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Weiser J, Tie Y, Crim SM, Riedel DJ, Shouse RL, Dasgupta S. Do HIV Care Outcomes Differ by Provider Type? J Acquir Immune Defic Syndr 2024; 96:180-189. [PMID: 38465906 DOI: 10.1097/qai.0000000000003410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 02/26/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND We compared HIV care outcomes by HIV provider type to inform efforts to strengthen the HIV provider workforce. SETTING United States. METHODS We analyzed data from Center for Disease Control and Prevention's Medical Monitoring Project collected during June, 2019-May, 2021 from 6323 adults receiving HIV medical care. Provider types include infectious disease physicians only (ID physicians), non-ID physicians only, nurse practitioners only, physician assistants only, and ID physicians plus nurse practitioners and/or physician assistants (mixed providers). We measured patient characteristics, social determinants of health, and clinical outcomes, including retention in care; antiretroviral therapy prescription; antiretroviral therapy adherence; viral suppression; gonorrhea, chlamydia, and syphilis testing; satisfaction with HIV care; and HIV provider trust. RESULTS Compared with patients of ID physicians, higher percentages of patients of other provider types had characteristics and social determinants of health associated with poor health outcomes and received HIV care at Ryan White HIV/AIDS Program-funded facilities. After accounting for these differences, most outcomes were not meaningfully different; however, higher percentages of patients of non-ID physicians, nurse practitioners, and mixed providers were retained in care (6.5, 5.6, and 12.7 percentage points, respectively) and had sexually transmitted infection testing in the past 12 months, if sexually active (6.9, 7.4, and 13.5 percentage points, respectively). CONCLUSION Most HIV outcomes were equivalent across provider types. However, patients of non-ID physicians, nurse practitioners, and mixed providers were more likely to be retained in care and have recommended sexually transmitted infection testing. Increasing delivery of comprehensive primary care by ID physicians and including primary care providers in ID practices could improve HIV primary care outcomes.
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Affiliation(s)
- John Weiser
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA; and
| | - Yunfeng Tie
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA; and
| | - Stacy M Crim
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA; and
| | - David J Riedel
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD
| | - R Luke Shouse
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA; and
| | - Sharoda Dasgupta
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA; and
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Person AK, Terndrup CP, Jain MK, Kelley CF. "Do We Stay or Do We Go?" The Impact of Anti-LGBTQ+ Legislation on the HIV Workforce in the South. Clin Infect Dis 2024; 78:411-413. [PMID: 37596931 DOI: 10.1093/cid/ciad493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/07/2023] [Accepted: 08/16/2023] [Indexed: 08/21/2023] Open
Abstract
The human immunodeficiency virus (HIV) workforce continues to face a crisis, particularly in the southern United States. Adding to known issues of administrative burden and less competitive compensation, recent anti- lesbian, gay, bisexual, transgender and queer (LGBTQ+) legislation threatens the already strained HIV workforce. HIV care providers advocate for all aspects of their patient's lives, including those needing gender-affirming care. The recent legislative targets against transgender patients, which involves many people with HIV, will clearly add to the burden on individual HIV care providers and therefore the HIV workforce. Recruitment and retention efforts in states impacted by these laws will become increasingly difficult without advocacy for the patients we serve. The HIV workforce must work together with LGBTQ+ populations to address these recent laws and promote the well-being of all our patients and colleagues.
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Affiliation(s)
- Anna K Person
- HIV Provider and HIV Medicine Association Board Member, Nashville, Tennessee, USA
| | | | - Mamta K Jain
- HIV Provider and HIV Medicine Association Board Member, Dallas, Texas, USA
| | - Colleen F Kelley
- HIV Provider and HIV Medicine Association Board Member, Atlanta, Georgia, USA
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Beer L, Williams D, Tie Y, McManus T, Yuan A(X, Crim SM, Demeke HB, Creel D, Blackwell AD, Craw JA, Weiser J. The Capacity of HIV Care Facilities to Implement Strategies Recommended by the Ending the HIV Epidemic Initiative: The Medical Monitoring Project Facility Survey. J Acquir Immune Defic Syndr 2023; 94:290-300. [PMID: 37643411 PMCID: PMC10615730 DOI: 10.1097/qai.0000000000003290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Data are needed to assess the capacity of HIV care facilities to implement recommended Ending the HIV Epidemic activities. SETTING US HIV care facilities. METHODS We analyzed 2021 survey data from 514 facilities that were recruited from a census of facilities providing care to a national probability sample of US adults with HIV. We present weighted estimates of facility characteristics, services, and policies and estimates of the proportion of all US HIV patients attending these facilities. RESULTS Among HIV care facilities, 37% were private practices, 72% were in areas with population >1 million, and 21% had more than 1000 HIV patients. Most provided preexposure prophylaxis (83%) and postexposure prophylaxis (84%). More than 67% of facilities provided HIV-specific stigma or discrimination training for all staff (covering 70% of patients) and 66% provided training on cultural competency (covering 74% of patients). A majority of patients attended facilities that provided on-site access to HIV/sexually transmitted infection (STI) transmission risk reduction counseling (89%); fewer had on-site access to treatment for substance use disorders (35%). We found low provision of on-site assistance with food banks or meal delivery (14%) and housing (33%). Approximately 71% of facilities reported using data to systematically monitor patient retention in care. On-site access to adherence tools was available at 58% of facilities; 29% reported notifying patients of missed prescription pickups. CONCLUSION Results indicate some strengths that support Ending the HIV Epidemic-recommended strategies among HIV care facilities, such as high availability of preexposure prophylaxis/postexposure prophylaxis, as well as areas for improvement, such as provision of staff antistigma trainings and adherence supports.
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Affiliation(s)
- Linda Beer
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Yunfeng Tie
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Timothy McManus
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Stacy M. Crim
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Hanna B. Demeke
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Angela D. Blackwell
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jason A. Craw
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - John Weiser
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Person AK, Harris SJ, Burdge J, Blue AV, Leedy NE, Villacorta E, Justo JA, Black E, Janelle J, Ahuja D, Chastain CA. Interprofessional Education: An Innovative Approach to Increase the Human Immunodeficiency Virus Workforce. Open Forum Infect Dis 2023; 10:ofad560. [PMID: 38023543 PMCID: PMC10665034 DOI: 10.1093/ofid/ofad560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023] Open
Abstract
Ending the human immunodeficiency virus (HIV) epidemic relies on a robust clinical workforce. The Southeast AIDS Education and Training Center's interprofessional education program is a novel approach to increasing the interest and ability of early health professional learners to provide high-quality, comprehensive, person-first care for people with HIV. Key Points: Interprofessional education (IPE) focusing on multidisciplinary care for people with HIV can serve as a novel way to increase the HIV workforce. This brief report describes the IPE program of the Southeast AIDS Education and Training Center.
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Affiliation(s)
- Anna K Person
- Southeast AIDS Education and Training Center, Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sadie J Harris
- Southeast AIDS Education and Training Center, Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jennifer Burdge
- Southeast AIDS Education and Training Center, Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amy V Blue
- Office of Interprofessional Education and College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
| | - Nicole E Leedy
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Evelyn Villacorta
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Julie Ann Justo
- College of Pharmacy, University of South Carolina,Columbia, South Carolina, USA
| | - Erik Black
- Office of Interprofessional Education, University of Florida Health Science Center, University of Florida, Gainesville, Florida, USA
| | - Jennifer Janelle
- Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Divya Ahuja
- Division of Infectious Diseases, Department of Internal Medicine, University of South Carolina, Columbia, South Carolina, USA
| | - Cody A Chastain
- Southeast AIDS Education and Training Center, Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Krishnan S, Lippincott CK, Bjerrum S, Martinez Rivera MB, Shah M. A National HIV Provider Survey of Antiretroviral Therapy Preferences for Management of Treatment-Naive and Experienced Individuals With Drug Resistance. Open Forum Infect Dis 2023; 10:ofad541. [PMID: 38023561 PMCID: PMC10655941 DOI: 10.1093/ofid/ofad541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Background HIV clinical practice guidelines outline broad treatment principles but offer less explicit recommendations by permutations of encountered viral resistance. We hypothesize that there is variability in antiretroviral (ARV) regimen decision making among providers when considering HIV drug resistance (HIVDR). Methods US HIV providers provided ARV regimen recommendations for case vignettes in a series of electronic surveys encompassing variations of HIVDR. Responses were characterized by drugs and classes selected and anticipated activity based on genotypic susceptibility. Heterogeneity was defined as the proportion of unique ARV regimens from total responses. Results An overall 119 providers from the United States participated. Among case vignettes with isolated M184V and viremia, 85.9% selected a regimen with 2 nucleoside reverse transcriptase inhibitors (NRTIs) + integrase strand transfer inhibitor (INSTI); 9.9% selected regimens with >3 ARVs. Alternatively, in scenarios of viremia with moderate to high-level NRTI resistance, >50% of providers selected an NRTI-sparing regimen, while a minority recommended 2 NRTIs + INSTI (21/123, 17%). In moderate to high-level INSTI resistance, there was response heterogeneity, with no common unifying approach to management (127 unique regimens/181 responses, 70% heterogeneity). Providers used cabotegravir/rilpivirine for treatment simplification in suppressed cases, despite a history of treatment failure (37/205, 36%). Conclusions Our national survey of US HIV providers revealed a consensus to management of HIV resistance with potential alternative options in cases with low heterogeneity. Providers selected cabotegravir/rilpivirine as a viable treatment simplification strategy in suppressed cases with a history of treatment failure. The responses to the case vignettes could be used an education tool for ARV decision making in HIVDR.
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Affiliation(s)
- Sonya Krishnan
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christopher K Lippincott
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Stephanie Bjerrum
- Department of Infectious Diseases, Copenhagen University Hospital–Rigshospitalet, Copenhagen, Denmark
| | - Marina B Martinez Rivera
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Maunank Shah
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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6
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Kreider EF, Ortega-Burgos Y, Dumeng-Rodriguez J, Gesualdi J, O’Brien C, Bracy D, Johnson J, Bowman J, Metzger D, Dine CJ, Favor K, Jordan-Sciutto KL, Momplaisir F. Early Engagement in HIV Research: Evaluation of the Penn CFAR Scholars Program Aimed at Increasing Diversity of the HIV/AIDS Workforce. J Acquir Immune Defic Syndr 2023; 94:S28-S35. [PMID: 37707845 PMCID: PMC10754256 DOI: 10.1097/qai.0000000000003260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
BACKGROUND Demographic diversity is not represented in the HIV/AIDS workforce. Engagement of underrepresented trainees as early as high school may address this disparity. METHODS We established the Penn Center for AIDS Research (CFAR) Scholars Program, a mentored research experience for underrepresented minority (URM) trainees spanning educational stages from high school to medical school. The program provides participants with tailored educational programming, professional skill building, and mentored research experiences. We conducted qualitative interviews with scholar, mentor, and leadership groups to evaluate the program's impact. RESULTS Eleven participants were selected to partake in 1 of 5 existing mentored research programs as CFAR scholars. Scholars attended an 8-week HIV Seminar Series that covered concepts in the basic, clinical, behavioral, and community-based HIV/AIDS research. Program evaluation revealed that scholars' knowledge of HIV pathophysiology and community impact increased because of these seminars. In addition, they developed tangible skills in literature review, bench techniques, qualitative assessment, data analysis, and professional network building. Scholars reported improved academic self-efficacy and achieved greater career goal clarity. Areas for improvement included clarification of mentor-mentee roles, expectations for longitudinal mentorship, and long-term engagement between scholars. Financial stressors, lack of social capital, and structural racism were identified as barriers to success for URM trainees. CONCLUSION The Penn CFAR Scholars Program is a novel mentored research program that successfully engaged URM trainees from early educational stages. Barriers and facilitators to sustained efforts of diversifying the HIV/AIDS workforce were identified and will inform future program planning.
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Affiliation(s)
- Edward F. Kreider
- Department of Medicine, Hospital of the University of Pennsylvania
- Perelman School of Medicine, University of Pennsylvania
| | - Yohaniz Ortega-Burgos
- Perelman School of Medicine, University of Pennsylvania
- Department of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia
| | | | | | | | - Danny Bracy
- Mixed Methods Research Lab, University of Pennsylvania
| | | | - Jacqui Bowman
- Center For Education, College of Physicians of Philadelphia
| | - David Metzger
- Department of Psychiatry, Perelman School of Medicine
| | - C. Jessica Dine
- Department of Medicine, Hospital of the University of Pennsylvania
- Leonard Davis Institute of Economics, University of Pennsylvania
| | - Kevin Favor
- Psychology and Human Services Department, Lincoln University
| | - Kelly L. Jordan-Sciutto
- Department of Medicine, Hospital of the University of Pennsylvania
- Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania
| | - Florence Momplaisir
- Department of Medicine, Hospital of the University of Pennsylvania
- Leonard Davis Institute of Economics, University of Pennsylvania
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7
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Guilamo-Ramos V, Thimm-Kaiser M, Benzekri A. Is the USA on track to end the HIV epidemic? Lancet HIV 2023; 10:e552-e556. [PMID: 37541707 DOI: 10.1016/s2352-3018(23)00142-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 05/26/2023] [Accepted: 06/09/2023] [Indexed: 08/06/2023]
Abstract
Despite progress in reducing new HIV infections in the USA, publicly available data suggest that new HIV infections continue to occur at an alarming rate. In this Viewpoint, we highlight the regularity with which the existing systems for HIV prevention and treatment delivery in the USA fail and the clearly inequitable effect of the systems' failure among several priority populations of the Ending the HIV Epidemic (EHE) initiative. Existing data cast doubt on whether the current EHE efforts will suffice to achieve its 2030 goal of reducing annual new HIV infections to fewer than 3000. We outline future directions in four priority areas to regain lost ground in pursuit of the 2030 EHE goals: reducing the stigma affecting people living with and most at risk of HIV; broadening the HIV workforce; mitigating harmful social determinants of health; and recommitting and reinvesting in health in the USA more broadly.
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Affiliation(s)
- Vincent Guilamo-Ramos
- Center for Latino Adolescent and Family Health and School of Nursing, Duke University, Durham, NC, USA; Department of Family Medicine and Community Health and Department of Infectious Diseases, School of Medicine, Duke University, Durham, NC, USA; Presidential Advisory Council on HIV/AIDS, US Department of Health and Human Services, Washington, DC, USA; CDC/HRSA Advisory Committee on HIV, Viral Hepatitis and STD Prevention and Treatment, US Department of Health and Human Services, Atlanta, GA, USA; Panel on Antiretroviral Guidelines for Adults and Adolescents, Office of AIDS Research Advisory Council, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, USA.
| | - Marco Thimm-Kaiser
- Center for Latino Adolescent and Family Health and School of Nursing, Duke University, Durham, NC, USA
| | - Adam Benzekri
- Center for Latino Adolescent and Family Health and School of Nursing, Duke University, Durham, NC, USA
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Bourdeau B, Shade SB, Koester KA, Rebchook GM, Steward WT, Agins BM, Myers JJ, Phan SH, Matosky M. Rapid start antiretroviral therapies for improved engagement in HIV care: implementation science evaluation protocol. BMC Health Serv Res 2023; 23:503. [PMID: 37198586 DOI: 10.1186/s12913-023-09500-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND In 2020, the Health Resources and Services Administration's HIV/AIDS Bureau funded an initiative to promote implementation of rapid antiretroviral therapy initiation in 14 HIV treatment settings across the U.S. The goal of this initiative is to accelerate uptake of this evidence-based strategy and provide an implementation blueprint for other HIV care settings to reduce the time from HIV diagnosis to entry into care, for re-engagement in care for those out of care, initiation of treatment, and viral suppression. As part of the effort, an evaluation and technical assistance provider (ETAP) was funded to study implementation of the model in the 14 implementation sites. METHOD The ETAP has used implementation science methods framed by the Dynamic Capabilities Model integrated with the Conceptual Model of Implementation Research to develop a Hybrid Type II, multi-site mixed-methods evaluation, described in this paper. The results of the evaluation will describe strategies associated with uptake, implementation outcomes, and HIV-related health outcomes for patients. DISCUSSION This approach will allow us to understand in detail the processes that sites to implement and integrate rapid initiation of antiretroviral therapy as standard of care as a means of achieving equity in HIV care.
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Affiliation(s)
- Beth Bourdeau
- Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA.
| | - Starley B Shade
- Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Kimberly A Koester
- Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Greg M Rebchook
- Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Wayne T Steward
- Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Bruce M Agins
- Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Janet J Myers
- Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Son H Phan
- Division of Policy and Data, Health Resources and Services Administration HIV/AIDS Bureau, Rockville, MD, USA
| | - Marlene Matosky
- Division of Policy and Data, Health Resources and Services Administration HIV/AIDS Bureau, Rockville, MD, USA
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9
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As K, Adam E, Livingston M, Root C, Sales JM. Support for Trauma-informed Care Implementation Among Ryan White HIV Clinics in the Southeastern United States. AIDS Behav 2023; 27:939-947. [PMID: 36048293 DOI: 10.1007/s10461-022-03830-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2022] [Indexed: 11/28/2022]
Abstract
Trauma histories are common among people with HIV and associated with poor HIV outcomes, underscoring the importance of integrating trauma-informed care (TIC) into HIV services. As part of the quantitative phase of an explanatory sequential mixed-methods study, we assessed individual and clinic-wide support (using the Attitudes Related to Trauma-informed Care-45 (ARTIC-45)) and factors influencing TIC support through surveys with 152 administrators, providers, and staff from 38 Ryan White Clinics (RWCs) in the Southeastern US. Mean responses to the ARTIC-45 Personal and System Support Subscales were 5.18 (SE = 0.09; range 1-7) and 4.45 (SE = 0.16; range 1-7), respectively. In bivariate analysis, higher personal and system support were associated with strong clinic leadership culture (personal support: β = 0.08, t-value = 2.66, p = 0.009; system support: β = 0.16, t-value = 4.71, p < 0.001) and lower staff burnout (personal support: β=-0.05, t-value=-3.10, p = 0.002; system support: β=-0.07, t-value=-3.63, p < 0.001). System support was also associated with rural clinic setting (β = 0.61, t-value = 2.34, p = 0.021), strong staff culture (β = 0.14, t-value = 4.70, p = < 0.001), and resource availability (β = 0.16, t-value = 5.76, p < 0.001), and negatively associated with academic clinic setting (β=-0.52, t-value=-2.25, p = 0.026). Thus, while there is encouraging individual support for TIC, RWCs need tools (training and/or resources) to foster leadership and staff culture and trauma support to enable their transition to trauma-informed HIV care.
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Affiliation(s)
- Kalokhe As
- Emory School of Medicine, Division of Infectious Diseases, Atlanta, GA, USA. .,Emory Rollins School of Public Health, Department of Global Health, Atlanta, GA, USA. .,Claudia Nance Rollins Building, 1518 Clifton Rd, 5003, 30322, Office, Atlanta, GA, USA.
| | - E Adam
- Emory Rollins School of Public Health, Department of Epidemiology, Atlanta, GA, USA
| | - M Livingston
- Emory Rollins School of Public Health, Department of Behavior, Social and Health Education Sciences, Atlanta, GA, USA
| | - C Root
- Emory School of Medicine, Division of Infectious Diseases, Atlanta, GA, USA
| | - J M Sales
- Emory Rollins School of Public Health, Department of Behavior, Social and Health Education Sciences, Atlanta, GA, USA
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10
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Person AK, Armstrong WS, Evans T, Fangman JJW, Goldstein RH, Haddad M, Jain MK, Keeshin S, Tookes HE, Weddle AL, Feinberg J. Principles for Ending Human Immunodeficiency Virus as an Epidemic in the United States: A Policy Paper of the Infectious Diseases Society of America and the HIV Medical Association. Clin Infect Dis 2023; 76:1-9. [PMID: 35965395 DOI: 10.1093/cid/ciac626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 07/27/2022] [Indexed: 01/26/2023] Open
Abstract
While we have the tools to achieve this goal, the persistent barriers to healthcare services experienced by too many individuals will need to be addressed to make significant progress and improve the health and quality of life of all people with human immunodeficiency virus (HIV). The necessary structural changes require actions by federal, state, and local policymakers and range from ensuring universal access to healthcare services to optimizing care delivery to ensuring a robust and diverse infectious diseases and HIV workforce. In this article, we outlines 10 key principles for policy reforms that, if advanced, would make ending the HIV epidemic in the United States possible and could have much more far-reaching effects in improving the health of our nation.
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Affiliation(s)
- Anna K Person
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wendy S Armstrong
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA.,Grady Healthcare System, Infectious Diseases Program, Atlanta, Georgia, USA
| | - Tyler Evans
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - John J W Fangman
- Mass General Brigham Community Physicians, Boston, Massachusetts, USA
| | - Robert H Goldstein
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marwan Haddad
- Center for Key Populations, Community Health Center, Inc, Middletown, Connecticut, USA
| | - Mamta K Jain
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Parkland Health and Hospital System, Dallas, Texas, USA
| | - Susana Keeshin
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Hansel E Tookes
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Andrea L Weddle
- HIV Medicine Association of the Infectious Diseases Society of America, Arlington, Virginia, USA
| | - Judith Feinberg
- Departments of Behavioral Medicine and Psychiatry and Medicine/Infectious Diseases, West Virginia University School of Medicine, Morgantown, West Virginia, USA
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11
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Pettit AC, Pichon LC, Ahonkhai AA, Robinson C, Randolph B, Gaur A, Stubbs A, Summers NA, Truss K, Brantley M, Devasia R, Teti M, Gimbel S, Dombrowski JC. Comprehensive Process Mapping and Qualitative Interviews to Inform Implementation of Rapid Linkage to HIV Care Programs in a Mid-Sized Urban Setting in the Southern United States. J Acquir Immune Defic Syndr 2022; 90:S56-S64. [PMID: 35703756 PMCID: PMC9204789 DOI: 10.1097/qai.0000000000002986] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 02/23/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rapid antiretroviral therapy (ART) initiation, in which people living with HIV start ART within days of diagnosis, is a key component of the US Ending the HIV Epidemic initiative. SETTING The Memphis Metropolitan Statistical Area ranked fourth in the United States for the highest HIV incidence per 100,000 population in 2018. Rapid ART programs are limited in the Memphis Metropolitan Statistical Area, and our objective was to identify local implementation barriers. METHODS We conducted participatory process mapping and in-depth interviews to detail steps between HIV testing at the municipal health department's Sexually Transmitted Infections Clinic and ART prescription from a nearby high-volume Ryan White-funded HIV Clinic. RESULTS Process mapping identified 4 modifiable, rate-limiting rapid ART barriers: (1) requiring laboratory-based confirmatory HIV results, (2) eligibility documentation requirements for Ryan White-funded services, (3) insufficient HIV Clinic medical provider availability, and (4) variability in ART initiation timing among HIV Clinic providers. Staff at both sites highlighted suboptimal communication and sense of shared management between facilities, limited resources to address important social determinants of health, and lack of Medicaid expansion in Tennessee as key barriers. In-depth interview themes negatively affecting rapid ART initiation included clinic burden; provider knowledge, attitudes, and beliefs; and client psychosocial needs. CONCLUSIONS Our preimplementation work identified modifiable and systemic barriers to systems flow and patient-level outcomes. This work will inform the design and implementation of a locally relevant rapid ART program in Memphis, a community disproportionately affected by the HIV epidemic.
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Affiliation(s)
| | | | | | | | | | - Aditya Gaur
- St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Andrea Stubbs
- St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Nathan A. Summers
- University of Tennessee Health Science Center and Regional One Health, Adult Special Care Clinic, Memphis, Tennessee
| | | | | | - Rose Devasia
- Tennessee Department of Health, Nashville, Tennessee
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12
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Weiser J, Tie Y, Lu JF, Colasanti JA, Fanfair RN, Beer L. Receipt of Baseline Laboratory Testing Recommended by the HIV Medicine Association for People Initiating HIV Care, United States, 2015-2019. Open Forum Infect Dis 2022; 9:ofac280. [PMID: 35873284 PMCID: PMC9297314 DOI: 10.1093/ofid/ofac280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 06/06/2022] [Indexed: 11/30/2022] Open
Abstract
Background The HIV Medicine Association of the Infectious Disease Society of America publishes Primary Care Guidance for Persons with Human Immunodeficiency Virus. We assessed receipt of recommended baseline tests among newly diagnosed patients initiating HIV care. Methods The Medical Monitoring Project is a Centers for Disease Control and Prevention survey designed to produce nationally representative estimates of behavioral and clinical characteristics of adults with diagnosed HIV in the United States. We analyzed data for 725 participants in the 2015–2019 data collection cycles who received an HIV diagnosis within the past 2 years and had ≥1 HIV provider visit. We estimated the prevalence of having recommended tests after the first HIV provider visit and between 3 months before and 3/6 months after the first HIV provider visit and estimated prevalence differences of having 4 combinations of tests by sociodemographic and clinical characteristics. Results Within 6 months of care initiation, HIV monitoring tests were performed for 91.3% (95% CI, 88.7%–93.8%) of patients; coinfection blood tests, 27.5% (95% CI, 22.5%–32.4%); site-based STI tests, 59.7% (95% CI, 55.4%–63.9%); and blood chemistry and hematology tests, 50.8% (95% CI, 45.8%–55.8%). Patients who were younger, gay, or bisexual were more likely to receive site-based STI tests, and patients receiving care at Ryan White HIV/AIDS Program (RWHAP)–funded facilities were more likely than patients at non-RWHAP-funded facilities to receive all test combinations. Conclusions Receipt of recommended baseline tests among patients initiating HIV care was suboptimal but was more likely among patients at RWHAP-funded facilities. Embedding clinical decision support in HIV provider workflow could increase recommended baseline testing.
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Affiliation(s)
- John Weiser
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, GA USA
| | - Yunfeng Tie
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, GA USA
| | | | - Jonathan A. Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Infectious Diseases Program, Grady Health System, Atlanta, GA USA
| | - Robyn Neblett Fanfair
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, GA USA
| | - Linda Beer
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, GA USA
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13
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Fuller SM, Koester KA, Botta EW, Zeman L, Lazar D, Guevara E, Steward WT. Patient and Provider Experiences From HIV Clinics in the United States That Integrated Primary Care: A Brief Report. J Assoc Nurses AIDS Care 2022; 33:353-358. [PMID: 32282429 DOI: 10.1097/jnc.0000000000000169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Shannon M Fuller
- Shannon M. Fuller, MS, is a Qualitative Analyst, Division of Prevention Science, University of California San Francisco, San Francisco, California, USA. Kimberly A. Koester, PhD, is an Assistant Professor of Medicine, Division of Prevention Science, University of California San Francisco, San Francisco, California, USA. Emma Wilde Botta, MS, was a Policy Analyst, Division of Prevention Science, University of California San Francisco, San Francisco, California, USA. Lindsay Zeman, MPH, is an Evaluation Specialist, Access Community Health Network, Chicago, Illinois, USA. Danielle Lazar, MA, is an Executive Director of Research, Evaluation and Innovation, Access Community Health Network, Chicago, Illinois, USA. Ernesto Guevara, RN, is a Compliance and Performance Improvement Officer, Special Health Resources, Longview, Texas, USA. Wayne T. Steward, PhD, MPH, is a Professor of Medicine, Division of Prevention Science, University of California San Francisco, San Francisco, California, USA
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14
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Marcelin JR, Brosnihan P, Swindells S, Fadul N, Bares SH. The Value of a Longitudinal HIV Track for Medical Students: Ten-Year Program Evaluation. Open Forum Infect Dis 2022; 9:ofac184. [PMID: 35794937 PMCID: PMC9251603 DOI: 10.1093/ofid/ofac184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 04/07/2022] [Indexed: 11/15/2022] Open
Abstract
We surveyed graduates of a longitudinal medical school human immunodeficiency virus curriculum to evaluate its impact. Respondents felt comfortable caring for people with human immunodeficiency virus (PWH) and found value from the curriculum regardless of ultimate career path. Programs like this contribute to the development of culturally sensitive clinicians comfortable caring for PWH.
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Affiliation(s)
- Jasmine R Marcelin
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Paul Brosnihan
- Department of Surgery, Harbor-University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Susan Swindells
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Nada Fadul
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sara H. Bares
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
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15
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Koester KA, Moran L, LeTourneau N, VanderZanden L, Coffey S, Crouch PC, Broussard J, Schneider J, Christopoulos KA. Essential elements of and challenges to rapid ART implementation: a qualitative study of three programs in the United States. BMC Infect Dis 2022; 22:316. [PMID: 35361148 PMCID: PMC8968260 DOI: 10.1186/s12879-022-07297-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) initiation on the day of an HIV diagnosis or as soon as possible after diagnosis, known as rapid ART (henceforth "RAPID"), is considered to be a safe and effective intervention to quickly reduce viral load and potentially improve engagement in care over time. However, implementation of RAPID programming is not yet widespread. To facilitate broader dissemination of RAPID, we sought to understand health care worker experiences with RAPID implementation and to identify essential programmatic elements. METHODS We conducted 27 key informant interviews with medical providers and staff involved in RAPID service delivery in three distinct clinical settings: an HIV clinic, a Federally Qualified Health Center and a sexual health and wellness clinic. Interviews were structured around domains associated with the Consolidated Framework for Implementation Research and were audio-recorded, transcribed, and thematically analyzed. FINDINGS We identified seven (7) essential elements across settings associated with successful RAPID program implementation. These high-impact elements represent essential components without which a RAPID program could not function. There was no one requisite formation. Instead, we observed a constellation of essential elements that could be operationalized in various formations and by various people in various roles. The essential elements included: (1) presence of an implementation champion; (2) comfort and competence prescribing RAPID ART; (3) expedited access to ART medications; (4) expertise in benefits, linkage, and care navigation; (5) RAPID team member flexibility and organizations' adaptive capacity; (6) patient-centered approach; and (7) strong communication methods and culture. CONCLUSIONS The RAPID model can be applied to a diverse range of clinical contexts. The operational structure of RAPID programs is shaped by the clinical setting in which they function, and therefore the essential elements identified may not apply equally to all programs. Based on the seven essential elements described above we recommend future implementers identify where these elements currently exist within a practice; leverage them when possible; strengthen them when necessary or develop them if they do not yet exist; and look to these elements when challenges arise for potential solutions.
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Affiliation(s)
- Kimberly A Koester
- Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA, USA.
| | - Lissa Moran
- Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA, USA
| | - Noelle LeTourneau
- Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
| | | | - Susa Coffey
- Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
| | | | - Janessa Broussard
- San Francisco AIDS Foundation, 470 Castro Street, San Francisco, CA, USA
| | - John Schneider
- Howard Brown Health Center, 4025 N. Sheridan Rd, Chicago, IL, USA
| | - Katerina A Christopoulos
- Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
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16
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Park SE, Pinto RM. Factors that Influence Co-production among Student Interns, Consumers, and Providers of Social and Public Health Services: Implications for Interprofessional Collaboration and Training. SOCIAL WORK IN PUBLIC HEALTH 2022; 37:71-83. [PMID: 34488568 PMCID: PMC8665028 DOI: 10.1080/19371918.2021.1974638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Providers of public health and social services ("providers") develop and deliver services by engaging in interprofessional collaboration (IPC), from seeking external advice to making referrals and linkages to various social and public health services. Providers collaborate with consumers of social and public health services ("consumers") and student interns (e.g., social work, public health) to explore, determine, and deliver relevant services through a process referred to as co-production. Both IPC and co-production are widespread strategies with the potential to improve service accessibility and quality. However, the intersection of co-production and IPC remains understudied. This study examines factors that influence co-production in IPC among service providers, consumers, and student interns. We used cross-sectional survey data from an NIMH-funded study, including 379 providers in 36 HIV-service organizations in New York City. We examined the relationships between providers' perspectives on co-production in IPC and multiple provider- and organization-level variables using random-effects logistic regression. Most respondents said that consumers and students in their agency participate in IPC on the issues that concern them. Providers who perceive greater flexibility in the IPC process were more likely to agree that their organizations' providers co-produced IPC. Organizational service offerings (i.e., multilingual services, a comprehensive range of services), job positions, and full-time employment status were strong predictors of co-production. Our findings indicate that intentional and inclusive models of flexible IPC are needed. Fostering co-production in the HIV service field requires more institutional support and incentives for organizations, providers, and student interns. Implications for research and practice are discussed.
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17
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Bolduc P, Day PG, Behl-Chadha B, Karapanos M, Carson-Sasso V, Simpson EH, Hebert S. Community-Based HIV and Viral Hepatitis Fellowship Evaluation: Results from a Qualitative Study. J Prim Care Community Health 2022; 13:21501319221138193. [PMID: 36377210 PMCID: PMC9666842 DOI: 10.1177/21501319221138193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE The UMass Chan Medical School/New England AIDS Education and Training Center Community-Based HIV and Viral Hepatitis Fellowship was launched in 2014 to train physicians and nurse practitioners to become experts in outpatient management of HIV, hepatitis B and C, and latent tuberculosis. The purpose of this study was to identify areas of strength and improvement and understand fellows' perceptions of the program and its impact on their current positions and career trajectories. METHODS Qualitative study utilizing a semi-structured interview guide with (11) fellowship graduates (8 MDs; 3 NPs). 45 to 60 min interviews were conducted in April and May 2021, recorded and transcribed. Transcripts were analyzed for representative themes and general patterns in the data. RESULTS Results indicate high satisfaction with the fellowship, which left a positive and indelible impact on their careers and patient care. Fellows highlighted the program's commitment to health equity, its role in transforming them into leaders and advocates for HIV in primary care, and their ability to balance their work and training demands with their personal lives and needs. The fellowship motivated them to become more involved in public health initiatives, serve marginalized communities and reduce their health disparities. They expressed confidence in their ability to independently manage outpatient HIV, viral hepatitis B and C, and latent tuberculosis, and found areas of overlap with their work in primary care. CONCLUSION As the care of people with HIV becomes more commonplace in primary care clinics, it is imperative that primary care providers receive the necessary training and education to meet this need. Our study of 11 former fellows shows that the Community-Based HIV and Viral Hepatitis Fellowship offers such training, spreads it to other institutions, and can be a model for other programs nationwide.
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Affiliation(s)
- Philip Bolduc
- New England AIDS Education and Training Center and Department of Family Medicine and Community Health, University of Massachusetts Chan Medical School, Worcester, MA, USA.,Family Health Center of Worcester, Worcester, MA, USA
| | - Philip G Day
- Department of Family Medicine and Community Health, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Bittie Behl-Chadha
- Office of Survey Research, Commonwealth Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Melissa Karapanos
- Office of Survey Research, Commonwealth Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Vanessa Carson-Sasso
- New England AIDS Education and Training Center and Department of Family Medicine and Community Health, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - E Hatheway Simpson
- New England AIDS Education and Training Center and Department of Family Medicine and Community Health, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Scott Hebert
- New England AIDS Education and Training Center and Department of Family Medicine and Community Health, University of Massachusetts Chan Medical School, Worcester, MA, USA
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18
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Guilamo-Ramos V, Thimm-Kaiser M, Benzekri A, Mead A, Hook EW, Rietmeijer CA. The National Academies Report on Sexually Transmitted Infections: Implications for Clinical Training, Licensing, and Practice Guidelines. Clin Infect Dis 2021; 73:1711-1716. [PMID: 34228791 DOI: 10.1093/cid/ciab609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Indexed: 11/14/2022] Open
Abstract
STIs represent a sizable, longstanding, and growing challenge and a national public health priority. A recent National Academies report outlines new directions for STI prevention and control, including the adoption of a new sexual health paradigm and broader ownership and accountability for addressing sexual health and STIs among diverse clinical and nonclinical actors. These recommendations have important implications for infectious disease providers with STI and HIV expertise. As part of the envisioned shift toward greater prioritization of sexual health across systems for healthcare and health promotion, STI and HIV specialty providers will need to increasingly take on responsibilities as leaders in the provision of STI-related training; provision of technical assistance; and alignment of clinical training curricula, licensing criteria, and practice guidelines for healthcare generalists.
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Affiliation(s)
- Vincent Guilamo-Ramos
- Center for Latino Adolescent and Family Health, New York University, New York, NY, USA.,Ending the HIV Epidemic Working Group (Co-Chair), HIV Medical Association, Arlington, VA, USA.,Panel on Antiretroviral Guidelines for Adults and Adolescents (Member), US Department of Health and Human Services, Rockville, MD, USA.,US Presidential Advisory Council on HIV/AIDS (Member), Washington, DC, USA
| | - Marco Thimm-Kaiser
- Center for Latino Adolescent and Family Health, New York University, New York, NY, USA
| | - Adam Benzekri
- Center for Latino Adolescent and Family Health, New York University, New York, NY, USA
| | - Aimee Mead
- National Academies of Sciences, Engineering, and Medicine, Washington, DC, USA
| | - Edward W Hook
- Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
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19
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Ramirez JA, Maddali MV, Nematollahi S, Li JZ, Shah M. New Strategies in Clinical Guideline Delivery: Randomized Trial of Online, Interactive Decision Support Versus Guidelines for Human Immunodeficiency Virus Treatment Selection by Trainees. Clin Infect Dis 2021; 72:1608-1614. [PMID: 32211758 DOI: 10.1093/cid/ciaa299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 03/17/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Support for clinicians in human immunodeficiency virus (HIV) medicine is critical given national HIV-provider shortages. The US Department of Health and Human Services (DHHS) guidelines are comprehensive but complex to apply for antiretroviral therapy (ART) selection. Human immunodeficiency virus antiretroviral selection support and interactive search tool (HIV-ASSIST) (www.hivassist.com) is a free tool providing ART decision support that could augment implementation of clinical practice guidelines. METHODS We conducted a randomized study of medical trainees at Johns Hopkins University, in which participants were asked to select an ART regimen for 10 HIV case scenarios through an electronic survey. Participants were randomized to receive either DHHS guidelines alone, or DHHS guidelines and HIV-ASSIST to support their decision making. ART selections were graded "appropriate" if consistent with DHHS guidelines, or concordant with regimens selected by HIV experts at 4 academic institutions. RESULTS Among 118 trainees, participants randomized to receive HIV-ASSIST had a significantly higher percentage of appropriate ART selections compared to those receiving DHHS guidelines alone (percentage of appropriate responses in DHHS vs HIV-ASSIST arms: median [Q1, Q3], 40% [30%, 50%] vs 90% [80%, 100%]; P < .001). The effect was seen for all case types, but most pronounced for complex cases involving ART-experienced patients with ongoing viremia (DHHS vs HIV-ASSIST: median [Q1, Q3], 0% [0%, 33%] vs 100% [66%, 100%]). CONCLUSIONS Trainees using HIV-ASSIST were significantly more likely to choose appropriate ART regimens compared to those using guidelines alone. Interactive decision support tools may be important to ensure appropriate implementation of HIV guidelines. CLINICAL TRIALS REGISTRATION NCT04080765.
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Affiliation(s)
- Jesus A Ramirez
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Manoj V Maddali
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Saman Nematollahi
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jonathan Z Li
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maunank Shah
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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20
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Bono RS, Dahman B, Sabik LM, Yerkes LE, Deng Y, Belgrave FZ, Nixon DE, Rhodes AG, Kimmel AD. Human Immunodeficiency Virus-Experienced Clinician Workforce Capacity: Urban-Rural Disparities in the Southern United States. Clin Infect Dis 2021; 72:1615-1622. [PMID: 32211757 DOI: 10.1093/cid/ciaa300] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/23/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-experienced clinicians are critical for positive outcomes along the HIV care continuum. However, access to HIV-experienced clinicians may be limited, particularly in nonmetropolitan areas, where HIV is increasing. We examined HIV clinician workforce capacity, focusing on HIV experience and urban-rural differences, in the Southern United States. METHODS We used Medicaid claims and clinician characteristics (Medicaid Analytic eXtract [MAX] and MAX Provider Characteristics, 2009-2011), county-level rurality (National Center for Health Statistics, 2013), and diagnosed HIV cases (AIDSVu, 2014) to assess HIV clinician capacity in 14 states. We assumed that clinicians accepting Medicaid approximated the region's HIV workforce, since three-quarters of clinicians accept Medicaid insurance. HIV-experienced clinicians were defined as those providing care to ≥ 10 Medicaid enrollees over 3 years. We assessed HIV workforce capacity with county-level clinician-to-population ratios, using Wilcoxon-Mann-Whitney tests to compare urban-rural differences. RESULTS We identified 5012 clinicians providing routine HIV management, of whom 28% were HIV-experienced. HIV-experienced clinicians were more likely to specialize in infectious diseases (48% vs 6%, P < .001) and practice in urban areas (96% vs 83%, P < .001) compared to non-HIV-experienced clinicians. The median clinician-to-population ratio for all HIV clinicians was 13.3 (interquartile range, 38.0), with no significant urban-rural differences. When considering HIV experience, 81% of counties had no HIV-experienced clinicians, and rural counties generally had fewer HIV-experienced clinicians per 1000 diagnosed HIV cases (P < .001). CONCLUSIONS Significant urban-rural disparities exist in HIV-experienced workforce capacity for communities in the Southern United States. Policies to improve equity in access to HIV-experienced clinical care for both urban and rural communities are urgently needed.
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Affiliation(s)
- Rose S Bono
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lauren E Yerkes
- Division of Population Health Data, Virginia Department of Health, Richmond, Virginia, USA.,Division of Disease Prevention, Virginia Department of Health, Richmond, Virginia, USA
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Faye Z Belgrave
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Daniel E Nixon
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Anne G Rhodes
- Division of Disease Prevention, Virginia Department of Health, Richmond, Virginia, USA
| | - April D Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
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21
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Budak JZ, Sears DA, Wood BR, Spach DH, Armstrong WS, Dhanireddy S, Teherani A, Schwartz BS. Human Immunodeficiency Virus Training Pathways in Residency: A National Survey of Curricula and Outcomes. Clin Infect Dis 2021; 72:1623-1626. [PMID: 32211781 DOI: 10.1093/cid/ciaa301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/18/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Ending the HIV Epidemic initiative, which aims to decrease the annual incidence of HIV infections in the United States (US) by 90% over the next decade, will require growth of a limited HIV provider workforce. Existing HIV training pathways within Family Medicine (FM) and Internal Medicine (IM) residency programs may address the shortage of HIV medical providers, but their curricula and outcomes have not previously been assessed. METHODS We identified HIV residency pathways via literature review, Internet search, and snowball sampling and designed a cross-sectional study of existing HIV pathways in the US. This survey of pathway directors included 33 quantitative items regarding pathway organization, curricular content, graduate outcomes, and challenges. We used descriptive statistics to summarize responses. RESULTS Twenty-five residency programs with dedicated HIV pathways in the US were identified (14 FM and 11 IM), with most located in the West and Northeast. All 25 (100%) pathway directors completed the survey. Since 2006, a total of 228 residents (77 FM and 151 IM) have graduated from these HIV pathways. Ninety (39%) of 228 pathway graduates provide primary care to persons with HIV (PWH). CONCLUSIONS HIV pathways are effective in graduating providers who can care for PWH, but generally are not located in nor do graduates practice in the geographic areas of highest need. Our findings can inform quality improvement for existing programs, development of new pathways, and workforce development strategies. Specifically, expanding pathways in regions of greatest need and incentivizing pathway graduates to work in these regions could augment the HIV workforce.
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Affiliation(s)
- Jehan Z Budak
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - David A Sears
- Division of Infectious Diseases, University of California, San Francisco, California, USA
| | - Brian R Wood
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA.,Mountain West AIDS Education and Training Center, Seattle, Washington, USA
| | - David H Spach
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Wendy S Armstrong
- Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Shireesha Dhanireddy
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Arianne Teherani
- Department of Medicine, University of California, San Francisco, California, USA
| | - Brian S Schwartz
- Division of Infectious Diseases, University of California, San Francisco, California, USA
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22
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Armstrong WS. The Human Immunodeficiency Virus Workforce in Crisis: An Urgent Need to Build the Foundation Required to End the Epidemic. Clin Infect Dis 2021; 72:1627-1630. [PMID: 32211784 DOI: 10.1093/cid/ciaa302] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/17/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Wendy S Armstrong
- Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
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23
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Koshy M, Mische L, Rizza S, Mahmood M, Bedimo R, Bhatia R, El Atrouni W, Curran J, Temesgen Z. Point-of-care program in HIV, tuberculosis, and associated conditions: A virtual global technical assistance platform to strengthen HIV and tuberculosis workforce capacity. J Clin Tuberc Other Mycobact Dis 2021; 23:100238. [PMID: 33997312 PMCID: PMC8102617 DOI: 10.1016/j.jctube.2021.100238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A global multi-disciplinary faculty was established to work collaboratively and provide virtual technical assistance, using a point-of-care continuing education model, to clinicians across the world engaged in the care of patients with either HIV infection or tuberculosis. Ancillary offerings included live or virtual lectures, case-based conferences, and courses. In spite of the considerable disruption of the program due to the COVID-19 pandemic, we engaged and assisted a substantial number of clinicians across the world and provided meaningful contributions to their continuous professional development and patient care. In light of the ongoing pandemic, virtual technical assistance models such as this should be scaled to continue essential high-quality HIV/TB services.
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Affiliation(s)
- Maria Koshy
- Internal Medicine, Bridgeport Hospital, Yale New Haven Health, CT, USA
| | | | - Stacey Rizza
- Mayo Clinic Center for Tuberculosis, Mayo Clinic HIV Program, Division of Infectious Diseases, Mayo Clinic, USA
| | - Maryam Mahmood
- Mayo Clinic Center for Tuberculosis, Mayo Clinic HIV Program, Division of Infectious Diseases, Mayo Clinic, USA
| | - Roger Bedimo
- VA North Texas Health Care System and University of Texas Southwestern Medical Center, USA
| | - Ramona Bhatia
- Department of Infectious Diseases, University of Illinois at Chicago, Chicago, IL, USA
| | - Wissam El Atrouni
- The University of Kansas School of Medicine, Division of Infectious Diseases, Kansas City, KS, USA
| | - Jennifer Curran
- Mayo Clinic School of Continuous Professional Development, USA
| | - Zelalem Temesgen
- Mayo Clinic Center for Tuberculosis, Mayo Clinic HIV Program, Division of Infectious Diseases, Mayo Clinic, USA
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24
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Weiser J, Dempsey A, Mandsager P, Shouse RL. Documenting Successes 30 Years After Passage of the Ryan White CARE Act: To the Editor. J Assoc Nurses AIDS Care 2021; 32:138-139. [PMID: 33427768 PMCID: PMC7914155 DOI: 10.1097/jnc.0000000000000224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- John Weiser
- Medical Epidemiologist, U.S., Department of Health and Human Services, Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia, USA
| | - Antigone Dempsey
- Director of Policy and Data, U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Rockville, Maryland, USA
| | - Paul Mandsager
- Health Scientist, U.S., Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Rockville, Maryland, USA
| | - R. Luke Shouse
- Medical Epidemiologist, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia, USA
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25
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Okeke NL, Schafer KR, Meissner EG, Ostermann J, Shah AD, Ostasiewski B, Phelps E, Kieler CA, Oladele E, Garg K, Naggie S, Bloomfield GS, Bosworth HB. Cardiovascular Disease Risk Management in Persons With HIV: Does Clinician Specialty Matter? Open Forum Infect Dis 2020; 7:ofaa361. [PMID: 32995348 PMCID: PMC7507875 DOI: 10.1093/ofid/ofaa361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/17/2020] [Indexed: 11/25/2022] Open
Abstract
Background The impact of clinician specialty on cardiovascular disease risk factor outcomes among persons with HIV (PWH) is unclear. Methods PWH receiving care at 3 Southeastern US academic HIV clinics between January 2014 and December 2016 were retrospectively stratified into 5 groups based on the specialty of the clinician managing their hypertension or hyperlipidemia. Patients were followed until first atherosclerotic cardiovascular disease event, death, or end of study. Outcomes of interest were meeting 8th Joint National Commission (JNC-8) blood pressure (BP) goals and National Lipid Association (NLA) non–high-density lipoprotein (HDL) goals for hypertension and hyperlipidemia, respectively. Point estimates for associated risk factors were generated using modified Poisson regression with robust error variance. Results Of 1667 PWH in the analysis, 965 had hypertension, 205 had hyperlipidemia, and 497 had both diagnoses. At study start, the median patient age was 52 years, 66% were Black, and 65% identified as male. Among persons with hypertension, 24% were managed by an infectious diseases (ID) clinician alone, and 5% were co-managed by an ID clinician and a primary care clinician (PCC). Persons managed by an ID clinician were less likely to meet JNC-8 hypertension targets at the end of observation than the rest of the cohort (relative risk [RR], 0.84; 95% CI, 0.75–0.95), but when mean study blood pressure was considered, there was no difference between persons managed by ID and the rest of the cohort (RR, 0.96; 95% CI, 0.88–1.05). There was no significant association between the ID clinician managing hyperlipidemia and meeting NLA non-HDL goals (RR, 0.89; 95% CI, 0.68–1.15). Conclusions Clinician specialty may play a role in suboptimal hypertension outcomes in persons with HIV.
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Affiliation(s)
- Nwora Lance Okeke
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Katherine R Schafer
- Division of Infectious Diseases, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Eric G Meissner
- Division of Infectious Diseases, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jan Ostermann
- Department of Health Services Policy and Management, University of South Carolina Arnold School of Public Health, Columbia, South Carolina, USA
| | - Ansal D Shah
- Division of Infectious Diseases, Prisma Health/University of South Carolina, Columbia, South Carolina, USA
| | - Brian Ostasiewski
- Center for Biomedical Informatics, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Evan Phelps
- Health Sciences South Carolina, Columbia, South Carolina, USA
| | - Curtis A Kieler
- Office of Academic Solutions and Information Systems, Duke University Medical Center, Durham, North Carolina, USA
| | - Eniola Oladele
- Office of Academic Solutions and Information Systems, Duke University Medical Center, Durham, North Carolina, USA
| | - Keva Garg
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Susanna Naggie
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Gerald S Bloomfield
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA.,Duke Global Health Institute, Durham, North Carolina, USA
| | - Hayden B Bosworth
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
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Abstract
PURPOSE OF REVIEW More than half of new HIV diagnoses occur in the Southern United States where the epidemic disproportionately affects persons of color. Although other areas of the country are seeing dramatic declines in the number of new cases, the progress in the South lags behind. This review will examine the reasons for that disparity. Many are unique to the South. RECENT FINDINGS Despite advances in antiretroviral therapy for HIV, many in the South are not benefiting from these medications, at either a personal or public health level. The reasons are complex and include lack of access to healthcare, lower levels of funding than other areas of the country, stigma, structural racism, increased barriers due to social determinants of health, coexisting mental health disorders, substance use disorders and sexually transmitted diseases and insufficient workforce capacity to meet the needs of those living with HIV. SUMMARY These findings should underline the need for investment in the South for a holistic healthcare approach to persons living with HIV including supporting basic needs such as access to food, transportation and housing. Prioritization among politicians for policy and systems changes and approaches to decrease stigma and enhance education about HIV will be key.
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Development and Validation of HIV-ASSIST, an Online, Educational, Clinical Decision Support Tool to Guide Patient-Centered ARV Regimen Selection. J Acquir Immune Defic Syndr 2020; 82:188-194. [PMID: 31513553 DOI: 10.1097/qai.0000000000002118] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Multiple antiretroviral (ARV) regimens are effective at achieving HIV viral suppression, but differ in pill burden, side effects, barriers to resistance, and impact on comorbidities. Current guidelines advocate for an individualized approach to ARV regimen selection, but synthesizing these modifying factors is complex and time-consuming. METHODS We describe the development of HIV-ASSIST (https://www.hivassist.com), a free, online decision support tool for ARV selection and HIV education. HIV-ASSIST ranks potential ARV options for any given patient scenario using a composite objective of achieving viral suppression while maximizing tolerability and adherence. We used a multiple-criteria decision analysis framework to construct mathematical algorithms and synthesize various patient-specific (eg, comorbidities and treatment history) and virus-specific (eg, HIV mutations) attributes. We then conducted a validation study to evaluate HIV-ASSIST with prescribing practices of experienced HIV providers at 4 large academic centers. We report on concordance of provider ARV selections with the 5 top-ranked HIV-ASSIST regimens for 10 diverse hypothetical patient-case scenarios. RESULTS In the validation cohort of 17 experienced HIV providers, we found 99% concordance between HIV-ASSIST recommendations and provider ARV selections for 4 case-scenarios of ARV-naive patients. Among 6 cases of ARV-experienced patients (3 with and 3 without viremia), there was 84% and 88% concordance, respectively. Among 3 cases of ARV-experienced patients with viremia, providers reported 20 different ARV selections, suggesting substantial heterogeneity in ARV preferences in clinical practice. CONCLUSIONS HIV-ASSIST is a novel patient-centric educational decision support tool that provides ARV recommendations concordant with experienced HIV providers for a diverse set of patient scenarios.
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Steward WT, Koester KA, Guzé MA, Kirby VB, Fuller SM, Moran ME, Botta EW, Gaffney S, Heath CD, Bromer S, Shade SB. Practice transformations to optimize the delivery of HIV primary care in community healthcare settings in the United States: A program implementation study. PLoS Med 2020; 17:e1003079. [PMID: 32214312 PMCID: PMC7098549 DOI: 10.1371/journal.pmed.1003079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 02/20/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The United States HIV care workforce is shrinking, which could complicate service delivery to people living with HIV (PLWH). In this study, we examined the impact of practice transformations, defined as efficiencies in structures and delivery of care, on demonstration project sites within the Workforce Capacity Building Initiative, a Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program Special Projects of National Significance (SPNS). METHODS AND FINDINGS Data were collected at 14 demonstration project sites in 7 states and the District of Columbia. Organizational assessments were completed at sites once before and 4 times after implementation. They captured 3 transformation approaches: maximizing the HIV care workforce (efforts to increase the number of existing healthcare workforce members involved in the care of PLWH), share-the-care (team-based care giving more responsibility to midlevel providers and staff), and enhancing client engagement in primary HIV care to reduce emergency and inpatient care (e.g., care coordination). We also obtained Ryan White HIV/AIDS Program Services Reports (RSRs) from sites for calendar years (CYs) 2014-2016, corresponding to before, during, and after transformation. The RSR include data on client retention in HIV care, prescription of antiretroviral therapy (ART), and viral suppression. We used generalized estimating equation (GEE) models to analyze changes among sites implementing each practice transformation approach. The demonstration projects had a mean of 18.5 prescribing providers (SD = 23.5). They reported data on more than 13,500 clients per year (mean = 969/site, SD = 1,351). Demographic characteristics remained similar over time. In 2014, a majority of clients were male (71% versus 28% female and 0.2% transgender), with a mean age of 47 (interquartile range [IQR] 37-54). Racial/ethnic characteristics (48% African American, 31% Hispanic/Latino, 14% white) and HIV risk varied (31% men who have sex with men; 31% heterosexual men and women; 7% injection drug use). A substantial minority was on Medicaid (41%). Across sites, there was significant uptake in practices consistent with maximizing the HIV care workforce (18% increase, p < 0.001), share-the-care (25% increase, p < 0.001), and facilitating patient engagement in HIV primary care (13% increase, p < 0.001). There were also significant improvements over time in retention in HIV care (adjusted odds ratio [aOR] = 1.03; 95% confidence interval [CI] 1.02-1.04; p < 0.001), ART prescription levels (aOR = 1.01; 95% CI 1.00-1.01; p < 0.001), and viral suppression (aOR = 1.03; 95% CI 1.02-1.04; p < 0.001). All outcomes improved at sites that implemented transformations to maximize the HIV care workforce or improve client engagement. At sites that implemented share-the-care practices, only retention in care and viral suppression outcomes improved. Study limitations included use of demonstration project sites funded by the Ryan White HIV/AIDS Program (RWHAP), which tend to have better HIV outcomes than other US clinics; varying practice transformation designs; lack of a true control condition; and a potential Hawthorne effect because site teams were aware of the evaluation. CONCLUSIONS In this study, we found that practice transformations are a potential strategy for addressing anticipated workforce challenges among those providing care to PLWH. They hold the promise of optimizing the use of personnel and ensuring the delivery of care to all in need while potentially enhancing HIV care continuum outcomes.
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Affiliation(s)
- Wayne T. Steward
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America
- * E-mail:
| | - Kimberly A. Koester
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America
| | - Mary A. Guzé
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America
| | - Valerie B. Kirby
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America
| | - Shannon M. Fuller
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America
| | - Mary E. Moran
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America
| | - Emma Wilde Botta
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America
| | - Stuart Gaffney
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America
| | - Corliss D. Heath
- U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), HIV/AIDS Bureau, Rockville, Maryland, United States of America
| | - Steven Bromer
- Department of Family and Community Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America
| | - Starley B. Shade
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America
- Institute for Global Health Sciences, University of California San Francisco (UCSF), San Francisco, California, United States of America
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Gamble-George JC, Longenecker CT, Webel AR, Au DH, Brown AF, Bosworth H, Crothers K, Cunningham WE, Fiscella KA, Hamilton AB, Helfrich CD, Ladapo JA, Luque A, Tobin JN, Wyatt GE. ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (the PRECluDE consortium): Combatting chronic disease comorbidities in HIV populations through implementation research. Prog Cardiovasc Dis 2020; 63:79-91. [PMID: 32199901 PMCID: PMC7237329 DOI: 10.1016/j.pcad.2020.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 02/08/2023]
Abstract
Antiretroviral therapy (ART) prevented premature mortality and improved the quality of life among people living with the human immunodeficiency virus (PLWH), such that now more than half of PLWH in the United States are 50 years of age and older. Increased longevity among PLWH has resulted in a significant rise in chronic, comorbid diseases. However, the implementation of guideline-based interventions for preventing, treating, and managing such age-related, chronic conditions among the HIV population is lacking. The PRECluDE consortium supported by the Center for Translation Research and Implementation Science at the National Heart, Lung, and Blood Institute catalyzes implementation research on proven-effective interventions for co-occurring heart, lung, blood, and sleep diseases and conditions among PLWH. These collaborative research studies use novel implementation frameworks with HIV, mental health, cardiovascular, and pulmonary care to advance comprehensive HIV and chronic disease healthcare in a variety of settings and among diverse populations.
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Affiliation(s)
- Joyonna Carrie Gamble-George
- Health Scientist Administrator and AAAS Science and Technology Policy Fellow, Implementation Science Branch (ISB), Center for Translation Research and Implementation Science (CTRIS), National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), U.S. Department of Health and Human Services, Bethesda, MD 20892, United States of America; Office of Science Policy (OSP), Office of the Director (OD), National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD 20892, United States of America.
| | - Christopher T Longenecker
- Department of Medicine, Case Western Reserve University School of Medicine, University Hospitals Harrington Heart and Vascular Institute, Cleveland, OH 44106, United States of America
| | - Allison R Webel
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106, United States of America
| | - David H Au
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle, WA 98195, United States of America; Seattle-Denver Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, United States of America
| | - Arleen F Brown
- Department of Medicine, Division of General Internal Medicine and Health Services Research (GIM and HSR), David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, United States of America; GIM and HSR, Olive View-UCLA Medical Center Sylmar, Los Angeles, CA 90095, United States of America; Community Engagement and Research Program, UCLA Clinical and Translational Science Institute, Los Angeles, CA 90095, United States of America
| | - Hayden Bosworth
- Department of Medicine, Duke University School of Medicine, Durham, NC 27701, United States of America; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27701, United States of America; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC 27701, United States of America
| | - Kristina Crothers
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle, WA 98195, United States of America; Pulmonary and Critical Care Section, VA Puget Sound Health Care System, Seattle, WA 98108, United States of America
| | - William E Cunningham
- Department of Medicine, GIM and HSR, David Geffen School of Medicine, UCLA, Los Angeles, CA 90095, United States of America; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA 90095, United States of America
| | - Kevin A Fiscella
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY 14620, United States of America; Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY 14620, United States of America; Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, NY 14620, United States of America; Center for Communication and Disparities Research, University of Rochester Medical Center, Rochester, NY 14620, United States of America; Greater Rochester Practice-Based Research Network, Clinical and Translational Science Institute (CTSI), University of Rochester Medical Center, Rochester, NY 14642, United States of America
| | - Alison B Hamilton
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095, United States of America; VA Health Services Research and Development (HSR&D) Service, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, North Hills, CA 91343, United States of America
| | - Christian D Helfrich
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA 98101, United States of America; Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Administration (VA) Puget Sound Health Care System, Seattle, WA 98108, United States of America
| | - Joseph A Ladapo
- Department of Medicine, GIM and HSR, David Geffen School of Medicine, UCLA, Los Angeles, CA 90095, United States of America; Department of Population Health, New York University (NYU) Grossman School of Medicine, New York, NY 10016, United States of America
| | - Amneris Luque
- HIV Clinical Services, Parkland Health and Hospital System, Dallas, TX 75235, United States of America; Department of Internal Medicine, University of Texas (UT) Southwestern Medical Center, Dallas, TX 75390, United States of America
| | - Jonathan N Tobin
- Clinical Directors Network, Inc. (CDN), New York, NY 10018; Community-Engaged Research, The Rockefeller University Center for Clinical and Translational Science, New York, NY 10065, United States of America
| | - Gail E Wyatt
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095, United States of America; Sexual Health Programs, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095, United States of America; The Center for Culture, Trauma, and Mental Health Disparities, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90024, United States of America; University of Cape Town, Rondebosch, Cape Town 7701, South Africa
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30
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Okeke NL, Webel AR, Bosworth HB, Aifah A, Bloomfield GS, Choi EW, Gonzales S, Hale S, Hileman CO, Lopez-Kidwell V, Muiruri C, Oakes M, Schexnayder J, Smith V, Vedanthan R, Longenecker CT. Rationale and design of a nurse-led intervention to extend the HIV treatment cascade for cardiovascular disease prevention trial (EXTRA-CVD). Am Heart J 2019; 216:91-101. [PMID: 31419622 DOI: 10.1016/j.ahj.2019.07.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/10/2019] [Indexed: 11/27/2022]
Abstract
Persons living with human immunodeficiency virus (PLHIV) are at increased risk of atherosclerotic cardiovascular disease (ASCVD). In spite of this, uptake of evidence-based clinical interventions for ASCVD risk reduction in the HIV clinic setting is sub-optimal. METHODS: EXTRA-CVD is a 12-month randomized clinical effectiveness trial that will assess the efficacy of a multi-component nurse-led intervention in reducing ASCVD risk among PLHIV. Three hundred high ASCVD risk PLHIV across three sites will be randomized 1:1 to usual care with generic prevention education or the study intervention. The study intervention will consist of four evidence-based components: (1) nurse-led care coordination, (2) nurse-managed medication protocols and adherence support (3) home BP monitoring, and (4) electronic health records support tools. The primary outcome will be change in systolic blood pressure and secondary outcome will be change in non-HDL cholesterol over the course of the intervention. Tertiary outcomes will include change in the proportion of participants in the following extended cascade categories: (1) appropriately diagnosed with hypertension and hyperlipidemia (2) appropriately managed; (3) at treatment goal (systolic blood pressure <130 mm Hg and non-HDL cholesterol < National Lipid Association targets). CONCLUSIONS: The EXTRA-CVD trial will provide evidence appraising the potential impact of nurse-led interventions in reducing ASCVD risk among PLHIV, an essential extension of the HIV care continuum beyond HIV viral suppression.
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Graciaa DS, Machaidze M, Kipiani M, Buziashvili M, Barbakadze K, Avaliani Z, Kempker RR. A survey of the tuberculosis physician workforce in the country of Georgia. Int J Tuberc Lung Dis 2019; 22:1286-1292. [PMID: 30355407 DOI: 10.5588/ijtld.18.0085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING A well-trained and sufficient tuberculosis (TB) workforce is essential for disease control, especially in an era of newly implemented diagnostics and medications. However, there are few reports on the status of the TB workforce in many endemic countries. OBJECTIVE To evaluate the demographics, salary, career satisfaction, and attitudes towards the field of TB among the physician TB workforce in the country of Georgia. DESIGN A cross-sectional study of physicians in the current Georgian National TB Programme (NTP) using an anonymous 31-item questionnaire. RESULTS Among 184 NTP physicians countrywide, 142 (77%) were contacted and 138 (75%) completed questionnaires. The median age was 56 years (interquartile range 50-64); most (81%) were female. The monthly salary from TB work was USD205 for 50% of respondents. Nearly half (47%) received an additional salary from another source. Many physicians (65%) indicated that they were satisfied with their work, but over half (55%) were unsatisfied with reimbursement. While most physicians (78%) were concerned about the lack of interest in TB, only 36% would recommend a career in TB care. CONCLUSION While the current TB workforce in Georgia finds their work fulfilling, an ageing workforce, low salaries and perceived lack of interest in the field are a matter of concern for future TB control.
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Affiliation(s)
- D S Graciaa
- Department of Medicine and Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - M Machaidze
- Division of Infectious Diseases, New York University School of Medicine, New York, New York, USA
| | - M Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - M Buziashvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - K Barbakadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - R R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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32
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Erlandson KM, Karris MY. HIV and Aging: Reconsidering the Approach to Management of Comorbidities. Infect Dis Clin North Am 2019; 33:769-786. [PMID: 31395144 PMCID: PMC6690376 DOI: 10.1016/j.idc.2019.04.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Health care for older adults with human immunodeficiency virus can be highly complex, resource intensive, and carry a high administrative burden. Data from aging longitudinal cohorts and feedback from the human immunodeficiency virus community suggest that the current model is not meeting the needs of these older adults. We introduce the 6 Ms approach, which acknowledges the multicomplexity of older adults with human immunodeficiency virus, simplifies geriatric principles for non-geriatrics-trained providers, and minimizes extensive training and specialized screening tests or tools. Implementing novel approaches to care requires support at local/national levels.
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Affiliation(s)
- Kristine M Erlandson
- University of Colorado, Anschutz Medical Campus, 12700 East 19th Avenue, Mail Stop B168, Aurora, CO 80045, USA.
| | - Maile Y Karris
- University of California San Diego, 200 West Arbor Drive #8208, San Diego, CA 92103-8208, USA
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Abstract
OBJECTIVE To estimate the prevalence of generalized anxiety disorder (GAD) symptoms among adults with diagnosed HIV (PWH) in the United States in order to inform effective HIV prevention and care efforts. DESIGN The Medical Monitoring Project (MMP) is a complex sample survey of adults with diagnosed HIV in the United States. METHODS We used MMP data collected during June 2015 to May 2016 to calculate the weighted prevalence of GAD symptoms among PWH (N = 3654) and prevalence ratios with predicted marginal means to evaluate significant differences between groups. RESULTS The estimated prevalence of GAD symptoms among PWH was 19%. GAD symptoms were associated with significantly lower antiretroviral therapy prescription and adherence, medical HIV care engagement, and sustained viral suppression. Persons with GAD symptoms were over three times as likely to have an unmet need for mental health services (23 vs. 7%) and had significantly more emergency room visits and hospitalizations than those without these symptoms. GAD symptoms were associated with significantly higher prevalence of condomless sex while not sustainably virally suppressed with a person not known to be taking preexposure prophylaxis (9 vs. 6%). CONCLUSION GAD symptom prevalence among PWH was considerably higher than among the US general adult population, indicating an excess burden of anxiety among PWH. Outcomes along the HIV care continuum were poorer, and risk for HIV transmission was higher, among persons with symptoms. Incorporating routine screening for GAD in HIV clinical settings may help improve health outcomes, reduce HIV transmission, and save healthcare costs.
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34
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Weiser J, Chen G, Beer L, Boccher-Lattimore D, Armstrong W, Kurth A, Shouse RL. Sustaining the HIV care provider workforce: Medical Monitoring Project HIV Provider Survey, 2013-2014. Health Serv Res 2019; 54:1065-1074. [PMID: 31264205 DOI: 10.1111/1475-6773.13192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To describe delivery of recommended HIV care and work satisfaction among infectious disease (ID) physicians, non-ID physicians, nurse practitioners (NPs), and physician assistants (PAs). DATA SOURCES Medical Monitoring Project 2013-2014 HIV Provider Survey. STUDY DESIGN Population-based complex sample survey. DATA COLLECTION/ANALYSIS METHODS We surveyed 2208 HIV care providers at 505 US HIV care facilities and computed weighted percentages of provider characteristics, stratified by provider type. Rao-Scott chi-square tests and logistic regression used to compare characteristics of ID physicians with each other provider type. PRINCIPAL FINDINGS The adjusted provider response rate was 64 percent. Among US HIV care providers, 45 percent were ID physicians, 35 percent non-ID physicians, 15 percent NPs, and 5 percent PAs. Satisfaction with administrative burden was lowest among non-ID physicians (27 percent). Compared with ID physicians, satisfaction with remuneration was lower among non-ID physicians and higher among NPs (37, 28, and 51 percent, respectively). NPs were more likely than ID physicians to report performing four of six services that are key to providing comprehensive HIV care, but more NPs planned to leave clinical practice within 5 years (19 vs 7 percent). CONCLUSION Addressing physician dissatisfaction with remuneration and administrative burden could help prevent a provider shortage. Strengthening the role of NPs may help sustain a high-quality workforce.
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Affiliation(s)
- John Weiser
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Linda Beer
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Wendy Armstrong
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Ann Kurth
- Yale School of Nursing, Yale University, Orange, Connecticut
| | - R Luke Shouse
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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Hackett S, Badell ML, Meade CM, Davis JM, Blue J, Curtin L, Camacho-Gonzalez A, Chahroudi A, Chakraborty R, Nguyen MLT, Palmore MP, Sheth AN. Improved Perinatal and Postpartum Human Immunodeficiency Virus Outcomes After Use of a Perinatal Care Coordination Team. Open Forum Infect Dis 2019; 6:ofz183. [PMID: 31198816 PMCID: PMC6545466 DOI: 10.1093/ofid/ofz183] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/08/2019] [Indexed: 11/14/2022] Open
Abstract
In a high-volume clinic in the Southeastern United States, pregnant women living with human immunodeficiency virus (HIV) had improved HIV outcomes up to 6 months after delivery following the introduction of a multidisciplinary perinatal care coordination team.
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Affiliation(s)
| | - Martina L Badell
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia.,Department of Gynecology and Obstetrics, Division of Maternal-Fetal Medicine, Atlanta, Georgia
| | | | | | - Jeronia Blue
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia
| | - Lisa Curtin
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia
| | - Andres Camacho-Gonzalez
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia.,Department of Pediatrics, Division of Infectious Diseases, Atlanta, Georgia
| | - Ann Chahroudi
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia.,Department of Pediatrics, Division of Infectious Diseases, Atlanta, Georgia
| | - Rana Chakraborty
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia.,Department of Pediatrics, Division of Infectious Diseases, Atlanta, Georgia
| | - Minh Ly T Nguyen
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia.,Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia
| | - Melody P Palmore
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia.,Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia
| | - Anandi N Sheth
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia.,Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia
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Valenti S, Johnson L, Szpunar S, Hilu R, Saravolatz L. Training Internal Medicine Residents to Provide Care and Treatment for Human Immunodeficiency Virus-1-Infected Patients. Open Forum Infect Dis 2019; 6:ofz093. [PMID: 30949537 PMCID: PMC6441781 DOI: 10.1093/ofid/ofz093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 02/21/2019] [Indexed: 11/13/2022] Open
Abstract
Background Human immunodeficiency virus (HIV) infection is now considered a chronic infection manageable on antiretroviral therapy. If trained in HIV care, primary care physicians would be well suited to work in consultation with infectious disease specialists to provide care for HIV patients. Methods Human immunodeficiency virus training was incorporated into our internal medicine residency program. All residents were given an internally developed preprogram survey about HIV infection to establish a baseline level of HIV knowledge; at the end of 1 year, a postprogram survey was distributed. These results were compared. Human immunodeficiency virus didactic lectures were mandatory for attendance. Human immunodeficiency virus training included methods of testing, treatment including all classes of antiretroviral therapy, and prevention methods. Additional, mandatory online training modules were used. All program year-2 residents were assigned to an outpatient HIV clinical rotation. Results Eighty-three residents participated. Residents received either 1 or 2 years of training. Results of preprogram scores and postprogram scores were calculated for each resident. Year 1-test scores preprogram were 52.2% vs postprogram 87.1%; year 2-test scores preprogram were 56.3% vs postprogram 89.8% (both P < .0001). There was no difference in posttest scores among residents who attended a clinical rotation. Conclusions Residents showed significant improvement in HIV knowledge between preprogram and postprogram test scores. Postgraduate surveys showed among those who completed the survey, and most found the program helpful to in their current practice.
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Affiliation(s)
- Sharon Valenti
- Department of Internal Medicine, Ascension St. John Hospital, Detroit, Michigan
| | - Leonard Johnson
- Department of Internal Medicine, Ascension St. John Hospital, Detroit, Michigan.,Department of Internal Medicine, Division of Infectious Diseases, Ascension St. John Hospital, Detroit, Michigan.,Wayne State University School of Medicine, Detroit, Michigan
| | - Susan Szpunar
- Department of Internal Medicine, Ascension St. John Hospital, Detroit, Michigan.,Department of Medical Education, Epidemiology, Biostatistics, Ascension St. John Hospital, Detroit, Michigan
| | - Raymond Hilu
- Department of Internal Medicine, Ascension St. John Hospital, Detroit, Michigan.,Wayne State University School of Medicine, Detroit, Michigan
| | - Louis Saravolatz
- Department of Internal Medicine, Ascension St. John Hospital, Detroit, Michigan.,Wayne State University School of Medicine, Detroit, Michigan
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Byrd KK, Hardnett F, Clay PG, Delpino A, Hazen R, Shankle MD, Camp NM, Suzuki S, Weidle PJ, Aguirre M, Akinbosoye O, Bamberger DM, Bluml B, Bullock K, Burrell DC, Bush T, Bush C, Cadwell C, Cardarelli R, Clark T, Crim A, Cure A, Darin K, Dean T, DeMayo M, Elrod S, Eschmann AL, Farmer D, Farnan R, Free H, Gudzelak A, Halbur A, Hardnett F, Hazen R, Hilker H, Hou J, Hujdich B, Johnson L, Kirkham H, Lecounte J, Lio S, Lo G, Middleton S, Mills B, Nguyen CM, Ortiz L, Pietrandoni G, Scarsi K, Schommer J, Shrestha R, Smith D, Taitel MS, Teferi GN, Tomer V, Terres L, Whitfield C, Willman JE. Retention in HIV Care Among Participants in the Patient-Centered HIV Care Model: A Collaboration Between Community-Based Pharmacists and Primary Medical Providers. AIDS Patient Care STDS 2019; 33:58-66. [PMID: 30648888 DOI: 10.1089/apc.2018.0216] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Poor retention in HIV care is associated with higher morbidity and mortality and greater risk of HIV transmission. The Patient-Centered HIV Care Model (PCHCM) integrated community-based pharmacists with medical providers. The model required sharing of patient clinical information and collaborative therapy-related action planning. The proportion of persons retained in care (≥1 medical visit in each 6-month period of a 12-month measurement period with ≥60 days between visits), pre- and post-PCHCM implementation, was modeled using log binomial regression. Factors associated with post-implementation retention were determined using multi-variable regression. Of 765 enrolled persons, the plurality were male (n = 555) and non-Hispanic black (n = 331), with a median age of 48 years (interquartile range = 38-55); 680 and 625 persons were included in the pre- and post-implementation analyses, respectively. Overall, retention improved 12.9% (60.7-68.5%, p = 0.002). The largest improvement was seen among non-Hispanic black persons, 22.6% increase (59.7-73.2%, p < 0.001). Persons who were non-Hispanic black [adjusted risk ratio (ARR) 1.27, 95% confidence interval (CI) 1.08-1.48] received one or more pharmacist-clinic developed action plan (ARR 1.51, 95% CI 1.18-1.93), had three or more pharmacist encounters (ARR 1.17, 95% CI 1.05-1.30), were more likely to be retained post-implementation. In the final multi-variable models, only race/ethnicity [non-Hispanic black (ARR 1.27, 95% CI 1.09-1.48) and "other or unknown" race/ethnicity (ARR 1.36, 95% CI 1.14-1.63)] showed an association with post-implementation retention. PCHCM demonstrated how collaborations between community-based pharmacists and primary medical providers can improve retention in HIV care. This care model may be particularly useful for non-Hispanic black persons who often are less likely to be retained in care.
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Affiliation(s)
- Kathy K. Byrd
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Felicia Hardnett
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Patrick G. Clay
- University of North Texas Health Science System College of Pharmacy, Fort Worth, Texas
| | | | | | | | | | - Sumihiro Suzuki
- Department of Biostatistics and Epidemiology, University of North Texas Health Science Center, Fort Worth, Texas
| | - Paul J. Weidle
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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Budak JZ, Volkman K, Wood BR, Dhanireddy S. Building HIV Workforce Capacity Through a Residency Pathway: Outcomes and Challenges. Open Forum Infect Dis 2018; 5:ofy317. [PMID: 30591922 PMCID: PMC6301186 DOI: 10.1093/ofid/ofy317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 11/19/2018] [Indexed: 12/03/2022] Open
Abstract
To help address the impending HIV physician shortage, we launched an HIV Medicine Pathway within our Internal Medicine Residency in 2008. Between 2015 and 2017, surveys showed a decrease in the number of graduates providing primary care for people living with HIV. We suggest evaluation of long-term outcomes from similar training programs and stronger support for HIV primary care career development.
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Affiliation(s)
- Jehan Z Budak
- Division of Infectious Diseases, University of California, San Francisco, California
| | - Kathleen Volkman
- Department of Medicine, University of Washington, Seattle, Washington
| | - Brian R Wood
- Department of Medicine, University of Washington, Seattle, Washington.,Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington.,Mountain West AIDS Education and Training Center, Seattle, Washington
| | - Shireesha Dhanireddy
- Department of Medicine, University of Washington, Seattle, Washington.,Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington
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Olea A, Grochowski J, Luetkemeyer AF, Robb V, Saberi P. Role of a clinical pharmacist as part of a multidisciplinary care team in the treatment of HCV in patients living with HIV/HCV coinfection. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2018; 7:105-111. [PMID: 30214893 PMCID: PMC6118274 DOI: 10.2147/iprp.s169282] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background The objective of the study was to evaluate the role of a clinical pharmacist in hepatitis C virus (HCV) treatment of patients living with HIV/HCV coinfection. Methods We conducted a descriptive study to quantify the functions of a clinical pharmacist in HCV treatment of patients living with HIV/HCV coinfection who were initiating HCV treatment at a publicly funded clinic between March 18, 2015 and September 15, 2016. The clinical pharmacist’s role was categorized into eight categories: 1) HCV prior authorization (PA) completion; 2) HCV medication adherence counseling; 3) HCV drug-drug interaction (DDI) counseling and screening; 4) HCV medication counseling regarding common adverse events (AEs); 5) HCV counseling regarding HCV treatment outcomes and risk of reinfection; 6) ordering laboratory tests and interpretation of HCV laboratory values; 7) HIV medication AE assessment; and 8) other (including refilling medications and management of other comorbidities). Results One hundred and thirty-five patients initiated treatment during this timeframe: 77.0% were males, 56.3% non-cirrhotic, 77.0% HCV treatment-naïve, 45.9% HCV genotype 1a, and 83.0% initiated on ledipasvir/sofosbuvir. The clinical pharmacist completed 150 PAs, counseled on HCV medication adherence in 79.2% of patients, conducted HCV DDI counseling and screening in 54.2%, and monitored HCV medication AEs in 54.2%. The clinical pharmacist counseled patients on HCV treatment outcomes and risk of reinfection in 53.1%, ordered laboratory tests in 44.8%, and reported and interpreted laboratory values in 44.8%. The clinical pharmacist assessed HIV medication AEs in 54.2% of patients and participated in other activities in 42.7%. Conclusion A clinical pharmacist’s expertise as part of a multidisciplinary care team facilitates optimal treatment outcomes and provides critical support in the management of DAA therapy in individuals living with HIV/HCV coinfection.
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Affiliation(s)
- Antonio Olea
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General, San Francisco, CA, USA,
| | - Janet Grochowski
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General, San Francisco, CA, USA,
| | - Anne F Luetkemeyer
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General, San Francisco, CA, USA,
| | - Valerie Robb
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General, San Francisco, CA, USA,
| | - Parya Saberi
- Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Colasanti J, Sumitani J, Mehta CC, Zhang Y, Nguyen ML, Del Rio C, Armstrong WS. Implementation of a Rapid Entry Program Decreases Time to Viral Suppression Among Vulnerable Persons Living With HIV in the Southern United States. Open Forum Infect Dis 2018; 5:ofy104. [PMID: 29992172 PMCID: PMC6022569 DOI: 10.1093/ofid/ofy104] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/20/2018] [Indexed: 11/13/2022] Open
Abstract
Background Rapid entry programs (REPs) improve time to antiretroviral therapy (ART) initiation (TAI) and time to viral suppression (TVS). We assessed the feasibility and effectiveness of a REP in a large HIV clinic in Atlanta, Georgia, serving a predominately un- or underinsured population. Methods The Rapid Entry and ART in Clinic for HIV (REACH) program was implemented on May 16, 2016. We performed a retrospective cohort study with the main independent variable being period of enrollment: January 1, 2016, through May 15, 2016 (pre-REACH); May 16, 2016, through July 31, 2016 (post-REACH). Included individuals were HIV-infected and new to the clinic with detectable HIV-1 RNA. Six-month follow-up data were collected for each participant. Survival analyses were conducted for TVS. Logistic and linear regression analyses were used to evaluate secondary outcomes: attendance at first clinic visit, viral suppression, TAI, and time to first attended provider visit. Results There were 117 pre-REACH and 90 post-REACH individuals. Median age (interquartile range [IQR]) was 35 (25-45) years, 80% were male, 91% black, 60% men who have sex with men, 57% uninsured, and 44% active substance users. TVS decreased from 77 (62-96) to 57 (41-70) days (P < .0022). Time to first attended provider visit decreased from 17 to 5 days, and TAI from 21 to 7 days (P < .0001), each remaining significant in adjusted models. Conclusions This is the largest rapid entry cohort described in the United States and suggests that rapid entry is feasible and could have a positive impact on HIV transmission at the population level.
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Affiliation(s)
- Jonathan Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Emory Center for AIDS Research, Atlanta, Georgia.,Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jeri Sumitani
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Yiran Zhang
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia
| | - Minh Ly Nguyen
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Emory Center for AIDS Research, Atlanta, Georgia.,Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Emory Center for AIDS Research, Atlanta, Georgia.,Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Wendy S Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Emory Center for AIDS Research, Atlanta, Georgia.,Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Wood BR, Bell C, Carr J, Aleshire R, Behrens CB, Dunaway SB, Shah JA, Barnabas RV, Green ML, Ramers CB, Fina PL, Kim HN, Harrington RD. Washington state satellite HIV clinic program: a model for delivering highly effective decentralized care in under-resourced communities. AIDS Care 2018; 30:1120-1127. [PMID: 29852744 DOI: 10.1080/09540121.2018.1481194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
To improve access to high-quality HIV care in underserved regions of Western Washington (WA) State, we collaborated with the WA State Department of Health (DOH) and community partners to launch four satellite HIV clinics. Here, we describe this innovative clinical care model, present an estimate of costs, and evaluate patient care outcomes, including virologic suppression rates. To accomplish this, we assessed virologic suppression rates 12 months before and 12 months after the satellite clinics opened, comparing people living with HIV (PLWH) who enrolled in the satellite clinics versus all PLWH in the same regions who did not. We also determined virologic suppression rates in 2015 comparing satellite clinic versus non-satellite clinic patients and compared care quality indicators between the satellite clinics and the parent academic clinic. Results demonstrate that the change in virologic suppression rate 12 months before to 12 months after the satellite clinics opened was higher for patients who enrolled in the satellite clinics compared to all those in the same region who did not (18% versus 6%, p < 0.001). Virologic suppression in 2015 was significantly higher for satellite clinic than non-satellite clinic patients at three of four sites. Care quality indicators were met at a high level at the satellite clinics, comparable to the parent academic clinic. Overall, through community partnerships and WA DOH support, the satellite clinic program increased access to best practice HIV care and improved virologic suppression rates in difficult-to-reach areas. This model could be expanded to other regions with inadequate access to HIV practitioners, though financial support is necessary.
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Affiliation(s)
- Brian R Wood
- a Division of Allergy and Infectious Diseases , University of Washington , Seattle , WA , USA.,b Madison Clinic at Harborview Medical Center , Seattle , WA , USA
| | - Christopher Bell
- b Madison Clinic at Harborview Medical Center , Seattle , WA , USA
| | - Jason Carr
- c Infectious Disease Assessment Unit , Washington State Department of Health , Olympia , WA , USA
| | - Richard Aleshire
- c Infectious Disease Assessment Unit , Washington State Department of Health , Olympia , WA , USA
| | - Christopher B Behrens
- a Division of Allergy and Infectious Diseases , University of Washington , Seattle , WA , USA.,b Madison Clinic at Harborview Medical Center , Seattle , WA , USA
| | - Shelia B Dunaway
- a Division of Allergy and Infectious Diseases , University of Washington , Seattle , WA , USA.,b Madison Clinic at Harborview Medical Center , Seattle , WA , USA
| | - Javeed A Shah
- a Division of Allergy and Infectious Diseases , University of Washington , Seattle , WA , USA.,b Madison Clinic at Harborview Medical Center , Seattle , WA , USA
| | - Ruanne V Barnabas
- a Division of Allergy and Infectious Diseases , University of Washington , Seattle , WA , USA.,b Madison Clinic at Harborview Medical Center , Seattle , WA , USA
| | - Margaret L Green
- a Division of Allergy and Infectious Diseases , University of Washington , Seattle , WA , USA.,b Madison Clinic at Harborview Medical Center , Seattle , WA , USA
| | - Christian B Ramers
- a Division of Allergy and Infectious Diseases , University of Washington , Seattle , WA , USA.,b Madison Clinic at Harborview Medical Center , Seattle , WA , USA
| | - Pegi L Fina
- b Madison Clinic at Harborview Medical Center , Seattle , WA , USA
| | - H Nina Kim
- a Division of Allergy and Infectious Diseases , University of Washington , Seattle , WA , USA.,b Madison Clinic at Harborview Medical Center , Seattle , WA , USA
| | - Robert D Harrington
- a Division of Allergy and Infectious Diseases , University of Washington , Seattle , WA , USA.,b Madison Clinic at Harborview Medical Center , Seattle , WA , USA
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Patel RR, Chan PA, Harrison LC, Mayer KH, Nunn A, Mena LA, Powderly WG. Missed Opportunities to Prescribe HIV Pre-Exposure Prophylaxis by Primary Care Providers in Saint Louis, Missouri. LGBT Health 2018; 5:250-256. [PMID: 29688800 DOI: 10.1089/lgbt.2017.0101] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE Optimal HIV pre-exposure prophylaxis (PrEP) scale-up in the United States requires prescribing by primary care providers (PCPs). We assessed barriers to patients obtaining PrEP from their PCPs. METHODS Patients seeking PrEP at an Infectious Diseases (ID) Clinic in St. Louis, Missouri from 2014 to 2016 were asked about demographics, sexual behaviors, whether PrEP was initially sought from their PCP, and barriers to obtaining PrEP from their PCP. Multivariable logistic regression was performed to identify predictors for having asked a PCP for PrEP. RESULTS Among 102 patients, the median age was 29 years, 58% were white, and 88% were men who have sex with men. Most (65%) had a PCP and, of these, 48% had asked their PCP for PrEP, but were not prescribed it. About half (52%) reported that their PCPs perceived prescribing PrEP as specialty care. Many (39%) indicated that they felt uncomfortable discussing their sexual behaviors with their PCP. Patients with an HIV-positive sex partner in the last 3 months were less likely to ask for PrEP from their PCPs than others (Adjusted Odds Ratio: 0.07; 95% CI: 0.01-0.53). Eighty-three percent of patients were referred to a new PCP with whom they could feel more comfortable discussing PrEP. CONCLUSIONS During initial PrEP implementation, ID specialists can play an important role in providing education and linking PrEP patients to PCPs. However, PCPs may need additional training about PrEP and how to provide culturally sensitive sexual healthcare, if widespread scale-up is to be effective in decreasing HIV incidence.
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Affiliation(s)
- Rupa R Patel
- 1 Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine , St. Louis, Missouri
| | - Philip A Chan
- 2 Division of Infectious Diseases, Department of Medicine, Brown University , Providence, Rhode Island
| | - Laura C Harrison
- 1 Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine , St. Louis, Missouri
| | - Kenneth H Mayer
- 3 Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center , Boston, Massachusetts.,4 Department of Medicine, Harvard Medical School , Boston, Massachusetts.,5 The Fenway Institute , Fenway Health, Boston, Massachusetts
| | - Amy Nunn
- 6 Department of Behavioral and Social Sciences, Brown University School of Public Health , Providence, Rhode Island.,7 The Rhode Island Public Health Institute , Providence, Rhode Island
| | - Leandro A Mena
- 8 Division of Infectious Diseases, Department of Medicine, University of Mississippi , Jackson, Mississippi
| | - William G Powderly
- 1 Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine , St. Louis, Missouri
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Freeman R, Gwadz MV, Silverman E, Kutnick A, Leonard NR, Ritchie AS, Reed J, Martinez BY. Critical race theory as a tool for understanding poor engagement along the HIV care continuum among African American/Black and Hispanic persons living with HIV in the United States: a qualitative exploration. Int J Equity Health 2017. [DOI: http:/doi.org.10.1186/s12939-017-0549-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
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44
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Freeman R, Gwadz MV, Silverman E, Kutnick A, Leonard NR, Ritchie AS, Reed J, Martinez BY. Critical race theory as a tool for understanding poor engagement along the HIV care continuum among African American/Black and Hispanic persons living with HIV in the United States: a qualitative exploration. Int J Equity Health 2017. [DOI: http://doi.org.10.1186/s12939-017-0549-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Ness TE, Annese MF, Martinez-Paz N, Unruh KT, Scott JD, Wood BR. Using an Innovative Telehealth Model to Support Community Providers Who Deliver Perinatal HIV Care. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2017; 29:516-526. [PMID: 29283274 DOI: 10.1521/aeap.2017.29.6.516] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Mountain West AETC (AIDS Education and Training Center) ECHO (Extension for Community Healthcare Outcomes), a longitudinal HIV telemen-toring program, connects community providers and a multidisciplinary specialist team at the University of Washington. The program employs focused lectures and real-time case discussions to educate and support providers in low-resource and rural settings. We assessed the impact of the program on management of perinatal HIV through surveying community providers who participate, and reviewing cases presented by providers for consultation. One hundred percent of providers who presented a perinatal HIV case for ECHO consultation reported that presentation "very much" impacted management of the case, and 93% of survey respondents reported that ECHO participation helped them stay up to date on national perinatal HIV guidelines. All 13 cases had the successful outcome of prevention of mother-to-child transmission of HIV. The ECHO model can effectively support and educate community providers who care for HIV-infected pregnant women.
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Affiliation(s)
- Tara E Ness
- University of Washington, Seattle, Washington
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Mary F Annese
- University of Washington, Seattle, Washington
- Mountain West AIDS Education and Training Center, Seattle, Washington
| | - Natalia Martinez-Paz
- University of Washington, Seattle, Washington
- Mountain West AIDS Education and Training Center, Seattle, Washington
| | - Kenton T Unruh
- University of Washington, Seattle, Washington
- Mountain West AIDS Education and Training Center, Seattle, Washington
| | | | - Brian R Wood
- University of Washington, Seattle, Washington
- Mountain West AIDS Education and Training Center, Seattle, Washington
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46
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Moore T, Dembry LM, Saag MS. Sunday in the Park with Infectious Disease: Workforce Mismatch in a Colorful Universe of Possibilities. J Infect Dis 2017; 216:S581-S587. [PMID: 28938044 PMCID: PMC5853217 DOI: 10.1093/infdis/jix323] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The decline in applications for infectious diseases (ID) fellowships has been an area of active introspection for the leadership of the Infectious Disease Society of America (IDSA). This prompted actions to address the problem, including surveys of current and former fellows. Ironically, the decline in applications to ID programs is occurring at a time when the need for ID providers has never been greater and the excitement and variety in the practice of ID has never been higher. Data regarding the current ID workforce are presented here, along with perspectives about the future of the profession in the decades to come.
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Affiliation(s)
- Thomas Moore
- Department of Medicine, Infectious Disease Consultants of Kansas and the University of Kansas School of Medicine−Wichita Campus
| | | | - Michael S Saag
- Department of Medicine, University of Alabama at Birmingham
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Weiser J, Beer L, Brooks JT, Irwin K, West BT, Duke CC, Gremel GW, Skarbinski J. Delivery of HIV Antiretroviral Therapy Adherence Support Services by HIV Care Providers in the United States, 2013 to 2014. J Int Assoc Provid AIDS Care 2017; 16:624-631. [PMID: 28899259 DOI: 10.1177/2325957417729754] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Little is known about clinicians' adoption of recommendations of the International Association of Providers of AIDS Care and others for supporting adherence to antiretroviral therapy (ART). METHODS We surveyed a probability sample of US HIV care providers to estimate the percentage offering 3 ART adherence support services to most or all patients and assessed the characteristics of providers offering all 3 services (comprehensive support) to most or all patients. RESULTS Almost all providers (95.5%) discussed ART adherence at every visit, 60.1% offered advice about tools to increase adherence, 53.5% referred nonadherent patients for supportive services, and 42.8% provided comprehensive support. Nurse practitioners were more likely to offer comprehensive support as were providers who practiced at Ryan White HIV/AIDS Program-funded facilities, provided primary care, or started caring for HIV-infected patients within 10 years. CONCLUSION Less than half of HIV care providers offered comprehensive ART adherence support. Certain subgroups may benefit from interventions to increase delivery of adherence support.
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Affiliation(s)
- John Weiser
- 1 Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Linda Beer
- 1 Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - John T Brooks
- 1 Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kathleen Irwin
- 1 Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Brady T West
- 2 Survey Research Center, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Jacek Skarbinski
- 1 Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Walensky RP, del Rio C, Armstrong WS. Charting the Future of Infectious Disease: Anticipating and Addressing the Supply and Demand Mismatch. Clin Infect Dis 2017; 64:1299-1301. [DOI: 10.1093/cid/cix173] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 02/13/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Rochelle P. Walensky
- Medical Practice Evaluation Center,
- Divisions of Infectious Disease, and
- General Internal Medicine, Massachusetts General Hospital, and
- the Harvard University Center for AIDS Research, Harvard Medical School, Boston, Massachusetts
| | - Carlos del Rio
- Division of Infectious Disease, Department of Medicine,
- Center for AIDS Research, and
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Wendy S. Armstrong
- Division of Infectious Disease, Department of Medicine,
- Center for AIDS Research, and
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Freeman R, Gwadz MV, Silverman E, Kutnick A, Leonard NR, Ritchie AS, Reed J, Martinez BY. Critical race theory as a tool for understanding poor engagement along the HIV care continuum among African American/Black and Hispanic persons living with HIV in the United States: a qualitative exploration. Int J Equity Health 2017; 16:54. [PMID: 28340589 PMCID: PMC5364619 DOI: 10.1186/s12939-017-0549-3] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 03/13/2017] [Indexed: 11/12/2022] Open
Abstract
Background African American/Black and Hispanic persons living with HIV (AABH-PLWH) in the U.S. evidence insufficient engagement in HIV care and low uptake of HIV antiretroviral therapy, leading to suboptimal clinical outcomes. The present qualitative study used critical race theory, and incorporated intersectionality theory, to understand AABH-PLWH’s perspectives on the mechanisms by which structural racism; that is, the macro-level systems that reinforce inequities among racial/ethnic groups, influence health decisions and behaviors. Methods Participants were adult AABH-PLWH in New York City who were not taking antiretroviral therapy nor well engaged in HIV care (N = 37). Participants were purposively sampled for maximum variation from a larger study, and engaged in semi-structured in-depth interviews that were audio-recorded and professionally transcribed verbatim. Data were analyzed using a systematic content analysis approach. Results We found AABH-PLWH experienced HIV care and medication decisions through a historical and cultural lens incorporating knowledge of past and present structural racism. This contextual knowledge included awareness of past maltreatment of people of color in medical research. Further, these understandings were linked to the history of HIV antiretroviral therapy itself, including awareness of the first HIV antiretroviral regimen; namely, AZT (zidovudine) mono-therapy, which was initially prescribed in unacceptably high doses, causing serious side effects, but with only modest efficacy. In this historical/cultural context, aspects of structural racism negatively influenced health care decisions and behavior in four main ways: 1) via the extent to which healthcare settings were experienced as overly institutionalized and, therefore, dehumanizing; 2) distrust of medical institutions and healthcare providers, which led AABH-PLWH to feel pressured to take HIV antiretroviral therapy when it was offered; 3) perceptions that patients are excluded from the health decision-making process; and 4) an over-emphasis on antiretroviral therapy compared to other non-HIV related priorities. We found that although participants were located at the intersection of multiple social categories (e.g., gender, social class, AABH race/ethnicity), race/ethnicity and social class were described as primary factors. Conclusions Critical race theory proved useful in uncovering how macro-level structural racism affects individual-level health decisions and behaviors. HIV clinical settings can counter-balance the effects of structural racism by building “structural competency,” and interventions fostering core self-determination needs including autonomy may prove culturally appropriate and beneficial for AABH-PLWH.
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Affiliation(s)
| | - Marya Viorst Gwadz
- Center for Drug Use and HIV Research (CDUHR), Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY, 10010, USA.
| | - Elizabeth Silverman
- Center for Drug Use and HIV Research (CDUHR), Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY, 10010, USA
| | - Alexandra Kutnick
- Center for Drug Use and HIV Research (CDUHR), Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY, 10010, USA
| | - Noelle R Leonard
- Center for Drug Use and HIV Research (CDUHR), Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY, 10010, USA
| | - Amanda S Ritchie
- Center for Drug Use and HIV Research (CDUHR), Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY, 10010, USA
| | - Jennifer Reed
- Center for Drug Use and HIV Research (CDUHR), Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY, 10010, USA
| | - Belkis Y Martinez
- Center for Drug Use and HIV Research (CDUHR), Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY, 10010, USA
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Weiser J, Garg S, Beer L, Skarbinski J. Prescribing of Human Immunodeficiency Virus (HIV) Pre-exposure Prophylaxis by HIV Medical Providers in the United States, 2013-2014. Open Forum Infect Dis 2017; 4:ofx003. [PMID: 28480276 DOI: 10.1093/ofid/ofx003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 01/12/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Clinical trials have demonstrated the effectiveness of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) for reducing HIV acquisition. Understanding how HIV care providers are prescribing PrEP is necessary to ensure success of this prevention strategy. METHODS During 2013-2014, we surveyed US HIV care providers who also provided care to HIV-negative patients. We estimated percentages who had prescribed PrEP and assessed associations between provider characteristics and PrEP prescribing. RESULTS An estimated 26% (95% confidence interval [CI], 20-31) had ever prescribed PrEP. Of these, 74% (95% CI, 61-87) prescribed for men who have sex with men (MSM), 30% (95% CI, 21-39) for women who have sex with men, 23% (95% CI, 9-37) for men who have sex with women, 23% (95% CI, 15-30) for uninfected partners in HIV-discordant couples trying to conceive, and 1% (95% CI, 0-2) for persons who inject drugs. The following provider characteristics were significantly associated with having prescribed PrEP: male vs female (32% vs 16%; adjusted prevalence ratio [aPR], 1.5; 95% CI, 1.0-2.2), lesbian/gay/bisexual vs heterosexual orientation (50% vs 21%; aPR, 2.0; 95% CI, 1.3-2.9), and HIV caseload (>200, 51-200, and ≤50 patients, 39%, 29%, and 14%, respectively; >200 vs ≤50 patients, aPR 2.4, 95% CI 1.1-5.2, and 51-200 vs ≤50 patients, aPR 2.2, 95% CI 1.2-4.0). CONCLUSIONS In 2013-2014, one quarter of HIV care providers reported having prescribed PrEP, most commonly for MSM and rarely for persons who inject drugs. Lesbian/gay/bisexual providers and male providers were more likely than others to have prescribed PrEP. Additional efforts may enable more providers to prescribe PrEP to underserved clients needing the service.
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Affiliation(s)
- John Weiser
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shikha Garg
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Linda Beer
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jacek Skarbinski
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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