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Jiancaro T, Bayoumi AM, Ibáñez-Carrasco F, Torres B, McDuff K, Brown DA, Chan Carusone S, Tang A, Loutfy M, Cobbing S, O’Brien KK. Factors influencing initial implementation of an online community-based exercise intervention with adults living with HIV: a systems approach. Front Rehabil Sci 2023; 4:1176960. [PMID: 37546578 PMCID: PMC10399961 DOI: 10.3389/fresc.2023.1176960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/05/2023] [Indexed: 08/08/2023]
Abstract
Introduction Online community-based exercise (CBE) is a digital health intervention and rehabilitation strategy that promotes health among people living with HIV. Our aim was to describe the factors influencing initial implementation of a pilot online CBE intervention with adults living with HIV using a systems approach, as recommended by implementation science specialists. Methods We piloted the implementation of a 6-month online CBE intervention and 6-month independent exercise follow up, in partnership with the YMCA in Toronto, Canada. We recruited adults living with HIV who identified themselves as safe to engage in exercise. The intervention phase included personalized exercise sessions online with a personal trainer; exercise equipment; access to online exercise classes; and a wireless physical activity monitor. Two researchers documented implementation factors articulated by participants and the implementation team during early implementation, defined as recruitment, screening, equipment distribution, technology orientation, and baseline assessments. Data sources included communication with participants; daily team communication; weekly team discussions; and in-person meetings. We documented implementation factors in meeting minutes, recruitment screening notes, and email communication; and analyzed the data using a qualitative descriptive approach using a systems engineering method called Cognitive Work Analysis. Results Thirty-three adults living with HIV enrolled in the study (n = 33; median age: 52 years; cis-men: 22, cis-women: 10, non-binary: 1). Fifty-five factors influencing implementation, spanned five layers: (i) Natural, including weather and the COVID-19 virus; (ii) Societal, including COVID-19 impacts (e.g. public transit health risks impacting equipment pick-ups); (iii) Organizational, including information dissemination (e.g. tech support) and logistics (e.g. scheduling); (iv) Personal, including physical setting (e.g. space) and digital setting (e.g. device access); and (v) Human, including health (e.g. episodic illness) and disposition (e.g. motivation). The implementation team experienced heightened needs to respond rapidly; sustain engagement; and provide training and support. Additional organizational factors included a committed fitness training and research team with skills spanning administration and logistics, participant engagement, technology training, physical therapy, and research ethics. Conclusion Fifty-five factors spanning multiple layers illustrate the complexities of online CBE with adults living with HIV. Initial implementation required a dedicated, rehabilitation-centred, multi-skilled, multi-stakeholder team to address a diverse set of factors.
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Affiliation(s)
- T. Jiancaro
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - A. M. Bayoumi
- Institute of Health Policy, Management and Evaluation (IHPME), Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- MAP Centre, St. Michael’s Hospital, Toronto, ON, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - F. Ibáñez-Carrasco
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - B. Torres
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - K. McDuff
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - D. A. Brown
- Therapies Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - S. Chan Carusone
- McMasterCollaborative Centre for Health and Aging, McMaster University, Hamilton, ON, Canada
| | - A. Tang
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - M. Loutfy
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Maple Leaf Medical Clinic, Toronto, ON, Canada
| | - S. Cobbing
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- The Institute of Education Research, University Health Network, Toronto, ON, Canada
- Department of Physiotherapy, University of KwaZulu-Natal, Durban, South Africa
| | - K. K. O’Brien
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation (IHPME), Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute (RSI), University of Toronto, Toronto, ON, Canada
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2
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Zhabokritsky A, Szadkowski L, Burchell AN, Cooper C, Hogg RS, Hull M, Kelly DV, Klein M, Loutfy M, McClean A, Montaner J, Walmsley SL. Immunological and virological response to initial antiretroviral therapy among older people living with HIV in the Canadian Observational Cohort (CANOC). HIV Med 2021; 22:759-769. [PMID: 34075683 DOI: 10.1111/hiv.13125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES The aim of this study was to assess the adequacy of immunological recovery and virological suppression in response to antiretroviral therapy (ART) in the growing population of older people living with HIV (PLWH), as treatment regimens become more effective and tolerable. METHODS An interprovincial Canadian cohort of treatment-naïve PLWH who initiated ART after 1 January 2000 was used and age assessed in decades. Longitudinal absolute CD4 count response to treatment was modelled using generalized estimating equations. Cumulative incidence functions and proportional hazards models with a competing risk of death were used to estimate time to: (1) CD4 ≥ 200 cells/µL, (2) CD4 ≥ 500 cells/µL, (3) virological suppression (≤ 50 copies/mL), and (4) virological failure (> 200 copies/mL). RESULTS In all, 12 489 individuals starting ART between 2000 and 2016 with one or more post-treatment CD4 count or viral load were included in the analysis. Age > 60 years was associated with lower absolute CD4 recovery (adjusted β = -31 cells/µL) compared with age ≤ 30 years when pre-treatment CD4 count and other covariates were accounted for. Older age groups were less likely to achieve a CD4 ≥ 500 cells/µL, with the greatest effect in the > 60 group [adjusted hazard ratio (aHR) = 0.69, 95% confidence interval (CI): 0.57-0.84 vs. age ≤ 30). Older age groups were more likely to achieve viral suppression (age > 60, aHR = 1.20, 95% CI: 1.05-1.37) and less likely to have virological failure (age > 60, aHR = 0.46, 95% CI: 0.3-0.71) compared with those aged ≤ 30 years. CONCLUSIONS Older adults have robust virological responses to ART; however, individuals over the age 60 are more likely to experience blunted CD4 recovery.
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Affiliation(s)
- A Zhabokritsky
- Department of Medicine, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - L Szadkowski
- Department of Medicine, University Health Network, Toronto, ON, Canada.,Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - A N Burchell
- Department of Family and Community Medicine and Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health, Toronto, ON, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - C Cooper
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - R S Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - M Hull
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - D V Kelly
- School of Pharmacy, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - M Klein
- McGill University Health Center, Montreal, QC, Canada
| | - M Loutfy
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - A McClean
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - J Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - S L Walmsley
- Department of Medicine, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
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3
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Nashid N, Khan S, Loutfy M, MacGillivray J, Yudin MH, Campbell DM, Barozzino T, Baqi M, Read SE, Bitnun A. Breastfeeding by Women Living With Human Immunodeficiency Virus in a Resource-Rich Setting: A Case Series of Maternal and Infant Management and Outcomes. J Pediatric Infect Dis Soc 2020; 9:228-231. [PMID: 30753640 DOI: 10.1093/jpids/piz003] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/10/2019] [Indexed: 11/14/2022]
Abstract
The reduction in human immunodeficiency virus (HIV) transmission through breastmilk with maternal combination antiretroviral therapy (cART) has led many pregnant women living with HIV and healthcare providers to question exclusive formula feeding in resource-rich settings. Here, we describe cART prophylaxis in 3 breastfed infants whose mothers had sustained virologic suppression; all 3 of these infants remained uninfected.
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Affiliation(s)
- N Nashid
- Department of Pediatrics, The Hospital For Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - S Khan
- Department of Pediatrics, Hamilton Health Sciences Centre, McMaster University, Hamilton, ON, Canada
| | - M Loutfy
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - J MacGillivray
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, ON, Canada.,Midwifery Education Program, Ryerson University, Toronto, ON, Canada
| | - M H Yudin
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, ON, Canada.,Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - D M Campbell
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,Department of Pediatrics, St. Michael's Hospital, Toronto, ON, Canada
| | - T Barozzino
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,Department of Pediatrics, St. Michael's Hospital, Toronto, ON, Canada
| | - M Baqi
- Department of Medicine, William Osler Health System, Toronto, ON, Canada
| | - S E Read
- Department of Pediatrics, The Hospital For Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - A Bitnun
- Department of Pediatrics, The Hospital For Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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4
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Yudin M, Kennedy V, Bekele T, Watson J, Globerman J, McGee A, Bertrand J, Antoniou T, Rourke S, Loutfy M. Fertility desires and intentions among heterosexual HIV-positive men: an important and overlooked population in obstetrics and gynecology. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2018.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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5
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Kendall CE, Raboud J, Donelle J, Loutfy M, Rourke SB, Kroch A, Liddy C, Rosenes R, Burchell AN. Lost but not forgotten: A population-based study of mortality and care trajectories among people living with HIV who are lost to follow-up in Ontario, Canada. HIV Med 2018; 20:88-98. [PMID: 30474908 PMCID: PMC9292000 DOI: 10.1111/hiv.12682] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2018] [Indexed: 11/27/2022]
Abstract
Objectives Selection as a consequence of volunteer participation in, and loss to follow‐up from, cohort studies may bias estimates of mortality and other health outcomes. To quantify this potential, we estimated mortality and health service use among people living with HIV (PLWH) who were lost to cohort follow‐up (LTCFU) from a volunteer clinical HIV‐infected cohort, and compared these to mortality and health service use in active cohort participants and non‐cohort‐participants living with HIV in Ontario, Canada. Methods We analysed population‐based provincial health databases from 1995 to 2014, identifying PLWH ≥ 18 years old; these included data from participants in the Ontario HIV Treatment Network Cohort Study (OCS), a volunteer, multi‐site clinical HIV‐infected cohort. We calculated all‐cause mortality, hospitalization and emergency department (ED) visit rates per 100 person‐years (PY) and estimated hazard ratios (HRs) of mortality, adjusting for age, sex, income, rurality, and immigration status. Results Among 23 043 PLWH, 5568 were OCS participants. Compared with nonparticipants, participants were younger and less likely to be female, to be an immigrant and to reside in a major urban centre, and had lower comorbidity. Mortality among active participants, participants LTCFU and nonparticipants was 2.52, 3.30 and 2.20 per 100 PY, respectively. After adjustment for covariates, mortality risk was elevated among participants LTCFU compared with active participants (HR 2.26; 95% confidence interval 1.91, 2.68). Age‐adjusted hospitalization rates and ED visit rates were highest among participants LTCFU. Conclusions Mortality risk and use of health care resources were lower among active cohort participants. Our findings may inform health outcome estimates based on volunteer cohorts, as well as quantitative bias adjustment to correct for such biases.
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Affiliation(s)
- C E Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.,ICES, Toronto, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - J Raboud
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - J Donelle
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - M Loutfy
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Maple Leaf Medical Clinic, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - S B Rourke
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - A Kroch
- Ontario HIV Treatment Network, Toronto, ON, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - C Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - R Rosenes
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | | | - A N Burchell
- ICES, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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6
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Wilton J, Light L, Gardner S, Rachlis B, Conway T, Cooper C, Cupido P, Kendall CE, Loutfy M, McGee F, Murray J, Lush J, Rachlis A, Wobeser W, Bacon J, Kroch AE, Gilbert M, Rourke SB, Burchell AN. Late diagnosis, delayed presentation and late presentation among persons enrolled in a clinical HIV cohort in Ontario, Canada (1999-2013). HIV Med 2018; 20:110-120. [PMID: 30430742 DOI: 10.1111/hiv.12686] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Timely HIV diagnosis and presentation to medical care are important for treatment and prevention. Our objective was to measure late diagnosis, delayed presentation and late presentation among individuals in the Ontario HIV Treatment Network Cohort Study (OCS) who were newly diagnosed in Ontario. METHODS The OCS is a multi-site clinical cohort study of people living with HIV in Ontario, Canada. We measured prevalence of late diagnosis [CD4 count < 350 cells/μL or an AIDS-defining condition (ADC) within 3 months of HIV diagnosis], delayed presentation (≥ 3 months from HIV diagnosis to presentation to care), and late presentation (CD4 count < 350 cells/μL or ADC within 3 months of presentation). We identified characteristics associated with these outcomes and explored their overlap. RESULTS A total of 1819 OCS participants were newly diagnosed in Ontario from 1999 to 2013. Late diagnosis (53.0%) and presentation (54.0%) were common, and a quarter (23.1%) of participants were delayed presenters. In multivariable models, the participants of delayed presentation decreased over calendar time, but that of late diagnosis/presentation did not. Late diagnosis contributed to the majority (> 87%) of late presentation, and the prevalence of delayed presentation was similar among those diagnosed late versus early (13.4 versus 13.4%, respectively; P = 0.99). Characteristics associated with higher odds of late diagnosis/presentation in multivariable analyses included older age at diagnosis/presentation; African, Caribbean and Black race/ethnicity; Indigenous race/ethnicity; female sex; and being a male who did not report sex with men. There were lower odds of late diagnosis/presentation among participants who had ever injected drugs. In contrast, delayed presentation risk factors included younger age at diagnosis and having ever injected drugs. CONCLUSIONS Late presentation is common in Ontario, as it is in other high-income countries. Our findings suggest that efforts to reduce late presentation should focus on facilitating earlier diagnosis for the populations identified in this analysis.
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Affiliation(s)
- J Wilton
- Ontario HIV Treatment Network, Toronto, Canada
| | - L Light
- Ontario HIV Treatment Network, Toronto, Canada
| | - S Gardner
- Baycrest Health Sciences, Toronto, Canada.,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - B Rachlis
- Ontario HIV Treatment Network, Toronto, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - T Conway
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Canadian Positive People Network, Ottawa, Canada
| | - C Cooper
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - P Cupido
- Ontario HIV Treatment Network, Toronto, Canada
| | - C E Kendall
- Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - M Loutfy
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - F McGee
- AIDS Bureau, Ontario Ministry of Health and Long-Term Care, Toronto, Canada
| | - J Murray
- AIDS Bureau, Ontario Ministry of Health and Long-Term Care, Toronto, Canada
| | - J Lush
- AIDS Bureau, Ontario Ministry of Health and Long-Term Care, Toronto, Canada
| | - A Rachlis
- Department of Medicine, University of Toronto, Toronto, Canada.,Sunnybrook Health Science Centre, Toronto, Canada
| | - W Wobeser
- Department of Molecular and Biomedical Sciences, Queen's University, Kingston, Canada.,Department of Public Health, Queen's University, Kingston, Canada
| | - J Bacon
- Ontario HIV Treatment Network, Toronto, Canada
| | - A E Kroch
- Ontario HIV Treatment Network, Toronto, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - M Gilbert
- Clinical Prevention Services, British Columbia Centre for Disease Control, Vancouver, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - S B Rourke
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - A N Burchell
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada.,Department of Family and Community Medicine, St Michael's Hospital, Toronto, Canada.,Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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7
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Khan S, Ion A, Alyass A, Greene S, Kwaramba G, Smith S, Carvalhal A, Kennedy VL, Walmsley S, Loutfy M. Loneliness and perceived social support in pregnancy and early postpartum of mothers living with HIV in Ontario, Canada. AIDS Care 2018; 31:318-325. [PMID: 30157684 DOI: 10.1080/09540121.2018.1515469] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The HIV Mothering Study (n = 72) was a prospective, observational, cohort study exploring psychosocial experiences and needs of WLWHIV in pregnancy and postpartum. We performed quantitative analysis of determinants of loneliness (UCLA Loneliness Scale) and lower perceived social support (SS) (Medical Outcomes Study-Social Support Survey). The hypothesized determinants included: age, years with HIV, racism (Everyday Discrimination Scale), depression (Edinburgh Postnatal Depression Scale [EPDS]), nadir CD4 (<200 cells/μL), tertiary vs. community HIV care, and marital status. The median age was 33 (IQR = 30-37); 65.3% were African/Caribbean/Black. Multivariable analyses revealed associations between marital status and perceived social support (β = -16.48, p < 0.0001), and this association was also seen with change over time (p = 0.02). Variables associated with SS that did not change over time were: income, EDS racism, EPDS score. Significant associations with loneliness were seen with the same variables associated with SS. Variables associated with loneliness that also changed over time were: EDS Racism (β = 0.22, p = 0.0005, and over time p = 0.003), and EPDS score (β = 0.74, p < 0.0001), and over time (p = 0.0211). Variables associated with loneliness but that did not change over time were: marital status and income. This analysis provides clinicians with prenatal risk factors which may be associated with increase loneliness and lower SS during pregnancy and postpartum: marital status, income, racism and depression.
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Affiliation(s)
- S Khan
- a Pediatric Infectious Diseases , McMaster University , Hamilton , Canada
| | - A Ion
- b Department of Social Work , McMaster University , Hamilton , Canada
| | - A Alyass
- c Department of Clinical Epidemiology , McMaser University , Hamilton , Canada
| | - S Greene
- b Department of Social Work , McMaster University , Hamilton , Canada
| | - G Kwaramba
- d Department of Medicine , University of Toronto, St. Michael's Hospital , Toronto , Canada
| | - S Smith
- d Department of Medicine , University of Toronto, St. Michael's Hospital , Toronto , Canada
| | - A Carvalhal
- e Department of Psychiatry , University of Toronto , Toronto , Canada
| | - V L Kennedy
- f Women's College Research Institute , Women's College Hospital, University of Toronto & Maple Leaf Medical Clinic , Toronto , Canada
| | - S Walmsley
- g Department of Medicine , University of Toronto, University Health Network , Toronto , Canada
| | - M Loutfy
- f Women's College Research Institute , Women's College Hospital, University of Toronto & Maple Leaf Medical Clinic , Toronto , Canada
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8
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Geretti AM, Loutfy M, D'Arminio Monforte A, Latysheva I, Pérez Elías MJ, Rymer J, Boffito M. Out of focus: tailoring the cascade of care to the needs of women living with HIV. HIV Med 2018; 18 Suppl 2:3-17. [PMID: 28880486 DOI: 10.1111/hiv.12533] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2017] [Indexed: 02/06/2023]
Abstract
Around half of the global adult HIV-positive population are women, yet historically women have been under-represented in clinical studies of antiretroviral therapy (ART) and there has been minimal exploration of gender-specific factors related to the response to and appropriateness of treatment choices in women living with HIV (WLWH). There are several key issues pertaining to the cascade of HIV care that make it important to differentiate WLWH from men living with HIV. Factors that are gender specific may impact on the status of WLWH, affecting access to diagnosis and treatment, optimal clinical management, ART outcomes, retention in care, and the overall long-term wellbeing of WLWH. In this review, we discuss the results of recently reported women-only clinical trials and highlight the key unmet needs of WLWH as they pertain to the cascade of HIV care across World Health Organization European Region countries. As significant knowledge gaps remain, the review identifies key areas where further research is required, in order to support improved management of WLWH and guide informed clinical decision-making, including addressing psychosocial factors as part of comprehensive care.
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Affiliation(s)
- A M Geretti
- Institute of Infection & Global Health, University of Liverpool, Liverpool, UK
| | - M Loutfy
- Women's College Research Institute, Women's College Hospital, University of Toronto, Toronto, Canada
| | | | - I Latysheva
- Republican Clinical Hospital of Infectious Diseases of Ministry of Health Russian Federation, St Petersburg, Russia
| | - M J Pérez Elías
- Infectious Diseases Hospital Ramón y Cajal, IRYCIS, University of Alcalá de Henares, Madrid, Spain
| | - J Rymer
- Guy's and St Thomas's Hospitals, King's College London, London, UK
| | - M Boffito
- Imperial College London, St. Stephen's Centre, Chelsea and Westminster Hospital, London, UK
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9
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Kowalska JD, Aebi-Popp K, Loutfy M, Post FA, Perez-Elias MJ, Johnson M, Mulcahy F. Promoting high standards of care for women living with HIV: position statement from the Women Against Viruses in Europe Working Group. HIV Med 2017; 19:167-173. [PMID: 29159861 DOI: 10.1111/hiv.12565] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Gender-related factors can influence management decisions, treatment outcomes and the overall long-term wellbeing of people living with HIV (PLWH). The Women Against Viruses in Europe (WAVE) Working Group was established to promote the health and wellbeing of women living with HIV (WLWH). WAVE is part of the European AIDS Clinical Society (EACS) and organizes annual workshops to discuss different issues in the management of WLWH. METHODS In 2016, 34 WAVE members including community representatives, HIV clinicians and researchers met to discuss standards of care for WLWH and to review current guidelines. Participants focused on three different themes: (1) access to and engagement and retention in care; (2) monitoring of women on antiretroviral therapy and management of comorbidities; and (3) review of EACS treatment guidelines. RESULTS Five priority areas for optimizing the care of WLWH were identified: (1) psychosocial aspects of HIV diagnosis and care; (2) mental health and wellbeing; (3) pharmacokinetics, toxicity and tolerability of antiretroviral therapy; (4) coinfections and comorbidities; and (5) sexual and reproductive health. WAVE recommendations are provided for each of these areas, and gaps in knowledge and needs for changes in currently existing standards are discussed. CONCLUSIONS This position statement provides an overview of the key recommendations to optimize the care of WLWH that emerged during the 2016 WAVE workshop.
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Affiliation(s)
- J D Kowalska
- HIV Out-patients Clinic, Hospital for Infectious Diseases, Medical University of Warsaw, Warsaw, Poland.,Department of Adults' Infectious Diseases, Medical University of Warsaw, Warsaw, Poland
| | - K Aebi-Popp
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - M Loutfy
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - F A Post
- Department of Sexual Health and HIV, King's College Hospital NHS Foundation Trust, London, UK
| | - M J Perez-Elias
- Department of Infectious Diseases, Hospital Ramón y Cajal, Intituto de Investigación Ramón y RYCIS, Alcala de Henares University, Madrid, Spain
| | - M Johnson
- Royal Free London NHS Foundation Trust, London, UK
| | - F Mulcahy
- Department of Genito Urinary Medicine and Infectious Diseases, Saint James's Hospital, Dublin, Ireland
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10
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Patterson S, Jose S, Samji H, Cescon A, Ding E, Zhu J, Anderson J, Burchell AN, Cooper C, Hill T, Hull M, Klein MB, Loutfy M, Martin F, Machouf N, Montaner J, Nelson M, Raboud J, Rourke SB, Tsoukas C, Hogg RS, Sabin C. A tale of two countries: all-cause mortality among people living with HIV and receiving combination antiretroviral therapy in the UK and Canada. HIV Med 2017; 18:655-666. [PMID: 28440036 PMCID: PMC5600099 DOI: 10.1111/hiv.12505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2017] [Indexed: 01/13/2023]
Abstract
Objectives We sought to compare all‐cause mortality of people living with HIV and accessing care in Canada and the UK. Methods Individuals from the Canadian Observational Cohort (CANOC) collaboration and UK Collaborative HIV Cohort (UK CHIC) study who were aged ≥ 18 years, had initiated antiretroviral therapy (ART) for the first time between 2000 and 2012 and who had acquired HIV through sexual transmission were included in the analysis. Cox regression was used to investigate the difference in mortality risk between the two cohort collaborations, accounting for loss to follow‐up as a competing risk. Results A total of 19 960 participants were included in the analysis (CANOC, 4137; UK CHIC, 15 823). CANOC participants were more likely to be older [median age 39 years (interquartile range (IQR): 33, 46 years) vs. 36 years (IQR: 31, 43 years) for UK CHIC participants], to be male (86 vs. 73%, respectively), and to report men who have sex with men (MSM) sexual transmission risk (72 vs. 56%, respectively) (all P < 0.001). Overall, 762 deaths occurred during 98 798 person‐years (PY) of follow‐up, giving a crude mortality rate of 7.7 per 1000 PY [95% confidence interval (CI): 7.1, 8.3 per 1000 PY]. The crude mortality rates were 8.6 (95% CI: 7.4, 10.0) and 7.5 (95% CI: 6.9, 8.1) per 1000 PY among CANOC and UK CHIC study participants, respectively. No statistically significant difference in mortality risk was observed between the cohort collaborations in Cox regression accounting for loss to follow‐up as a competing risk (adjusted hazard ratio 0.86; 95% CI: 0.72–1.03). Conclusions Despite differences in national HIV care provision and treatment guidelines, mortality risk did not differ between CANOC and UK CHIC study participants who acquired HIV through sexual transmission.
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Affiliation(s)
- S Patterson
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - S Jose
- Research Department of Infection and Population Health, University College London, London, UK
| | - H Samji
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - A Cescon
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - E Ding
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - J Zhu
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - J Anderson
- Homerton University Hospital NHS Trust, London, UK
| | - A N Burchell
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - C Cooper
- The Ottawa Hospital Division of Infectious Diseases, University of Ottawa, Ottawa, ON, Canada
| | - T Hill
- Research Department of Infection and Population Health, University College London, London, UK
| | - M Hull
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - M B Klein
- Faculty of Medicine, McGill University, Montreal, QC, Canada.,The Montreal Chest Institute, McGill University Health Centre, Montreal, QC, Canada
| | - M Loutfy
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Maple Leaf Medical Clinic, Toronto, ON, Canada.,Women's College Research Institute, Toronto, ON, Canada
| | - F Martin
- York Teaching Hospital NHS Foundation Trust, York, UK
| | - N Machouf
- Clinique Medicale l'Actuel, Montreal, QC, Canada
| | - Jsg Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - M Nelson
- Chelsea and Westminster Hospital NHS Trust, London, UK
| | - J Raboud
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - S B Rourke
- Ontario HIV Treatment Network, Toronto, ON, Canada
| | - C Tsoukas
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - R S Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - C Sabin
- Research Department of Infection and Population Health, University College London, London, UK
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11
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Kesselring S, Cescon A, Colley G, Osborne C, Zhang W, Raboud JM, Hosein SR, Burchell AN, Cooper C, Klein MB, Loutfy M, Machouf N, Montaner J, Rachlis A, Tsoukas C, Hogg RS, Lima VD. Quality of initial HIV care in Canada: extension of a composite programmatic assessment tool for HIV therapy. HIV Med 2016; 18:151-160. [PMID: 27385643 DOI: 10.1111/hiv.12409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To document the quality of initial HIV care in Canada using the Programmatic Compliance Score (PCS), to explore the association of the PCS with mortality, and to identify factors associated with higher quality of care. METHODS We analysed data from the Canadian Observational Cohort Collaboration (CANOC), a multisite Canadian cohort of HIV-positive adults initiating combination antiretroviral therapy (ART) from 2000 to 2011. PCS indicators of noncompliance with HIV treatment guidelines include: fewer than three CD4 count tests in the first year of ART; fewer than three viral load tests in the first year of ART; no drug resistance testing before initiation; baseline CD4 count < 200 cells/mm3 ; starting a nonrecommended ART regimen; and not achieving viral suppression within 6 months of initiation. Indicators are summed for a score from 0 to 6; higher scores indicate poorer care. Cox regression was used to assess the association between PCS and mortality and ordinal logistic regression was used to explore factors associated with higher quality of care. RESULTS Of the 7460 participants (18% female), the median score was 1.0 (Q1-Q3 1.0-2.0); 21% scored 0 and 8% scored ≥ 4. In multivariable analysis, compared with a score of 0, poorer PCS was associated with mortality for scores > 1 [score = 2: adjusted hazard ratio (AHR) 1.64; 95% confidence interval (CI) 1.13-2.36; score = 3: AHR 2.02; 95% CI 1.38-2.97; score ≥ 4: AHR 2.14; 95% CI 1.43-3.21], after adjustments for age, sex, province, ART start year, hepatitis C virus (HCV) coinfection, and baseline viral load. Women, individuals with HCV coinfection, younger people, and individuals starting ART earlier (2000-2003) had poorer scores. CONCLUSIONS Our findings further validate the PCS as a predictor of all-cause mortality. Disparities identified suggest that further efforts are needed to ensure that care is equitably accessible.
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Affiliation(s)
- S Kesselring
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - A Cescon
- Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - G Colley
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - C Osborne
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - W Zhang
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - J M Raboud
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | | | - A N Burchell
- University of Toronto, Toronto, ON, Canada.,Ontario HIV Treatment Network, Toronto, ON, Canada
| | - C Cooper
- University of Ottawa, Ottawa, ON, Canada
| | - M B Klein
- McGill University, Montreal, QC, Canada
| | - M Loutfy
- University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Toronto, ON, Canada.,Maple Leaf Medical Clinic, Toronto, ON, Canada
| | - N Machouf
- Clinique médicale l'Actuel, Montreal, QC, Canada
| | - Jsg Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,University of British Columbia, Vancouver, BC, Canada
| | - A Rachlis
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - C Tsoukas
- McGill University, Montreal, QC, Canada
| | - R S Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Simon Fraser University, Burnaby, BC, Canada
| | - V D Lima
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,University of British Columbia, Vancouver, BC, Canada
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Tremblay C, Trottier B, Rachlis A, Baril J, Loutfy M, Lalonde R, Sampalis J, Boulerice F. Treatment Durability, Effectiveness, and Safety with Atazanavir/Ritonavir-Based HAART Regimen in Treatment-Naïve HIV-lnfected Patients. HIV Clinical Trials 2015; 12:151-60. [DOI: 10.1310/hct1203-151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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13
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Moses E, Blitz S, Raboud J, Singer J, Loutfy M, Smaill F, Walmsley S, Money D. P3.209 Low Rates of STI Co Infection Observed in HIV Positive Women Participating in an HPV Vaccine Study In Canada. Br J Vener Dis 2013. [DOI: 10.1136/sextrans-2013-051184.0666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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14
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Sadaka M, Loutfy M, Sobhy M. Partial revascularization plus medical treatment versus medical treatment alone in patients with multivessel coronary artery disease not eligible for CABG. Egypt Heart J 2013. [DOI: 10.1016/j.ehj.2012.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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15
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Kim CJ, Nazli A, Rojas OL, Chege D, Alidina Z, Huibner S, Mujib S, Benko E, Kovacs C, Shin LYY, Grin A, Kandel G, Loutfy M, Ostrowski M, Gommerman JL, Kaushic C, Kaul R. A role for mucosal IL-22 production and Th22 cells in HIV-associated mucosal immunopathogenesis. Mucosal Immunol 2012; 5:670-80. [PMID: 22854709 DOI: 10.1038/mi.2012.72] [Citation(s) in RCA: 142] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Interleukin-22 (IL-22) is a cytokine with epithelial reparative and regenerative properties that is produced by Th22 cells and by other immune cell subsets. Therefore, we explored the hypothesis that disruption of the gut barrier during HIV infection involves dysregulation of these cells in the gastrointestinal mucosa. Sigmoid IL-22-producing T cell and Th22 cells were dramatically depleted during chronic HIV infection, epithelial integrity was compromised, and microbial translocation was increased. These alterations were reversed after long-term antiretroviral therapy. While all mucosal IL-22-producing T-cell subsets were also depleted very early during HIV infection, at these early stages IL-22 production by non-T-cell populations (including NKp44+ cells) was increased and gut epithelial integrity was maintained. Circulating Th22 cells expressed a higher level of the HIV co-receptor/binding molecules CCR5 and α4β7 than CD4+ T-cell subsets in HIV-uninfected participants, but this was not the case after HIV infection. Finally, recombinant IL-22 was protective against HIV and tumor necrosis factor-α-induced gut epithelial damage in a validated in vitro gut epithelial system. We conclude that reduced IL-22 production and Th22 depletion in the gut mucosa are important factors in HIV mucosal immunopathogenesis.
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MESH Headings
- Anti-HIV Agents/pharmacology
- Anti-HIV Agents/therapeutic use
- Cell Lineage
- Colon, Sigmoid/immunology
- Colon, Sigmoid/pathology
- Colon, Sigmoid/virology
- HIV/physiology
- HIV Infections/drug therapy
- HIV Infections/immunology
- HIV Infections/pathology
- HIV Infections/virology
- Humans
- Immunity, Mucosal
- Interleukins/deficiency
- Interleukins/immunology
- Interleukins/pharmacology
- Intestinal Mucosa/drug effects
- Intestinal Mucosa/immunology
- Intestinal Mucosa/pathology
- Intestinal Mucosa/virology
- Killer Cells, Natural/immunology
- Killer Cells, Natural/pathology
- Killer Cells, Natural/virology
- Lymphocyte Count
- Lymphocyte Depletion
- Receptors, CCR5/immunology
- Recombinant Proteins/immunology
- Recombinant Proteins/pharmacology
- T-Lymphocytes, Helper-Inducer/immunology
- T-Lymphocytes, Helper-Inducer/pathology
- T-Lymphocytes, Helper-Inducer/virology
- Time Factors
- Tumor Necrosis Factor-alpha/immunology
- Tumor Necrosis Factor-alpha/pharmacology
- Interleukin-22
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Affiliation(s)
- C J Kim
- Department of Medicine, University of Toronto, Ontario, Canada.
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16
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Zhang Y, Yudin M, Raboud J, Shapiro H, Margolese S, Loutfy M. Desires, demand, perceptions, and knowledge of assisted reproductive technologies of HIV-positive women of reproductive age in ontario, Canada. Fertil Steril 2011. [DOI: 10.1016/j.fertnstert.2011.07.1017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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17
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Hornberger J, Rajagopalan R, Shewade A, Loutfy M. Cost consequences of HIV-associated lipoatrophy. J Int AIDS Soc 2008. [DOI: 10.1186/1758-2652-11-s1-p318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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18
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Kamel MI, Rashed S, Foda N, Mohie A, Loutfy M. Gender differences in health care utilization and outcome of respiratory tuberculosis in Alexandria. East Mediterr Health J 2003. [DOI: 10.26719/2003.9.4.741] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A study of gender differences in health care utilization and outcome of respiratory tuberculosis was carried out in Alexandria, Egypt. A cohort of 334 patients was followed-up for 8 months; 69.2% of cases were males. The pattern of tuberculosis symptoms was similar for both sexes. Women started treatment earlier than men. Women had significantly lower scores in knowledge, beliefs and attitudes about tuberculosis than men. Compliance was unsatisfactory for both sexes. Men tended to be more adherent to drugs and to sputum and X-ray examinations but there were no sex differences in compliance with health education and medical examinations. No significant sex differences in treatment outcome were found: the overall cure rate was 60.5% and treatment failure was 4.8%. Multiple regression analysis showed satisfaction with medical care was the only significant predictor of treatment failure
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19
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Kamel MI, Rashed S, Foda N, Mohie A, Loutfy M. Gender differences in health care utilization and outcome of respiratory tuberculosis in Alexandria. East Mediterr Health J 2003; 9:741-56. [PMID: 15748071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
A study of gender differences in health care utilization and outcome of respiratory tuberculosis was carried out in Alexandria, Egypt. A cohort of 334 patients was followed-up for 8 months; 69.2% of cases were males. The pattern of tuberculosis symptoms was similar for both sexes. Women started treatment earlier than men. Women had significantly lower scores in knowledge, beliefs and attitudes about tuberculosis than men. Compliance was unsatisfactory for both sexes. Men tended to be more adherent to drugs and to sputum and X-ray examinations but there were no sex differences in compliance with health education and medical examinations. No significant sex differences in treatment outcome were found: the overall cure rate was 60.5% and treatment failure was 4.8%. Multiple regression analysis showed satisfaction with medical care was the only significant predictor of treatment failure.
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Affiliation(s)
- M I Kamel
- Department of Community Medicine, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
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