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Haines CF, Fleishman JA, Yehia BR, Lau B, Berry SA, Agwu AL, Moore RD, Gebo KA. Closing the Gap in Antiretroviral Initiation and Viral Suppression: Time Trends and Racial Disparities. J Acquir Immune Defic Syndr 2016; 73:340-347. [PMID: 27763997 PMCID: PMC5119893 DOI: 10.1097/qai.0000000000001114] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND In the current antiretroviral (ART) era, the evolution of HIV guidelines and emergence of new ART agents might be expected to impact the times to ART initiation and HIV virologic suppression. We sought to determine if times to AI and virologic suppression decreased and if disparities exist by age, race/ethnicity, and HIV risk. METHODS We performed a retrospective cohort study of data from 12 sites of the HIV Research Network, a consortium of US clinics caring for HIV-infected patients. HIV-infected adults (≥18 year old) newly presenting for care between 2003 and 2013 were included in this study. Times to AI and virologic suppression were defined as time from enrollment to AI and HIV RNA <400 copies per milliliter, respectively. We conducted time-to-event analyses using competing risk regression in the HIV Research Network cohort from 2003 to 2012 in 2-year intervals, with follow-up through 2013. RESULTS Among 15,272 participants, 76.9% were male, 48.4% black, and 10.9% were injection drug use with median age of 38 years (interquartile range: 29-46 years). The adjusted subdistribution hazards ratios (SHRs) for AI and virologic suppression each increased for years 2007-2008 [SHR 1.23 (1.16-1.30), and SHR 1.25 (1.17-1.34), respectively], 2009-2010 [1.55 (1.46-1.64), and 1.54 (1.43-1.65), respectively], and 2011-2012 [1.94 (1.83-2.07), and 1.73 (1.61-1.86), respectively] compared with 2003-2004. Blacks had a lower probability of AI than whites and Hispanics. CONCLUSIONS Since 2007, times from enrollment to AI and virologic suppression have decreased significantly compared with 2003-2004, but persisting disparities should be addressed.
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Affiliation(s)
- Charles F Haines
- *Department of Medicine, Division of Infectious Disease, The John Hopkins School of Medicine, Baltimore, MD;†Agency for Healthcare Research and Quality (AHRQ);‡University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA;§Department of Epidemiology, The Johns Hopkins University School of Public Health, Baltimore, MD; and‖The Johns Hopkins Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD
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Haines CF, Fleishman JA, Yehia BR, Berry SA, Moore RD, Bamford LP, Gebo KA. Increase in CD4 count among new enrollees in HIV care in the modern antiretroviral therapy era. J Acquir Immune Defic Syndr 2014; 67:84-90. [PMID: 24872131 PMCID: PMC4134357 DOI: 10.1097/qai.0000000000000228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Earlier HIV diagnosis and engagement in care improve outcomes and is cost effective, as a result, in 2006, the Centers for Disease Control and Prevention (CDC) revised the HIV-screening guidelines. We sought to determine whether the CD4 count (CD4) at presentation, a surrogate for time to presentation, increased during the study period. Our a priori hypothesis was that the CD4 at presentation increased during the study period, particularly after the CDC guideline revision. METHODS We performed a retrospective cohort study and analyzed data from the HIV Research Network, a consortium of 18 US clinics caring for HIV-infected patients. HIV-infected adults (≥18 years old) newly presenting for care between 2003 and 2011 were included in this study. Multivariable linear regression examined associations with CD4 at enrollment. Calendar year was modeled as a linear spline with a change in slope at 2008, allowing determination of the mean change in CD4 per year during 2003-2007 and 2008-2011. RESULTS Over 13,543 newly presenting subjects enrolled from 2003 to 2011. Median CD4 at enrollment rose from 285 to 317 cells per cubic millimeter between 2003-2007 and 2008-2011 (P < 0.001). After adjusting for age, race/ethnicity, gender, HIV risk factor, and clinic site, the mean increase in the CD4 count at presentation per year was 13.3 cells per cubic millimeter per year (95% confidence interval 6.4 to 20.1 cells per cubic millimeter per year) greater during 2008-2011 than during 2003-2007. CONCLUSIONS We demonstrate a small, but statistically significant, increase in CD4 at presentation after the CDC guideline revision. More efforts are needed to decrease time to presentation to HIV care.
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Affiliation(s)
- Charles F Haines
- *Division of Infectious Diseases, Department of Medicine, The Johns Hopkins of Medicine, Baltimore, MD; †Agency for Healthcare Research and Quality (AHRQ); ‡Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and §Jonathan Lax Treatment Center, Philadelphia, PA
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Abstract
OBJECTIVES The purpose of this review is to identify and analyze published studies that have evaluated disparities for opportunistic infection (OI) prophylaxis between blacks and whites with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in the United States. METHODS The authors conducted a web-based search of MEDLINE (1950-2009) to identify original research articles evaluating the use of OI prophylaxis between blacks and whites with HIV/AIDS. The search was conducted utilizing the following MeSH headings and search terms alone and in combination: HIV, AIDS, Black, race, ethnicity, disparities, differences, access, opportunistic infection, and prophylaxis. The search was then expanded to include any relevant articles from the referenced citations of the articles that were retrieved from the initial search strategy. Of the 29 articles retrieved from the literature search, 19 articles were excluded. RESULTS Ten publications met inclusion criteria, collectively published between 1991 and 2005. The collective time periods of these studies spanned from 1987 to 2001. Four studies identified a race-based disparity in that blacks were less likely than whites to use OI prophylaxis, whereas 5 studies failed to identify such a relationship between race and OI prophylaxis. One study identified disparities for Mycobacterium avium complex prophylaxis, but not for Pneumocystis jiroveci pneumonia prophylaxis. CONCLUSIONS The evidence regarding race-based disparities in OI prophylaxis is inconclusive. Additional research is warranted to explore potential race-based disparities in OI prophylaxis.
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Wilson LE, Korthuis T, Fleishman JA, Conviser R, Lawrence PB, Moore RD, Gebo KA. HIV-related medical service use by rural/urban residents: a multistate perspective. AIDS Care 2011; 23:971-9. [PMID: 21400307 DOI: 10.1080/09540121.2010.543878] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Geographic location may be related to the receipt of quality HIV health care services. Clinical outcomes and health care utilization were evaluated in rural, urban, and peri-urban patients seen at high-volume US urban-based HIV care sites. METHODS Zip codes for 8773 HIV patients followed in 2005 at seven HIV Research Network sites were categorized as rural (population <10,000), peri-urban (10,000-100,000), and urban (>100,000). Clinical and demographic characteristics, inpatient and outpatient (OP) utilization, AIDS-defining illness rates, receipt of highly active antiretroviral therapy (HAART), opportunistic infection (OI) prophylaxis usage, and virologic suppression were compared among patients, using χ(2) tests for categorical variables, t-tests for means, and logistic regression for HAART utilization. RESULTS HIV-infected rural (n=170) and peri-urban (n=215) patients were less likely to be Black or Hispanic than urban HIV patients. Peri-urban subjects were more likely to report MSM as their HIV risk factor than rural or urban subjects. Age, gender, CD4 or HIV-RNA distribution, virologic suppression, HAART usage, or OI prophylaxis did not differ by geographic location. In multivariate analysis, rural and peri-urban patients were less likely to have four or more annual outpatient visits than urban patients. Rural patients were less likely to receive HAART if they were Black. Overall, geographic location (as defined by home zip code) did not affect receipt of HAART or OI prophylaxis. CONCLUSION Although demographic and health care utilization differences were seen among rural, peri-urban, and urban HIV patients, most HIV outcomes and medication use were comparable across geographic areas. As with HIV care for urban-dwelling patients, areas for improvement for non-urban HIV patients include access to HAART among minorities and injection drug users.
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Affiliation(s)
- Lucy E Wilson
- Maryland Department of Health and Mental Hygiene, Infectious Disease and Environmental Health Administration, Baltimore, MD, USA.
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Gebo KA, Fleishman JA, Conviser R, Hellinger J, Hellinger FJ, Josephs JS, Keiser P, Gaist P, Moore RD. Contemporary costs of HIV healthcare in the HAART era. AIDS 2010; 24:2705-15. [PMID: 20859193 PMCID: PMC3551268 DOI: 10.1097/qad.0b013e32833f3c14] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The delivery of HIV healthcare historically has been expensive. The most recent national data regarding HIV healthcare costs were from 1996-1998. We provide updated estimates of expenditures for HIV management. METHODS We performed a cross-sectional review of medical records at 10 sites in the HIV Research Network, a consortium of high-volume HIV care providers across the United States. We assessed inpatient days, outpatient visits, and prescribed antiretroviral and opportunistic illness prophylaxis medications for 14 691 adult HIV-infected patients in primary HIV care in 2006. We estimated total care expenditures, stratified by the median CD4 cell count obtained in 2006 (≤50, 51-200, 201-350, 351-500, >500 cells/μl). Per-unit costs of care were based on Healthcare Cost and Utilization Project (HCUP) data for inpatient care, discounted average wholesale prices for medications, and Medicare physician fees for outpatient care. RESULTS Averaging over all CD4 strata, the mean annual total expenditures per person for HIV care in 2006 in three sites was US $19 912, with an interquartile range from US $11 045 to 22 626. Average annual per-person expenditures for care were greatest for those with CD4 cell counts 50 cell/μl or less (US $40 678) and lowest for those with CD4 cell counts more than 500 cells/μl (US $16 614). The majority of costs were attributable to medications, except for those with CD4 cell counts 50 cells/μl or less, for whom inpatient costs were highest. CONCLUSION HIV healthcare in the United States continues to be expensive, with the majority of expenditures attributable to medications. With improved HIV survival, costs may increase and should be monitored in the future.
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Affiliation(s)
- Kelly A Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Inpatient health services utilization among HIV-infected adult patients in care 2002-2007. J Acquir Immune Defic Syndr 2010; 53:397-404. [PMID: 19841589 DOI: 10.1097/qai.0b013e3181bcdc16] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study examines the frequency of inpatient hospitalization, the number of inpatient days, and factors associated with inpatient utilization in a multistate HIV cohort between 2002 and 2007. DESIGN A prospective cohort study of HIV-infected adults in care at 11 US HIV primary and specialty care sites located in different geographic regions. METHODS Demographic, clinical, and resource utilization data were collected from medical records for the years 2002-2007. Rates of resource use were calculated for number of hospital admissions, total inpatient days, and mean length of stay per admission. RESULTS Annual inpatient hospitalization rates significantly decreased from 35 to 27 per 100 persons from 2002 to 2007. The number of inpatient days per year significantly decreased over time, whereas mean length of stay per admission was stable. Women, patients 50 years or older, blacks, injection drug users, and patients without private insurance had higher hospitalization rates than their counterparts. Admission rates were lower for patients with high CD4 counts and low HIV-1 RNA levels. CONCLUSIONS Inpatient hospitalization rates and number of inpatient days decreased for HIV patients in this multistate cohort between 2002 and 2007. Sociodemographic disparities in inpatient utilization persist.
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Chander G, Himelhoch S, Fleishman JA, Hellinger J, Gaist P, Moore RD, Gebo KA. HAART receipt and viral suppression among HIV-infected patients with co-occurring mental illness and illicit drug use. AIDS Care 2009; 21:655-63. [PMID: 19444675 DOI: 10.1080/09540120802459762] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Mental illness (MI) and illicit drug use (DU) frequently co-occur. We sought to determine the individual and combined effects of MI and DU on highly active antiretroviral therapy (HAART) receipt and HIV-RNA suppression among individuals engaged in HIV care. Using 2004 data from the HIV Research Network (HIVRN), we performed a cross-sectional study of HIV-infected patients followed at seven primary care sites. Outcomes of interest were HAART receipt and virological suppression, defined as an HIV-RNA <400 copies/ml. Independent variables of interest were: (1) MI/DU; (2) DU only; (3) MI only; and (4) Neither. We used chi-squared analysis for comparison of categorical variables, and logistic regression to adjust for age, race, sex, frequency of outpatient visits, years in clinical care, CD4 nadir, and study site. During 2004, 10,284 individuals in the HIVRN were either on HAART or HAART eligible defined as a CD4 cell count < or =350. Nearly half had neither MI nor DU (41%), 22% MI only, 15% DU only, and 22% both MI and DU. In multivariate analysis, co-occurring MI/DU was associated with the lowest odds of HAART receipt (Adjusted Odds Ratio: 0.63 (95% CI: (0.55-0.72]), followed by those with DU only (0.75(0.63-0.87)), compared to those with neither. Among those on HAART, concurrent MI/DU (0.66 (0.58-0.75)), DU only (0.77 (0.67-0.88)), were also associated with a decreased odds of HIV-RNA suppression compared to those with neither. MI only was not associated with a statistically significant decrease in HAART receipt (0.93(0.81-1.07)) or viral suppression (0.93 (0.82-1.05)) compared to those with neither. Post-estimation testing revealed a significant difference between those with MI/DU and DU only, and MI/DU and MI only. Co-occurring MI and DU is associated with lower HAART receipt and viral suppression compared to individuals with either MI or DU or neither. Integrating HIV, substance abuse, and mental healthcare may improve outcomes in this population.
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Affiliation(s)
- Geetanjali Chander
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Abstract
OBJECTIVE We examined whether having a psychiatric disorder among HIV-infected individuals is associated with differential rates of discontinuation of HAART and whether the number of mental health visits impact these rates. DESIGN This longitudinal study (fiscal year: 2000-2005) used discrete time survival analysis to evaluate time to discontinuation of HAART. The predictor variable was presence of a psychiatric diagnosis (serious mental illness versus depressive disorders versus none). SETTING Five United States outpatient HIV sites affiliated with the HIV Research Network. PATIENTS The sample consisted of 4989 patients. The majority was nonwhite (74.0%) and men (71.3%); 24.8% were diagnosed with a depressive disorder, and 9% were diagnosed with serious mental illness. MAIN OUTCOME MEASURES Time to discontinuation of HAART adjusting for demographic factors, injection drug use history, and nadir CD4 cell count. RESULTS Relative to those with no psychiatric disorders, the hazard probability for discontinuation of HAART was significantly lower in the first and second years among those with SMI [adjusted odds ratio: first year, 0.57 (0.47-0.69); second year, 0.68 (0.52-0.89)] and in the first year among those with depressive disorders [adjusted odds ratio: first year, 0.61 (0.54-0.69)]. The hazard probabilities did not significantly differ among diagnostic groups in subsequent years. Among those with psychiatric diagnoses, those with six or more mental health visits in a year were significantly less likely to discontinue HAART compared with patients with no mental health visits. CONCLUSION Individuals with psychiatric disorders were significantly less likely to discontinue HAART in the first and second years of treatment. Mental health visits are associated with decreased risk of discontinuing HAART.
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Josephs JS, Fleishman JA, Korthuis PT, Moore RD, Gebo KA. Emergency department utilization among HIV-infected patients in a multisite multistate study. HIV Med 2009; 11:74-84. [PMID: 19682102 DOI: 10.1111/j.1468-1293.2009.00748.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of this study was to examine Emergency Department (ED) utilization and clinical and sociodemographic correlates of ED use among HIV-infected patients. METHODS During 2003, 951 patients participated in face-to-face interviews at 14 HIV clinics in the HIV Research Network. Respondents reported the number of ED visits in the preceding 6 months. Using logistic regression, we identified factors associated with visiting the ED in the last 6 months and admission to the hospital from the ED. RESULTS Thirty-two per cent of respondents reported at least one ED visit in the last 6 months. In multivariate analysis, any ED use was associated with Medicaid insurance, high levels of pain (the third or fourth quartile), more than seven primary care visits in the last 6 months, current or former illicit drug use, social alcohol use and female gender. Of those who used ED services, 39% reported at least one admission to the hospital. Patients with pain in the highest quartile reported increased admission rates from the ED as did those who made six or seven primary care visits, or more than seven primary care visits vs. three or fewer. CONCLUSIONS The likelihood of visiting the ED has not diminished since the advent of highly active antiretroviral therapy (HAART). More ED visits are to treat illnesses not related to HIV or injuries than to treat direct sequelae of HIV infection. With the growing prevalence of people living with HIV infection, the numbers of HIV-infected patients visiting the ED may increase, and ED providers need to understand potential complications produced by HIV disease.
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Affiliation(s)
- J S Josephs
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Lemly DC, Shepherd BE, Hulgan T, Rebeiro P, Stinnette S, Blackwell RB, Bebawy S, Kheshti A, Sterling TR, Raffanti SP. Race and sex differences in antiretroviral therapy use and mortality among HIV-infected persons in care. J Infect Dis 2009; 199:991-8. [PMID: 19220139 DOI: 10.1086/597124] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND There are conflicting data regarding race, sex, and mortality among persons infected with human immunodeficiency virus (HIV). We studied all-cause mortality among persons in care during the highly-active antiretroviral therapy (HAART) era. METHODS This retrospective cohort study included patients who made>or=1 clinic visit from January 1998 through December 2005. RESULTS Of 2605 patients (with 6657 person-years of follow-up), 38% were black and 24% were female. The percentage of time in care while receiving HAART was lower for blacks than for nonblacks (47% vs. 76%; P<.001) and for females than for males (57% vs. 71%; P=.01). There were 253 deaths (38 per 1000 person-years). After adjustment for characteristics at baseline, death was associated with black race (hazard ratio [HR], 1.33; P .04), female sex (HR, 1.53; P .007), injection drug use (IDU) as a risk factor for HIV infection (HR, 1.61; P .009), older age (HR, 1.45 per 10 years; P<.001), a lower CD4 cell count (HR, 0.59 for 200 vs. 350 cells/mm3; P<.001) and a higher HIV type 1 RNA level (HR, 1.35; P<.001). After adjustment for the length of time that HAART was received, black race (HR, 1.00; P .99) and IDU (HR, 1.37; P .09) were no longer associated with death, but female sex was (HR, 1.62; P=.002). CONCLUSIONS Race-associated differences in mortality likely resulted from HAART use. Women had an increased risk of death even after adjustment for HAART use. Addressing racial disparities will require improved HAART utilization. Increased mortality among women requires further study.
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Affiliation(s)
- Diana C Lemly
- School of Medicine, Department of Biostatistics, Vanderbilt University, Nashville, TN 37203, USA
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Himelhoch S, Josephs JS, Chander G, Korthuis PT, Gebo KA. Use of outpatient mental health services and psychotropic medications among HIV-infected patients in a multisite, multistate study. Gen Hosp Psychiatry 2009; 31:538-45. [PMID: 19892212 PMCID: PMC3144858 DOI: 10.1016/j.genhosppsych.2009.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2008] [Revised: 05/20/2009] [Accepted: 05/20/2009] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Although co-occurring psychiatric disorders are highly prevalent among those with HIV, little is known about the use of outpatient mental health services (MHS) and psychotropic medication in the highly active antiretroviral therapy (HAART) era. METHODS During 2003, 951 patients were interviewed at 14 sites in the HIV Research Network. Patients were questioned about use of MHS and psychotropic medications. Logistic regression was used to identify socio-demographic and clinical factors associated with MHS and psychotropic medication utilization. RESULTS The sample characteristics were as follows: 68% male, 52% black, 14% Hispanic, median age 46 years (range 20-85), 69% were on HAART. Approximately 34% reported at least one MHS within 6 months and 37% reported use of psychotropic medication for a mental health condition. In multivariate logistic regression, MHS was greater among disabled patients [adjusted odds ratio 2.39 (95% CI 1.53-3.72)], current [2.26 (1.53-3.35)] and former drug users [1.84 (1.24-2.73)], and those with more than seven primary care visits in the past 6 months. Blacks [0.61 (0.41-0.92)] were significantly less likely to use MHS compared to whites. Similarly, usage of psychotropic medications was greater among disabled patients [1.79 (1.14-2.82)], women [1.66 (1.13-2.43)], )] and those with more than seven primary care visits. Blacks [0.37 (0.24-0.58])] and Hispanics [0.39 (0.22-0.72)] were less likely to use a psychotropic medication. HAART utilization was not associated with MHS or psychiatric medication use. CONCLUSIONS In the HAART era, self-reported rates of mental health service and psychotropic medication utilization are high. Blacks continue to report lower use of MHS and psychotropic medication compared to whites.
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Affiliation(s)
- Seth Himelhoch
- Department of Psychiatry, University of Maryland, Baltimore, MD 21201, USA.
| | | | | | - P. Todd Korthuis
- Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Kelly A. Gebo
- Department of Medicine, Johns Hopkins University, Baltimore MD
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Yehia BR, Gebo KA, Hicks PB, Korthuis PT, Moore RD, Ridore M, Mathews WC. Structures of care in the clinics of the HIV Research Network. AIDS Patient Care STDS 2008; 22:1007-13. [PMID: 19072107 DOI: 10.1089/apc.2008.0093] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
As the HIV epidemic has evolved to become a chronic, treatable condition the focus of HIV care has shifted from the inpatient to the outpatient arena. The optimal structure of HIV care in the outpatient setting is unknown. Using the HIV Research Network (HIVRN), a federally sponsored consortium of 21 sites that provide care to HIV-infected individuals, this study attempted to: (1) document key features of the organization of care in HIVRN adult clinics and (2) estimate variability among clinics in these parameters. A cross-sectional survey of adult clinic directors regarding patient volume, follow-up care, provider characteristics, acute patient care issues, wait times, patient safety procedures, and prophylaxis practices was conducted from July to December 2007. All 15 adult HIVRN clinic sites responded: 9 academic and 6 community-based. The results demonstrate variability in key practice parameters. Median (range) of selected practice characteristics were: (1) annual patient panel size, 1300 (355-5600); (2) appointment no-show rate, 28% (8%-40%); (3) annual loss to follow-up, 15% (5%-25%); (4) wait time for new appointments, 5 days (0.5-22.5), and follow-up appointment, 8 days (0-30). The majority of clinics had an internal mechanism to handle acute patient care issues and provide a number of onsite consultative services. Nurse practitioners and physician assistants were highly utilized. These data will facilitate improvements in chronic care management of persons living with HIV.
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Chander G, Josephs J, Fleishman JA, Korthuis PT, Gaist P, Hellinger J, Gebo K. Alcohol use among HIV-infected persons in care: results of a multi-site survey. HIV Med 2008; 9:196-202. [PMID: 18366443 DOI: 10.1111/j.1468-1293.2008.00545.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We sought to determine the prevalence of any alcohol use and hazardous alcohol consumption among HIV-infected individuals engaged in care and to identify factors associated with hazardous alcohol use. METHODS During 2003, 951 patients were interviewed at 14 HIV primary care sites in the USA. Hazardous drinking was defined as >14 drinks/week or >or=5 drinks/occasion for men and >7 drinks/week or >or=4 drinks/occasion for women. Moderate alcohol use was consumption at less than hazardous levels. We used logistic regression to identify factors associated with any alcohol use and hazardous alcohol use. RESULTS Forty per cent of the sample reported any alcohol use in the 4 weeks prior to the interview; 11% reported hazardous use. In multivariate regression, male sex [adjusted odds ratio (AOR) 1.52 (95% confidence interval, CI, 1.07-2.16)], a college education (compared to<high school) [AOR 1.87 (1.10-3.18)] and illicit drug use [AOR 2.69 (1.82-3.95)] were associated positively with any alcohol use, while CD4 nadir >or=500 cells/microL [AOR 2.65 (1.23-5.69)] and illicit drug use [AOR 2.67 (1.48-4.82)] were associated with increased odds of hazardous alcohol use (compared to moderate and none). CONCLUSIONS Alcohol use is prevalent among HIV-infected individuals and is associated with a variety of socioeconomic and demographic characteristics. Screening for alcohol use should be routine practice in HIV primary care settings.
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Affiliation(s)
- G Chander
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Hicks PL, Mulvey KP, Chander G, Fleishman JA, Josephs JS, Korthuis PT, Hellinger J, Gaist P, Gebo KA. The impact of illicit drug use and substance abuse treatment on adherence to HAART. AIDS Care 2008; 19:1134-40. [PMID: 18058397 DOI: 10.1080/09540120701351888] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
High levels of adherence to highly active antiretroviral therapy (HAART) are essential for virologic suppression and longer survival in patients with HIV. We examined the effects of substance abuse treatment, current versus former substance use, and hazardous/binge drinking on adherence to HAART. During 2003, 659 HIV patients on HAART in primary care were interviewed. Adherence was defined as > or =95% adherence to all antiretroviral medications. Current substance users used illicit drugs and/or hazardous/binge drinking within the past six months, while former users had not used substances for at least six months. Logistic regression analyses of adherence to HAART included demographic, clinical and substance abuse variables. Sixty-seven percent of the sample reported 95% adherence or greater. However, current users (60%) were significantly less likely to be adherent than former (68%) or never users (77%). In multivariate analysis, former users in substance abuse treatment were as adherent to HAART as never users (Adjusted Odds Ratio (AOR)=0.82; p>0.5). In contrast, former users who had not received recent substance abuse treatment were significantly less adherent than never users (AOR=0.61; p=0.05). Current substance users were significantly less adherent than never users, regardless of substance abuse treatment (p<0.01). Substance abuse treatment interacts with current versus former drug use status to affect adherence to HAART. Substance abuse treatment may improve HAART adherence for former substance users.
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Affiliation(s)
- P L Hicks
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Korthuis PT, Josephs JS, Fleishman JA, Hellinger J, Himelhoch S, Chander G, Morse EB, Gebo KA. Substance abuse treatment in human immunodeficiency virus: the role of patient-provider discussions. J Subst Abuse Treat 2008; 35:294-303. [PMID: 18329222 DOI: 10.1016/j.jsat.2007.11.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2007] [Revised: 11/01/2007] [Accepted: 11/18/2007] [Indexed: 10/22/2022]
Abstract
Substance abuse treatment is associated with decreases in human immunodeficiency virus (HIV) risk behavior and can improve HIV outcomes. The purpose of this study was to examine factors associated with substance abuse treatment utilization, including patient-provider discussions of substance use issues. We surveyed 951 HIV-infected adults receiving care at 14 HIV Research Network primary care sites regarding drug and alcohol use, substance abuse treatment, and provider discussions of substance use issues. Although 71% reported substance use, only 24% reported receiving substance abuse treatment and less than half reported discussing substance use issues with their HIV providers. In adjusted logistic regression models, receipt of substance abuse treatment was associated with patient-provider discussions. Patient-provider discussions of substance use issues were associated with current drug use, hazardous or binge drinking, and Black race or ethnicity, though substance use was comparable between Blacks and Whites. These data suggest potential opportunities for improving engagement in substance abuse treatment services.
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Affiliation(s)
- Philip Todd Korthuis
- Department of Medicine, Oregon Health and Science University, Portland, OR 97239, USA.
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Himelhoch S, Chander G, Fleishman JA, Hellinger J, Gaist P, Gebo KA. Access to HAART and utilization of inpatient medical hospital services among HIV-infected patients with co-occurring serious mental illness and injection drug use. Gen Hosp Psychiatry 2007; 29:518-25. [PMID: 18022045 PMCID: PMC2629392 DOI: 10.1016/j.genhosppsych.2007.03.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2006] [Revised: 03/22/2007] [Accepted: 03/26/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Among HIV-infected individuals, we examined whether having co-occurring serious mental illness (SMI) and injection drug use (IDU) impacts: (a) receipt of highly active antiretroviral therapy (HAART), and (b) utilization of inpatient HIV services, compared to those who have SMI only, IDU only or neither SMI nor IDU. METHOD Demographic, clinical and resource utilization data were collected from medical records of 5119 patients in HIV primary care at four US HIV care sites in different geographic regions with on-site mental health services in 2001. We analyzed receipt of HAART using multivariate logistic regression and the number of medical hospital admissions using multivariate logistic and Poisson regression analyses, which controlled for demographic factors, receipt of HAART, CD4 count and HIV-1 RNA. RESULTS Those with co-occurring SMI and IDU [adjusted odds ratio (AOR)=0.52; 95% confidence interval (95% CI)=0.41-0.81] and those with IDU alone (AOR=0.64; 95% CI=0.58-0.85) were significantly less likely to receive HAART than those with neither SMI nor IDU, controlling for demographic and clinical factors. Those with co-occurring SMI and IDU were more likely to use any inpatient medical services (AOR=2.22; 95% CI=1.64-3.01) and were significantly more likely to use them more frequently (incidence rate ratio=1.33; 95% CI=1.13-1.55) than those with neither SMI nor IDU, SMI only or IDU only. CONCLUSION HIV-infected individuals with co-occurring SMI and IDU are significantly more likely to utilize HIV-related medical inpatient services than individuals with no comorbidity or with only one comorbidity. Individuals with both SMI and IDU did not differ from those with IDU only in receipt of HAART. Inpatient hospitalizations are expensive, and efforts should be targeted towards these populations to reduce potentially avoidable inpatient care.
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Affiliation(s)
- Seth Himelhoch
- Division of Services Research, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21212, USA.
| | - Geetanjali Chander
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Paul Gaist
- Office of AIDS Research, National Institute of Health, Bethesda, Maryland
| | - Kelly A. Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Lin D, Tucker MJ, Rieder MJ. Increased adverse drug reactions to antimicrobials and anticonvulsants in patients with HIV infection. Ann Pharmacother 2006; 40:1594-601. [PMID: 16912251 DOI: 10.1345/aph.1g525] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the incidence, signs, symptoms, and mechanisms of adverse drug reactions (ADRs) to sulfonamides, anticonvulsants, and antimycobacterial medications among people with HIV. DATA SOURCES Searches of MEDLINE/PubMed (1980-November 2005) and National Library of Medicine Meeting Abstracts (1989-November 2005), as well as hand searches of journals and abstracts, were conducted to identify primary literature. Reference lists were reviewed to identify additional relevant reports. STUDY SELECTION AND DATA EXTRACTION Relevant articles and abstracts, particularly of in vitro experiments and clinical studies, were compiled and reviewed. DATA SYNTHESIS ADRs, especially in HIV-infected patients, are a cause for concern. Sulfonamides, anticonvulsants, and antimycobacterial drugs are commonly used to prevent and treat complications of HIV, including seizures and opportunistic infections. Patients with HIV have a much greater rate of ADRs to these drug classes, including severe and life-threatening hypersensitivity reactions. Several mechanisms of these ADRs have been postulated. Sulfamethoxazole and anticonvulsant hypersensitivity may involve the increased formation and decreased detoxification of reactive metabolites. The mechanisms for the marked increase in hypersensitivity ADRs to antimycobacterial drugs may be related to an altered immune profile in patients infected with both tuberculosis and HIV. CONCLUSIONS ADRs to antimicrobial and anticonvulsant therapy cause markedly increased morbidity and mortality in HIV-positive patients. Further research involving the interaction between HIV and the increased ADRs to these drugs is required.
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Affiliation(s)
- Daren Lin
- Department of Pediatrics, University of Western Ontario, London, Ontario, Canada
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Betz ME, Gebo KA, Barber E, Sklar P, Fleishman JA, Reilly ED, Christopher Mathews W. Patterns of diagnoses in hospital admissions in a multistate cohort of HIV-positive adults in 2001. Med Care 2005; 43:III3-14. [PMID: 16116304 DOI: 10.1097/01.mlr.0000175632.83060.eb] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Admissions for AIDS-related illnesses decreased soon after the introduction of highly active antiretroviral therapy (HAART), but it is unclear if the trends have continued in the current HAART era. An understanding of healthcare utilization patterns is important for optimization of care and resource allocation. We examined the diagnoses for hospitalizations of patients with HIV in 2001. METHODS Demographic and healthcare data were collected for 8376 patients from 6 U.S. HIV care sites in 2001. We categorized diagnoses into 18 disease groups and used Poisson regression to analyze the number of admissions for each of the 4 most common groups. We also compared patients with admissions for AIDS-defining illnesses (ADI) with patients admitted for other diagnoses. RESULTS Twenty-one percent of patients had at least 1 hospitalization. Among patients hospitalized at least once, 28% were hospitalized for an ADI. Comparing diagnosis categories, the most common hospitalizations were AIDS-defining illnesses (21.6%), gastrointestinal (GI) diseases (9.5%), mental illnesses (9.0%), and circulatory diseases (7.4%). In multivariate analysis, women had higher hospitalization rates than men for ADI (incidence rate ratio [IRR], 1.50; 95% confidence interval [CI], 1.25-1.79) and GI diseases (IRR, 1.52; 95% CI, 1.15-2.00). Compared with whites, blacks had higher admission rates for mental illnesses (IRR, 1.70; 95% CI, 1.22-2.36), but not for ADI. As expected, CD4 count and viral load were associated with ADI admission rates; CD4 counts were also related to hospitalizations for GI and circulatory conditions. CONCLUSIONS Five years after the introduction of HAART, AIDS-defining illnesses continue to have the highest hospitalization rate among the diagnosis categories examined. This result emphasizes the importance of vaccination for pneumonia and influenza, as well as prophylaxis for Pneumocystis jiroveci pneumonia. The relatively large number of mental illness admissions highlights the need for comanagement of psychiatric disease, substance abuse, and HIV. Overall, the majority of patients were hospitalized for reasons other than ADI, illustrating the importance of managing comorbid conditions in this population. Data from this cohort of patients with HIV may help guide the allocation of healthcare resources by enhancing our understanding of factors associated with variation in inpatient utilization rates.
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Affiliation(s)
- Marian E Betz
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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