What Do Placebo and Nocebo Effects Have to Do With Health Equity? The Hidden Toll of Nocebo Effects on Racial and Ethnic Minority Patients in Clinical Care

A placebo effect is a positive clinical response to non-specific elements of treatment with a sham or inert replica of a drug, device, or surgical intervention. There is considerable evidence that placebo effects are driven by expectation of benefit from the intervention. Expectation is shaped by a patient's past experience, observations of the experience of others, and written, verbal, or non-verbal information communicated during treatment. Not surprisingly, expectation in the clinical setting is strongly influenced by the attitude, affect, and communication style of the healthcare provider. While positive expectations can produce beneficial effects, negative information and experiences can lead to negative expectations, and consequently negative or nocebo effects. Key components identified and studied in the placebo and nocebo literature intersect with factors identified as barriers to quality care in the clinical setting for Black patients and other patients of color, including poor patient-clinician communication, medical mistrust, and perceived discrimination. Thus, in the context of discrimination and bias, the absence of placebo and presence of nocebo-generating influences in clinical settings could potentially reinforce racial and ethnic inequities in clinical outcomes and care. Healthcare inequities have consequences that ripple through the medical system, strengthening adverse short- and long-term outcomes. Here, we examine the potential for the presence of nocebo effects and absence of placebo effects to play a role in contributing to negative outcomes related to unequal treatment in the clinical encounter.

Rallying Against Racism: Hospitals Join the Fight for Racial Justice

This article highlights the timely situation that resident physicians, faculty, and staff are facing after the recent highly publicized murders of Black Americans and its impact on our healthcare communities. We discuss our experiences of how the hospital can serve as a meeting place for anti-racism, as well as how anti-racist events at the hospital can raise public consciousness and be catalysts for creating a more inclusive, diverse, and welcoming environment for all members of hospital communities.

How Do Presenting Symptoms and Outcomes Differ by Race/Ethnicity Among Hospitalized Patients with COVID-19 Infection? Experience in Massachusetts

Background

Population-based literature suggests severe acute respiratory syndrome coronavirus 2 infection may disproportionately affect racial/ethnic minorities; however, patient-level observations of hospitalization outcomes by race/ethnicity are limited. Our aim in this study was to characterize coronavirus disease 2019 (COVID-19)–associated morbidity and in-hospital mortality by race/ethnicity.

Methods

This was a retrospective analysis of 9 Massachusetts hospitals including all consecutive adult patients hospitalized with laboratory-confirmed COVID-19. Measured outcomes were assessed and compared by patient-reported race/ethnicity, classified as white, black, Latinx, Asian, or other. Student t test, Fischer exact test, and multivariable regression analyses were performed.

Results

A total of 379 patients (aged 62.9 ± 16.5 years; 55.7% men) with confirmed COVID-19 were included (49.9% white, 13.7% black, 29.8% Latinx, 3.7% Asian), of which 376 (99.2%) were insured (34.3% private, 41.2% public, 23.8% public with supplement). Latinx patients were younger, had fewer cardiopulmonary disorders, were more likely to be obese, more frequently reported fever and myalgia, and had lower D-dimer levels compared with white patients (P < .05). On multivariable analysis controlling for age, gender, obesity, cardiopulmonary comorbidities, hypertension, and diabetes, no significant differences in in-hospital mortality, intensive care unit admission, or mechanical ventilation by race/ethnicity were found. Diabetes was a significant predictor for mechanical ventilation (odds ratio [OR], 1.89; 95% confidence interval [CI], 1.11–3.23), while older age was a predictor of in-hospital mortality (OR, 4.18; 95% CI, 1.94–9.04).

Conclusions

In this multicenter cohort of hospitalized COVID-19 patients in the largest health system in Massachusetts, there was no association between race/ethnicity and clinically relevant hospitalization outcomes, including in-hospital mortality, after controlling for key demographic/clinical characteristics. These findings serve to refute suggestions that certain races/ethnicities may be biologically predisposed to poorer COVID-19 outcomes.

HIV Treatment in African Americans: Challenges and Opportunities

This article reviews the current standard of care for HIV infection as well as how health disparities in the HIV care of African Americans present challenges for both providers and patients. The potential side effects in these antiretroviral treatment regimens that may be a source of additional challenges in treating African Americans are highlighted. A brief review of these issues as they relate to treatment adherence further demonstrates how adherence is closely linked to the medical and psychosocial issues African Americans face including access to HIV care services. The article concludes with a discussion of gender-related issues that affect treatment and that may confound effective behavioral interventions aimed at reducing HIV risk and increasing treatment adherence.

Perception of Faces and Bodies

Human faces and bodies are both complex and interesting perceptual objects, and both convey important social information. Given these similarities between faces and bodies, we can ask how similar are the visual processing mechanisms used to recognize them. It has long been argued that faces are subject to dedicated and unique perceptual processes, but until recently, relatively little research has focused on how we perceive the human body. Some recent paradigms indicate that faces and bodies are processed differently; others show similarities in face and body perception. These similarities and differences depend on the type of perceptual task and the level of processing involved. Future research should take these issues into account.

Promoting Success: A Professional Development Coaching Program for Interns in Medicine

BACKGROUND

Residency is an intense period. Challenges, including burnout, arise as new physicians develop their professional identities. Residency programs provide remediation, but emotional support for interns is often limited. Professional development coaching of interns, regardless of their performance, has not been reported.

OBJECTIVE

Design, implement, and evaluate a program to support intern professional development through positive psychology coaching.

METHODS

We implemented a professional development coaching program in a large residency program. The program included curriculum development, coach-intern interactions, and evaluative metrics. A total of 72 internal medicine interns and 26 internal medicine faculty participated in the first year. Interns and coaches were expected to meet quarterly; expected time commitments per year were 9 hours (per individual coached) for coaches, 5 1/2 hours for each individual coachee, and 70 hours for the director of the coaching program. Coaches and interns were asked to complete 2 surveys in the first year and to participate in qualitative interviews.

RESULTS

Eighty-two percent of interns met with their coaches 3 or more times. Coaches and their interns assessed the program in multiple dimensions (participation, program and professional activities, burnout, coping, and coach-intern communication). Most of the interns (94%) rated the coaching program as good or excellent, and 96% would recommend this program to other residency programs. The experience of burnout was lower in this cohort compared with a prior cohort.

CONCLUSIONS

There is early evidence that a coaching program of interactions with faculty trained in positive psychology may advance intern development and partially address burnout.

Perspectives on HIV prevention among urban black women: a potential role for HIV pre-exposure prophylaxis

Limited data exist regarding attitudes and acceptability of topical and oral HIV pre-exposure prophylaxis (PrEP) among US black women. This investigation explored interest in HIV chemoprophylaxis and modes of use. Five focus groups enrolled 26 black women recruited from an inner-city community health center and affiliated HIV testing sites. Thematic analysis utilized Atlas.ti. Most women expressed interest in PrEP, as many reported condom failure concerns. Most women preferred a pill formulation to intravaginal gel because of greater perceived privacy and concerns about vaginal side effects and gel leakage. Women who had taken pills previously advocated daily dosing and indicated adherence concerns about episodic or post-coital PrEP. Many women desired prophylactic strategies that included partner testing. Urban black women are interested in utilizing PrEP; however, misgivings exist about gel inconvenience and potential side effects for themselves and their partners. Most women preferred oral PrEP, dosed daily.

Implementing a pilot leadership course for internal medicine residents: design considerations, participant impressions, and lessons learned

BACKGROUND

Effective clinical leadership is associated with better patient care. We implemented and evaluated a pilot clinical leadership course for second year internal medicine residents at a large United States Academic Medical Center that is part of a multi-hospital health system.

METHODS

The course met weekly for two to three hours during July, 2013. Sessions included large group discussions and small group reflection meetings. Topics included leadership styles, emotional intelligence, and leading clinical teams. Course materials were designed internally and featured "business school style" case studies about everyday clinical medicine which explore how leadership skills impact care delivery. Participants evaluated the course's impact and quality using a post-course survey. Questions were structured in five point likert scale and free text format. Likert scale responses were converted to a 1-5 scale (1 = strongly disagree; 3 = neither agree nor disagree; 5 = strongly agree), and means were compared to the value 3 using one-way T-tests. Responses to free text questions were analyzed using the constant comparative method.

RESULTS

All sixteen pilot course participants completed the survey. Participants overwhelmingly agreed that the course provided content and skills relevant to their clinical responsibilities and leadership roles. Most participants also acknowledged that taking the course improved their understanding of their strengths and weaknesses as leaders, different leadership styles, and how to manage interpersonal conflict on clinical teams. 88% also reported that the course increased their interest in pursuing additional leadership training.

CONCLUSIONS

A clinical leadership course for internal medicine residents designed by colleagues, and utilizing case studies about clinical medicine, resulted in significant self-reported improvements in clinical leadership competencies.

Influence of providers and nurses on completion of non-targeted HIV screening in an urgent care setting

Introduction

Despite recommendations by the Centers for Disease Control (CDC) that all adults be offered non-targeted HIV screening in all care settings, screening in acute-care settings remains unacceptably low. We performed an observational study to evaluate an HIV screening pilot in an academic-community partnership health center urgent care clinic.

Methods

We collected visit data via encounter forms and demographic and laboratory data from electronic medical records. A post-pilot survey of perceptions of HIV screening was administered to providers and nurses. Multivariable analysis was used to identify factors associated with completion of testing.

Results

Visit provider and triage nurse were highly associated with both acceptance of screening and completion of testing, as were younger age, male gender, and race/ethnicity. 23.5% of patients completed tests, although 36.0% requested screening; time constraints as well as risk perceptions by both the provider and patient were cited as limiting completion of screening. Post-pilot surveys showed mixed support for ongoing HIV screening in this setting by providers and little support by nurses.

Conclusions

Visit provider and triage nurse were strongly associated with acceptance of testing, which may reflect variable opinions of HIV screening in this setting by clinical staff. Among patients accepting screening, visit provider remained strongly associated with completion of testing. Despite longstanding recommendations for non-targeted HIV screening, further changes to improve the testing and results process, as well as provider education and buy-in, are needed to improve screening rates.

Ambulatory training for primary care general internists: innovation with the affordable care act in mind

BACKGROUND

Although primary care general internists (PCGIs) are essential to the physician workforce and the success of the Affordable Care Act, they are becoming an endangered species.

OBJECTIVE

We describe an expanded program to educate PCGIs to meet the needs of a reformed health care system and detail the competencies PCGIs will need for their roles in team-based care.

INTERVENTION

We recommended 5 initiatives to stabilize and expand the PCGI workforce: (1) caring for a defined patient population, (2) leading and serving as members of multidisciplinary health care teams, (3) participating in a medical neighborhood, (4) improving capacity for serving complex patients in group practices and accountable care organizations, and (5) finding an academic role for PCGIs, including clinical, population health, and health services research. A revamped approach to PCGI education based in teaching health centers formed by community health center and academic medical center partnerships would facilitate these curricular innovations.

ANTICIPATED OUTCOMES

New approaches to primary care education would include multispecialty group practices facilitated by electronic consultation and clinical decision-support systems provided by the academic medical center partner. Multiprofessional and multidisciplinary education would prepare PCGI trainees with relevant skills for 21st century practice. The centers would also serve as sites for state and federal Medicaid graduate medical education (GME) expansion funding, making this funding more accountable to national health workforce priorities.

CONCLUSIONS

The proposed innovative approach to PCGI training would provide an innovative educational environment, enhance general internist recruitment, provide team-based care for underserved patients, and ensure accountability of GME funds.

The major genetic determinants of HIV-1 control affect HLA class I peptide presentation

Infectious and inflammatory diseases have repeatedly shown strong genetic associations within the major histocompatibility complex (MHC); however, the basis for these associations remains elusive. To define host genetic effects on the outcome of a chronic viral infection, we performed genome-wide association analysis in a multiethnic cohort of HIV-1 controllers and progressors, and we analyzed the effects of individual amino acids within the classical human leukocyte antigen (HLA) proteins. We identified >300 genome-wide significant single-nucleotide polymorphisms (SNPs) within the MHC and none elsewhere. Specific amino acids in the HLA-B peptide binding groove, as well as an independent HLA-C effect, explain the SNP associations and reconcile both protective and risk HLA alleles. These results implicate the nature of the HLA-viral peptide interaction as the major factor modulating durable control of HIV infection.

Association of race, substance abuse, and health insurance coverage with use of highly active antiretroviral therapy among HIV-infected women, 2005

OBJECTIVES

We examined racial/ethnic disparities in highly active antiretroviral therapy (HAART) use and whether differences are moderated by substance use or insurance status, using data from the Women's Interagency HIV Study (WIHS).

METHODS

Logistic regression examined HAART use in a longitudinal cohort of women for whom HAART was clinically indicated in 2005 (N = 1354).

RESULTS

Approximately 3 of every 10 eligible women reported not taking HAART. African American and Hispanic women were less likely than were White women to use HAART. After we adjusted for potential confounders, the higher likelihood of not using HAART persisted for African American but not for Hispanic women. Uninsured and privately insured women, regardless of race/ethnicity, were less likely than were Medicaid enrollees to use HAART. Although alcohol use was related to HAART nonuse, illicit drug use was not.

CONCLUSIONS

These findings suggest that expanding and improving insurance coverage should increase access to antiretroviral therapy across racial/ethnic groups, but it is not likely to eliminate the disparity in use of HAART between African American and White women with HIV/AIDS.

Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus: 2009 Update by the HIV Medicine Association of the Infectious Diseases Society of America

Evidence-based guidelines for the management of persons infected with human immunodeficiency virus (HIV) were prepared by an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America. These updated guidelines replace those published in 2004. The guidelines are intended for use by health care providers who care for HIV-infected patients or patients who may be at risk for acquiring HIV infection. Since 2004, new antiretroviral drugs and classes have become available, and the prognosis of persons with HIV infection continues to improve. However, with fewer complications and increased survival, HIV-infected persons are increasingly developing common health problems that also affect the general population. Some of these conditions may be related to HIV infection itself and its treatment. HIV-infected persons should be managed and monitored for all relevant age- and gender-specific health problems. New information based on publications from the period 2003–2008 has been incorporated into this document.

Transforming clinical practice to eliminate racial-ethnic disparities in healthcare

Racial-ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial-ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial-ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial-ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices.

Brief report: perception of body posture--what individuals with autism spectrum disorder might be missing

Autism has been associated with atypical face and configural processing, as indicated by the lack of a face inversion effect (better recognition of upright than inverted faces). We investigated whether such atypical processing was restricted to the face or extended to social information found in body postures. An inversion paradigm compared recognition of upright and inverted faces, body postures, and houses. Typical adults demonstrated inversion effects for both faces and body postures, but adults with autism demonstrated only a face inversion effect. Adults with autism may not have a configural processing deficit per se, but instead may have strategies for recognizing faces not used for body postures. Results have implications for therapies employing training in imitation and body posture perception.

Recommendations for teaching about racial and ethnic disparities in health and health care

Racial and ethnic minorities often receive lower-quality health care than white patients, even when socioeconomic status, education, access, and other factors are used as controls. To address these pervasive disparities, health care professionals should learn more about them and the roles they can play in eliminating them, but few curricula are focused on understanding and addressing racial and ethnic health disparities, and well-accepted guidelines on what and how to teach in this complex area are lacking. The Society of General Internal Medicine Health Disparities Task Force used a review and consensus process to develop specific recommendations and guidelines for curricula focusing on health disparities. Learning objectives, content, methods for teaching, and useful resources are provided. Although the guidelines were developed primarily for teaching medical students, residents, and practitioners in primary care, the Task Force's general recommendations can apply to learners in any specialty. The Task Force recommends that a curricula address 3 areas of racial and ethnic health disparities and focus on the following specific learning objectives:1) examining and understanding attitudes, such as mistrust, subconscious bias, and stereotyping, which practitioners and patients may bring to clinical encounters; 2) gaining knowledge of the existence and magnitude of health disparities, including the multifactorial causes of health disparities and the many solutions required to diminish or eliminate them; and 3) acquiring the skills to effectively communicate and negotiate across cultures, languages, and literacy levels, including the use of key tools to improve communication. The broad goal of a curriculum on disparities should be for learners to develop a commitment to eliminating inequities in health care quality by understanding and assuming their professional role in addressing this pressing health care crisis.

Internal medicine residents' perceptions of cross-cultural training. Barriers, needs, and educational recommendations

BACKGROUND

Physicians increasingly face the challenge of managing clinical encounters with patients from a range of cultural backgrounds. Despite widespread interest in cross-cultural care, little is known about resident physicians' perceptions of what will best enable them to provide quality care to diverse patient populations.

OBJECTIVES

To assess medicine residents' (1) perceptions of cross-cultural care, (2) barriers to care, and (3) training experiences and recommendations.

DESIGN, SETTING, AND PATIENTS

Qualitative individual interviews were conducted with 26 third-year medicine residents at Massachusetts General Hospital in Boston (response rate=87%). Interviews were recorded, transcribed, and analyzed.

RESULTS

Despite significant interest in cross-cultural care, almost all of the residents reported very little training during residency. Most had gained cross-cultural skills through informal learning. A few were skeptical about formal training, and some expressed concern that it is impossible to understand every culture. Challenges to the delivery of cross-cultural care included managing patients with limited English proficiency, who involve family in critical decision making, and who have beliefs about disease that vary from the biomedical model. Residents cited many implications to these barriers, ranging from negatively impacting the patient-physician relationship to compromised care. Training recommendations included making changes to the educational climate and informal and formal training mechanisms.

CONCLUSIONS

If cross-cultural education is to be successful, it must take into account residents' perspectives and be focused on overcoming residents' cited barriers. It is important to convey that cross-cultural education is a set of skills that can be taught and applied, in a time-efficient manner, rather than requiring an insurmountable knowledge base.

Turning configural processing upside down: Part and whole body postures

Like faces, body postures are susceptible to an inversion effect in untrained viewers. The inversion effect may be indicative of configural processing, but what kind of configural processing is used for the recognition of body postures must be specified. The information available in the body stimulus was manipulated. The presence and magnitude of inversion effects were compared for body parts, scrambled bodies, and body halves relative to whole bodies and to corresponding conditions for faces and houses. Results suggest that configural body posture recognition relies on the structural hierarchy of body parts, not the parts themselves or a complete template match. Configural recognition of body postures based on information about the structural hierarchy of parts defines an important point on the configural processing continuum, between recognition based on first-order spatial relations and recognition based on holistic undifferentiated template matching.

Physician contributions to disparities in HIV/AIDS care: The role of provider perceptions regarding adherence

Racial/ethnic minorities in the United States are disproportionately affected by HIV/AIDS. In addition to having higher rates of HIV/AIDS, minorities with HIV/AIDS have higher mortality rates than others in the United States. Disparities in the care received by minorities living with HIV/AIDS contribute to these higher mortality rates. This article provides a review of HIV/AIDS health care disparities and explores providers' contributions to these disparities. An important source of provider contribution to disparities appears to be differential prescribing based on perceptions and assumptions that minority patients may have lower adherence to highly active antiretroviral therapy. Literature regarding this topic is reviewed and strategies for reducing disparities are suggested.

HIV/AIDS: a minority health issue

HIV infection among racial and ethnic minorities is an ongoing health crisis. The disproportionate impact of HIV infection on racial and ethnic minorities has affected communities already struggling with many social and economic challenges, such as poverty, substance abuse, homelessness,unequal access to health care, and unequal treatment once in the health care system. Superimposed on these challenges is HIV infection, the transmission of which is facilitated by many of these factors. Although the epidemic is disproportionately affecting all racial and ethnic minorities, within these minority populations women are particularly affected. The care and management of racial and ethnic minorities who have HIV infection has been complicated by the unequal access to health care and the unequal treatment once enrolled in health care. Health insurance status, lack of concordance between the race of the patient and the provider, and satisfaction with the quality of their care all impact on treatment outcomes in this population. In addition, the provider must be aware of the many comorbid conditions that may affect the delivery of care to minority patients living with HIV infection: depression, substance and alcohol abuse, and posttraumatic stress disorders. The impact of these comorbid conditions on the therapeutic relationship, including treatment and adherence, warrants screening for these disorders and treating them when identified. Because the patient provider relationship has been repeatedly identified as a predictor of higher adherence, developing and maintaining a strong therapeutic alliance is critical. Participation of racial and ethnic minorities in HIV clinical trials, as in other disease states, has been very poor. Racial and ethnic minorities have been chronically underrepresented in HIV clinical trials, despite their overrepresentation in the HIV epidemiology. This underrepresentation seems to be the result of a combination of factors including (1) provider bias in referring to clinical trials, (2) mistrust of clinical research, (3) past poor experience with the health care system, and (4) the conspiracy theories of HIV disease. The paucity of minority health care professionals and minority investigators in HIV research further affects minority participation in clinical research. To improve racial and ethnic minority participation in clinical trials a sustained effort is necessary at multiple levels. Increased recruitment and retention is an ongoing need, and one that will not be satisfactorily addressed until there are better community-academic and research partner-ships, and the research questions posed also address issues of concern and significance to the affected community. Reduction in barriers to participation in clinical trials, especially given the many competing needs of racial and ethnic minority patients, is also needed. Multidisciplinary HIV care teams and research staff with training in cultural competency and cultural sensitivity may also be helpful. Prevention of HIV infection remains essential, especially among those seeking care for HIV infection. Despite several published recommendations for the inclusion of HIV prevention in the clinical care setting, studies have documented how few providers actually achieve this goal, especially those who care for disadvantaged patients. Although there are many barriers to discussing HIV risk behaviors and prevention strategies in an office visit,including time constraints and potential provider discomfort in discussing these matters, clinical visits represent an important opportunity to reinforce HIV prevention and possibly decrease further HIV transmission.

Perspectives on Adherence and Simplicity for HIV-Infected Patients on Antiretroviral Therapy

BACKGROUND

Adherence to highly active antiretroviral therapy (HAART) of 95% or greater seems to be required for successful treatment of HIV/AIDS. Efforts to simplify regimens to improve adherence are ongoing, including the advent of once-daily (QD) dosing regimens, which are presumed to be beneficial, although data regarding their overall impact on adherence are not yet available.

OBJECTIVE

To assess patient perceptions of the impact on adherence of 10 attributes of HAART, including QD dosing, and to compare 7 actual regimens based on patients' perceptions of their likelihood to promote adherence.

METHODS

Two hundred ninety-nine highly treatment-experienced patients with HIV/AIDS completed a questionnaire that evaluated perceptions of the impact on adherence of 10 HAART regimen attributes using a modified adaptive conjoint analysis. Patients' perceptions of the likelihood that they would adhere to 7 actual HAART regimens were scored on Likert scales.

RESULTS

: Pill count, dosing frequency, and adverse events had the greatest impact on patients' perceived ability to adhere to antiretroviral medication regimens. QD was the preferred dosing frequency, but QD dosing regimens did not score better than other regimens. Among actual regimens, predicted adherence was highest for a twice-daily (BID) regimen with 2 pills daily, no dietary restrictions, and 1 prescription and copayment and lowest for a BID regimen with 13 pills daily, food requirements, and 3 prescriptions and copayments.

CONCLUSIONS

All HAART regimen attributes studied were perceived to have an impact on adherence, but pill count, dosing frequency, and adverse events had the greatest perceived impact. These data are of potential importance to clinicians as they seek to structure HAART regimens to which their patients are most likely to adhere.

Optimizing the care of minority patients with HIV/AIDS

Persons belonging to racial/ethnic minorities are disproportionately affected by human immunodeficiency virus (HIV) infection and/or acquired immunodeficiency syndrome (AIDS) in the United States, with higher numbers of infected individuals and higher HIV/AIDS-related death rates. Despite its substantial medical toll among minorities, HIV/AIDS has had a complex sociocultural legacy in many minority communities in the United States, especially in the African American community, which can present a challenge for patients and medical care providers. Many studies have found that minorities receiving care for HIV/AIDS are less likely to be satisfied with their HIV care and less likely to receive highly active antiretroviral therapy (HAART) than are other patients. The root causes of these disparities in care have not yet been well delineated. However, clinicians can optimize the care they provide for minority patients by using a cultural competence framework, enhancing patient-provider communication, diversifying their clinical staff, proactively enhancing receipt of HAART, and being attentive to issues related to adherence to HAART.

The body-inversion effect

Researchers argue that faces are recognized via the configuration of their parts. An important behavioral finding supporting this claim is the face-inversion effect, in which inversion impairs recognition of faces more than nonface objects. Until recently, faces were the only class of objects producing the inversion effect for untrained individuals. This study investigated whether the inversion effect extends to human body positions, a class of objects whose exemplars are structurally similar to each other. Three experiments compared the recognition of upright and inverted faces, houses, and body positions using a forced-choice, same/different paradigm. For both reaction time and error data, the recognition of possible human body postures was more affected by inversion than the recognition of houses. Further, the recognition of possible human body postures and recognition of faces showed similar effects of inversion. The inversion effect was diminished for impossible body positions that violated the biomechanical constraints of human bodies. These data suggest that human body positions, like faces, may be processed configurally by untrained viewers.

An examination of HIV/AIDS patients who have excellent adherence to HAART

This paper examines the attitudes and beliefs of HIV/AIDS patients with excellent adherence to highly active antiretroviral therapy (HAART) and how they differ from those with suboptimal adherence. Forty-four persons with HIV/AIDS, 28 men and 16 women, participated in a qualitative semi-structured interview which was based on the Health Belief Model. The main outcomes were themes consistent with several dimensions of this model, reflecting differences in the health-related attitudes and beliefs of the excellent adherers compared to the suboptimal adherers. Patients with excellent adherence voiced the following themes when compared to less adherent patients: (1) believed adherence rates needed to be 90-100% for medication efficacy; (2) trusted their primary providers greatly; (3) took medications even when actively using substances of abuse; (4) were open about their HIV status and received substantial social support; (5) cited staying healthy as their key motivator; (6) were not actively depressed; all had normal CESD scores. Our study suggests that patients with excellent adherence to HAART differ from their less adherent counterparts in terms of key health-related attitudes and beliefs. Identifying and studying excellent adherers provides new insights and strategies for enhancing adherence to HAART.

Acquired theory of mind impairments in individuals with bilateral amygdala lesions

Studies in humans suggest that the amygdala plays a role in processing social information. A key component of social information processing is what developmental psychologists call "theory of mind": the ability to infer others' mental states. Recent studies have raised the possibility that the amygdala is involved in theory of mind, showing amygdala activation during a theory of mind task, or showing impairment on theory of mind tasks in a patient with amygdala damage acquired in childhood. Here, we present the first evidence of theory of mind deficits following amygdala damage acquired in adulthood. Two participants, D.R. and S.E., with acquired bilateral amygdala damage showed difficulties with two theory of mind tasks, "Recognition of Faux Pas" (for D.R., z=-5.17; for S.E., z=-1.83) and "Reading the Mind in the Eyes" (for S.E., z=-1.91; for D.R., z=-1.4). The items on which D.R. and S.E. made errors on these tasks were uncorrelated with the items that control participants found most difficult, indicating that these deficits cannot be attributed solely to the cognitive difficulty of the tasks. These results indicate that the amygdala's critical role in theory of mind may not be just in development, but also in "on-line" theory of mind processing in the adult brain.

A prospective study of adherence and viral load in a large multi-center cohort of HIV-infected women

OBJECTIVES

To examine the relationship between antiretroviral adherence and viral load, and to determine the predictors of adherence over time in HIV-infected women.

DESIGN

Prospective observational study.

METHODS

One-hundred sixty-one HIV-infected women who were taking antiretroviral therapy for a median of 3.0 years were recruited from the HIV Epidemiology Research Study, a multicenter cohort study of HIV infection in women. Antiretroviral adherence (percent of doses taken as prescribed) was measured over a 6-month period using MEMS caps. At baseline and follow-up, CD4 lymphocyte count and viral load were measured, and a standardized interview was administered to elicit medication history and drug use behaviors. To examine changes in adherence over time, the mean adherence to all antiretroviral agents was calculated for each monitored month.

RESULTS

Adherence varied significantly over time (P < 0.001), ranging from a mean of 64% in month 1 to 45% in month 6. Nearly one-fourth of the participants had a 10% or greater decrease in adherence between consecutive months. Virologic failure occurred in 17% of women with adherence of > or = 88%, 28% of those with 45-87% adherence, 43% of those with 13-44% adherence, and 71% of those with < or = 12% adherence. In multivariate analysis, factors predicting lower adherence included active drug use, alcohol use, more frequent antiretroviral dosing, shorter duration of antiretroviral use, younger age, and lower initial CD4 lymphocyte count.

CONCLUSIONS

Antiretroviral adherence is not stable over time. Interventions aimed at monitoring and improving long-term adherence in women are urgently needed.

Selective impairment of reasoning about social exchange in a patient with bilateral limbic system damage

Social exchange is a pervasive feature of human social life. Models in evolutionary biology predict that for social exchange to evolve in a species, individuals must be able to detect cheaters (nonreciprocators). Previous research suggests that humans have a cognitive mechanism specialized for detecting cheaters. Here we provide neurological evidence indicating that social exchange reasoning can be selectively impaired while reasoning about other domains is left intact. The patient, R.M., had extensive bilateral limbic system damage, affecting orbitofrontal cortex, temporal pole, and amygdala. We compared his performance on two types of reasoning problem that were closely matched in form and equally difficult for control subjects: social contract rules (of the form, "If you take the benefit, then you must satisfy the requirement") and precaution rules (of the form, "If you engage in hazardous activity X, then you must take precaution Y"). R.M. performed significantly worse in social contract reasoning than in precaution reasoning, when compared both with normal controls and with other brain-damaged subjects. This dissociation in reasoning performance provides evidence that reasoning about social exchange is a specialized and separable component of human social intelligence, and is consistent with other research indicating that the brain processes information about the social world differently from other types of information.

Directly observed therapy for the treatment of people with human immunodeficiency virus infection: a work in progress

The principle of directly observed therapy (DOT) has its roots in the treatment of tuberculosis (TB), for which DOT programs have improved cure rates in hard-to-reach populations. Human immunodeficiency virus (HIV) and TB affect similar populations, and there are concerns about both regarding the development of drug resistance associated with poor adherence to therapy. Accordingly, DOT may benefit certain HIV-infected people who have difficulty adhering to highly active antiretroviral therapy. However, important differences exist in the treatment of these diseases that raise questions about how DOT can be adapted to HIV therapy. DOT for management of HIV infection has been effective among prisoners and in pilot programs in Haiti, Rhode Island, and Florida. Although DOT can successfully treat HIV infection in marginalized populations in the short term, a multitude of questions remain. This review provides an account of the preliminary development of DOT programs for the treatment of HIV-infected individuals.

Antiretroviral regimen complexity, self-reported adherence, and HIV patients' understanding of their regimens: survey of women in the her study

BACKGROUND

Research regarding treatment adherence in chronic diseases, such as hypertension, suggests that increasing complexity in the medication regimen is associated with decreasing patient adherence. However, less is known about the relationship between regimen complexity and adherence in the treatment of HIV/AIDS.

OBJECTIVE

To examine the relationship between antiretroviral (ART) regimen complexity and patient understanding of correct regimen dosing to adherence (missing doses in the past 1 and 3 days).

METHODS

Cross-sectional survey of a cohort of women living with HIV/AIDS and enrolled in the HER (HIV Epidemiologic Research) Study.

RESULTS

Seventy-five percent of patients correctly understood the dosing frequency of their ART medications, 80% understood the food-dosing restrictions, whereas only 63% understood both. The percentage of patients with a correct understanding of dosing decreased with increasing regimen complexity (increased dosing frequency and food-dosing restrictions). Patients were more likely to have missed doses in the previous 3 days if they were taking ART medications three or more times per day or had to take one or more antiretrovirals on an empty stomach. A multivariate logistic regression model demonstrated that patients with less complex regimens (twice daily or less in frequency, no food-dosing restrictions) who correctly understood the dosing and food restrictions of their ART regimen were less likely to have skipped doses in the past three days (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.2-0.7) than those with more complex regimens. Younger age and higher CD4 count were also associated with a reduced likelihood of skipping doses. No association was found between adherence and race/ethnicity, current or past injection drug use, or education.

CONCLUSIONS

Self-reported adherence is better among patients with less complex ART regimens. This is in part because patients' understanding of regimen dosing decreases as regimen complexity increases. Therefore, simplifying antiretroviral regimens may have an important role in improving patients' adherence.

Strategies for optimizing adherence to highly active antiretroviral therapy: lessons from research and clinical practice

Successful treatment of human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) with highly active antiretroviral therapy (HAART) requires that patients maintain nearly perfect adherence to the prescribed regimen. Suboptimal adherence to antiretroviral therapy is clearly the most common cause of virologic failure of HAART regimens. Given the critical role of adherence in successful antiretroviral therapy, it is essential that providers of care for patients with HIV infection have a strategy that proactively assists and supports their patients' efforts to adhere to medication regimens. This review endeavors to provide a clinically focused approach to optimizing adherence of patients to HAART.

Relation of physician specialty and HIV/AIDS experience to choice of guideline-recommended antiretroviral therapy

BACKGROUND

Controversy exists regarding who should provide care for those with HIV/AIDS. While previous studies have found an association between physician HIV experience and patient outcomes, less is known about the relationship of physician specialty to HIV/AIDS outcomes or quality of care.

OBJECTIVE

To examine the relationship between choice of appropriate antiretroviral therapy (ART) to physician specialty and HIV/AIDS experience.

DESIGN

Self-administered physician survey.

PARTICIPANTS

Random sample of 2,478 internal medicine (IM) and infectious disease (ID) physicians.

MEASUREMENTS

Choice of guideline-recommended ART.

RESULTS

Two patients with HIV disease, differing only by CD4+ count and HIV RNA load, were presented. Respondents were asked whether ART was indicated, and if so, what ART regimen they would choose. Respondents' ART choices were categorized as "recommended" or not by Department of Health and Human Services guidelines. Respondents' HIV/AIDS experience was categorized as moderate to high (MOD/HI) or none to low (NO/LO). For Case 1, 72.9% of responding physicians chose recommended ART. Recommended ART was more likely (P <.01) to be chosen by ID physicians (88.2%) than by IM physicians (57.1%). Physicians with MOD/HI experience were also more likely (P <.01) to choose recommended ART than those with NO/LO experience. Finally, choice of ART was examined using logistic regression: specialty and HIV experience were found to be independent predictors of choosing recommended ART (for ID physicians, odds ratio [OR], 4.66; 95% confidence interval [95% CI], 3.15 to 6.90; and for MOD/HI experience, OR, 2.05; 95% CI, 1.33 to 3.16). Results for Case 2 were similar. When the analysis was repeated excluding physicians who indicated they would refer the HIV "patient," specialty and HIV experience were not significant predictors of choosing recommended ART.

CONCLUSIONS

Guideline-recommended ART appears to be less likely to be chosen by generalists and physicians with less HIV/AIDS experience, although many of these physicians report they would refer these patients in clinical practice. These results lend support to current recommendations for routine expert consultant input in the management of those with HIV/AIDS.

Primary care of the patient with HIV/AIDS

Primary care of the person with HIV/AIDS is a complex endeavor with many components. The primary care provider's goal is to combine preventive health care interventions that are known to be effective, with ongoing surveillance and treatment of HIV-related and non-HIV-related medical problems, and effective antiretroviral therapy when indicated. The provider needs to have an approach that enhances trust, involves the patient in important health care decisions, and meets the patient's own expectations for health care.