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Ma J, Luu B, Ruderman SA, Whitney BM, Merrill JO, Mixson LS, Nance RM, Drumright LN, Hahn AW, Fredericksen RJ, Chander G, Lau B, McCaul ME, Safren S, O'Cleirigh C, Cropsey K, Mayer KH, Mathews WC, Moore RD, Napravnik S, Christopoulos K, Willig A, Jacobson JM, Webel A, Burkholder G, Mugavero MJ, Saag MS, Kitahata MM, Crane HM, Delaney JAC. Alcohol and drug use severity are independently associated with antiretroviral adherence in the current treatment era. AIDS Care 2024; 36:618-630. [PMID: 37419138 PMCID: PMC10771542 DOI: 10.1080/09540121.2023.2223899] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 06/05/2023] [Indexed: 07/09/2023]
Abstract
Substance use in people with HIV (PWH) negatively impacts antiretroviral therapy (ART) adherence. However, less is known about this in the current treatment era and the impact of specific substances or severity of substance use. We examined the associations of alcohol, marijuana, and illicit drug use (methamphetamine/crystal, cocaine/crack, illicit opioids/heroin) and their severity of use with adherence using multivariable linear regression in adult PWH in care between 2016 and 2020 at 8 sites across the US. PWH completed assessments of alcohol use severity (AUDIT-C), drug use severity (modified ASSIST), and ART adherence (visual analogue scale). Among 9400 PWH, 16% reported current hazardous alcohol use, 31% current marijuana use, and 15% current use of ≥1 illicit drugs. In multivariable analysis, current methamphetamine/crystal use, particularly common among men who had sex with men, was associated with 10.1% lower mean ART adherence (p < 0.001) and 2.6% lower adherence per 5-point higher severity of use (ASSIST score) (p < 0.001). Current and more severe use of alcohol, marijuana, and other illicit drugs were also associated with lower adherence in a dose-dependent manner. In the current HIV treatment era, individualized substance use treatment, especially for methamphetamine/crystal, and ART adherence should be prioritized.
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Affiliation(s)
- J Ma
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - B Luu
- Department of Medicine, University of Toronto, Toronto, Canada
| | - S A Ruderman
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - B M Whitney
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - J O Merrill
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - L S Mixson
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - R M Nance
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - L N Drumright
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA
| | - A W Hahn
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - R J Fredericksen
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - G Chander
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - B Lau
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - M E McCaul
- Department of Psychiatry, Johns Hopkins University, Baltimore, MD, USA
| | - S Safren
- Department of Psychology, University of Miami, Miami, FL, USA
| | - C O'Cleirigh
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychology, Harvard Medical School, Boston, MA, USA
| | - K Cropsey
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - K H Mayer
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- The Fenway Institute, Boston, MA, USA
| | - W C Mathews
- Department of Medicine, University of California, San Diego, CA, USA
| | - R D Moore
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - S Napravnik
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - K Christopoulos
- Department of Medicine, University of California, San Francisco, CA, USA
| | - A Willig
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J M Jacobson
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - A Webel
- Department of Child, Family, and Population Health Nursing, Unviersity of Washington, Seattle, WA, USA
| | - G Burkholder
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - M J Mugavero
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - M S Saag
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - M M Kitahata
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - H M Crane
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - J A C Delaney
- Department of Medicine, University of Washington, Seattle, WA, USA
- College of Pharmacy, University of Manitoba, Winnipeg, Canada
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Fredericksen RJ, Baker R, Sibley A, Estadt AT, Colston D, Mixson LS, Walters S, Bresett J, Levander XA, Leichtling G, Davy-Mendez T, Powell M, Stopka TJ, Pho M, Feinberg J, Ezell J, Zule W, Seal D, Cooper HLF, Whitney BM, Delaney JAC, Crane HM, Tsui JI. Motivation and context of concurrent stimulant and opioid use among persons who use drugs in the rural United States: a multi-site qualitative inquiry. Harm Reduct J 2024; 21:74. [PMID: 38561753 PMCID: PMC10985853 DOI: 10.1186/s12954-024-00986-z] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 03/12/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND In recent years, stimulant use has increased among persons who use opioids in the rural U.S., leading to high rates of overdose and death. We sought to understand motivations and contexts for stimulant use among persons who use opioids in a large, geographically diverse sample of persons who use drugs (PWUD) in the rural settings. METHODS We conducted semi-structured individual interviews with PWUD at 8 U.S. sites spanning 10 states and 65 counties. Content areas included general substance use, injection drug use, changes in drug use, and harm reduction practices. We used an iterative open-coding process to comprehensively itemize and categorize content shared by participants related to concurrent use. RESULTS We interviewed 349 PWUD (64% male, mean age 36). Of those discussing current use of stimulants in the context of opioid use (n = 137, 39%), the stimulant most used was methamphetamine (78%) followed by cocaine/crack (26%). Motivations for co-use included: 1) change in drug markets and cost considerations; 2) recreational goals, e.g., seeking stronger effects after heightened opioid tolerance; 3) practical goals, such as a desire to balance or alleviate the effects of the other drug, including the use of stimulants to avoid/reverse opioid overdose, and/or control symptoms of opioid withdrawal; and 4) functional goals, such as being simultaneously energized and pain-free in order to remain productive for employment. CONCLUSION In a rural U.S. cohort of PWUD, use of both stimulants and opioids was highly prevalent. Reasons for dual use found in the rural context compared to urban studies included changes in drug availability, functional/productivity goals, and the use of methamphetamine to offset opioid overdose. Education efforts and harm reduction services and treatment, such as access to naloxone, fentanyl test strips, and accessible drug treatment for combined opioid and stimulant use, are urgently needed in the rural U.S. to reduce overdose and other adverse outcomes.
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Affiliation(s)
| | - R Baker
- Oregon Health & Science University, Portland, USA
| | - A Sibley
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - A T Estadt
- The Ohio State University, Colombus, USA
| | - D Colston
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | | | | | - J Bresett
- Southern Illinois University School of Medicine, Springfield, USA
| | - X A Levander
- Oregon Health & Science University, Portland, USA
| | | | - T Davy-Mendez
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - M Powell
- University of Washington, Seattle, USA
| | - T J Stopka
- Tufts University School of Medicine, Department of Public Health and Community Medicine, Medford, USA
| | - M Pho
- University of Chicago, Chicago, USA
| | - J Feinberg
- West Virginia University, Morgantown, USA
| | - J Ezell
- Cornell University, Ithaca, USA
| | - W Zule
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - D Seal
- Tulane University, New Orleans, USA
| | | | | | | | - H M Crane
- University of Washington, Seattle, USA
| | - J I Tsui
- University of Washington, Seattle, USA
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Stopka TJ, Estadt AT, Leichtling G, Schleicher JC, Mixson LS, Bresett J, Romo E, Dowd P, Walters SM, Young AM, Zule W, Friedmann PD, Go VF, Baker R, Fredericksen RJ. Barriers to opioid use disorder treatment among people who use drugs in the rural United States: A qualitative, multi-site study. Soc Sci Med 2024; 346:116660. [PMID: 38484417 PMCID: PMC10997882 DOI: 10.1016/j.socscimed.2024.116660] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/26/2023] [Accepted: 02/05/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND In 2020, 2.8 million people required substance use disorder (SUD) treatment in nonmetropolitan or 'rural' areas in the U.S. Among this population, only 10% received SUD treatment from a specialty facility, and 1 in 500 received medication for opioid use disorder (MOUD). We explored the context surrounding barriers to SUD treatment in the rural United States. METHODS We conducted semi-structured, in-depth interviews from 2018 to 2019 to assess barriers to SUD treatment among people who use drugs (PWUD) across seven rural U.S. study sites. Using the social-ecological model (SEM), we examined individual, interpersonal, organizational, community, and policy factors contributing to perceived barriers to SUD treatment. We employed deductive and inductive coding and analytical approaches to identify themes. We also calculated descriptive statistics for participant characteristics and salient themes. RESULTS Among 304 participants (55% male, mean age 36 years), we identified barriers to SUD treatment in rural areas across SEM levels. At the individual/interpersonal level, relevant themes included: fear of withdrawal, the need to "get things in order" before entering treatment, close-knit communities and limited confidentiality, networks and settings that perpetuated drug use, and stigma. Organizational-level barriers included: strict facility rules, treatment programs managed like corrections facilities, lack of gender-specific treatment programs, and concerns about jeopardizing employment. Community-level barriers included: limited availability of treatment in local rural communities, long distances and limited transportation, waitlists, and a lack of information about treatment options. Policy-level themes included insurance challenges and system-imposed barriers such as arrest and incarceration. CONCLUSION Our findings highlight multi-level barriers to SUD treatment in rural U.S. communities. Salient barriers included the need to travel long distances to treatment, challenges to confidentiality due to small, close-knit communities where people are highly familiar with one another, and high-threshold treatment program practices. Our findings point to the need to facilitate the elimination of treatment barriers at each level of the SEM in rural America.
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Affiliation(s)
- T J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA.
| | - A T Estadt
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | | | - J C Schleicher
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Medicine, Madison, WI, USA
| | - L S Mixson
- University of Washington, Department of Medicine, Seattle, WA, USA
| | - J Bresett
- Southern Illinois University at Carbondale, Dept of Public Health, Carbondale, IL, USA
| | - E Romo
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - P Dowd
- Chan Medical School-Baystate, University of Massachusetts, Springfield, MA, USA
| | - S M Walters
- New York University's Grossman School of Medicine, New York, NY, USA
| | - A M Young
- College of Public Health, University of Kentucky, Lexington, KY, USA
| | - W Zule
- RTI International, Research Triangle, NC, USA
| | - P D Friedmann
- Chan Medical School-Baystate, University of Massachusetts, Springfield, MA, USA
| | - V F Go
- University, of North Carolina, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - R Baker
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | - R J Fredericksen
- University of Washington, Department of Medicine, Seattle, WA, USA
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Fredericksen RJ, Fitzsimmons E, Drumright LN, Loo S, Dougherty S, Brown S, Pearce J, Nance RM, Whitney BM, Ruderman S, O'Cleirigh C, Cropsey K, Mayer KH, Mugavero MJ, Delaney JAC, Crane HM, Hahn A. Vaporized nicotine use among patients in HIV care who smoke tobacco: perceived health effects and effectiveness as a smoking cessation tool. AIDS Care 2023; 35:1741-1748. [PMID: 36912767 PMCID: PMC10497704 DOI: 10.1080/09540121.2023.2180476] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 01/13/2023] [Indexed: 03/14/2023]
Abstract
Evidence suggests adverse health effects from vaporized nicotine (VN) use, such as electronic "e" cigarettes, and limited efficacy to aid tobacco cessation. People with HIV (PWH) smoke tobacco at higher rates than the general population, with greater morbidity, highlighting the necessity of effective tobacco cessation tools. PWH may be more vulnerable to adverse effects of VN. Using semi-structured 1:1 interviews, we examined health beliefs regarding VN, patterns of use, and perceived effectiveness for tobacco cessation among PWH in HIV care at three geographically diverse U.S. sites. PWH (n = 24) had limited understanding of VN product content or health effects, presuming VN less harmful than tobacco cigarettes (TC). VN failed to adequately replicate the psychoactive effects or desired ritual of smoking TC. Concurrent TC use, and continuous VN use throughout the day, was common. Satiety using VN was elusive, and consumption quantity was difficult to track. VN had limited desirability and durability as a TC cessation tool among the interviewed PWH.
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Affiliation(s)
| | - E Fitzsimmons
- Department of Medicine, University of Washington, Seattle, USA
| | - L N Drumright
- Department of Medicine, University of Washington, Seattle, USA
| | - S Loo
- Fenway Community Health, Boston, USA
| | - S Dougherty
- Department of Medicine, University of Alabama-Birmingham, Birmingham, AL, USA
| | - S Brown
- Department of Medicine, University of Washington, Seattle, USA
| | - J Pearce
- Department of Medicine, University of Washington, Seattle, USA
| | - R M Nance
- Department of Medicine, University of Washington, Seattle, USA
| | - B M Whitney
- Department of Medicine, University of Washington, Seattle, USA
| | - S Ruderman
- Department of Medicine, University of Washington, Seattle, USA
| | | | - K Cropsey
- Fenway Community Health, Boston, USA
| | - K H Mayer
- Fenway Community Health, Boston, USA
| | - M J Mugavero
- Department of Medicine, University of Alabama-Birmingham, Birmingham, AL, USA
| | - J A C Delaney
- Department of Medicine, University of Washington, Seattle, USA
| | - H M Crane
- Department of Medicine, University of Washington, Seattle, USA
| | - A Hahn
- Department of Medicine, University of Washington, Seattle, USA
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5
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Fredericksen RJ, Whitney BM, Trejo E, Nance RM, Fitzsimmons E, Altice FL, Carrico AW, Cleland CM, Del Rio C, Duerr A, El-Sadr WM, Kahana S, Kuo I, Mayer K, Mehta S, Ouellet LJ, Quan VM, Rich J, Seal DW, Springer S, Taxman F, Wechsberg W, Crane HM, Delaney JAC. Individual and poly-substance use and condomless sex among HIV-uninfected adults reporting heterosexual sex in a multi-site cohort. BMC Public Health 2021; 21:2002. [PMID: 34736425 PMCID: PMC8567631 DOI: 10.1186/s12889-021-12026-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/15/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND We analyzed the association between substance use (SU) and condomless sex (CS) among HIV-negative adults reporting heterosexual sex in the Seek, Test, Treat, and Retain (STTR) consortium. We describe the impact of SU as well as person/partner and context-related factors on CS, identifying combinations of factors that indicate the highest likelihood of CS. METHODS We analyzed data from four US-based STTR studies to examine the effect of SU on CS using two SU exposures: 1) recent SU (within 3 months) and 2) SU before/during sex. Behavioral data were collected via 1:1 or self-administered computerized interviews. Adjusted individual-study, multivariable relative risk regression was used to examine the relationship between CS and SU. We also examined interactions with type of sex and partner HIV status. Pooled effect estimates were calculated using traditional fixed-effects meta-analysis. We analyzed data for recent SU (n = 6781; 82% men, median age = 33 years) and SU before/during sex (n = 2915; 69% men, median age = 40 years). RESULTS For both exposure classifications, any SU other than cannabis increased the likelihood of CS relative to non-SU (8-16%, p-values< 0.001). In the recent SU group, however, polysubstance use did not increase the likelihood of CS compared to single-substance use. Cannabis use did not increase the likelihood of CS, regardless of frequency of use. Type of sex was associated with CS; those reporting vaginal and anal sex had a higher likelihood of CS compared to vaginal sex only for both exposure classifications (18-21%, p < 0.001). Recent SU increased likelihood of CS among those reporting vaginal sex only (9-10%, p < 0.001); results were similar for those reporting vaginal and anal sex (5-8%, p < 0.01). SU before/during sex increased the likelihood of CS among those reporting vaginal sex only (20%; p < 0.001) and among those reporting vaginal and anal sex (7%; p = 0.002). Single- and poly-SU before/during sex increased the likelihood of CS for those with exclusively HIV-negative partners (7-8%, p ≤ 0.02), and for those reporting HIV-negative and HIV-status unknown partners (9-13%, p ≤ 0.03). CONCLUSION Except for cannabis, any SU increased the likelihood of CS. CS was associated with having perceived HIV-negative partners and with having had both anal/vaginal sex.
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Affiliation(s)
- R. J. Fredericksen
- UW Center for AIDS Research, Harborview Medical Center, 325 Ninth Avenue, Box 359931, Seattle, WA 98104-2499 USA
| | - B. M. Whitney
- UW Center for AIDS Research, Harborview Medical Center, 325 Ninth Avenue, Box 359931, Seattle, WA 98104-2499 USA
| | - E. Trejo
- UW Center for AIDS Research, Harborview Medical Center, 325 Ninth Avenue, Box 359931, Seattle, WA 98104-2499 USA
| | - R. M. Nance
- UW Center for AIDS Research, Harborview Medical Center, 325 Ninth Avenue, Box 359931, Seattle, WA 98104-2499 USA
| | - E. Fitzsimmons
- UW Center for AIDS Research, Harborview Medical Center, 325 Ninth Avenue, Box 359931, Seattle, WA 98104-2499 USA
| | - F. L. Altice
- Yale University AIDS Program, 135 College Street, Suite 323, New Haven, CT 06510-2283 USA
| | - A. W. Carrico
- Division of Prevention Science and Community Health, University of Miami, 1120 NW 14th St, Miami, FL 33136 USA
| | - C. M. Cleland
- Center for Drug Use and HIV Research, NYU School of Global Public Health, 665 Broadway, 11th Floor, New York, NY 10012 USA
| | - C. Del Rio
- Rollins School of Public Health, Emory University, 1518 Clifton Road, NE Room 7011, Atlanta, GA 30322 USA
| | - A. Duerr
- Fred Hutchinson Cancer Research Center, HIV Vaccine Trials Network, Box 358080 (LE 500), Seattle, WA 98109 USA
| | - W. M. El-Sadr
- Mailman School of Public Health, Columbia University, 722 West 168th Street, 13th floor, New York, NY 10032 USA
| | - S. Kahana
- National Institute on Drug Abuse, 6001 Executive Blvd, Rockville, Maryland 20852 USA
| | - I. Kuo
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave NW #2, Washington, DC 20052 USA
| | - K. Mayer
- The Fenway Institute, 1340 Boylston Street, Boston, MA 02215 USA
| | - S. Mehta
- Johns Hopkins University, Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, Maryland 21205 USA
| | - L. J. Ouellet
- School of Public Health, University of Illinois at Chicago, 1603 W. Taylor St, Chicago, IL USA
| | - V. M. Quan
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, 615 N. Wolfe Street, Baltimore, Maryland 21205 USA
| | - J. Rich
- Center for Prisoner Health and Human Rights, Immunology Center, The Miriam Hospital, Warren Alpert Medical School, Brown University, 1125 North Main St, Providence, RI 02904 USA
| | - D. W. Seal
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, 1440 Canal St, Suite 2200, New Orleans, LA 70112 USA
| | - S. Springer
- Department of Internal Medicine, School of Medicine, Yale University, 135 College Street, New Haven, CT 06510 USA
| | - F. Taxman
- Center for Advancing Correctional Excellence, Institute of Biohealth Innovation, George Mason University, 4461 Rockfish Creek Lane, Fairfax, VA 22030 USA
| | - W. Wechsberg
- Department of Health Policy and Management, Gillings School of Public Health, University of North Carolina Chapel Hill, 135 Dauer Dr, Chapel Hill, NC 27599 USA
| | - H. M. Crane
- UW Center for AIDS Research, Harborview Medical Center, 325 Ninth Avenue, Box 359931, Seattle, WA 98104-2499 USA
| | - J. A. C. Delaney
- College of Pharmacy, University of Manitoba, Apotex Centre, 750 McDermot Avenue, Winnipeg, Manitoba R3E 0T5 Canada
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Fredericksen RJ, Nance RM, Whitney BM, Harding BN, Fitzsimmons E, Del Rio C, Eron J, Feaster DJ, Kalokhe AS, Mathews WC, Mayer KH, Metsch LR, Mugavero MJ, Potter J, O'Cleirigh C, Napravnik S, Rodriguez B, Ruderman S, Jac D, Crane HM. Correlates of psychological intimate partner violence with HIV care outcomes on patients in HIV care. BMC Public Health 2021; 21:1824. [PMID: 34627181 PMCID: PMC8502266 DOI: 10.1186/s12889-021-11854-x] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/24/2021] [Indexed: 11/27/2022] Open
Abstract
Background Among people living with HIV (PLWH), physical intimate partner violence (IPV) is associated with poor virologic, psychiatric, and behavioral outcomes. We examined non-physical, psychological intimate partner violence (psy-IPV) and HIV care outcomes using data from two U.S. consortia. Methods We conducted multivariable analyses with robust standard errors to compare patients indicating/not indicating psy-IPV. Results Among PLWH (n = 5950), 9.5% indicated psy-IPV; these individuals were younger (− 3; 95% CI [− 2,-4], p-value < 0.001), less likely to be on antiretroviral treatment (ART) (0.73 [0.55,0.97], p = 0.03), less adherent to ART (− 4.2 [− 5.9,-2.4], p < 0.001), had higher odds of detectable viral load (1.43 [1.15,1.78], p = 0.001) and depression (2.63 [2.18,3.18], p < 0.001), and greater use of methamphetamines/crystal [2.98 (2.30,3.87),p < 0.001], cocaine/crack [1.57 (1.24,1.99),p < 0.001], illicit opioids [1.56 (1.13,2.16),p = 0.007], and marijuana [1.40 (1.15,1.70), p < 0.001]. Conclusion Psychological IPV, even in the absence of physical or sexual IPV, appears to be associated with HIV care outcomes and should be included in IPV measures integrated into routine HIV care. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11854-x.
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Affiliation(s)
- R J Fredericksen
- Department of Medicine, University of Washington, Seattle, Washington, USA.
| | - R M Nance
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - B M Whitney
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - B N Harding
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - E Fitzsimmons
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - C Del Rio
- Department of Global Health, Emory University, Atlanta, Georgia
| | - J Eron
- School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - D J Feaster
- Department of Public Health Sciences, University of Miami, Miami, Florida, USA
| | - A S Kalokhe
- Department of Medicine, Emory University, Atlanta, Georgia
| | - W C Mathews
- Department of Medicine, University of California - San Diego, San Diego, California, USA
| | - K H Mayer
- The Fenway Institute, Boston, MA, USA
| | - L R Metsch
- Department of Sociomedical Sciences, Columbia University, New York, NY, USA
| | - M J Mugavero
- Department of Medicine, University of Alabama - Birmingham, Birmingham, AL, USA
| | - J Potter
- Department of Medicine, Harvard University, Cambridge, MA, USA
| | - C O'Cleirigh
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - S Napravnik
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - B Rodriguez
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - S Ruderman
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Delaney Jac
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, USA
| | - H M Crane
- Department of Medicine, University of Washington, Seattle, Washington, USA
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7
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Fredericksen RJ, Gibbons LE, Fitzsimmons E, Nance RM, Schafer KR, Batey DS, Loo S, Dougherty S, Mathews WC, Christopoulos K, Mayer KH, Mugavero MJ, Kitahata MM, Crane PK, Crane HM. Impact and correlates of sub-optimal social support among patients in HIV care. AIDS Care 2021; 33:1178-1188. [PMID: 33443445 DOI: 10.1080/09540121.2020.1853660] [Citation(s) in RCA: 4] [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] [Indexed: 01/31/2023]
Abstract
Social support (SS) predicts health outcomes among patients living with HIV. We administered a brief, validated measure of SS, the Multifactoral Assessment of Perceived Social Support, within a patient-reported outcomes assessment of health domains in HIV care at 4 U.S. clinics in English and Spanish (n = 708). In univariate analysis, low SS was associated with poorer engagement in care, antiretroviral adherence, and health-related quality of life; current methamphetamine/crystal use, depression, anxiety, and HIV stigma (all p < 0.001); any use of either methamphetamines/crystal, illicit opioids, or cocaine/crack (p = 0.001), current marijuana use (p = 0.012), nicotine use (p = 0.005), and concern for sexually transmitted infection exposure (p = 0.001). High SS was associated with undetectable viral load (p = 0.031). Multivariate analyses found low SS independently associated with depression (risk ratio (RR) 3.72, 95% CI 2.93-4.72), lower adherence (RR 0.76, 95% CI 0.64-0.89), poor engagement in care (RR 2.05, 95% CI 1.44-2.96), and having more symptoms (RR 2.29, 95% CI 1.92-2.75). Medium SS was independently associated with depression (RR 2.59, 95% CI 2.00-3.36), poor engagement in care (RR 1.62, 95% CI 1.15-2.29) and having more symptoms (RR 1.75, 95% CI 1.44-2.13). SS assessment may help identify patients at risk for these outcomes.
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Affiliation(s)
| | - L E Gibbons
- Medicine, University of Washington, Seattle, WA, USA
| | - E Fitzsimmons
- Medicine, University of Washington, Seattle, WA, USA
| | - R M Nance
- Medicine, University of Washington, Seattle, WA, USA
| | - K R Schafer
- Internal Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - D S Batey
- Medicine, University of Alabama, Birmingham, AL, USA
| | - S Loo
- Fenway Community Health, Boston, MA, USA
| | - S Dougherty
- Medicine, University of Alabama, Birmingham, AL, USA
| | - W C Mathews
- Medicine, University of California, San Diego, CA, USA
| | | | - K H Mayer
- Fenway Community Health, Boston, MA, USA
| | - M J Mugavero
- Medicine, University of Alabama, Birmingham, AL, USA
| | - M M Kitahata
- Medicine, University of Washington, Seattle, WA, USA
| | - P K Crane
- Medicine, University of Washington, Seattle, WA, USA
| | - H M Crane
- Medicine, University of Washington, Seattle, WA, USA
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8
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Fredericksen RJ, Harding BN, Ruderman SA, McReynolds J, Barnes G, Lober WB, Fitzsimmons E, Nance RM, Whitney BM, Delaney JAC, Mathews WC, Willig J, Crane PK, Crane HM. Patient acceptability and usability of a self-administered electronic patient-reported outcome assessment in HIV care: relationship with health behaviors and outcomes. AIDS Care 2020; 33:1167-1177. [PMID: 33190523 DOI: 10.1080/09540121.2020.1845288] [Citation(s) in RCA: 1] [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] [Indexed: 10/23/2022]
Abstract
We assessed acceptability/usability of tablet-based patient-reported outcome (PRO) assessments among patients in HIV care, and relationships with health outcomes using a modified Acceptability E-Scale (AES) within a self-administered PRO assessment. Using multivariable linear regression, we measured associations between patient characteristics and continuous combined AES score. Among 786 patients (median age=48; 91% male; 49% white; 17% Spanish-speaking) overall mean score was 26/30 points (SD: 4.4). Mean scores per dimension (max 5, 1=lowest acceptability, 5=highest): ease of use 4.7, understandability 4.7, time burden 4.3, overall satisfaction 4.3, helpfulness describing symptoms/behaviors 4.2, and enjoyability 3.8. Higher overall score was associated with race/ethnicity (+1.3 points/African-American patients (95%CI:0.3-2.3); +1.6 points/Latino patients (95%CI:0.9-2.3) compared to white patients). Patients completing PROs in Spanish scored +2.4 points on average (95%CI:1.6-3.3). Higher acceptability was associated with better quality of life (0.3 points (95%CI:0.2-0.5)) and adherence (0.4 points (95%CI:0.2-0.6)). Lower acceptability was associated with: higher depression symptoms (-0.9 points (95%CI:-1.4 to -0.4)); recent illicit opioid use (-2.0 points (95%CI:-3.9 to -0.2)); multiple recent sex partners (-0.8 points (95%CI:-1.5 to -0.1)). While patients endorsing depression symptoms, recent opioid use, condomless sex, or multiple sex partners found PROs less acceptable, overall, patients found the assessments highly acceptable and easy to use.
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Affiliation(s)
| | | | | | | | - G Barnes
- University of Washington, Seattle, WA, USA
| | - W B Lober
- University of Washington, Seattle, WA, USA
| | | | - R M Nance
- University of Washington, Seattle, WA, USA
| | | | | | - W C Mathews
- University of California at San Diego, San Diego, CA, USA
| | - J Willig
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - P K Crane
- University of Washington, Seattle, WA, USA
| | - H M Crane
- University of Washington, Seattle, WA, USA
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9
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Fredericksen RJ, Yang FM, Gibbons LE, Edwards TC, Brown S, Fitzsimmons E, Alperovitz-Bichell K, Godfrey M, Wang A, Church A, Gutierrez C, Paez E, Dant L, Loo S, Walcott M, Mugavero MJ, Mayer KH, Mathews WC, Patrick DL, Crane PK, Crane HM. Development and content validation of measures assessing adherence barriers and behaviors for use in clinical care. Res Social Adm Pharm 2018; 15:1168-1176. [PMID: 30327183 DOI: 10.1016/j.sapharm.2018.10.001] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 09/26/2018] [Accepted: 10/04/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND Providers are often unaware of poor adherence to prescribed medications for their patients with chronic diseases. OBJECTIVE To develop brief, computer-administered patient-reported measures in English and Spanish assessing adherence behaviors and barriers. Design, Participants, and Main Measures: Item pools were constructed from existing measures of medication adherence behaviors and barriers, which informed development of a patient concept elicitation interview guide to identify medication adherence behavior and barrier-related concepts. Two hundred six patients either living with HIV (PLWH) or without were interviewed. Interviews were coded, concepts matched to item pool content, and new items were developed for novel concepts. A provider/investigator team highlighted clinically relevant items. Cognitive interviews were conducted with patients on final candidate items (n = 37). The instruments were administered to 2081 PLWH. KEY RESULTS Behavioral themes from concept elicitation interviews included routines incorporating time of day, placement, visual cues, and intentionality to miss or skip doses. Barrier themes included health-related (e.g. depressed mood, feeling ill), attitudes/beliefs (e.g., need for medication), access (e.g., cost/insurance problems), and circumstantial barriers (e.g., lack of privacy, disruption of daily routine). The final instruments included 6 behavior items, and 1 barrier item with up to 23 response options. PLWH endorsed a mean (SD) of 3.5 (1.1) behaviors. The 201 PLWH who missed ≥2 doses in the previous week endorsed a mean (SD) of 3.1 (2.5) barriers. The intraclass correlation coefficient (ICC) for the numbers of behaviors endorsed in 61 PLWH after 4-16 days was 0.54 and for the number of barriers for the 20 PLWH with ≥2 missed doses the ICC was 0.89, representing fair and excellent test-retest reliability. CONCLUSION Measures of medication adherence behaviors and barriers were developed for use with patients living with chronic diseases focusing on clinical relevance, brevity, and content validity for use in clinical care.
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Affiliation(s)
- R J Fredericksen
- University of Washington, Center for AIDS Research, 325 Ninth Avenue, Box 359931, Seattle, WA, 98104, USA.
| | - F M Yang
- Augusta University, 1120 15th Street Augusta, GA, 30912, USA
| | - L E Gibbons
- University of Washington, Center for AIDS Research, 325 Ninth Avenue, Box 359931, Seattle, WA, 98104, USA
| | - T C Edwards
- University of Washington, Quality of Life Group, Box 359455, Seattle, WA, 98195, USA
| | - S Brown
- University of Washington, Center for AIDS Research, 325 Ninth Avenue, Box 359931, Seattle, WA, 98104, USA
| | - E Fitzsimmons
- University of Washington, Center for AIDS Research, 325 Ninth Avenue, Box 359931, Seattle, WA, 98104, USA
| | | | - M Godfrey
- Beaufort Jasper Hampton Comprehensive Health Services, 1520 Grays Highway, Ridgeland, SC, 29936, USA
| | - A Wang
- Chase Brexton Health Care, 5500 Knoll N Dr #370, Columbia, MD, 21045, USA
| | - A Church
- University of Washington, Center for AIDS Research, 325 Ninth Avenue, Box 359931, Seattle, WA, 98104, USA
| | - C Gutierrez
- Fenway Community Health, 1340 Boylston Street, Boston, MA, 02215, USA
| | - E Paez
- University of California-San Diego, The Owen Clinic, 4168 Front Street, San Diego, CA, 92103, USA
| | - L Dant
- Fenway Community Health, 1340 Boylston Street, Boston, MA, 02215, USA
| | - S Loo
- Fenway Community Health, 1340 Boylston Street, Boston, MA, 02215, USA
| | - M Walcott
- University of Alabama-Birmingham, 1917 Clinic, Community Care Building, 908 South 20th Street, Birmingham, AL, 35294, USA
| | - M J Mugavero
- University of Alabama-Birmingham, 1917 Clinic, Community Care Building, 908 South 20th Street, Birmingham, AL, 35294, USA
| | - K H Mayer
- Fenway Community Health, 1340 Boylston Street, Boston, MA, 02215, USA
| | - W C Mathews
- University of California-San Diego, The Owen Clinic, 4168 Front Street, San Diego, CA, 92103, USA
| | - D L Patrick
- University of Washington, Quality of Life Group, Box 359455, Seattle, WA, 98195, USA
| | - P K Crane
- University of Washington, Center for AIDS Research, 325 Ninth Avenue, Box 359931, Seattle, WA, 98104, USA
| | - H M Crane
- University of Washington, Center for AIDS Research, 325 Ninth Avenue, Box 359931, Seattle, WA, 98104, USA
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10
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Fredericksen RJ, Gibbons L, Brown S, Edwards TC, Yang FM, Fitzsimmons E, Alperovitz-Bichell K, Godfrey M, Wang A, Church A, Gutierrez C, Paez E, Dant L, Loo S, Walcott M, Mugavero MJ, Mayer K, Mathews WC, Patrick DL, Crane PK, Crane HM. Medication understanding among patients living with multiple chronic conditions: Implications for patient-reported measures of adherence. Res Social Adm Pharm 2017; 14:540-544. [PMID: 28651924 DOI: 10.1016/j.sapharm.2017.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/10/2017] [Accepted: 06/17/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Low health literacy is associated with poor medication adherence and poor health outcomes. Limited understanding of prescribed medications may decrease validity of patient-reported adherence measures. OBJECTIVES To assess knowledge of names and purposes of prescribed medications among patients with multiple chronic conditions. METHODS Individual interviews were conducted with a convenience sample of patients from six U.S. primary care clinics. Participants (n = 57) were English and/or Spanish-speaking patients prescribed 3+ medications for chronic conditions, for which non-adherence may lead to disability or death. In individual interviews, patients were asked to name their medications, explain the purpose of each, and to explain how they distinguish them from one another. Interviews were audio recorded, transcribed, and coded; coded content was quantified by 1) whether or not the patient could name medications; 2) method of categorizing medications; 3) whether or not the purpose of the medication was understood. Descriptive statistics were compiled using Fisher's exact test to determine the relationship between patient knowledge and medication characteristics. RESULTS Thirty percent of patients could not name at least one of their medications; 19% did not know their purpose; 30% held misconceptions about the purpose of one or more medications. There was no significant difference in ability to name medications or state their medication's purpose between patients using medi-sets, pre-packaged rolls, or blister packs, and patients who stored pills in their original containers (p = 0.56 and p = 0.73, respectively), or across demographic groups (p = 0.085 to 0.767). CONCLUSIONS Many patients demonstrated difficulty identifying the name and purpose of prescribed medications; this did not differ by demographic group or medication storage type. Patients may benefit from routine review of medications with their provider in order to improve health literacy, outcomes, and patient-reported adherence measurement.
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Affiliation(s)
| | - L Gibbons
- University of Washington, Center for AIDS Research, USA
| | - S Brown
- University of Washington, Center for AIDS Research, USA
| | - T C Edwards
- University of Washington, Seattle Quality of Life Group, USA
| | | | - E Fitzsimmons
- University of Washington, Center for AIDS Research, USA
| | | | - M Godfrey
- Beaufort Jasper Hampton Comprehensive Health Services, USA
| | - A Wang
- Chase Brexton Health Care, USA
| | - A Church
- University of Washington, Center for AIDS Research, USA
| | | | - E Paez
- University of California at San Diego, USA
| | - L Dant
- Fenway Community Health, USA
| | - S Loo
- Fenway Community Health, USA
| | - M Walcott
- University of Alabama at Birmingham, USA
| | | | - K Mayer
- Fenway Community Health, USA
| | | | - D L Patrick
- University of Washington, Seattle Quality of Life Group, USA
| | - P K Crane
- University of Washington, Center for AIDS Research, USA
| | - H M Crane
- University of Washington, Center for AIDS Research, USA
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11
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Fredericksen RJ, Tufano J, Ralston J, McReynolds J, Stewart M, Lober WB, Mayer KH, Mathews WC, Mugavero MJ, Crane PK, Crane HM. Provider perceptions of the value of same-day, electronic patient-reported measures for use in clinical HIV care. AIDS Care 2016; 28:1428-33. [PMID: 27237187 DOI: 10.1080/09540121.2016.1189501] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 10/21/2022]
Abstract
Strong evidence suggests that patient-reported outcomes (PROs) aid in managing chronic conditions, reduce omissions in care, and improve patient-provider communication. However, provider acceptability of PROs and their use in clinical HIV care is not well known. We interviewed providers (n = 27) from four geographically diverse HIV and community care clinics in the US that have integrated PROs into routine HIV care, querying perceived value, challenges, and use of PRO data. Perceived benefits included the ability of PROs to identify less-observable behaviors and conditions, particularly suicidal ideation, depression, and substance use; usefulness in agenda setting prior to a visit; and reduction of social desirability bias in patient-provider communication. Challenges included initial flow integration issues and ease of interpretation of PRO feedback. Providers value same-day, electronic patient-reported measures for use in clinical HIV care with the condition that PROs are (1) tailored to be the most clinically relevant to their population; (2) well integrated into clinic flow; and (3) easy to interpret, highlighting chief patient concerns and changes over time.
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Affiliation(s)
- R J Fredericksen
- a Center for AIDS Research , University of Washington , Seattle , WA , USA
| | - J Tufano
- b Department of Medicine , University of Washington , Seattle , WA , USA
| | - J Ralston
- c Department of Internal Medicine , Group Health Research Institute , Seattle , WA , USA
| | - J McReynolds
- d Biobehavioral Nursing and Health Systems , University of Washington , Seattle , WA , USA
| | - M Stewart
- d Biobehavioral Nursing and Health Systems , University of Washington , Seattle , WA , USA
| | - W B Lober
- e Biomedical and Health Informatics , University of Washington , Seattle , WA , USA
| | - K H Mayer
- f Fenway Community Health , Boston , MA , USA
| | - W C Mathews
- g Owen Clinic , UCSD Medical Center , San Diego , CA , USA
| | - M J Mugavero
- h Department of Medicine/Infectious Diseases , University of Alabama at Birmingham , Birmingham , AL , USA
| | - P K Crane
- b Department of Medicine , University of Washington , Seattle , WA , USA
| | - H M Crane
- i Department of Medicine, Harborview Medical Center , University of Washington , Seattle , WA , USA
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12
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Feldman BJ, Fredericksen RJ, Crane PK, Safren SA, Mugavero MJ, Willig JH, Simoni JM, Wilson IB, Saag MS, Kitahata MM, Crane HM. Evaluation of the single-item self-rating adherence scale for use in routine clinical care of people living with HIV. AIDS Behav 2013; 17:307-18. [PMID: 23108721 DOI: 10.1007/s10461-012-0326-7] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [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: 11/26/2022]
Abstract
The self-rating scale item (SRSI) is a single-item self-report adherence measure that uses adjectives in a 5-point Likert scale, from "very poor" to "excellent," to describe medication adherence over the past 4 weeks. This study investigated the SRSI in 2,399 HIV-infected patients in routine care at two outpatient primary HIV clinics. Correlations between the SRSI and four commonly used adherence items ranged from 0.37 to 0.64. Correlations of adherence barriers, such as depression and substance use, were comparable across all adherence items. General estimating equations suggested the SRSI is as good as or better than other adherence items (p's <0.001 vs. <0.001-0.99) at predicting adherence-related clinical outcomes, such as HIV viral load and CD4(+) cell count. These results and the SRSI's low patient burden suggest its routine use could be helpful for assessing adherence in clinical care and should be more widespread, particularly where more complex instruments may be impractical.
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Affiliation(s)
- B J Feldman
- Department of Medicine, Harborview Medical Center, University of Washington, 325 9th Ave, Box 359931, Seattle, WA 98104, USA.
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