Evaluation of an HIV homecare program for lost-to-follow-up populations: a mixed methods study in Detroit, Michigan

BACKGROUND

Maintaining people living with HIV (PLWHIV) in clinical care is a global priority. In the Metro Detroit area of Michigan, approximately 30% of PLWHIV are out of care. To re-engage lost-to-follow-up patients, Wayne Health Infectious Disease clinic launched an innovative Homecare program in 2017. In addition to home healthcare delivery, the program included links to community resources and quarterly community meetings. We aimed to evaluate Homecare's impact on participants' ability to stay engaged in HIV care and reach viral suppression. We included data from PLWHIV and their healthcare workers.

METHODS

We used a convergent mixed-methods design, including first year program record review, semi-structured interviews, and a validated Likert scale questionnaire rating illness perception before and after Homecare. Interview data were collected from 15 PLWHIV in Metro Detroit and two healthcare workers responsible for program delivery. Semi-structured interviews focused on obstacles to clinic-based care, support networks, and illness perceptions. Interview data were transcribed and analyzed using a thematic approach. A fully coded analysis was used to create a conceptual framework of factors contributing to Homecare's success. Means in eight categories of the Brief Illness Perception (IPQ) were compared using paired T-tests.

RESULTS

In the first year of Homecare, 28 of 34 participants (82%) became virally suppressed at least once. The program offered (1) social support and stigma reduction through strong relationships with healthcare workers, (2) removal of physical and resource barriers such as transportation, and (3) positive changes in illness perceptions. PLWHIV worked towards functional coping strategies, including improvements in emotional regulation, acceptance of their diagnosis, and more positive perspectives of control. Brief-IPQ showed significant changes in six domains before and after Homecare.

CONCLUSION

Homecare offers an innovative system for successfully re-engaging and maintaining lost-to-follow-up PLWHIV in care. These findings have implications for HIV control efforts and could inform the development of future programs for difficult to reach populations.

Best Practices in Patient Education: Medical Students' Perceptions and Implementations

Effective patient education can help achieve better clinical outcomes, especially when a patient is managing a chronic illness. Despite patient education being an important skill in the professional formation of physicians, little is known about medical students' perceptions and implementations of such strategies. After completing a chronic illness educational module, second-year medical students were asked to rate the importance of specific patient education strategies and to assess their use of said strategies in the module's project assignment. Results indicated students utilized different patient education strategies from those they initially identified as most effective.

Use of multiple anticholinergic medications can predispose patients to severe non-exertional hyperthermia

We present a case of a 64-year-old woman who developed severe non-exertional hyperthermia (NEHT) due to excessive anticholinergic effects from her psychiatric medications. The patient was found unresponsive in a non-air-conditioned room where the outside temperature was over 33°C. She presented with altered mental status, hypotension and an oral temperature of 42°C. Drug–drug interactions from her home medications for depression, bipolar disorder and seizures (amitriptyline, cyclobenzaprine, benztropine, topiramate, clonazepam, trazodone) were suspected. Blood cultures grew Staphylococcus hominis. The patient quickly returned to baseline with supportive care in the intensive care unit. She was treated for the Staph hominis bacteraemia with a 7-day course of vancomycin. Due to her quick recovery and lack of neurological findings, severe NEHT with associated bacteraemia was determined to have caused her presenting symptoms. This patient’s multiple anticholinergic medications increased her susceptibility to develop NEHT by inhibited sweating, this patient’s natural cooling mechanism.

Challenging diagnosis of indolent systemic mastocytosis isolated to the GI tract

Mastocytosis is a rare group of disorders that presents with heterogenous phenotypes depending on the organ system involved. In the absence of cutaneous involvement-mast cell aggregates that may present as papules, nodules or plaques-classically associated with indolent systemic mastocytosis (SM), the diagnosis of this rare condition is particularly challenging. When localised to the gastrointestinal (GI) tract, symptoms of indolent SM are often non-specific and mimic common conditions such as inflammatory bowel disease or irritable bowel syndrome. Diagnosis may be suspected by clinical presentation, but biopsy with histopathological analysis is necessary to confirm. We present a rare case of indolent SM without cutaneous features. In the absence of typical cutaneous features, indolent SM should be considered in the differential diagnosis of a patient with persistent GI symptoms refractory to medical treatment, as failure to do so can lead to delay in the appropriate diagnosis and treatment.

606. HIV Homecare: Understanding its Impact for Lost-to-Follow-Up Populations

Background

Maintaining people living with HIV (PLWH) in clinical care is a global priority. In the metro-Detroit area of Michigan, approximately 30% of PLWH are out of care. To re-engage lost-to-follow-up patients, the Wayne State University Physician Group – Infectious Disease clinic launched an innovative Homecare program in 2017. In addition to home healthcare delivery, the program included links to community resources and quarterly community meetings. In the first year of Homecare, 28 of 34 participants became virally suppressed at least once. We aimed to understand reasons why people who left clinic-based treatment were able to become virally suppressed in this program. We included data from PLWH and their healthcare workers.

Methods

We used a mixed-methods design, including (1) semi-structured interviews with PLWH and healthcare workers, and (2) a validated Likert scale questionnaire rating illness perception before and after Homecare. Data were collected from 15 PLWH in metro-Detroit and two healthcare workers responsible for program delivery. Semi-structured interviews focused on obstacles to clinic-based care, support networks, and illness perceptions. Interview data were transcribed and analyzed using a grounded theory approach. A fully coded analysis was used to create a conceptual framework of factors contributing to Homecare’s success. Means in eight categories of the brief illness perception questionnaire (BIPQ) were compared using paired T-tests.

Results

The Homecare program offered (1) social support and stigma reduction through strong relationships with healthcare workers; (2) removal of physical and resource barriers such as transportation; and (3) positive changes in illness perceptions. PLWH worked towards functional coping strategies, including improvements in emotional regulation, acceptance of their diagnosis, and more positive perspectives of control. BIPQ showed significant changes in six domains before and after Homecare.

Homecare Conceptual Framework

General

Joint Display: Brief Illness Perception Questionnaire

Conclusion

Homecare offers an innovative system for successfully re-engaging and maintaining lost-to-follow-up PLWH in care. These findings have implications for HIV control efforts and could inform the development of future programs for difficult to reach populations.

Disclosures

All Authors: No reported disclosures

Dual infection in pregnancy: Disseminated Mycoplasma hominis and necrotizing herpes simplex 2 hepatitis

Mycoplasma hominis is part of the genitourinary flora in sexually active people and can cause disseminated infection in immunocompromised patients. We describe a rare case of an immunocompetent pregnant woman with simultaneous necrotizing HSV hepatitis and disseminated M. hominis infection. Detection of M. hominis and antimicrobial susceptibility testing of this fastidious organism in the clinical laboratory is discussed.