Integrating hypertension and HIV care in Namibia: A quality improvement collaborative approach

Background

Hypertension (HTN) is highly prevalent among people with HIV (PWH) in Namibia, but screening and treatment for HTN are not routinely offered as part of HIV care delivery. We report the implementation of a quality improvement collaborative (QIC) to accelerate integration of HTN and HIV care within public-sector health facilities in Namibia.

Methods

Twenty-four facilities participated in the QIC with the aim of increasing HTN screening and treatment among adult PWH (>15 years). HTN was defined according to national treatment guidelines (i.e., systolic blood pressure >140 and/or diastolic blood pressure >90 across three measurements and at least two occasions), and decisions regarding initiation of treatment were made by physicians only. Teams from participating hospitals used quality improvement methods, monthly measurement of performance indicators, and small-scale tests of change to implement contextually tailored interventions. Coaching of sites was performed on a monthly basis by clinical officers with expertise in QI and HIV, and sites were convened as part of learning sessions to facilitate diffusion of effective interventions.

Results

Between March 2017 and March 2018, hypertension screening occurred as part of 183,043 (86%) clinical encounters at participating facilities. Among 1,759 PWH newly diagnosed with HTN, 992 (56%) were initiated on first-line treatment. Rates of treatment initiation were higher in facilities with an on-site physician (61%) compared to those without one (51%). During the QIC, facility teams identified fourteen interventions to improve HTN screening and treatment. Among barriers to implementation, teams pointed to malfunctions of blood pressure machines and stock outs of antihypertensive medications as common challenges.

Conclusions

Implementation of a QIC provided a structured approach for integrating HTN and HIV services across 24 high-volume facilities in Namibia. As rates of HTN treatment remained low despite ongoing facility-level changes, policy-level interventions—such as task sharing and supply chain strengthening—should be pursued to further improve delivery of HTN care among PWH beyond initial screening.

Roll-out of HIV pre-exposure prophylaxis: a gateway to mental health promotion

HIV remains a pressing global health problem, with 1.5 million new infections reported globally in 2020. HIV pre-exposure prophylaxis (PrEP) can lower the likelihood of HIV acquisition among populations at elevated risk, yet its global roll-out has been discouragingly slow. Psychosocial factors, such as co-occurring mental illness and substance use, are highly prevalent among populations likely to benefit from PrEP, and have been shown to undermine persistence and adherence. In this analysis, we review the high burden of mental health problems among PrEP candidates and contend that inattention to mental health stands to undermine efforts to implement PrEP on a global scale. We conclude that integration of mental health screening and treatment within PrEP scale-up efforts represents an important strategy for maximising PrEP effectiveness while addressing the high burden of mental illness among at-risk populations. As implementers seek to integrate mental health services within PrEP services, efforts to keep access to PrEP as low-threshold as possible should be maintained. Moreover, programmes should seek to implement mental health interventions that are sensitive to local resource constraints and seek to reduce intersecting stigmas associated with HIV and mental illness.

Beyond tokenism in quality management policy and programming: moving from participation to meaningful involvement of people with HIV in New York State

BACKGROUND

Consumer involvement in health-care policy and quality management (QM) programming is a key element in making health systems people-centered. Involvement of health-care consumers in these areas, however, remains underdeveloped and under-prioritized. When consumer involvement is actively realized, few mechanisms for assessing its impact have been developed. The New York State Department of Health (NYSDOH) embraces consumer involvement of people with HIV in QM as a guiding principle, informed by early HIV/AIDS advocacy and a framework of people-centered quality care.

METHOD

HIV consumer involvement is implemented statewide and informs all quality of care programming as a standard for QM in health-care organizations, implemented through four key several initiatives: (i) a statewide HIV Consumer Quality Advisory Committee; (ii) leadership and QM trainings for consumers; (iii) specific tools and activities to engage consumers in QM activities at state, regional and health-care facility levels and (iv) formal organizational assessments of consumer involvement in health-care facility QM programs.

RESULTS

We review the literature on this topic and place the methods used by the NYSDOH within a theoretical framework for consumer involvement.

CONCLUSION

We present a model that offers a paradigm for practical implementation of routine consumer involvement in QM programs that can be replicated in other health-care settings, both disease-specific and general, reflecting the priority of active participation of consumers in QM activities at all levels of the health system.

Improving the cascade of global tuberculosis care: moving from the "what" to the "how" of quality improvement

Tuberculosis is preventable, treatable, and curable, yet it has the highest mortality rate of infectious diseases worldwide. Over the past decade, services to prevent, screen, diagnose, and treat tuberculosis have been developed and scaled up globally, but progress to end the disease as a public health threat has been slow, particularly in low-income and middle-income countries. In these settings, low-quality tuberculosis prevention, diagnostic, and treatment services frustrate efforts to translate use of existing tools, approaches, and treatment regimens into improved individual and public health outcomes. Increasingly sophisticated methods have been used to identify gaps in quality of tuberculosis care, but inadequate work has been done to apply these findings to activities that generate population-level improvements. In this Personal View, we contend that shifting the focus from the "what" to the "how" of quality improvement will require National Tuberculosis Programmes to change the way they organise, use data, implement, and respond to the needs and preferences of people with tuberculosis and at-risk communities.

Implementing quality improvement in tuberculosis programming: Lessons learned from the global HIV response

The quality of care and treatment for tuberculosis (TB) is a major barrier in global efforts to end TB as a global health emergency. Despite a growing recognition of the need to measure, assure, and improve quality of TB services, implementation of quality improvement (QI) activities remains limited. Applying principles of systems thinking, continuous measurement, and root cause analysis, QI represents a proven approach for identifying and addressing performance gaps in healthcare delivery, with demonstrated success in low- and middle-income settings in the areas of HIV/AIDS, maternal, newborn, and child health, and infection control, among others. Drawing from lessons learned in the development of QI programming as part of the global response to HIV, we review key enablers to implementation that may assist NTPs in turning aspirations of high-quality service delivery into action. Under the umbrella of a formal quality management (QM) program, NTPs' attention to planning and coordination, commitment to tracking key processes of care, investment in QI capacity building, and integration of TB QI activities within efforts to advance universal health coverage provide a framework to sustainably implement QI activities.

A quality improvement approach to the reduction of HIV-related stigma and discrimination in healthcare settings

HIV-related stigma and discrimination (S&D) in healthcare settings represents a potent barrier to achieving global aims to end the HIV epidemic, particularly in Southeast Asia (Cambodia, Lao People’s Democratic Republic, Thailand and Vietnam). Evidence-based approaches for measuring and reducing S&D in healthcare settings exist, but their incorporation into routine practice remains limited, in part due to a lack of attention to how unique organisational practices—beyond the knowledge and attitudes of individuals—may abet and reinforce S&D. Application of a quality improvement (QI) approach in which facilities leverage routine measurement of S&D among healthcare workers and people living with HIV, team-based learning, root cause analysis, and tests of change offers a novel means through which to address S&D in local contexts and develop interventions to address individual-level and organisation-level drivers of S&D. To support the adoption of a QI approach to S&D reduction, the Southeast Asia Stigma Reduction QI Learning Network was launched with Ministries of Health from Cambodia, Lao PDR, Thailand and Vietnam, to co-develop strategies for implementing QI activities in participating facilities. Since the inception of Network activities in 2017, Ministry-led QI activities to address S&D have been implemented in 83 facilities and 29 provinces across participating countries. Moreover, 27 strategies and interventions have been tested to date and are being evaluated for scale up by participating facilities, spanning multiple drivers and organisational domains. Lessons learned through Network activities offer national-level and facility-level HIV programmes best practices for implementing a QI approach to S&D reduction.

The Facility-Level HIV Treatment Cascade: Using a Population Health Tool in Health Care Facilities to End the Epidemic in New York State

Background

The HIV treatment cascade is a tool for characterizing population-level gaps in HIV care, yet most adaptations of the cascade rely on surveillance data that are ill-suited to drive quality improvement (QI) activities at the facility level. We describe the adaptation of the cascade in health care organizations and report its use by HIV medical providers in New York State (NYS).

Methods

As part of data submissions to the NYS Department of Health, sites that provide HIV medical care in NYS developed cascades using facility-generated data. Required elements included data addressing identification of people living with HIV (PLWH) receiving any service at the facility, linkage to HIV medical care, prescription of antiretroviral therapy (ART), and viral suppression (VS). Sites also submitted a methodology report summarizing how cascade data were collected and an improvement plan identifying care gaps.

Results

Two hundred twenty-two sites submitted cascades documenting the quality of care delivered to HIV patients presenting for HIV- or non-HIV-related services during 2016. Of 101 341 PLWH presenting for any medical care, 75 106 were reported as active in HIV programs, whereas 21 509 had no known care status. Sites reported mean ART prescription and VS rates of 94% and 80%, respectively, and 60 distinct QI interventions.

Conclusions

Submission of facility-level cascades provides data on care utilization among PLWH that cannot be assessed through traditional HIV surveillance efforts. Moreover, the facility-level cascade represents an effective tool for identifying care gaps, focusing data-driven improvement efforts, and engaging frontline health care providers to achieve epidemic control.

Understanding Determinants of Racial and Ethnic Disparities in Viral Load Suppression

Racial and ethnic disparities in viral load suppression (VLS) have been well documented among people living with HIV (PLWH). The authors hypothesized that a contemporary analytic technique could reveal factors underlying these disparities and provide more explanatory power than broad stereotypes. Classification and regression tree analysis was used to detect factors associated with VLS among 11 419 adult PLWH receiving treatment from 186 New York State HIV clinics in 2013. A total of 8885 (77.8%) patients were virally suppressed. The algorithm identified 8 mutually exclusive subgroups characterized by age, housing stability, drug use, and insurance status but neither race nor ethnicity. Our findings suggest that racial and ethnic disparities in VLS exist but likely reflect underlying social and behavioral determinants of health.

Factors Associated with the Successful Implementation of a Quality Improvement Project in Human Immunodeficiency Virus Ambulatory Care Clinics

We examined a quality improvement (QI) program, offered to ambulatory care clinics (N = 82) serving human immunodeficiency virus-positive clients, to determine what factors predicted the clinic independently implementing QI processes without their program consultant's help. Initial analyses examined clinics at 4 levels of involvement: withdrew from the project, initial QI proficiency, advanced QI proficiency, and consultant independent. The initial and advanced stages were collapsed into 1 group (consultant dependent) and compared with consultant-independent clinics for multivariate logistic regression. In the multivariate models, 3 factors significantly predicted the clinic being consultant independent: staffing level (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.2-2.2), the number of participating months (OR = 1.4, 95% CI = 1.0-2.0), and baseline QI readiness (OR = 1.1, 95% CI = 1.0-1.3). Receiver operator curves were calculated for significant predictors; the strongest predictor was staffing (c statistic = .79). Clinics that are organizationally prepared for QI, allow adequate time to adopt QI methods into their organization, and provide adequate QI staffing are more likely to independently apply QI methods.

The HIV Workforce in New York State: Does Patient Volume Correlate with Quality?

BACKGROUND

Knowledge of care practices among clinicians who annually treat <20 human immunodeficiency virus (HIV)-positive patients with antiretroviral therapy (ART) is insufficient, despite their number, which is likely to increase given shifting healthcare policies. We analyze the practices, distribution and quality of care provided by low-volume prescribers (LVPs) based on available data sources in New York State.

METHODS

We communicated with 1278 (66%) of the LVPs identified through a statewide claims database to determine the circumstances under which they prescribed ART in federal fiscal year 2009. We reviewed patient records from 84 LVPs who prescribed ART routinely and compared their performance with that of experienced clinicians practicing in established HIV programs.

RESULTS

Of the surveyed LVPs, 368 (29%) provided routine ambulatory care for 2323 persons living with HIV/AIDS, and 910 LVPs cited other reasons for prescribing ART. Although the majority of LVPs (73%) practiced in New York City, patients living upstate were more likely to be cared for by a LVP (odds ratio, 1.7; 95% confidence interval, 1.4-1.9). Scores for basic HIV performance measures, including viral suppression, were significantly higher in established HIV programs than for providers who wrote prescriptions for <20 persons living with HIV/AIDS (P < .01). We estimate that 33% of New York State clinicians who provide ambulatory HIV care are LVPs.

CONCLUSIONS

Our findings suggest that the quality of care associated with providers who prescribe ART for <20 patients is lower than that provided by more experienced providers. Access to experienced providers as defined by patient volume is an important determinant of delivering high-quality care and should guide HIV workforce policy decisions.

Nonoccupational post-exposure prophylaxis for HIV in New York State Emergency Departments

New York State (NYS) established guidelines for nonoccupational post-exposure prophylaxis (nPEP) to HIV in 1997. To assess current nPEP practices in NYS Emergency Departments (EDs), we electronically surveyed all ED directors in NYS, excluding Veterans' Affairs hospitals, about nPEP and linkage-to-care protocols in the EDs. Basic descriptive statistics were used for analysis. The response rate was 96% (184/191). Of respondents, 88% reported evaluating any patient with a possible nonoccupational exposure to HIV, in accordance with NYS guidelines. Of these, 83% provided the patient with a starter pack of medications, while 4% neither supplied nor prescribed antiretroviral drugs in the ED. Sexually transmitted infection screening, risk reduction counseling, and education about symptoms of acute HIV seroconversion were performed inconsistently, despite NYS guidelines recommendations. Only 22% of EDs confirmed whether linkage to follow-up care was successful. Most NYS EDs prescribe nPEP to appropriate patients but full implementation of guidelines remains incomplete.

Factors associated with returning to HIV care after a gap in care in New York State

BACKGROUND

Retention in HIV care has important implications. Few studies examining retention include comprehensive and heterogeneous populations, and few examine factors associated with returning to care after gaps in care. We identified reasons for gaps in care and factors associated with returning to care.

METHODS

We extracted medical record and state-wide reporting data from 1865 patients with 1 HIV visit to a New York facility in 2008 and subsequent 6-month gap in care. Using mixed effect logistic regression, we examined sociodemographic, clinical, and facility characteristics associated with returning to care.

RESULTS

Most patients were men (63.2%), black (51.4%), had Medicaid (53.9%). Many had CD4 counts >500 cells per cubic millimeter (34.4%) and undetectable viral loads (45.0%). Most (55.9%) had unknown reasons for gaps in care; of those with known reasons, reasons varied considerably. After a gap, 54.6% returned to care. Patients who did (vs. did not) return to care were more likely to have stable housing, longer duration of HIV, high CD4 count, suppressed viral load, antiretroviral medications, and had facilities attempt to contact them. Those who returned to care were less likely to be uninsured and have mental health problems or substance use histories.

CONCLUSION

Over half of our sample of patients in New York with 1 HIV visit and subsequent 6-month gap in care returned to care; no major reasons for gaps emerged. Nevertheless, our findings emphasize that stabilizing patients' psychosocial factors and contacting patients after a gap in care are key strategies to retain HIV-positive patients in care in New York.

Legislated human immunodeficiency virus testing in New York State Emergency Departments: reported experience from Emergency Department providers

In 2010, New York (NY) passed new legislation mandating Emergency Departments (EDs) to offer HIV tests to patients 13-64 presenting for care. We evaluated the requirement's implementation and determined differences based on HIV prevalence or site-specific designated AIDS centers (DACs). We also evaluated policies for linkage to care of new HIV positive patients. An electronic survey on testing practices and linkage to care was administered to all NY EDs, excluding VA hospitals. Basic descriptive statistics were used for analysis. The response rate was 96% (184/191). All respondents knew of the legislation and 86% offered testing, but only 65% (159/184) to all patients required by the law. EDs in NYC, high prevalence areas, and DACs were more likely to offer HIV testing. Most facilities (104/159, 65%) used separate written consent despite elimination of this requirement. Most EDs (67%) used rapid testing: oral point-of-care ED testing and rapid laboratory testing. Only 61% of EDs provided results to patients while in the ED. Most (94%) had a linkage-to-care protocol. However, only 29% confirm linkage. We provide the first report of NY ED HIV testing practices since the mandatory testing law. Most EDs offer HIV testing but challenges still exist. Linkage-to-care plans are in place, but few EDs confirm it occurs.

Improved quality of HIV care over time among participants in a national quality improvement initiative

Ensuring comprehensive quality HIV and primary care is critical for effective HIV management. This study evaluates the impact of long-term engagement in a quality management (QM) initiative on performance measures. HIVQUAL-US is a federally-funded program to build clinic QM capacity to improve care for people living with HIV/AIDS. Forty-five facilities with four or more years of HIVQUAL-US performance measurement between 2002 and 2009 were included. Composite quality scores were constructed for HIV care, primary care and overall quality. Unadjusted analyses showed significant improvements in HIV care (76.2% to 88.8%, p&lt;.0001), primary care (65.7% to 71.4%, p&lt;.05) and overall (70.6% to 79.6%, p&lt;.0001). Improvement was higher among clinics performing in the lowest quartile. Adjusting for clinic factors, the probability of improvement increased with each additional year of data submission for all scores. Engagement in a QM capacity building program was associated with continuing improvement in quality of HIV and primary care.

Evaluation of regional HIV provider quality groups to improve care for people living with HIV served in the United States

HIVQUAL-US is a capacity-building quality initiative for federally-funded HIV primary care clinics. Since 2004, HIVQUAL-US has supported the formation of regional groups, geographically-clustered clinics that build quality management capacity through collective learning about quality improvement. The purpose of this qualitative study was to examine members' experiences participating in groups and their self-reported quality management and improvement outcomes related to HIV primary care. Interviews were conducted with a sample of three HIVQUAL-US coaches who facilitated 11 regional groups and with nine of the clinic representatives participating in the regional groups. The regional groups were heterogeneous in composition, focus and style, but shared common activities. Benefits included implementation of group quality improvement projects and opportunities for sharing activities and challenges. Improved performance in targeted areas, enhanced understanding/use of improvement methods, and increased quality management capacity were reported outcomes. Regional groups can effectively promote peer-to-peer learning, develop leadership, strengthen quality management capacity, and improve quality of care for the HIV population.

Using computer-based monitoring and intervention to prevent harmful combinations of antiretroviral drugs in the New York State AIDS Drug Assistance Program

BACKGROUND

Despite the growing number of HIV-infected people and the acknowledged complexity of HIV therapy, there are no standard safeguards in the outpatient setting against dangerous antiretroviral (ARV) therapy combinations in the publicly financed arena.

METHODS

Using quarterly pharmacy claims data from the New York State AIDS Drug Assistance Program, a three-phase approach was developed: The extent of contraindicated ARV combinations was ascertained; prescriber alerts were developed; and, finally, the reimbursement of contraindicated ARV combinations was blocked at pharmacy. ARV dosages, the number of ARV medications in a regimen, clinical adequacy of the regimen, medication claim denials, clinician adjudication, and subsequent clinician prescribing patterns were analyzed.

RESULTS

For the 27-month study period (October 1, 2006-December 31, 2009), 112,383 ARV regimens involving 396,303 ARV medications for 25,463 unique recipients were individually analyzed. A total of 1,089 interventions occurred; denials and interventions increased per quarter from a baseline of 129 to 217 by the study's end. All contraindicated combinations referred for adjudication during the study were upheld. More than 88.3% (range, 87.1% to 89.9%) of regimens per quarter were consistent with effective ARV as promulgated by current guidelines. The targeted dissemination of ARV drug interaction safety alerts to previous prescribers of contraindicated combinations during the first year of the review curtailed the practice by 77.3%.

CONCLUSION

A systems-level intervention can be used on a state level to reduce ARV contraindicated medication errors in the outpatient setting through a coordinated approach of prescriber clinical education and electronic pharmacy and billing systems and provides an effective safety and quality monitoring model.

HIVQUAL-T: monitoring and improving HIV clinical care in Thailand, 2002-08

OBJECTIVE

We report experience of HIVQUAL-T implementation in Thailand.

DESIGN

Program evaluation.

SETTING

Twelve government hospital clinics.

PARTICIPANTS

People living with HIV/AIDS (PLHAs) aged ≥15 years with two or more visits to the hospitals during 2002-08.

INTERVENTION

HIVQUAL-T is a process for HIV care performance measurement (PM) and quality improvement (QI). The program includes PM using a sample of eligible cases and establishment of a locally led QI infrastructure and process. PM indicators are based on Thai national HIV care guidelines. QI projects address needs identified through PM; regional workshops facilitate peer learning. Annual benchmarking with repeat measurement is used to monitor progress.

MAIN OUTCOME MEASURE

Percentages of eligible cases receiving various HIV services.

RESULTS

Across 12 participating hospitals, HIV care caseloads were 4855 in 2002 and 13 887 in 2008. On average, 10-15% of cases were included in the PM sample. Percentages of eligible cases receiving CD4 testing in 2002 and 2008, respectively, were 24 and 99% (P< 0.001); for ARV treatment, 100 and 90% (P= 0.74); for Pneumocystis jiroveci pneumonia prophylaxis, 94 and 93% (P= 0.95); for Papanicolau smear, 0 and 67% (P< 0.001); for syphilis screening, 0 and 94% (P< 0.001); and for tuberculosis screening, 24 and 99% (P< 0.01). PM results contributed to local QI projects and national policy changes.

CONCLUSIONS

Hospitals participating in HIVQUAL-T significantly increased their performance in several fundamental areas of HIV care linked to health outcomes for PLHA. This model of PM-QI has improved clinical care and implementation of HIV guidelines in hospital-based clinics in Thailand.

Retaining HIV-infected patients in care: Where are we? Where do we go from here?

Retaining human immunodeficiency virus (HIV)-infected patients in medical care at regular intervals has been shown to be linked to positive health outcomes. This article examines the available literature and research on retention and engagement in care of HIV-infected patients. We identify the extent of the problem of keeping patients engaged in care, as well as analyze which groups of patients are likely to be lost to follow-up. A review of different ways to measure patient retention is considered, as well as some preliminary data that suggest successful ways to re-engage patients in care. The need to ensure that HIV-infected patients are retained in care is a pressing public health issue and one that affects multiple populations. Further research and exchange of information are needed to keep patients in continuous care and to ensure that all patients are provided with regular, high-quality care that achieves both desired patient and population health outcomes.

Nonoccupational postexposure prophylaxis for exposure to HIV in New York State emergency departments

We investigate emergency department (ED) directors' knowledge of protocols and practices for nonoccupational postexposure prophylaxis (nPEP) after potential exposure to HIV after sexual assault and consensual sexual exposures in New York State (NYS) EDs. Every ED director in NYS was queried through an electronic survey about protocols, antiretroviral drugs supplied, resources and barriers to implementation. They were also asked for retrospective data, including the number and type of cases seen and percentage in which nPEP was initiated. One hundred eighty-eight of 207 ED directors (91%) responded. One hundred seventy-eight (95%) have a protocol for sexual assault and 111 (59%) have a protocol for voluntary sexual exposure. After sexual assault, 163 ED directors (87%) reported that they typically initiate nPEP in the ED; 25 (13%) either write a prescription only or refer to another facility. After voluntary sexual exposure 132 (70%) typically initiate nPEP in the ED; 55 (29%) either write a prescription only or refer to another facility (p < 0.001). Self-reported ED data indicate that 3439 sexual assault exposures and 6858 voluntary sexual exposures and were seen in NYS EDs in 2005. The nPEP initiation rate was 65% (2244/3439) for sexual assault exposures and 43% (2931/6858) for consensual sexual exposures (p < 0.001). These results suggest that NYS nPEP guidelines are not widely implemented, and raise several important public health policy issues, including access to medication and follow-up care. Our results indicated resources, primarily number of dedicated staff, and physician education as two major factors contributing to this problem.

Defining a high performance healthcare organisation

Composite measures of performance are insufficient on their own

Prevalence of drug-resistant and nonsubtype B HIV strains in antiretroviral-naïve, HIV-infected individuals in New York State

The duration of HIV infection is usually unknown for most patients entering into HIV care. Data on the frequency at which resistance mutations are detected in these patients are needed to support practical guidance on the use of resistance testing in this clinical situation. Furthermore, little is known about HIV subtype diversity in much of the United States. Therefore, we analyzed the prevalence of drug resistance mutations and nonsubtype B strains of HIV among antiretroviral-naïve individuals presenting for HIV care in New York State between September 2000 and January 2004. Sequences were obtained using a commercial HIV genotyping assay. Seventeen of 151 subjects (11.3%; 95% confidence interval 7.2%-17.3%) had at least one drug-resistance mutation, including 5 subjects with fewer than 200 CD4(+) T cells, indicative of advanced infection. Nucleoside reverse transcriptase inhibitor, non-nucleoside reverse transcriptase inhibitor, and protease inhibitor resistance mutations were detected in 6.6%, 5.3%, and 0.7% of subjects, respectively. Subjects from New York City-based clinics were less likely to have resistant virus than subjects from clinics elsewhere in New York State. Nonsubtype B strains of HIV were detected in 9 (6.0%) individuals and were associated with heterosexual contact. Two nonsubtype B strains from this cohort also carried drug-resistance mutations. These data indicate that drug-resistant virus is frequently detected in antiretroviral-naïve individuals entering HIV care in New York State. Furthermore, a diverse set of nonsubtype B strains were identified and evidence suggests that nonsubtype B strains, including those carrying drug-resistance mutations, are being transmitted in New York State.

Training HIV clinicians and building a clinical workforce: the experience in New York State

In the late 1980s, New York State faced projected shortages in the supply of clinicians to meet the burgeoning HIV epidemic. In 1990, the New York State Department of Health AIDS Institute (AI), in collaboration with selected academic, medical center-based Designated AIDS Centers, responded by developing a two-year fellowship training program that provides skills training in the management of HIV disease and the public health aspects of the HIV epidemic. Its primary goal is to increase the number of highly qualified, broadly trained physicians, nurse practitioners, physician assistants, and dentists who can assume leadership roles in HIV-related direct care and program administration in New York State. In May 2002, each of the 74 scholars who had completed the full two-year program was mailed a survey that assessed the degree to which program goals had been met. Of the 48 survey respondents, 96 percent (46) had worked in HIV care at some time after completing the program and 90 percent were employed in HIV clinical settings. Of the 25 respondents with no HIV care experience prior to entering the program, 22 (88 percent) pursued careers in the field of HIV care after completing the program and remained in those jobs at the time of the survey. Of the 48 respondents, 42 (88 percent) held leadership positions (as program directors or medical directors), filled leadership roles as members of advisory boards, had published articles in professional journals, or had made presentations at national and international HIV/AIDS conferences; 91 percent of the respondents rated the overall quality of their training experience as "good" or "very good," the highest possible rating. The survey results indicate that this clinical training and leadership development program successfully met its primary goal of building the HIV/AIDS clinical healthcare workforce in New York State. Its success demonstrates that a state-funded, targeted clinical education program can address acute shortages in the public healthcare professional workforce in the absence of other privately or publicly funded professional development initiatives.

Hospitalization of patients infected with active TB in New York State, 1987-1992: the effect of the HIV epidemic

Hospital discharge records were used to study the relationship between human immunodeficiency virus (HIV) epidemic and hospitalized patients with tuberculosis in New York State from 1987 through 1992. The discharges of patients coinfected with HIV and tuberculosis increased by 270%, rising from 1,573 in 1987 to 5,825 in 1992. This constitutes an increase from 19.8 to 49.1% of all discharges of patients with tuberculosis. Discharges of tuberculosis patients who were not infected with HIV decreased slightly during this time, going from 6,359 to 6,039. Postdischarge treatment plans, HIV prevention, HIV testing, and HIV educational programs for the tuberculosis population require special consideration, given the significant rise of HIV in the tuberculosis-infected population.

Managing early HIV infection. Agency for Health Care Policy and Research

This Quick Reference Guide for Clinicians contains highlights from the Clinical Practice Guideline on Evaluation and Management of Early HIV Infection, which was developed by a private-sector panel of health care providers and consumers. Selected aspects of evaluating and managing patients, both adults and children, who are in the early stages of human immunodeficiency virus infection are presented. Topics covered include disclosure of HIV status, monitoring of CD4 lymphocyte counts, prevention of Pneumocystis carinii pneumonia and infection with Mycobacterium tuberculosis, initiation of antiretroviral therapy, treatment of syphilis, eye and oral care, performance of Papanicolaou smears, diagnosis of HIV infection in infants and children, preventive therapy for PCP and assessment of neurologic problems in HIV-infected children, pregnancy counseling, and development of a comprehensive case management system. Algorithms are included that show the sequence of events related to evaluating and managing early HIV infection in adults and children, as well as drug dosing tables for antiretroviral, PCP, and M. tuberculosis therapies.