Support for Trauma-informed Care Implementation Among Ryan White HIV Clinics in the Southeastern United States

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.

A collaborative care intervention to improve opioid prescribing among providers caring for persons with HIV: Impact on satisfaction, confidence, and trust

BACKGROUND

HIV clinicians report low confidence and satisfaction prescribing chronic opioid therapy (COT). We hypothesized that the Targeting Effective Analgesia in Clinics for HIV (TEACH) intervention [a system-level improvement to increase guideline concordant care for COT] would improve satisfaction, confidence, and trust among PWH and their clinicians.

METHODS

We conducted a two-arm, unblinded cluster randomized controlled trial (RCT) to assess the TEACH intervention. Clinicians were randomized in a 1:1 ratio to receive either the TEACH intervention (an IT-enabled nurse care manager, opioid education, academic detailing, and access to addiction specialists) or usual care. Outcomes were the following: clinician satisfaction (primary); confidence prescribing COT; patient satisfaction with COT; and trust in clinician. Intention-to-treat analyses were conducted using linear and logistic regression models.

RESULTS

Clinicians (n = 41) were randomized and their 114 patients assessed. At 12 months, the adjusted mean difference in satisfaction with COT was 1.11 points for intervention vs control clinicians (Scale 1-10; 95% confidence interval [CI]: -0.04 to 2.26, p = 0.06). The adjusted mean confidence with prescribing COT was 1.01 points higher among intervention clinicians (Scale 1-10; 95% CI: 0.05-1.96, p = 0.04). There were no significant differences in patient satisfaction with COT (adjusted odds ratio (AOR) 1.17, 95% CI: 0.50-2.76, p = 0.72) or trust in provider (AOR 1.63, 95% CI: 0.65-4.09, p = 0.30).

CONCLUSIONS

TEACH did not significantly affect prescriber satisfaction, patient satisfaction with pain management or patient trust; however, it did improve prescriber confidence. TEACH is a promising strategy to improve provider prescribing of COT for PWH without adverse patient satisfaction or trust in provider.

Improving the Delivery of Chronic Opioid Therapy Among People Living With Human Immunodeficiency Virus: A Cluster Randomized Clinical Trial

BACKGROUND

Chronic pain is prevalent among people living with human immunodeficiency virus (PLWH); managing pain with chronic opioid therapy (COT) is common. Human immunodeficiency virus (HIV) providers often diverge from prescribing guidelines.

METHODS

This 2-arm, unblinded, cluster-randomized clinical trial assessed whether the Targeting Effective Analgesia in Clinics for HIV (TEACH) intervention improves guideline-concordant care compared to usual care for PLWH on COT. The trial was implemented from 2015 to 2018 with 12-month follow-up at safety-net hospital-based HIV clinics in Boston and Atlanta. We enrolled 41 providers and their 187 patients on COT. Prescribers were randomized 1:1 to either a 12-month intervention consisting of a nurse care manager with an interactive electronic registry, opioid education, academic detailing, and access to addiction specialists or a control condition consisting of usual care. Two primary outcomes were assessed through electronic medical records: ≥2 urine drug tests and any early COT refills by 12 months. Other outcomes included possible adverse consequences.

RESULTS

At 12 months, the TEACH intervention arm had higher odds of ≥2 urine drug tests than the usual care arm (71% vs 20%; adjusted odds ratio [AOR], 13.38 [95% confidence interval {CI}, 5.85-30.60]; P < .0001). We did not detect a statistically significant difference in early refills (22% vs 30%; AOR, 0.55 [95% CI, .26-1.15]; P = .11), pain severity (6.30 vs 5.76; adjusted mean difference, 0.10 [95% CI, -1.56 to 1.75]; P = .91), or HIV viral load suppression (86.9% vs 82.1%; AOR, 1.21 [95% CI, .47-3.09]; P = .69).

CONCLUSIONS

TEACH is a promising intervention to improve adherence to COT guidelines without evident adverse consequences.

Chronic Opioid Therapy in People Living With Human Immunodeficiency Virus: Patients' Perspectives on Risks, Monitoring, and Guidelines

Background

Chronic opioid therapy (COT) is common in people living with human immunodeficiency virus (PLHIV), but is not well studied. We assessed opioid risk behaviors, perceptions of risk, opioid monitoring, and associated Current Opioid Misuse Measure (COMM) scores of PLHIV on COT.

Methods

COT was defined as ≥3 opioid prescriptions ≥21 days apart in the past 6 months. Demographics, substance use, COMM score, and perceptions of and satisfaction with COT monitoring were assessed among PLHIV on COT from 2 HIV clinics.

Results

Among participants (N = 165) on COT, 66% were male and 72% were black, with a median age of 55 (standard deviation, 8) years. Alcohol and drug use disorders were present in 17% and 19%, respectively. In 43%, the COMM score, a measure of potential opioid misuse, was high. Thirty percent had an opioid treatment agreement, 66% a urine drug test (UDT), and 12% a pill count. Ninety percent acknowledged opioids' addictive potential. Median (interquartile range) satisfaction levels (1-10 [10 = highest]) were 10 (7-10) for opioid treatment agreements, 9.5 (6-10) for pill counts, and 10 (8-10) for UDT. No association was found between higher COMM score and receipt of or satisfaction with COT monitoring.

Conclusions

Among PLHIV on COT, opioid misuse and awareness of the addictive potential of COT are common, yet COT monitoring practices were not guideline concordant. Patients who received monitoring practices reported high satisfaction. Patient attitudes suggest high acceptance of guideline concordant care for PLHIV on COT when it occurs.

Study protocol for the targeting effective analgesia in clinics for HIV (TEACH) study - a cluster randomized controlled trial and parallel cohort to increase guideline concordant care for long-term opioid therapy among people living with HIV

Background: People living with HIV (PLWH) frequently experience chronic pain and receive long-term opioid therapy (LTOT). Adherence to opioid prescribing guidelines among their providers is suboptimal. Objective: This paper describes the protocol of a cluster randomized trial, targeting effective analgesia in clinics for HIV (TEACH), which tested a collaborative care intervention to increase guideline-concordant care for LTOT among PLWH. Methods: HIV physicians and advanced practice providers (n = 41) were recruited from September 2015 to December 2016 from two HIV clinics in Boston and Atlanta. Patients receiving LTOT from participating providers were enrolled through a waiver of informed consent (n = 187). After baseline assessment, providers were randomized to the control group or the year-long TEACH intervention involving: (1) a nurse care manager and electronic registry to assist with patient management; (2) opioid education and academic detailing; and (3) facilitated access to addiction specialists. Randomization was stratified by site and LTOT patient volume. Primary outcomes (≥2 urine drug tests, early refills, provider satisfaction) were collected at 12 months. In parallel, PLWH receiving LTOT (n = 170) were recruited into a longitudinal cohort at both clinics and underwent baseline and 12-month assessments. Secondary outcomes were obtained through patient self-report among participants enrolled in both the cohort and the RCT (n = 117). Conclusions: TEACH will report the effects of an intervention on opioid prescribing for chronic pain on both provider and patient-level outcomes. The results may inform delivery of care for PLWH on LTOT for chronic pain at a time when opioid practices are being questioned in the US.

Provider opioid prescribing practices and the belief that opioids keep people living with HIV engaged in care: a cross-sectional study

We describe HIV providers' opioid prescribing practices and assess whether belief that chronic opioid therapy (COT) keeps people living with HIV (PLWH) engaged in care is associated with differences in these practices among providers from two HIV clinics. We conducted logistic regression to evaluate the association between the belief that COT keeps PLWH engaged in care and at least one component of guideline-recommended care (i.e., urine drug tests, treatment agreements, and/or prescription monitoring program use). The sample included 41 providers with a median age of 42 years, 63% female, 37% non-white. Routine adherence to guideline-recommended practices was: 34% urine drug tests, 27% treatment agreements, and 17% prescription monitoring program. Over half [54%] agreed that COT keeps PLWH engaged in care. There was no significant association between belief that COT keeps PLWH engaged in care and routinely providing any recommended COT care component (aOR 2.38; 95% CI 0.65-8.73). Most HIV providers do not routinely follow guidelines for opioid prescribing. We observed a positive association between belief that COT keeps PLWH engaged in care and following any guideline-recommended prescribing practices, although the result was not statistically significant. Interventions are needed to improve guideline-concordant care for COT by HIV providers.

The Perilous Road from HIV Diagnosis in the Hospital to Viral Suppression in the Outpatient Clinic

The HIV care continuum has received considerable attention in recent years, however, few care continua focus on the population of patients who are diagnosed during an inpatient hospital admission. We aimed to describe the HIV care continuum for patients newly diagnosed during hospitalization through 24-month follow-up. A retrospective chart review of HIV patients diagnosed at Grady Memorial Hospital from 2011 to 2012 was performed and records were matched to Georgia Department of Public Health HIV/AIDS surveillance data. Descriptive statistics and statistical tests of independence were utilized. Ninety-four new diagnoses were confirmed during the 2-year study period. Median age was 43 years (interquartile range [IQR] 30-51), 77% were male, 72% were non-Hispanic Black, 31% were men who have sex with men (MSM), and 77% were uninsured. Median CD4 count at diagnosis was 134 cells/μL (IQR 30-307). Eighty-four percent received their diagnosis before hospital discharge, 68% linked to care by 90 days, 73% were retained for 12 months, 48% were virologically suppressed by 12 months, 58% were retained for 24 continuous months, and 38% achieved continuous viral suppression (VS) during the initial 24 months after diagnosis. Late diagnosis is a persistent problem in hospitalized patients. Despite relative success with linkage to care and 12-month retention in care, a minority of patients maintained retention and VS for 24 continuous months.

Continuous Retention and Viral Suppression Provide Further Insights Into the HIV Care Continuum Compared to the Cross-sectional HIV Care Cascade

BACKGROUND

The human immunodeficiency virus (HIV) care continuum has become an important tool for evaluating HIV care. Current depictions of the care continuum are often cross-sectional and evaluate retention and viral suppression (VS) in a single year, yet the National HIV/AIDS Strategy calls for programs with long-lasting outcomes.

METHODS

Retrospective chart review of HIV-infected patients enrolled in a large, urban clinic in 2010 followed longitudinally for 36 months. McNemar comparisons and logistic regression analyses were conducted to evaluate covariate association with continuous retention and VS. Generalized estimating equation log-linear models were used to integrate time into the model.

RESULTS

Among 655 patients (77% male, 83% black, 54% men who have sex with men (MSM), 78% uninsured) continuous retention/VS at 12 months (84%/64%), 24 months (60%/48%), and 36 months (49%/39%) showed significant attrition (P < .0001) over time. Continuous retention was associated with prevalent VS at the end of 36 months (adjusted prevalence ratio 3.12; 95% confidence interval [CI], 2.40, 4.07). 12-month retention for black (84%) and nonblack (85%) patients was equivalent, yet fewer blacks (46%) than nonblacks (63%) achieved 36-month continuous retention due to a significant interaction between race and time (aOR 0.75, 95% CI, .59, .95).

CONCLUSIONS

Continuous retention is a critically important measure of long-term success in HIV treatment and the crucial component of successful treatment-as-prevention but is infrequently evaluated. Single cross-sections may overestimate successful retention and virologic outcomes. A longitudinal HIV care continuum provides greater insight into long-term outcomes and exposes disparities not evident with traditional cross-sectional care continua.

The link between maltreatment and juvenile firesetting: correlates and underlying mechanisms

OBJECTIVE

Despite the widely held belief that abuse is a risk factor for childhood firesetting, the role of maltreatment in firesetting is largely unexplored. This study reports on a sample of children and adolescents referred to a brief assessment and intervention program for juvenile firesetters. Firesetting histories of maltreated youth were compared to a group of firesetting youth with no maltreatment history.

METHODS

Participants included 205 children and youth aged 4-17 years and their caregivers. Assessments were completed with a standardized protocol. Forty-eight percent of the sample had a history of maltreatment as reported by caregivers; 26% of the sample had experienced more than one type of maltreatment.

RESULTS

When compared to the non-maltreated group, children with histories of maltreatment demonstrated more frequent fire involvement, more versatility regarding ignition sources and targets, and a greater likelihood of an immediate family stressor as a motive for firesetting (all p<.05). Maltreated children were more likely to become involved with fire out of anger (p=.001), and there was also a trend towards higher rates of recidivism (p=.07). Children's externalizing behavior partially mediated the influence of maltreatment on specific fire-related outcomes of children (OR=1.10; 95% CI=1.04-1.17; p=.001).

CONCLUSIONS

Within a juvenile firesetting population, the presence of maltreatment is a risk factor for a more severe course of firesetting. The findings also suggest that the link between maltreatment and firesetting is operating partially through heightened emotional and behavioral difficulties.

PRACTICE IMPLICATIONS

This study demonstrates that maltreatment is a risk factor that contributes to a more severe course of juvenile fire involvement, and that the link between maltreatment and firesetting operates largely through heightened behavioral and emotional difficulties. These findings highlight the need for mental health clinicians to (a) be aware that these two serious clinical issues frequently co-occur, (b) screen for fire-related behaviors and maltreatment during general assessments, and (c) consider maltreatment status when thinking about the risk of firesetting.

Ultrafast changes of molecular crystal structure induced by dipole solvation

Femtosecond photoexcitation of organic chromophores in a molecular crystal induces strong changes of the electronic dipole moment via intramolecular charge transfer as is evident from transient vibrational spectra. The structural response of the crystal to the dipole change is mapped directly for the first time by ultrafast x-ray diffraction or diffuse scattering. Changes of diffracted and transmitted x-ray intensity demonstrate an angular rearrangement of molecules around excited dipoles following the 10 ps kinetics of charge transfer and leaving lattice plane spacings unchanged. Transient x-ray scattering is governed by solvation, masking changes of the chromophore molecular structure.

On the unusual fluorescence properties of xanthone in water

Photo-excited xanthone is known to undergo ultrafast intersystem crossing (ISC) in the 1 ps time domain. Correspondingly, its fluorescence quantum yield in most solvents is very small ( approximately 10(-4)). Surprisingly, the quantum yield in water is 100 times larger, while ISC is still rapid ( approximately 1 ps), as seen by ultrafast pump probe absorption spectroscopy. Temperature dependent steady state and time resolved fluorescence experiments point to a delayed fluorescence mechanism, where the triplet (3)npi* state primarily accessed by ISC is nearly isoenergetic with the photo-excited (1)pipi* state. The delayed fluorescence of xanthone in water decays with a time constant of 700 ps, apparently by internal conversion between the (3)npi* state and the lowest lying triplet state (3)pipi*.

Photoswitchable Elements within a Peptide BackboneUltrafast Spectroscopy of Thioxylated Amides

A series of thioxo compounds, thioacetamide, N-methylthioacetamide, a cyclic thioxoamide [(S)-5-thioxopyrrolidine-2-carboxylic acid ethyl ester], two thioxylated dipeptides (Ala-Psi[CS-NH]-Ala and Phe-Psi[CS-NH]-Ala) and a thioxylated dodecapeptide (Lys-Glu-Thr-Ala-Ala-Ala-Lys-Phe-Glu-Arg-Gln-His-Psi[CS-NH]-Nle-Asp-Ser-Ser-Thr-Ser-Ala-Ala, or [thioxo-His(12)]-S-peptide; Nle = norleucine) are investigated by ultrafast spectroscopy in the visible and near UV. The different molecules show very similar absorption dynamics featuring a rise of a strong visible absorption band on the subpicosecond and picosecond time scale. The decay of the visible absorption occurs within 150-600 ps. The observations are interpreted by the ultrafast formation of triplet states and their decay on the subnanosecond time scale. Comparison with published IR experiments on N-methylthioacetamide indicates that the cis-trans isomerization around the thioxopeptide bond is terminated within less than 1 ns.

Inhibition of ileal sodium-dependent bile acid transport by 2164U90

Inhibition of the ileal bile acid active transport system, previously shown to be mechanism underlying the hypocholesterolemic activity of 2164U90 in rodents, was further characterized in isolated intestinal preparations from three species. 2164U90 inhibited sodium-dependent transport of taurocholic acid by Caco-2 cells and by monkey and human ileal brush border membrane vesicles in a concentration-dependent manner with IC50s of 7 microM, 5 microM, and 2 microM, respectively. In rat ileal brush border membrane vesicles, 2164U90 was a competitive inhibitor of sodium-dependent taurocholic acid uptake with an estimated Ki of 1.8 +/- 0.2 microM. In anesthetized rats, 5 microM 2164U90 placed in the isolated distal ileum with 3 mM [3H]taurocholic acid decreased ileal uptake, transport into the bile, and transport rate of taurocholic acid by 31-35%. Stereospecificity of inhibition by 2164U90 was demonstrated by the relative inactivity of three other possible stereoisomers in rat ileal sacs and brush border membrane vesicles. 2164U90 did not inhibit sodium-dependent glucose transport by monkey jejunal brush border membrane vesicles, indicating that 2164U90 may be specific for the bile acid transporter. These results suggest that 2164U90 is a potent, selective, stereospecific, competitive inhibitor of the sodium-dependent bile acid transporter in the ileal mucosal cell brush border membrane.

Effects of 2164U90 on ileal bile acid absorption and serum cholesterol in rats and mice

2164U90, [(3R,5R)-trans-3-butyl-3-ethyl-2,3,4,5-tetrahydro-5-phenyl-1,4- benzothiazepine 1,1-dioxide], was found to be a potent inhibitor of the ileal bile acid active transport system. In vitro, 2164U90 decreased uptake and active transport of taurocholic acid by rat everted ileal sacs with IC50s of 4.0 microM and 1.5 microM, respectively. In vivo, 2164U90 produced dose-dependent increases in 23,25-75Se-labeled homocholic acid taurine (SeHCAT) fecal excretion in rats and mice at doses of 3-30 mg/kg and 1-10 mg/kg, respectively. In rats, 30 mg/kg 2164U90 was equivalent to 500 mg/kg cholestyramine. Two days oral administration of 10 mg/kg 2164U90 to rats decreased the bile concentrations of total bile acids 42%, orally administered [3H]taurocholic acid ([3H]TC) 82%, and cholesterol 35%. Cholestyramine (500 mg/kg) had effects similar to 2164U90 on total bile acid and orally administered [3H]TC concentrations but had no effect on biliary cholesterol. The hypocholesterolemic activity of 2164U90 was determined in cholesterol-cholic acid-fed rats and cholesterol-cholic acid-coconut oil-fed mice. 2164U90 inhibited the dietary-induced increase in dextran sulfate-precipitable lipoprotein cholesterol (VLDL+LDL) at doses comparable to doses needed to increase the fecal excretion of bile acids. These data indicate that 2164U90 decreases bile acid absorption by inhibiting the ileal bile acid active transport system, resulting in hypocholesterolemic activity.

In vivo transport kinetics and distribution of taurocholate by rat ileum and jejunum

The transport kinetics and distribution of taurocholate (TC) from the ileum and jejunum were evaluated in anesthetized Sprague-Dawley rats. Uptake and transport kinetics were determined after simultaneous administration of equimolar solutions of [3H]taurocholic acid ([3H]TC) in the ileum and [24-14C]taurocholic acid ([14C]TC) in the jejunum of anesthetized rats. At TC concentrations between 0.3 and 15 mM, total ileal absorption exceeded jejunal absorption 15- to 25-fold. The apparent Km and Vmax for ileal absorption of TC were 5.6 mM and 65.5 nmol.min-1.cm-1, respectively. Tissue distribution studies following uptake from the ileum and jejunum were done with 75Se-labeled homocholic acid taurine (75Se-HCAT). In the ileum, 82% of the 75Se-HCAT removed from the lumen was found in the bile, 10.6% was found in the ileal wall, and 7.3% was found in the liver. In the jejunum, 24.1% was found in bile, 0.6% was found in the liver, and 75.3% remained in the jejunal wall. These data show that the ileum is much more efficient and better equipped than the jejunum to take up and transport TC at concentrations up to 15 mM.

Nasolacrimal duct anomaly in calves

Supernumerary openings of the nasolacrimal drainage apparatus were found in 13 Brown Swiss calves. The cause of the anomaly was not determined but was assumed to be similar to that in man.