Community and Health Care Provider Preferences for Bacterial Sexually Transmitted Infection Testing Interventions for Gay, Bisexual, and Other Men Who Have Sex With Men: e-Delphi Study

BACKGROUND

Canadian clinical guidelines recommend at least annual and up to quarterly bacterial sexually transmitted infection (STI) testing among sexually active gay, bisexual, and other men who have sex with men (GBM). However, testing rates are suboptimal. Innovative solutions are needed to close the gap because there is currently limited knowledge on how best to approach this issue.

OBJECTIVE

Our aim was to build consensus regarding interventions with the greatest potential for improving local STI testing services for GBM communities in Toronto, Ontario, Canada, using a web-based e-Delphi process.

METHODS

The e-Delphi method involves using a panel format to conduct successive rounds of prioritization, with feedback between rounds, to determine priorities among groups. We recruited experts separately from the community (GBM who sought or underwent STI testing in the preceding 18 months; conducted between October 2019 and November 2019) and health care providers (those who offered STI testing to GBM in the past 12 months; conducted between February 2020 and May 2020). The experts prioritized 6 to 8 potential interventions on a 7-point Likert scale ranging from definitely not a priority to definitely a priority over 3 survey rounds and ranked their top 3 interventions. Consensus was defined as ≥60% within a ±1 response point. Summaries of responses were provided in successive rounds. We reported the percentage of a priority (encompassing somewhat a priority, a priority, and definitely a priority responses) at the end of the final round of the survey.

RESULTS

Of the community experts (CEs), 84% (43/51) completed all rounds; 19% (8/43) were living with HIV; 37% (16/43) were HIV negative and on pre-exposure prophylaxis; and 42% (18/43) were HIV negative and not on pre-exposure prophylaxis. We reached consensus on 6 interventions: client reminders (41/43, 95%), express testing (38/43, 88%), routine testing (36/43, 84%), an online booking app (36/43, 84%), online-based testing (33/43, 77%), and nurse-led testing (31/43, 72%). The CEs favored convenient interventions that also maintain a relationship with their provider. Of the provider experts (PEs), 77% (37/48) completed all rounds; 59% (22/37) were physicians. Consensus was reached on the same 6 interventions (range 25/37, 68%, to 39/39, 100%) but not for provider alerts (7/37, 19%) and provider audit and feedback (6/37, 16%). Express testing, online-based testing, and nurse-led testing were prioritized by >95% (>37/39) of the PEs by the end of round 2 because of streamlined processes and decreased need to see a provider.

CONCLUSIONS

Both panels were enthusiastic about innovations that make STI testing more efficient, with express testing rating highly in both the prioritizations and top 3 rankings. However, CEs preferred convenient interventions that involved their provider, whereas PEs favored interventions that prioritized patient independence and reduced patient-provider time.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/13801.

Utility and Impact of the Implementation of Same-Day, Self-administered Electronic Patient-Reported Outcomes Assessments in Routine HIV Care in two North American Clinics

The PROgress study assessed the value and feasibility of implementing web-based patient-reported outcomes assessments (PROs) within routine HIV care at two North American outpatient clinics. People with HIV (PWH) completed PROs on a tablet computer in clinic before their routine care visit. Data collection included PROs from 1632 unique PWH, 596 chart reviews, 200 patient questionnaires, and 16 provider/staff questionnaires. During an initial setup phase involving 200 patients, PRO results were not delivered to providers; for all subsequent patients, providers received PRO results before the consultation. Chart review demonstrated that delivery of PRO results to providers improved patient-provider communication and increased the number of complex health and behavioral issues identified, recorded, and acted on, including suicidal ideation (88% with vs 38% without PRO feedback) and anxiety (54% with vs 24% without PRO feedback). In post-visit questionnaires, PWH (82%) and providers (82%) indicated that the PRO added value to the visit.

Risk Factors for Suboptimal Adherence Identified by Patient-Reported Outcomes Assessments in Routine HIV Care at 2 North American Clinics

PURPOSE

Use of patient-reported outcomes assessments (PROs) can improve patient-provider communication and focus provider attention on current health issues. This analysis examines the association between suboptimal antiretroviral therapy (ART) adherence and factors obtained through PROs among people with HIV (PWH) at 2 North American outpatient clinics.

PATIENTS AND METHODS

Immediately before a clinic visit, PWH completed self-administered PROs. Unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated from logistic regression models to identify sociodemographic and health-related factors (satisfaction with ART, difficulty meeting housing costs, depression, intimate partner violence, risk of malnutrition, smoking status, alcohol use, and substance use) associated with suboptimal adherence (defined as self-reporting <95% or <80% adherence). Multiple imputation was performed to account for missing data in the multivariate analyses.

RESULTS

Of 1632 PWH, 1239 (76%) responded to the adherence assessment; of these, 268 (22%) and 106 (9%) reported <95% and <80% adherence, respectively. Of 1580 PWH who responded, 354 (22%) were dissatisfied with their HIV medication. Of responding PWH, 19% reported moderate-to-severe depression, 23% indicated they were at risk of malnutrition, 34% were current smokers, and 62% reported substance use in the past 3 months. Dissatisfaction with ART was significantly associated with <95% and <80% adherence in the unadjusted analysis (unadjusted OR [95% CI], 3.38 [2.51-4.56] and 4.26 [2.82-6.42], respectively) and adjusted analysis (adjusted OR [95% CI], 2.76 [1.91-4.00] and 3.28 [1.95-5.52], respectively); significance remained after multiple imputation. In adjusted analyses, no risk of malnutrition was significantly associated with reduced odds of <95% adherence after multiple imputation (adjusted OR [95% CI], 0.714 [0.511-0.997]); no other factors were associated with <95% or <80% adherence.

CONCLUSION

These results suggest that implementation of PROs evaluating treatment satisfaction may provide value to adherence management in routine HIV care.

462 COUNSELLING IN CARE HOMES

Introduction

Although many people live well within care homes, it is estimated that 60% of those living in residential care have poor mental health (Age Concern & Mental Health Foundation, 2006) and 40% suffer from depression (The Royal College of General Practitioners, 2014). Antidepressant prescribing has been reported to be nearly four times greater in care homes than for older people living in the community (Harris, Carey, Shah, Dewilde & Cook, 2012). However, antidepressants have been found to be ineffective for people with dementia (Dudas, Malouf, McCleery & Dening, 2018). With two-thirds of care home residents having some form of dementia, there is a need to find alternative interventions. Talking therapies, such as counselling, may be a useful alternative.

Method

Adopting a qualitative approach using semi-structured interviews and focus groups with counsellors (N = 12) who have experience of working in this context and with care home managers (N = 3) and care teams (N = 6), this study aimed to explore the feasibility of implementing counselling in a care home setting. We explored the views of care home staff towards counselling and identify barriers to service implementation, alongside the experience of counsellors who have delivered counselling in care homes to understand what service delivery models are currently adopted. Data were analysed thematically.

Results

Findings fell under the following key themes: The funding and referral process for counselling in a care home; skills and competences required; training needs; adaptations to practice; barriers to implementing counselling in a care home.

Conclusions

It is timely to consider the role of psychological therapy in supporting the mental health of care home residents. There is a need for further research to explore a service delivery model of counselling in care homes.

Survey of Health Care Providers' Practices and Opinions Regarding Bacterial Sexually Transmitted Infection Testing Among Gay, Bisexual, and Other Men Who Have Sex With Men

BACKGROUND

Rates of bacterial sexually transmitted infections (STIs) continue to rise among gay, bisexual, and other men who have sex with men (GBMSM) globally. Testing and treatment can prevent morbidity and transmission. However, testing rates remain suboptimal.

METHODS

In 2018, we conducted an online cross-sectional survey to explore STI testing ordering practices, 14 potential barriers for testing and 11 possible ways to improve testing from the perspective of health care providers in Toronto, Ontario. An estimated 172 providers were invited from primary care and sexual health clinic settings. Providers were eligible to complete the survey if they provided care for ≥1 GBMSM per week and were involved in the decision-making process in providing STI tests. We used descriptive statistics to summarize survey responses.

RESULTS

Ninety-five providers (55% response rate) participated, of whom 68% worked in primary care and 32% in sexual health settings. Most (66%) saw ≤10 GBMSM clients per week. In primary care (65%) and sexual health (40%) clinic settings, insufficient consultation time was the most common barrier to STI testing. In primary care, other common barriers included difficulty introducing testing during unrelated consultations (53%), forgetting (47%), and patients being sexually inactive (31%) or declining testing (27%). The following were most likely to improve testing: express/fast-track testing services (89%), provider alerts when patients are due for testing (87%), patient-collected specimens (84%), nurse-led STI testing (79%), and standing orders (79%).

CONCLUSIONS

Promising interventions to improve bacterial STI testing included initiatives that simplify and expedite testing and expand testing delivery to other health care professionals.

Hazard Group 3 agent decontamination using hydrogen peroxide vapour in a class III microbiological safety cabinet

AIMS

This study investigated the efficacy of hydrogen peroxide vapour (HPV) at inactivating hazard group 3 bacteria that have been presented dried from their growth medium to present a realistic challenge.

METHODS AND RESULTS

Hydrogen peroxide vapour technology (Bioquell) was used to decontaminate a class III microbiological safety cabinet containing biological indicators (BIs) made by drying standard working suspensions of the following agents: Bacillus anthracis (Ames) spores, Brucella abortus (strain S99), Burkholderia pseudomallei (NCTC 12939), Escherichia coli O157 ST11 (NCTC 12079), Mycobacterium tuberculosis (strain H37Rv) and Yersinia pestis (strain CO92) on stainless steel coupons. Extended cycles were used to expose the agents for 90 min. The HPV cycle completely inactivated B. anthracis spores, B. abortus, B. pseudomallei, E. coli O157 and Y. pestis when BIs were processed using quantitative and qualitative methods. Whilst M. tuberculosis was not completely inactivated, it was reduced by 4 log₁₀ from a starting concentration of 10⁶ colony-forming units.

CONCLUSIONS

This study demonstrates that HPV is able to inactivate a range of HG3 agents at high concentrations with associated organic matter, but M. tuberculosis showed increased resistance to the process.

SIGNIFICANCE AND IMPACT OF THE STUDY

This publication demonstrates that HPV can inactivate HG3 agents that have an organic load associated with them. It also shows that M. tuberculosis has higher resistance to HPV than other agents. This shows that an appropriate BI to represent the agent of interest should be chosen to demonstrate a decontamination is successful.

Community-Directed Bacterial Sexually Transmitted Infection Testing Interventions Among Men Who Have Sex With Men: Protocol for an E-Delphi Study in Toronto, Canada

Background

HIV-positive and HIV-negative (gay, bisexual, and other) men who have sex with men (MSM) have experienced a dramatic increase in bacterial sexually transmitted infections (STIs)—syphilis, gonorrhea, and chlamydia. STI testing and treatment mitigate adverse health outcomes and substantially reduce transmission; yet, testing rates remain below recommended levels. Innovation is needed to produce the required increases in testing levels, frequency, and the use of appropriate testing technologies in ways that are engaging, nonstigmatizing, and acceptable to men.

Objective

The aim of this study is to build consensus with regard to interventions with the greatest potential for improving local STI testing services for MSM communities in Toronto, Canada.

Methods

Following a literature review of evidence regarding the effectiveness of novel testing interventions, and focus groups, and surveys to describe local barriers and facilitators of testing among MSM, we will conduct a Web-based, modified Delphi study (e-Delphi). We will form expert panels of community members and STI test providers. Panelists will rate potential interventions in terms of their priority, using a 7-point Likert scale from definitely not a priority to definitely a priority. They will also rank their preferences by selecting their top 3 preferred interventions. Surveys will be distributed in 3 rounds, with feedback on the distribution of responses from preceding rounds provided in rounds 2 and 3. We will define consensus as having ≥60% (18/30) members indicate a preference within 2 adjacent response points. Qualitative data on disagreements will be obtained using open-ended text responses to explain for ratings and rankings that are different from the majority.

Results

On the basis of a literature review and identification of barriers and facilitators to STI testing among community members and test providers in Toronto, we have selected 8 potential interventions for inclusion in the e-Delphi panel surveys. These include 4 interventions that streamline STI testing for asymptomatic individuals, 2 interventions that are targeted at clients and 2 interventions that are targeted at providers.

Conclusions

Findings will provide community direction for informed decision making regarding the implementation of STI testing interventions in this setting. They will characterize the intervention climate for innovation to STI testing services, including perceived needs for changes to test delivery, relative priorities for change, and readiness for implementation. These methods may be transferable to other urban jurisdictions experiencing similar epidemics and for other contexts where stakeholder input is needed to manage sensitive areas of concern.

International Registered Report Identifier (IRRID)

PRR1-10.2196/13801

Late diagnosis, delayed presentation and late presentation among persons enrolled in a clinical HIV cohort in Ontario, Canada (1999-2013)

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.

Elevated Mortality and Associated Social Determinants of Health in a Community-Based Sample of People Living with HIV in Ontario, Canada: Findings from the Positive Spaces, Healthy Places (PSHP) Study

We examined social determinants of health associated with all-cause mortality among 602 people living with HIV/AIDS in Ontario, Canada. Mortality status was verified at 1-, 3-, and 5-year follow-up visits with information obtained from proxies (family members, partners, and friends), obituaries, and local AIDS memorial lists. Of the 454 people for whom mortality information was available, 53 individuals died yielding a crude mortality rate of 22.3 deaths per 1000 person-years, a rate substantially higher than the rate in the general population (6.8 per 1000 population). Experiencing both homelessness and incarceration independently predicted high risk of mortality among men who have sex with men (MSM) while suboptimal self-rated general health at previous visit predicted higher greater risk of mortality in both MSM and women and heterosexual men. Homelessness and incarceration may contribute to HIV disease progression and mortality. Intensive case management that increases retention in care and facilitates linkage to housing services may help to reduce excess deaths among people with HIV.

Trends and Correlates of Cigarette Smoking and Its Impacts on Health-Related Quality of Life Among People Living with HIV: Findings from the Ontario HIV Treatment Network Cohort Study, 2008-2014

We sought to examine the trends of cigarette smoking, identify correlates of smoking, and examine the impacts of smoking on health-related quality of life (HRQOL) among people living with HIV in Ontario, Canada. Study sample included 4473 individuals receiving care and enrolled in the Ontario HIV Treatment Network Cohort Study. Self-report data on cigarette smoking, HRQOL, and demographic and sociobehavioral variables were collected between 2008 and 2014 through annual face-to-face interviews. Clinical data were abstracted from participants' medical records and enhanced through linkage with a provincial public health laboratory database. Analyses included descriptive statistics, generalized logit regression, and linear mixed-effects modeling. At first interview, 1760 participants (39.3%) were current cigarette smokers. Smoking prevalence declined annually by 1.6% between 2008 and 2014, but remained much higher than the prevalence in the general population. Current cigarette smokers were more likely to be younger, male, white or indigenous, Canadian-born, single, unemployed with lower education, heavy drinkers, nonmedicinal drug users, and to have current depression than former cigarette smokers or those who never smoked. Current cigarette smokers also had significantly (p < 0.001) worse SF-12 physical component summary (β = -2.07) and SF-12 mental component summary (β = -1.08) scores than those who never smoked after adjusting for demographic, socioeconomic, and HIV-related clinical variables. To reduce the burden of cigarette smoking, cessation interventions that take into account the complex social, economic, and medical needs of people living with HIV are needed urgently.

Social determinants of health and retention in HIV care in a clinical cohort in Ontario, Canada

Continuous HIV care supports antiretroviral therapy initiation and adherence, and prolongs survival. We investigated the association of social determinants of health (SDH) and subsequent retention in HIV care in a clinical cohort in Ontario, Canada. The Ontario HIV Treatment Network Cohort Study is a multi-site cohort of patients at 10 HIV clinics. Data were collected from medical charts, interviews, and via record linkage with the provincial public health laboratory for viral load tests. For participants interviewed in 2009, we used three-category multinomial logistic regression to identify predictors of retention in 2010-2012, defined as (1) continuous care (≥2 viral loads ≥90 days in all years; reference category); (2) discontinuous care (only 1 viral load/year in ≥1 year); and (3) a gap in care (≥1 year in 2010-2012 with no viral load). In total, 1838 participants were included. In 2010-2012, 71.7% had continuous care, 20.9% had discontinuous care, and 7.5% had a gap in care. Discontinuous care in 2009 was predictive (p < .0001) of future retention. SDH associated with discontinuous care were Indigenous ethnicity, being born in Canada, being employed, reporting hazardous drinking, and non-injection drug use. Being a heterosexual male was associated with having a gap in care, and being single and younger were associated with discontinuous care and a gap in care. Various SDH were associated with retention. Care discontinuity was highly predictive of future gaps. Targeted strategic interventions that better engage those at risk of suboptimal retention merit exploration.

ABBREVIATIONS

AOR: adjusted odds ratio; ART: antiretroviral therapy; AUDIT: Alcohol Use Disorders Identification Test; CES-D: Center for Epidemiologic Studies Depression Scale; CIs: confidence intervals; HIV: human immunodeficiency virus; IQR: interquartile range; MSM: men who have sex with men; NA-ACCORD: North American AIDS Cohort Collaboration on Research and Design; OCS: Ontario HIV Treatment Network Cohort Study; OHTN: Ontario HIV Treatment Network; OR: odds ratio; PHOL: Public Health Ontario Laboratories; REB: Research Ethics Board; SDH: social determinants of health; US: United States.

Prevalence, Recurrence, and Incidence of Current Depressive Symptoms among People Living with HIV in Ontario, Canada: Results from the Ontario HIV Treatment Network Cohort Study

Introduction

Current studies of depression among people living with HIV focus on describing its point prevalence. Given the fluctuating nature of depression and its profound impacts on clinical and quality-of-life outcomes, this study aimed to examine the prevalence, recurrence and incidence of current depressive symptoms and its underlying catalysts longitudinally and systematically among these individuals.

Methods

We conducted a prospective cohort study between October 1, 2007 and December 31, 2012 using longitudinal linked data sources. Current depressive symptoms was identified using the Centre for Epidemiologic Studies Depression Scale or the Kessler Psychological Distress Scale, first at baseline and again during follow-up interviews. Multivariable regressions were used to characterize the three outcomes.

Results

Of the 3,816 HIV-positive participants, the point prevalence of depressive symptoms was estimated at 28%. Of the 957 participants who were identified with depressive symptoms at baseline and who had at least two years of follow-up, 43% had a recurrent episode. The cumulative incidence among 1,745 previously depressive symptoms free participants (at or prior to baseline) was 14%. During the five-year follow-up, our multivariable models showed that participants with greater risk of recurrent cases were more likely to feel worried about their housing situation. Participants at risk of developing incident cases were also likely to be younger, gay or bisexual, and unable to afford housing-related expenses.

Conclusions

Depressive symptoms are prevalent and likely to recur among people living with HIV. Our results support the direction of Ontario’s HIV/AIDS Strategy to 2026, which addresses medical concerns associated with HIV (such as depression) and the social drivers of health in order to enhance the overall well-being of people living with or at risk of HIV. Our findings reinforce the importance of providing effective mental health care and demonstrate the need for long-term support and routine management of depression, particularly for individuals at high risk.

Adequacy of Mental Health Services for HIV-Positive Patients with Depression: Ontario HIV Treatment Network Cohort Study

Background

Major depression can profoundly impact clinical and quality-of-life outcomes of people living with HIV, and this disease is underdiagnosed and undertreated in many HIV-positive individuals. Here, we describe the prevalence of publicly funded primary and secondary mental health service use and antidepressant use, as well as mental health care for depression in accordance with existing Canadian guidelines for HIV-positive patients with depression in Ontario, Canada.

Methods

We conducted a prospective cohort study linking data from the Ontario HIV Treatment Network Cohort Study with administrative health databases in the province of Ontario, Canada. Current depression was assessed using the Center for Epidemiologic Depression Scale or the Kessler Psychological Distress Scale. Multivariable regressions were used to characterize prevalence outcomes.

Results

Of 990 HIV-positive patients with depression, 493 (50%) patients used mental health services; 182 (18%) used primary services (general practitioners); 176 (18%) used secondary services (psychiatrists); and 135 (14%) used both. Antidepressants were used by 407 (39%) patients. Patients who identified as gay, lesbian, or bisexual, as having low income or educational attainment, or as non-native English speakers or immigrants to Canada were less likely to obtain care. Of 493 patients using mental health services, 250 (51%) received mental health care for depression in accordance with existing Canadian guidelines.

Conclusions

Our results showed gaps in delivering publicly funded mental health services to depressed HIV-positive patients and identified unequal access to these services, particularly among vulnerable groups. More effective mental health policies and better access to mental health services are required to address HIV-positive patient needs and reduce depression’s impact on their lives.

Economic Evaluation of Community-Based HIV Prevention Programs in Ontario: Evidence of Effectiveness in Reducing HIV Infections and Health Care Costs

Investments in community-based HIV prevention programs in Ontario over the past two and a half decades are assumed to have had an impact on the HIV epidemic, but they have never been systematically evaluated. To help close this knowledge gap, we conducted a macro-level evaluation of investment in Ontario HIV prevention programs from the payer perspective. Our results showed that, from 1987 to 2011, province-wide community-based programs helped to avert a total of 16,672 HIV infections, saving Ontario's health care system approximately $6.5 billion Canadian dollars (range 4.8-7.5B). We also showed that these community-based HIV programs were cost-saving: from 2005 to 2011, every dollar invested in these programs saved about $5. This study is an important first step in understanding the impact of investing in community-based HIV prevention programs in Ontario and recognizing the impact that these programs have had in reducing HIV infections and health care costs.

Housing characteristics and their influence on health-related quality of life in persons living with HIV in Ontario, Canada: results from the positive spaces, healthy places study

Although lack of housing is linked with adverse health outcomes, little is known about the impacts of the qualitative aspects of housing on health. This study examined the association between structural elements of housing, housing affordability, housing satisfaction and health-related quality of life over a 1-year period. Participants were 509 individuals living with HIV in Ontario, Canada. Regression analyses were conducted to examine relationships between housing variables and physical and mental health-related quality of life. We found significant cross-sectional associations between housing and neighborhood variables-including place of residence, housing affordability, housing stability, and satisfaction with material, meaningful and spatial dimensions of housing-and both physical and mental health-related quality of life. Our analyses also revealed longitudinal associations between housing and neighborhood variables and health-related quality of life. Interventions that enhance housing affordability and housing satisfaction may help improve health-related quality of life of people living with HIV.

Inequalities in determinants of health among Aboriginal and Caucasian persons living with HIV/AIDS in Ontario: results from the Positive Spaces, Healthy Places Study

OBJECTIVES

Aboriginal Canadians (i.e., First Nations, Inuit and Métis) are disproportionately affected by HIV/AIDS, and experience greater social and economic marginalization and poorer housing conditions. This study sought to understand the differences in the determinants of health and housing-related characteristics between samples of Aboriginal and Caucasian adults living with HIV/AIDS in Ontario.

METHODS

We analyzed baseline demographic, socio-economic, health, and housing-related data from 521 individuals (79 Aboriginal and 442 Caucasian) living with HIV/AIDS and enrolled in the Positive Spaces, Healthy Places study. We compared the characteristics of Aboriginal and Caucasian participants to identify determinants of health and housing-related characteristics independently associated with Aboriginal ethnicity.

RESULTS

Compared to Caucausian participants living with HIV, Aboriginal participants were more likely to be younger, female or transgender women, less educated, unemployed, and homeless or unstably housed. They were also more likely to have low incomes and to have experienced housing-related discrimination. In a multivariate model, gender, income, and experiences of homelessness were independently associated with Aboriginal ethnicity.

CONCLUSION

Aboriginal individuals living with HIV/AIDS in our sample are coping with significantly worse social and economic conditions and are more likely to experience challenging housing situations than a comparison group of Caucasian individuals living with HIV/AIDS. To develop effective care, treatment and support strategies for Aboriginal peoples with HIV, it is critical to address and improve their socio-economic and housing conditions.

Social determinants of health associated with hepatitis C co-infection among people living with HIV: results from the Positive Spaces, Healthy Places study

BACKGROUND

Social determinants of health (SDOH) may influence the probability of people living with HIV also being infected with hepatitis C virus (HCV). We compared the SDOH of adults co-infected with HCV/HIV with that of HIV mono-infected adults to identify factors independently associated with HCV infection.

METHODS

In this cross-sectional study, face-to-face interviews were conducted with 509 HIV-infected adults affiliated with or receiving services from community-based AIDS service organizations (CBAOs). The primary outcome measure was self-reported HCV infection status. Chi-square, Student's t tests, and Wilcoxon rank-sum tests were performed to compare SDOH of HCV/HIV co-infected participants with that of HIV mono-infected participants. Multivariable hierarchical logistic regression was used to identify factors independently associated with HCV co-infection.

RESULTS

Data on 482 (95 HCV/HIV co-infected and 387 HIV mono-infected) adults were analyzed. Compared with participants infected with HIV only, those who were co-infected with HIV and HCV were more likely to be heterosexual, Aboriginal, less educated and unemployed. They were more likely to have a low income, to not be receiving antiretroviral treatment, to live outside the Greater Toronto Area (GTA), to use/abuse substances, experience significant depression, and utilize addiction counselling and needle-exchange services. They also were more likely to report a history of homelessness and perceived housing-related discrimination and to have moved twice or more in the previous 12 months. Factors independently associated with HCV/HIV co-infection were history of incarceration (odds ratio [OR] 8.81, 95% CI 4.43-17.54), history of homelessness (OR 3.15, 95% CI 1.59-6.26), living outside of the GTA (OR 3.13, 95% CI 1.59-6.15), and using/abusing substances in the past 12 months (OR 2.05, 95% CI 1.07-3.91).

CONCLUSION

Differences in SDOH exist between HIV/HCV co-infected and HIV mono-infected adults. History of incarceration, history of homelessness, substance use, and living outside the GTA were independently associated with HCV/HIV co-infection. Interventions that reduce homelessness and incarceration may help prevent HCV infection in people living with HIV.

Impact of social support on cognitive symptom burden in HIV/AIDS

As many as 50% of people living with HIV/AIDS report cognitive difficulties, which can be associated with objective neuropsychological impairments and depression. A number of studies have demonstrated an association between higher social support and lower rates of depression. Using a cross-sectional design, we examined the role social support may play in attenuating the effects of both neuropsychological status and depression on cognitive difficulties. A total of 357 participants completed a battery of neuropsychological tests, questionnaires about cognitive difficulties and depression, and an interview that included an assessment of perceived level of social support. A multivariate linear regression analysis revealed that higher levels of cognitive symptom burden were significantly associated with depression (P<0.05) while lower levels of cognitive symptom burden were significantly associated with greater social support (P<0.01) and higher level of education (P<0.05). There was a significant interaction between neuropsychological status and depression (P<0.001); the presence of neuropsychological impairment with depression was associated with higher levels of cognitive symptom burden. There was also a significant interaction between social support and depression (P<0.05). Interestingly, social support was also associated with a lower cognitive symptom burden for non-depressed individuals living with HIV/AIDS. These findings have important clinical implications for promoting psychological well-being in persons living with HIV/AIDS. To improve quality of life, it is important to screen for and identify individuals with HIV/AIDS who may be depressed and to intervene appropriately. Further research should examine the potential role of social support interventions in modifying the effects of both depression and neuropsychological status on cognitive symptom burden.

Community capacity to acquire, assess, adapt, and apply research evidence: a survey of Ontario's HIV/AIDS sector

Background

Community-based organizations (CBOs) are important stakeholders in health systems and are increasingly called upon to use research evidence to inform their advocacy, program planning, and service delivery. To better support CBOs to find and use research evidence, we sought to assess the capacity of CBOs in the HIV/AIDS sector to acquire, assess, adapt, and apply research evidence in their work.

Methods

We invited executive directors of HIV/AIDS CBOs in Ontario, Canada (n = 51) to complete the Canadian Health Services Research Foundation's "Is Research Working for You?" survey.

Findings

Based on responses from 25 organizations that collectively provide services to approximately 32,000 clients per year with 290 full-time equivalent staff, we found organizational capacity to acquire, assess, adapt, and apply research evidence to be low. CBO strengths include supporting a culture that rewards flexibility and quality improvement, exchanging information within their organization, and ensuring that their decision-making processes have a place for research. However, CBO Executive Directors indicated that they lacked the skills, time, resources, incentives, and links with experts to acquire research, assess its quality and reliability, and summarize it in a user-friendly way.

Conclusion

Given the limited capacity to find and use research evidence, we recommend a capacity-building strategy for HIV/AIDS CBOs that focuses on providing the tools, resources, and skills needed to more consistently acquire, assess, adapt, and apply research evidence. Such a strategy may be appropriate in other sectors and jurisdictions as well given that CBO Executive Directors in the HIV/AIDS sector in Ontario report low capacity despite being in the enviable position of having stable government infrastructure in place to support them, benefiting from long-standing investment in capacity building, and being part of an active provincial network. CBOs in other sectors and jurisdictions that have fewer supports may have comparable or lower capacity. Future research should examine a larger sample of CBO Executive Directors from a range of sectors and jurisdictions.

Inequalities in determinants of health among Aboriginal and Caucasian persons living with HIV/AIDS in Ontario: results from the Positive Spaces, Healthy Places Study

OBJECTIVES

Aboriginal Canadians (i.e., First Nations, Inuit and Métis) are disproportionately affected by HIV/AIDS, and experience greater social and economic marginalization and poorer housing conditions. This study sought to understand the differences in the determinants of health and housing-related characteristics between samples of Aboriginal and Caucasian adults living with HIV/AIDS in Ontario.

METHODS

We analyzed baseline demographic, socio-economic, health, and housing-related data from 521 individuals (79 Aboriginal and 442 Caucasian) living with HIV/AIDS and enrolled in the Positive Spaces, Healthy Places study. We compared the characteristics of Aboriginal and Caucasian participants to identify determinants of health and housing-related characteristics independently associated with Aboriginal ethnicity.

RESULTS

Compared to Caucausian participants living with HIV, Aboriginal participants were more likely to be younger, female or transgender women, less educated, unemployed, and homeless or unstably housed. They were also more likely to have low incomes and to have experienced housing-related discrimination. In a multivariate model, gender, income, and experiences of homelessness were independently associated with Aboriginal ethnicity.

CONCLUSION

Aboriginal individuals living with HIV/AIDS in our sample are coping with significantly worse social and economic conditions and are more likely to experience challenging housing situations than a comparison group of Caucasian individuals living with HIV/AIDS. To develop effective care, treatment and support strategies for Aboriginal peoples with HIV, it is critical to address and improve their socio-economic and housing conditions.

Treatment, care and support for people co-infected with HIV and hepatitis C: a scoping review

BACKGROUND

Providing care for people who are co-infected with both HIV and hepatitis C virus (HCV) is becoming increasingly complex and requires integrated prevention, screening, support and programming efforts. We undertook a scoping review to provide a summary of the existing evidence base and to identify and assess the quality of treatment guidelines and systematic reviews related to 3 domains of interest: treatment; epidemiology; and care, support, programming and prevention.

METHODS

We searched 7 databases, hand-searched 8 journals and contacted key informants to identify relevant literature. We included all primary research (including systematic reviews and meta-analyses) or treatment guidelines that assessed pegylated interferon and ribavirin for HCV or highly active antiretroviral therapy for HIV treatment, or both. In the epidemiology domain, we included all primary research (including systematic reviews and meta-analyses). Studies that included only people with hemophilia and those conducted in developing countries were excluded. In the care, support, programming and prevention domain, we included all studies and reports that focused on co-infection. Two reviewers independently applied coding criteria and assessed the quality of the treatment guidelines and systematic reviews using the Appraisal of Guidelines Research and Evaluation and A MeaSurement Tool to Assess Reviews instruments.

RESULTS

Our search strategy yielded 1633 unique references. Of these, 227 references met the final inclusion criteria: 114 addressed treatment, 52 epidemiology and 79 care, support, programming or prevention. The references included 9 treatment guidelines: 4 were assessed as "strongly recommend," 3 as "recommend (with provisos or alterations)" and 1 as "would not recommend" (1 could not be located). Of 10 systematic reviews that were located, 7 were assessed as being high quality, 2 as medium quality and 1 as low quality.

CONCLUSION

This quality-assessed inventory of treatment guidelines and systematic reviews can be used by physicians and service providers to rapidly locate research about HIV-HCV co-infection. However, many treatment guidelines and reviews often indicate that treatment of current injection drug users and/or people with mental health issues should proceed on a "case-by-case basis." Therefore, much of the evidence (particularly in the treatment literature) is limited in its scope and applicability to important populations that are vulnerable to HIV or HCV infection or co-infection.

Religiosity, spirituality and antenatal anxiety in Southern U.S. women

INTRODUCTION

We investigated the association between religiosity, spirituality, and anxiety in pregnant women, taking into account potential confounders.

MATERIALS AND METHODS

From September 2005 through March 2006, pregnant women in three obstetrics practices in the American South were included in a cross-sectional study. The anxiety subscale of the Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety.

RESULTS

Of the 344 participating women, 23 screened positive for moderate to severe anxiety (HADS [anxiety] score greater than 10). Overall religiosity or spirituality (odds ratio [OR], 0.53; p=0.006) and social support (OR, 0.42; p<0.0001) were significantly associated with significantly lower odds of a positive anxiety screen. Among the specific measures of religiosity or spirituality, self-rated religiosity, self-rated spirituality, and participation in nonorganizational religious activities were significantly associated with lower odds of moderate to severe anxiety symptoms.

DISCUSSION AND CONCLUSIONS

Religiosity and spirituality are associated with reduced anxiety in pregnant women. Additional study is needed to evaluate whether the association is causal.

An audit of the management of soft tissue sarcoma within a health region in the UK

AIMS

Soft tissue sarcomas are rare and heterogeneous tumours only occasionally seen by most individual clinicians. Early recognition, appropriate referral and timely investigations markedly improve outcomes. Our aim was to retrospectively assess the referral patterns, investigation, surgery and outcomes of patients with soft tissue sarcoma in the Trent region of the UK.

METHODS

Two hundred and four patients with soft tissue sarcoma registered with the Trent Cancer Registry in 1995-1997 were first studied. Clinical details, tumour characteristics, presentation, management and follow-up were recorded from the case notes and analysed.A further group of 40 patients referred to a single cancer centre in 1999 were audited to establish whether there had been any improvements/changes over the 2 years, since the completion of the first audit.

RESULTS

In the first audit, 49.5% were first referred to general surgeons and 16% to orthopaedic surgeons. Only 15% of patients fit for surgery were referred to a surgeon with a specialist sarcoma interest prior to definitive exploration. Of the deep tumours, 64% had a preoperative biopsy and only 68% had a scan before biopsy or definitive surgery. Tumour grade, completeness of excision and site of the sarcoma influenced survival. The second audit performed on patients treated in 1999 showed only a marginal improvement in management when compared to the first audit.

A model of OASIS role-based access control and its support for active security

OASIS is a role-based access control architecture for achieving secure interoperation of services in an open, distributed environment. The aim of OASIS is to allow autonomous management domains to specify their own access control policies and to interoperate subject to service level agreements (SLAs). Services define roles and implement formally specified policy to control role activation and service use; users must present the required credentials, in an appropriate context, in order to activate a role or invoke a service. All privileges are derived from roles, which are activated for the duration of a session only. In addition, a role is deactivated immediately if any of the conditions of the membership rule associated with its activation becomes false. These conditions can test the context, thus ensuring active monitoring of security.To support the management of privileges, OASIS introduces appointment . Users in certain roles are authorized to issue other users with appointment certificates , which may be a prerequisite for activating one or more roles. The conditions for activating a role at a service may include appointment certificates as well as prerequisite roles and constraints on the context. An appointment certificate does not therefore convey privileges directly but can be used as a credential for role activation. The lifetime of appointment certificates is not restricted to the issuing session, so they can be used as long-lived credentials to represent academic and professional qualification, or membership of an organization.Role-based access control (RBAC), in associating privileges with roles, provides a means of expressing access control that is scalable to large numbers of principals. However, pure RBAC associates privileges only with roles, whereas applications often require more fine-grained access control. Parametrized roles extend the functionality to meet this need.We motivate our approach and formalise OASIS. We first present the overall architecture through a basic model, followed by an extended model that includes parametrization.

Application of a modified BCR sequential extraction (three-step) procedure for the determination of extractable trace metal contents in a sewage sludge amended soil reference material (CRM 483), complemented by a three-year stability study of acetic acid and EDTA extractable metal content

This paper provides additional data on a sewage sludge amended soil certified reference material, CRM 483, which was certified in 1997 for its EDTA and acetic acid extractable contents of some trace metals, following standardised extraction procedures. The additional work aimed to test the long-term stability of the material and the applicability of an improved version of the BCR three-step sequential extraction procedure on the sewage sludge amended soil (CRM 483). The paper demonstrates the CRM 483 long-term stability for EDTA and acetic acid extractable contents of Cd, Cr, Cu, Ni, Pb and Zn and gives the results (obtained in the framework of an interlaboratory study) for the extractable contents of the same elements in the CRM 483, following the BCR three-step sequential extraction scheme. The aqua regia extractable contents following the ISO 11466 Standard are also given. The data are given as indicative (not certified) values.

Attitudes toward colon cancer gene testing: survey of relatives of colon cancer patients

OBJECTIVES

Various studies have identified psychosocial factors that may influence attitudes toward colon cancer gene testing. Whereas family history of colon cancer has been associated with interest in gene testing, this has not been examined extensively. We hypothesized that the strength of family history of colon cancer is associated with risk perception and willingness to undergo gene testing.

MATERIALS AND METHODS

We evaluated attitudes toward colon cancer gene testing among persons who had at least one first-degree relative with colon cancer. A total of 2680 at-risk relatives in 863 kindreds were identified and mailed an extensive survey regarding sociodemographic variables, family history, health behaviors and knowledge, and willingness to take a colon cancer gene test. A total of 56.6% of persons completed and returned surveys. We conducted a brief telephone survey of a random sample of 200 persons who did not respond to the mail survey.

RESULTS

The combined study sample of 1373 people was 42% male, had a mean age of 55 +/- 15 years, was 96% white, and had moderate-to-high SES. A total of 77.4% were very likely to take the gene test, and 92.4% were somewhat or very likely to take the gene test. A total of 78% of the sample perceived a higher colon cancer risk, although patterns of risk perception and worry differed significantly between mail survey and telephone survey respondents. More of the telephone survey respondents were also somewhat unlikely or very unlikely to take the gene test compared to the mail survey respondents (13.7% versus 6.9%). In the combined sample, concern about developing colon cancer and risk perception increased with number of relatives with colon cancer (P < 0.0001). Eight percent expressed no concern about developing colon cancer; 4.8% felt their chance of developing colon cancer was lower than others of the same age, sex, and race; and 3.3% felt that they were very unlikely to develop colon cancer in their lifetime. However, there was strong interest in gene testing regardless of the number of affected relatives, and persons with more affected relatives were generally willing to pay more for the gene test (up to $1000).

CONCLUSIONS

The strength of family history of colon cancer is associated with risk perception but not with willingness to undergo gene testing.

Effect of ethnicity on adherence to diabetic regimen

OBJECTIVE

Evaluating the effectiveness of treatment of diabetic patients in our institution led us to seek the relationship between adherence to diabetic regimens and several demographic variables. Of primary importance was ethnicity, which the practitioners believed affected adherence. Other variables researched were: marital status, gender, weight, age, type and duration of diabetes, socioeconomic status, occupation and education.

PATIENTS

Adult diabetic patients (215) seen in the diabetic clinic of a large health maintenance organization who had their diabetes for at least 6 months.

METHODS

Data were collected from interviews and medical records over a two-year period.

RESULTS

Ethnicity, the major test variable, did not show a relationship to adherence. Two variables, gender and weight, showed a trend to significant relationship to adherence. Chi square and t tests were used, depending on the type of data.

CONCLUSIONS

Since there is no difference in adherence between ethnic groups, standardized care protocols are warranted, since they are cost-efficient.

Anomalous origin of the left main coronary artery from the pulmonary trunk masquerading as peripartum cardiomyopathy

We present a 16-year-old girl who developed congestive heart failure during and after delivery of her first child, and who was diagnosed as having peripartum cardiomyopathy. Cardiac catheterization with coronary arteriography confirmed the correct diagnosis of anomalous origin of the left main coronary artery from the pulmonary trunk.

Hepatoblastoma and APC gene mutation in familial adenomatous polyposis

BACKGROUND

Hepatoblastoma is a rare, rapidly progressive, usually fatal childhood malignancy, which if confined to the liver can be cured by radical surgical resection. An association between hepatoblastoma and familial adenomatous polyposis (FAP), which is due to germline mutation of the APC (adenomatous polyposis coli) gene, has been confirmed, but correlation with site of APC mutation has not been studied.

AIM

To analyse the APC mutational spectrum in FAP families with hepatoblastoma as a possible basis to select kindreds for surveillance.

PATIENTS

Eight patients with hepatoblastoma in seven FAP kindreds were compared with 97 families with identified APC gene mutation in a large Registry.

METHODS

APC gene mutation was evaluated by RNase protection assay or in vitro synthesis protein assay. The chi 2 test and correlation were used for data analysis.

RESULTS

APC gene mutation was identified in all seven FAP kindreds in which an at risk member developed hepatoblastoma. A male predominance was noted (six of eight), similar to literature cases (18 of 25, p < 0.01. Mutations were restricted to codons 141 to 1230, but no significant difference in site of mutation between pedigrees with and without hepatoblastoma was identified.

CONCLUSIONS

Hepatoblastoma occurs primarily in boys in FAP kindreds and is associated with germline APC mutation in the 5' end of the gene. However, the site of APC mutation cannot be used to predict occurrence of this extracolonic cancer in FAP pedigrees.

Rural trauma care: role of the general surgeon

BACKGROUND

Care of the patient injured in the rural setting poses many unique challenges. This report profiles the experience of a solo, rural general surgeon with patients with multiple injuries during a 7-year period.

METHODS

Emergency department (ED) contact sheets for 43,308 patients treated from September 1, 1988 through August 31, 1995 were reviewed. Eighty-four patients met selection criteria based on injuries with Abbreviated Injury Scale score > or = 3 in a single body region or > or = 2 in two or more body regions. Prehospital and hospital records were reviewed.

RESULTS

Injury Severity Score ranged from 8 to 43 (mean, 16). Four patients died in the ED, 54 (64%) were transferred to a referral trauma center, and 26 (31%) were admitted to the community hospital.

CONCLUSIONS

Roles of the general surgeon in the management of multiple trauma in the rural hospital are: (1) to coordinate trauma care in the community, including educational and organizational efforts; (2) to perform the necessary techniques in the ED to achieve optimal resuscitation and stabilization; (3) to rationally prioritize patients for transfer to a referral trauma center based upon assessment of patient injuries and institutional capabilities; and (4) to provide definitive care for a subset of patients with no need for subspecialty intervention.

Evidence that histamine is a neurotransmitter in an insect extraocular photoreceptor pathway

The pair of vasopressin-like immunoreactive (VPLI) neurones of the locust Locusta migratoria have cell bodies in the suboesophageal ganglion and extensive arborization throughout the central nervous sytem. The activity of the VPLI neurone is regulated by a spontaneously active excitatory descending interneurone (DI) that is, in turn, inhibited by an uncharacterised extraocular photoreceptor (EOP) system located in the brain. Light directed at the brain results in inhibition of DI activity, which thereby deprives the VPLI neurone of its major synaptic input. We present evidence that histamine plays an important role in the EOP&shy;DI&shy;VPLI pathway. Histamine mimics the EOP-mediated inhibition of the DI, and the H2-specific histamine antagonists cimetidine and ranitidine block its inhibitory action. Histamine application to various areas of the brain localises the area where histaminergic inhibition occurs; this region is confined to the medial protocerebrum. At least six bilaterally paired histamine-like immunoreactive neurones send axonal projections into this area. Depolarisation of the brain region containing the soma of these neurones with high-K+ saline deactivates the VPLI neurone through the removal of the DI excitatory synaptic input.