIV+ pregnant women (ages 15-49 years) who had a delivery (full term, preterm, miscarriage) between 2008 and 2013 with their insurance enrollment status available in the electronic medical records database of a HIV healthcare system in Kenya. We estimated linear and logistic regression models and implemented matching and inverse probability weighting (IPW) to improve balance on observable individual characteristics. Additionally, we estimated heterogeneous effects stratified by HIV disease severity (CD4 < 350 as "Severe HIV disease", and CD4 > 350 otherwise).

FINDINGS

Health Insurance enrollment is associated with improved obstetric health services utilization among HIV+ pregnant women in Kenya. Specifically, HIV+ pregnant women covered by NHIF have greater access to institutional delivery (12.5-percentage points difference) and skilled birth attendants (19-percentage points difference) compared to uninsured. Notably, the effect of NHIF on obstetric health service use is much greater for those who are sicker (CD4 < 350) - 20 percentage points difference.

CONCLUSION

This study confirms conceptual and practical considerations around health insurance and healthcare access for HIV+ persons. Further, it helps to inform relevant policy development for health insurance and HIV financing and delivery in Kenya and in similar countries in sub-Saharan Africa in the universal health coverage (UHC) era.

Predictors of Medication Utilization for Opioid Use Disorder Among Medicaid-Insured HIV Patients in New York

BACKGROUND AND OBJECTIVES

This paper investigates the prevalence and predictors for opioid use disorder (OUD) pharmacotherapy utilization for Medicaid-insured patients with human immunodeficiency virus (HIV) in New York.

METHODS

We identified patients with HIV and OUD in 2014 in the New York State Medicaid claims data (n = 5621). The claims were used to identify individual client medication for addiction treatment (MAT) utilization, demographic information, and other medical and psychiatric health conditions. The logistic regression analyses were performed to explore the potential predictors of MAT service utilization among people with HIV and OUD.

RESULTS

Of 5621 identified patients with HIV and OUD, 3647 (65%) received some type of MAT. Eighty-seven percent of treated patients received methadone while 10% received buprenorphine and 3% utilized both the therapies.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

A substantial number of patients with HIV and OUD did not receive MAT. Findings suggest that there are opportunities to improve OUD care for patients with HIV and OUD, particularly among the younger generation, blacks, individuals living outside of New York City, and among those with serious psychiatric conditions. This initial study suggests that an additional research is needed to better understand how the gap in care affects this population. (Am J Addict 2020;29:151-154).

Association between Types of Usual Source of Care and User Perception of Overall Health Care Service Quality in Korea

Background

Patients’ perceptions of care tend to correlate with the quality of care provided. Different health care systems and service environments may show different associations between types of usual source of care (USC) and overall service quality assessment. We attempted to analyze this association as a benefit of having a USC.

Methods

This study used the 2012 Korea Health Panel data version 1.1 as representative national household survey data. The total number of subjects aged 18 years or more was 12,708. The number of subjects in the final analysis was 10,665. Multiple logistic regression analysis was used to assess the association between types of USC and overall health care service quality. The main outcome variable was users’ ratings of the quality of health care service.

Results

People having a usual doctor (n=1,796) were more likely to positively assess the quality of health care they received than those not having a USC (n=7,920; odds ratio [OR], 1.39; 95% confidence interval [CI], 1.20–1.60) or with those having only a place as a USC without a usual doctor (n=949; OR, 1.29; 95% CI, 1.05–1.58) after adjustment for demographic characteristics and health-related variables.

Conclusion

People having a usual doctor rated overall health care service quality as high, which might be due to benefits of primary care attributes related to usual doctors. Further studies are needed to elucidate the causal relationship. This finding implies that health policies encouraging people to have a usual doctor are needed in Korea.

Medicaid's Impact on Chronic Disease Biomarkers: A Cohort Study of Community Health Center Patients

BACKGROUND

Understanding the impact of health insurance is critical, particularly in the era of Affordable Care Act Medicaid expansion. The electronic health record (EHR) provides new opportunities to quantify health outcomes.

OBJECTIVE

To assess changes in biomarkers of chronic disease among community health center (CHC) patients who gained Medicaid coverage with the Oregon Medicaid expansion (2008-2011).

DESIGN

Prospective cohort. Patients were followed for 24 months, and rate of mean biomarker change was calculated. Time to a controlled follow-up measurement was compared using Cox regression models.

SETTING/PATIENTS

Using EHR data from OCHIN (a non-profit network of CHCs) linked to state Medicaid data, we identified three cohorts of patients with uncontrolled chronic conditions (diabetes, hypertension, and hyperlipidemia). Within these cohorts, we included patients who gained Medicaid coverage along with a propensity score-matched comparison group who remained uninsured (diabetes n = 608; hypertension n = 1244; hyperlipidemia n = 546).

MAIN MEASURES

Hemoglobin A1c (HbA1c) for the diabetes cohort, systolic and diastolic blood pressure (SBP and DBP, respectively) for the hypertension cohort, and low-density lipoprotein (LDL) for the hyperlipidemia cohort.

KEY RESULTS

All cohorts improved over time. Compared to matched uninsured patients, adults in the diabetes and hypertension cohorts who gained Medicaid coverage were significantly more likely to have a follow-up controlled measurement (hazard ratio [HR] =1.26, p = 0.020; HR = 1.35, p < 0.001, respectively). No significant difference was observed in the hyperlipidemia cohort (HR = 1.09, p = 0.392).

CONCLUSIONS

OCHIN patients with uncontrolled chronic conditions experienced objective health improvements over time. In two of three chronic disease cohorts, those who gained Medicaid coverage were more likely to achieve a controlled measurement than those who remained uninsured. These findings demonstrate the effective care provided by CHCs and the importance of health insurance coverage within a usual source of care setting.

CLINICAL TRIALS REGISTRATION

NCT02355132 [ https://clinicaltrials.gov/ct2/show/NCT02355132 ].

Impact of HIV care facility characteristics on the cascade of care in HIV-infected patients in the Netherlands

OBJECTIVE

Successful treatment of people infected with HIV requires that patients are retained in HIV care, use combination antiretroviral therapy (cART) and ultimately reach and sustain viral suppression. Our aim was to identify health facility characteristics associated with these steps in the cascade of HIV care.

DESIGN

Retrospective cohort study.

METHODS

We included data from all adult HIV-1-infected patients who entered care in the Netherlands between 2007 and 2013 (N = 7120). Multivariate logistic regression was used to examine the associations between health facility characteristics and the outcomes 'currently in care', 'initiated cART', and 'viral suppression'.

RESULTS

The proportion of patients 'currently in care' was high in all 26 treatment centres. cART initiation was positively associated with the accreditation of the health facility [OR (odds ratio): 1.62; 95% CI (confidence interval): 1.18-2.23] and the performance of an internal audit in the preceding 3 years (OR: 1.36; 95% CI: 1.02-1.81). The odds of cART initiation were higher in middle-sized (OR: 2.00; 95% CI: 1.25-3.21) and large HIV treatment centres (OR: 1.80; 95% CI: 1.14-2.84) compared with small centres (<300 HIV-infected patients). Viral suppression was negatively associated with the presence of a social worker in the HIV treatment team (OR: 0.62; 95% CI: 0.43-0.91).

CONCLUSIONS

Our results confirm that appointing expert HIV treatment centres facilitates retention in care and that a minimum volume requirement may be desirable. Our findings suggest that quality assessment through accreditation and the measurement of performance benefits the delivery of HIV care.

Usual source of care and the quality of primary care: a survey of patients in Guangdong province, China

Introduction

Usual source of care (USC) refers to the provider or place a patient consults when sick or in need of medical advice. No studies have been conducted in China to compare the quality of primary care provided with or without USC. The purpose of this study was to fill this gap in the literature by examining the quality of primary care provided between those having a USC and those without. Results of the study would provide implications for policymakers in terms of improving primary care performance in China, and help guide patients in their health care seeking behaviors.

Methods

A cross-sectional survey with patients was conducted in Guangdong province of China, using the Chinese validated Primary Care Assessment Tool (PCAT). ANOVA was performed to compare the overall and ten domains of primary care quality for patients with and without USC. Multivariate analyses were used to assess the association between USC and quality of primary care attributes while controlling for sociodemographic and health care characteristics.

Results

The study added evidence that having a USC can provide higher quality of primary care to patients than those without a USC. Results of this study showed that the PCAT score associated with those having a USC was significantly higher than those not having a USC. Moreover, the study showed that having a usual provider of care was also independently and significantly associated with patients’ satisfaction with care.

Conclusions

This study added evidence that in China, patients with a USC reported higher quality of medical care experiences compared with those without a USC. The efforts to improve quality of care should include policies promoting USC.

Comparison of HIV outcomes for patients linked at hospital versus community-based clinics

Outpatient care for people living with HIV is delivered in diverse settings. Differences in setting may impact HIV outcomes. We evaluated HIV-infected adults in care at Ryan White-funded clinics in Philadelphia, PA, between 2008 and 2011 to determine how setting of care (hospital versus community-based) influenced HIV outcomes. Clinics were categorized as hospital-based if they were located onsite at a hospital. The composite outcome was completion of the final three steps of the HIV care continuum: (1) retention in care; (2) use of antiretroviral therapy (ART); and (3) viral suppression. Mixed-effects logistic regression, accounting for patient and clinic factors, examined the relationship between care setting and the outcome. In total, 12,637 patients, contributing 32,515 patient-years, received care at 25 clinics (12 hospital-based). Women, non-Hispanic blacks, those with private insurance, and individuals with higher household incomes more commonly attended hospital-based clinics (p<0.05). Of the 12,962 patient-years (40%) during which patients attended community-based clinics, 59% met the outcome. Similarly, 59% of the 19,553 patient-years (60%) in which patients attended hospital-based clinics met the outcome. Adjusting for patient and clinic factors, setting was not associated with the outcome (adjusted odds ratio=1.24, 95% CI=0.84-1.84). In summary, demographics differ among patients visiting hospital and community-based clinics. Completion of the final three steps of the HIV care continuum did not vary between hospital and community-based clinics, which may reflect advances in HIV therapy and the wide availability of HIV care resources.

System and Patient Barriers to Care among People Living with HIV/AIDS in Houston/Harris County, Texas: HIV Medical Care Providers' Perspectives

In the United States, a considerable number of people diagnosed with HIV are not receiving HIV medical care due to some barriers. Using data from the Medical Monitoring Project survey of HIV medical care providers in Houston/Harris County, Texas, we assessed the HIV medical care providers' perspectives of the system and patient barriers to HIV care experienced by people living with HIV/AIDS (PLWHA). The study findings indicate that of the 14 HIV care barriers identified, only 1 system barrier and 7 patient barriers were considered of significant (P ≤ .05) importance, with the proportion of HIV medical care providers' agreement to these barriers ranging from 73.9% (cost of health care) to 100% (lack of social support systems and drug abuse problems). Providers' perception of important system and patient barriers varied significantly (P ≤ .05) by profession, race/ethnicity, and years of experience in HIV care. To improve access to and for consistent engagement in HIV care, effective intervention programs are needed to address the barriers identified especially in the context of the new health care delivery system.

Usual source of care and outcomes following acute myocardial infarction

BACKGROUND

The quality of the relationship between a patient and their usual source of care may impact outcomes, especially after an acute clinical event requiring regular follow-up.

OBJECTIVE

To examine the association between the presence and strength of a usual source of care with mortality and readmission after hospitalization for acute myocardial infarction (AMI).

DESIGN

Prospective Registry Evaluating Myocardial Infarction: Event and Recovery (PREMIER), an observational, 19-center study.

PATIENTS

AMI patients discharged between January 2003 and June 2004.

MAIN MEASURES

The strength of the usual source of care was categorized as none, weak, or strong based upon the duration and familiarity of the relationship. Main outcome measures were readmissions and mortality at 6 months and 12 months post-AMI, examined in multivariable analysis adjusting for socio-demographic characteristics, access and barriers to care, financial status, baseline risk factors, and AMI severity.

KEY RESULTS

Among 2,454 AMI patients, 441 (18.0 %) reported no usual source of care, whereas 247 (10.0 %) and 1,766 (72.0 %) reported weak and strong usual sources of care, respectively. When compared with a strong usual source of care, adults with no usual source of care had higher 6-month mortality rates [adjusted hazard ratio (aHR) = 3.15, 95 % CI, 1.79-5.52; p < 0.001] and 12-month mortality rates (aHR = 1.92, 95 % CI, 1.19-3.12; p = 0.01); adults with a weak usual source of care trended toward higher mortality at 6 months (aHR = 1.95, 95 % CI, 0.98-3.88; p = 0.06), but not 12 months (p = 0.23). We found no association between the usual source of care and readmissions.

CONCLUSIONS

Adults with no or weak usual sources of care have an increased risk for mortality following AMI, but not for readmission.

Substance abuse treatment in persons with HIV/AIDS: challenges in managing triple diagnosis

Clinical management of HIV must account for the "triple diagnosis" of HIV, psychiatric diagnosis, and substance use disorders and requires integrated treatment services that focus beyond just mitigation of substance use and psychiatric and medical symptoms but also address other health behaviors. Because clinical management of HIV/AIDS has shifted significantly with the advent of highly active antiretroviral therapies (HAART) in the mid 1990s, a literature review focusing on literature published since 2000, and using relevant key words was conducted using a wide range of literature search databases. This literature review was complemented by studies to expand on specific treatment modalities for which there was a dearth of literature addressing HIV infected cohorts and to provide discussion of issues around substance abuse treatment as an HIV prevention tool. Existing models of substance abuse treatment including cognitive behavioral therapy and motivational interviewing have proven to be useful for enhancing adherence and reducing substance use in outpatient populations, while methadone maintenance and directly observed treatment have been useful with specific subgroups of users. Contextualization of services heightens the likelihood of successful outcomes and relapse prevention.

Documentation of psychiatric disorders and related factors in a large sample population of HIV-positive patients in California

This retrospective cohort study examined electronic medical records of HIV-positive patients in California (N = 7,834) to find the prevalence of any psychiatric condition and the associations between several factors and the likelihood of these disorders. Approximately 53 % of the patients in this study had a documented psychiatric condition, including 23 % who had a mood disorder, 19 % who had a substance-related disorder, and 16 % who had an anxiety disorder. After controlling for potential confounders, significant positive associations (p < 0.001) were found between female gender and the presence of any mood disorder (adjusted odds ratio [95 % confidence interval, 95 %CI] = 1.58 [1.26-1.99]) or anxiety disorder (AOR = 1.54 [1.18-2.02]) and between homosexual orientation and the presence of any psychiatric condition (AOR = 1.33 [1.15-1.55]), mood disorder (AOR = 1.71 [1.42-2.07]), or anxiety disorder (AOR = 1.41 [1.22-1.88]). There were also significant negative associations between African-American race and the presence of any psychiatric condition (AOR = 0.68 [0.60-0.77]), mood disorder (AOR = 0.74 [0.64-0.86]), anxiety disorder (AOR = 0.43 [0.36-0.52]), or substance-related disorder (AOR = 0.78 [0.67-0.91]) and between state/federal insurance and the presence of any psychiatric condition (AOR = 0.70 [0.62-0.79]), mood disorder (AOR = 0.71 [0.62-0.80]), or anxiety disorder (AOR = 0.77 [0.66-0.89]).

Interventions to promote linkage to and utilization of HIV medical care among HIV-diagnosed persons: a qualitative systematic review, 1996-2011

This qualitative systematic review examined interventions that promote linkage to or utilization of HIV care among HIV-diagnosed persons in the United States. We conducted automated searches of electronic databases (i.e., MEDLINE, EMBASE, PsycINFO, CINAHL) and manual searches of journals, reference lists, and listservs. Fourteen studies from 19 published reports between 1996 and 2011 met our inclusion criteria. We developed a three-tier approach, based on strength of study design, to evaluate 6 findings on linkage to care and 18 findings on HIV care utilization. Our review identified similar strategies for the two outcomes, including active coordinator's role in helping with linking to or utilizing HIV care; offering information and education about HIV care; providing motivational or strengths-based counseling; accompanying clients to medical appointments and helping with appointment coordination. The interventions focused almost exclusively on individual-level factors. More research is recommended to examine interventions that address system and structural barriers.

Interventions to improve retention in HIV primary care: a systematic review of U.S. studies

Retaining HIV-diagnosed persons in care is a national priority, but little is known on what intervention strategies are most effective for promoting retention in care. We conducted a systematic search and qualitatively reviewed 13 published studies and three recent conference presentations to identify evidence-informed retention strategies. We extracted information on study design, methods, and intervention characteristics. Strengths-based case management that encourages clients to recognize and use their own internal abilities to access resources and solve problems offered strong evidence for retention in care. Other evidence-informed strategies included peer navigation, reducing structural- and system-level barriers, including peers as part of a health care team, displaying posters and brochures in waiting rooms, having medical providers present brief messages to patients, and having clinics stay in closer contact with patients across time. Opportunities for additional intervention strategies include using community-based organizations as a setting for engaging HIV-infected persons about the importance of regular care and involving patients' significant others in retention in care interventions.

Substance abuse treatment utilization among adults living with HIV/AIDS and alcohol or drug problems

This is a prospective cohort study to identify factors associated with receipt of substance abuse treatment (SAT) among adults with alcohol problems and HIV/AIDS. Data from the HIV Longitudinal Interrelationships of Viruses and Ethanol study were analyzed. Generalized estimating equation logistic regression models were fit to identify factors associated with any service utilization. An alcohol dependence diagnosis had a negative association with SAT (adjusted odds ratio [AOR] = 0.36, 95% confidence interval [95% CI] = 0.19-0.67), as did identifying sexual orientation other than heterosexual (AOR = 0.46, CI = 0.29-0.72) and having social supports that use alcohol/drugs (AOR = 0.62, CI = 0.45-0.83). Positive associations with SAT include presence of hepatitis C antibody (AOR = 3.37, CI = 2.24-5.06), physical or sexual abuse (AOR = 2.12, CI = 1.22-3.69), social supports that help with sobriety (AOR = 1.92, CI = 1.28-2.87), homelessness (AOR = 2.40, CI = 1.60-3.62), drug dependence diagnosis (AOR = 2.64, CI = 1.88-3.70), and clinically important depressive symptoms (AOR = 1.52, CI = 1.08-2.15). While reassuring that factors indicating need for SAT among people with HIV and alcohol problems (e.g., drug dependence) are associated with receipt, nonneed factors (e.g., sexual orientation, age) that should not decrease likelihood of receipt of treatment were identified.

Using Administrative Claims Data to Estimate Virologic Failure Rates among Human Immunodeficiency Virus–Infected Patients with Antiretroviral Regimen Switches

Objective. To develop and validate a claims signature model that estimates proportions of HIV-infected patients in administrative claims databases who switched combination antiretroviral therapy (cART) regimens because of virologic failure. Methods. The authors used an HIV-specific registry (development data set) to develop logistic regression models to estimate odds of virologic failure among patients who switched cART regimens. Models were validated in a sample of administrative claims with laboratory values (validation data set). The final model was applied to an application data set as a worked example. Results. There were 1691, 1073, and 3954 eligible patients with cART switches in the development, validation, and application data sets, respectively. In the development data set, virologic failure before a switch was observed 21.8% of the time. Failure more likely caused the regimen switch among patients who were treatment experienced, had been receiving their baseline regimen for > 180 days, had ≥ 2 or more physician visits within 90 days, had > 1 HIV RNA or CD4 cell count test within 30 days, had any resistance test within 180 days, or had a change in regimen type. The final model had good discriminatory ability (C = 0.885) and fit (Hosmer-Lemeshow P = 0.8692). Failure was estimated to occur in 18.9% (v. 18.6% observed) of switches in the validation data set and 13.8% in the application data set. Conclusions. This claims signature model allows payers to use claims data to estimate virologic failure rates in their patient populations, thereby better understanding plan costs of failure.

Usual source of care and the quality of medical care experiences: a cross-sectional survey of patients from a Taiwanese community

OBJECTIVE

This study used a recent patient survey to examine the relationship between having a usual source of care (USC) and the quality of ambulatory medical care experiences in Taiwan, where there is universal health insurance coverage.

RESEARCH DESIGN, SUBJECTS, AND MEASURES

The study design was a cross-sectional survey of 879 patients in Taichung County, Taiwan. Children and adults visiting hospital-based physicians were included. Quality of care was measured using items from the Primary Care Assessment Tool (PCAT), representing 7 ambulatory medical care domains: first contact (ie, access and utilization), longitudinality (ie, ongoing care), coordination (ie, referrals and information systems), comprehensiveness (ie, services available and provided), family centeredness, community orientation, and cultural competence. USC was defined based on responses to 3 survey items from the PCAT.

RESULTS

Having a USC was significantly associated with higher quality of medical care experiences. Specifically, having a USC was associated with improved accessibility and utilization, ongoing care, coordination of referrals, and healthcare providers' family centeredness and cultural competence. However, having a USC was not strongly related with comprehensiveness of services, coordination of information systems, or healthcare providers' community orientation.

CONCLUSION

In a region with universal health insurance, patients with a USC reported higher quality of medical care experiences compared with those without a USC. Beyond the provision of health insurance coverage, efforts to improve quality of care should include policies promoting USC.

Antiretroviral use among active injection-drug users: the role of patient-provider engagement and structural factors

HIV-seropositive, active injection-drug users (IDUs), compared with other HIV populations, continue to have low rates of highly active antiretroviral therapy (HAART) use, contributing to disparities in their HIV health outcomes. We sought to identify individual-level, interpersonal, and structural factors associated with HAART use among active IDUs to inform comprehensive, contextually tailored intervention to improve the HAART use of IDUs. Prospective data from three semiannual assessments were combined, and logistic general estimating equations were used to identify variables associated with taking HAART 6 months later. Participants were a community sample of HIV-seropositive, active IDUs enrolled in the INSPIRE study, a U.S. multisite (Baltimore, Miami, New York, San Francisco) prevention intervention. The analytic sample included 1,225 observations, and comprised 62% males, 75% active drug users, 75% non-Hispanic blacks, and 55% with a CD4 count <350; 48% reported HAART use. Adjusted analyses indicated that the later HAART use of IDUs was independently predicted by patient-provider engagement, stable housing, medical coverage, and more HIV primary care visits. Significant individual factors included not currently using drugs and a positive attitude about HAART benefits even if using illicit drugs. Those who reported patient-centered interactions with their HIV primary care provider had a 45% greater odds of later HAART use, and those with stable housing had twofold greater odds. These findings suggest that interventions to improve the HIV treatment of IDUs and to reduce their HIV health disparities should be comprehensive, promoting better patient-provider engagement, stable housing, HAART education with regard to illicit drug use, and integration of drug-abuse treatment with HIV primary care.

The role of usual source of care in cholesterol treatment

BACKGROUND

A usual source of care (USOC) has been associated with improved preventive and chronic care, but its relationship with lipid management has not been well described. The objectives of this study were (1) to examine the association of USOC with statin use among persons meeting eligibility guidelines for treatment, and (2) to examine the association of USOC with low-density lipoprotein goal attainment among those receiving statins.

METHODS

We examined statin use among adults aged 21 to 79 years who participated in the National Health and Nutrition Examination Survey, 1999 to 2006. We used criteria from the third Adult Treatment Panel about the treatment of high cholesterol to assess eligibility and the examined factors that predicted current use of statins. Among those currently taking statins, we assessed achievement of target low-density lipoprotein cholesterol based on the third Adult Treatment Panel's goals.

RESULTS

Among the 12,979 participants, nearly 14% were eligible. Having a USOC was significantly associated with the use of statins among those who were eligible but not with goal attainment among those taking statins. Significant predictors of goal attainment were higher income and education and being in a more recent cohort.

CONCLUSION

In a national sample USOC was significantly associated with the use of statins among eligible adults but not with low-density lipoprotein cholesterol goal attainment for those using statins.

Impact of service delivery model on health care access among HIV-positive women in New York City

As the New York City HIV=AIDS epidemic began generalizing beyond traditionally high-risk groups in the early 1990s, AIDS Service Organizations (ASO) sought to increase access to medical care and broaden service offerings to incorporate the needs of low-income women and their families. Strategies to achieve entry into and retention in medical care included the development of integrated care facilities, case management, and a myriad of supportive service offerings. This study examines a nonrandom sample of 60 HIV-positive women receiving case management and supportive services at New York City ASOs. Over 55% of the women interviewed reported high access to care, 43% reported the ability to access urgent care all of the time and 94% reported high satisfaction with obstetrics=gynecology (OB=GYN) care. This held true across race=ethnicity, income level, medical coverage, and service delivery model.Women who accessed services at integrated care facilities offering onsite medical care and case management=supportive services perceived lower access to medical specialists as compared to those who received services at nonintegrated sites. Data from this analysis indicate that supportive services increase access to and satisfaction with both HIV and non-HIV-related health care. Additionally, women who received services at a medical model agency were more likely to report accessing non-HIV care at a clinic compared to those receiving services at a nonmedical model agencies, these women were more likely to report receiving non-HIV care at a hospital.

Utilization of mental health and substance abuse care for people living with HIV/AIDS, chronic mental illness, and substance abuse disorders

OBJECTIVE

To examine the effects of race/ethnicity, insurance, and type of substance abuse (SA) diagnosis on utilization of mental health (MH) and SA services among triply diagnosed adults with HIV/AIDS and co-occurring mental illness (MI) and SA disorders.

DATA SOURCE

Baseline (2000 to 2002) data from the HIV/AIDS Treatment Adherence, Health Outcomes, and Cost Study.

STUDY DESIGN

A multiyear cooperative agreement with 8 study sites in the United States. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) was administered by trained interviewers to determine whether or not adults with HIV/AIDS had co-occurring MI and SA disorders.

DATA COLLECTION/EXTRACTION METHODS

Subjects were interviewed in person about their personal characteristics and utilization of MH and SA services in the prior 3 months. Data on HIV viral load were abstracted from their medical records.

PRINCIPAL FINDINGS

Only 33% of study participants received concurrent treatment for MI and SA, despite meeting diagnostic criteria for both: 26% received only MH services, 15% received only SA services, and 26% received no services. In multinomial logistic analysis, concurrent utilization of MH and SA services was significantly lower among nonwhite and Hispanic participants as a group and among those who were not dependent on drugs and alcohol. Concurrent utilization was significantly higher for people with Veterans Affairs Civilian Health and Medical Program of the Uniformed Services (VA CHAMPUS) insurance coverage. Two-part models were estimated for MH outpatient visits and 3 SA services: (1) outpatient, (2) residential, and (3) self-help groups. Binary logistic regression was estimated for any use of psychiatric drugs. Nonwhites and Hispanics as a group were less likely to use 3 of the 5 services; they were more likely to attend SA self-help groups. Participants with insurance were significantly more likely to receive psychiatric medications and residential SA treatment. Those with Medicaid were more likely to receive MH outpatient services. Participants who were alcohol dependent but not drug dependent were significantly less likely to receive SA services than those with dual alcohol and drug dependence.

CONCLUSION

Among adults with HIV/AIDS and co-occurring MH and SA disorders, utilization of MH and SA services needs to be improved.

Implications of Medicaid coverage in a program for Latino substance users

BACKGROUND

This cross-sectional study explored baseline differences between Medicaid covered and uninsured clients (n=368) in the Project La Voz, a community outreach program targeting Latino substance users.

METHODS

Independent variables included client demographics, health status and health service use; the dependent variable was Medicaid coverage vs. uninsured. Bi-variate analyses and three binomial logistic regression models were conducted.

RESULTS

The first logistic regression model examining client characteristics indicated that La Voz enrollees with Medicaid coverage were more likely to be women, reside in stable housing, and report poor health status. Employment and educational status were not significantly associated with having Medicaid. A second model, examining the association between health care utilization in the past 30 days and Medicaid coverage, indicated that LaVoz enrollees with Medicaid were significantly more likely to have entered substance use treatment. In the third model, client characteristics and health care use were examined in one model; all variables remained significant except for gender. IMPLICATIONS FOR PROGRAM PLANNING: Massachusetts recent health care reform efforts include substance abuse treatment benefits through Medicaid. Specific strategies are needed to ensure that Latinos substance abusers, particularly those who are homeless, gain Medicaid coverage and then have access to needed services.

Microsocial environmental influences on highly active antiretroviral therapy outcomes among active injection drug users: the role of informal caregiving and household factors

Active injection drug users (IDUs) are at high risk of unsuccessful highly active antiretroviral therapy (HAART). We sought to identify baseline factors differentiating IDUs' treatment success versus treatment failure over time among those taking HAART. Interventions for Seropositive Injectors-Research and Evaluation (INSPIRE) study participants were assessed at baseline and at 6- and 12-month follow-ups. Multinominal regression determined baseline predictors of achieving or maintaining viral suppression relative to maintaining detectable viral loads over 12 months. Of 199 participants who were retained and remained on HAART, 133 (67%) had viral load change patterns included in the analysis. At follow-up, 66% maintained detectable viral loads and 15% achieved and 19% maintained viral suppression. Results indicated that those having informal care (instrumental or emotional support) were 4.6 times more likely to achieve or maintain viral suppression relative to experiencing treatment failure. Those who maintained viral suppression were 3.5 times less likely to live alone or to report social discomfort in taking HAART. Study results underscore the importance of microsocial factors of social network support, social isolation, and social stigma for successful HAART outcomes among IDUs. The findings suggest that adherence interventions for IDUs should promote existing informal HIV caregiving, living with supportive others, and positive medication-taking norms among social networks.

Black-White mortality from HIV in the United States before and after introduction of highly active antiretroviral therapy in 1996

OBJECTIVES

We sought to describe Black-White differences in HIV disease mortality before and after the introduction of highly active antiretroviral treatment (HAART).

METHODS

Black-White mortality from HIV is described for the nation as a whole. We performed regression analyses to predict county-level mortality for Black men aged 25-84 years and the corresponding Black:White male mortality ratios (disparities) in 140 counties with reliable Black mortality for 1999-2002.

RESULTS

National Black-White disparities widened significantly after the introduction of HAART, especially among women and the elderly. In county regression analyses, contextual socioeconomic status (SES) was not a significant predictor of Black:White mortality rate ratio after we controlled for percentage of the population who were Black and percentage of the population who were Hispanic, and neither contextual SES nor race/ethnicity were significant predictors after we controlled for pre-HAART mortality. Contextual SES, race, and pre-HAART mortality were all significant and independent predictors of mortality among Black men.

CONCLUSIONS

Although nearly all segments of the Black population experienced widened post-HAART disparities, disparities were not inevitable and tended to reflect pre-HAART levels. Public health policymakers should consider the hypothesis of unequal diffusion of the HAART innovation, with place effects rendering some communities more vulnerable than others to this potential problem.

Type and pattern of illicit drug use and access to health care services for HIV-infected people

Approximately 28% of HIV-infected people in treatment in the United States report using illicit drugs. Illicit drug users have poorer course of HIV disease than non-drug users, which is thought to be due to their irregular use of HIV medical services. We examined associations between type (cocaine versus opioids) and pattern of drug use (drug use at baseline, 6-month follow-up, both periods, and nonuse) and health care utilization for a large sample of HIV-infected individuals drawn from a multisite project that evaluated the impact of medical outreach interventions for populations at risk of poor retention in HIV care. Across all types and patterns of drug use, drug users were more likely to have suboptimal ambulatory care, miss scheduled appointments, use the emergency department, have unmet support services needs, and were less likely to take antiretroviral medications. Additionally, while people who started using drugs during the follow-up period and consistently used drugs across both periods differed from nonusers on missed appointments (odds ratio [OR] = 2.20 for starters versus nonusers, OR = 2.92 for consistent users versus nonusers), emergency department use (OR = 4.93 for starters versus nonusers, OR = 2.24 for consistent users versus nonusers), and antiretroviral medication use at follow-up (OR = 0.23 starters versus nonusers, OR = 0.19 for consistent users versus nonusers), those who stopped using drugs after the baseline period did not differ from nonusers. We conclude that health care utilization is poorer for people who use illicit drugs than those who do not, and stopping drug use may facilitate improvements in health care utilization and HIV outcomes for this population.

Age difference in rates of mental health/substance abuse and behavioral care in HIV-positive adults

This study aims to investigate age differences in rates of mental health/substance abuse and behavioral health treatment in HIV-positive adults. One-hundred and nine HIV-positive adults (21-88 years old) were recruited from the University of Pennsylvania Center for AIDS Research (CFAR) infectious disease clinics. Each subject participated in a 3-hour comprehensive behavioral/psychosocial interview. Over half of the sample displayed significant mental health and substance abuse symptoms, of which approximately a third were actively participating in behavioral health care. Major depression and illicit drug use appeared to be the most prevalent syndromes. However, individuals with mania and psychosis were most likely to be participating in behavioral health treatment, while individuals with at-risk drinking and illicit drug use were least likely to be participating in treatment. Furthermore, older-aged adults were less likely to be receiving behavioral health care when there was evidence of need. The findings of this investigation generally concluded that HIV-positive adults, especially older-aged adults, are in need of improved behavioral health management for mental health/substance abuse.

Appropriateness of antiretroviral therapy in clients of an HIV/AIDS case management organization

We sought to assess appropriateness of antiretroviral therapy (ART) reported by clients of an HIV/AIDS case management organization and identify variables associated with appropriate ART receipt. A total of 295 such clients were mailed a survey asking them to identify antiretroviral medications they were taking. Of them 220 (75%) returned surveys; 201 (93%) were taking antiretrovirals. Of these, 159 were on appropriate and 36 on inappropriate ART, as determined by guidelines created by the CDC, the International AIDS Society (USA Panel), and the Panel on Clinical Practices for Treatment of HIV Infection. In unadjusted analyses, age, sex, race, sexual orientation, history of injection drug use, history of sexual risk, and HIV knowledge were associated (p< or =0.10) with appropriate ART and entered into one of two logistic regression models. The first model indicated that women (p=0.003) and heterosexuals (p=0.001) were less likely to receive appropriate ART than men and gay/bisexuals (and variables interacted, p=0.001). HIV knowledge--a proxy indicator determined by self-report of a CD4 cell count and viral load--was added to variables retained in first model to create a second model. Only sexual orientation was retained in this second model (p=0.02, in the same direction as in the first model), and those with less versus more HIV knowledge (p=0.04) were found to be less likely to receive appropriate ART (and variables interacted, p=0.04). Findings suggest that heterosexual men are less likely than women who, in turn, are less likely than gay/bisexual men to receive appropriate ART. HIV-related knowledge appears to increase likelihood of receiving appropriate ART and it attenuates the effect of sex.

Depressive symptoms in HIV disease

Although depressive symptoms are common in people living with HIV/AIDS, their reported prevalence varies greatly across HIV-positive populations, ranging from 21% to 97%. Comparing these rates is complicated by the varied conceptualization of depression as a major depressive disorder (clinical depression) or depressive symptoms, and by the use of multiple methods of measurement. Knowledge of predictors of depressive symptoms can assist health care providers in the identification of those who are most at risk. Appropriate diagnosis, treatment, and referral are critical, because depressive symptoms have been associated with poorer disease outcomes. Additionally, self-management symptoms can be used to supplement more traditional treatment methods.