Reversal of diabetic retinopathy in two patients following the use of physiologic insulin Resensitization

We followed two patients with diabetic retinopathy over the course of their treatment with physiologic Insulin resensitization. Both patients showed improvement of their diabetic retinopathy, after treatment.

Cancer Patient Acceptance of HIV Screening at a Large Tertiary Cancer Center

The U.S. Centers for Disease Control and Prevention (CDC), the U.S. Preventive Services Task Force (USPSTF) and the National Comprehensive Cancer Network (NCCN) recommend offering HIV testing for patients presenting for cancer care. Not recognizing and treating HIV infection adversely impacts both cancer treatment and HIV outcomes. Acceptance rates of oncology patients for HIV screening are not known. Our tertiary cancer center inserted language requesting permission to screen for HIV infection into the consent forms for initial presentation for cancer care. Willingness to undergo testing was examined in 29,549 consecutive new patients. These were analyzed by gender and age. Overall, 80.9% of patients agreed to HIV screening. Incorporation of language requesting permission for HIV screening into the consent form provided at presentation for cancer care, relieves clinicians from adding this task.

Has Diarrhea Ceased to be a Concern in Persons Living With HIV? Results From a Cross-sectional Study

ABSTRACT

Diarrhea has been associated with HIV throughout the epidemic. Few recent studies have addressed diarrhea in persons living with HIV (PLWH) despite evolving knowledge and ever-changing practice standards. The fact that patient care has become more complex, with comorbid conditions requiring additional attention without additional time allotment, potentiates the risk of common symptoms being overlooked. Patients (n = 190) 18 years and older, living with HIV, completed a questionnaire collecting information specific to attitudes, definitions, and beliefs regarding diarrhea. Of the 190 participants, only 5.3% said that they had diarrhea, but 11.1% described their bowel movements as being in the group associated with diarrhea. Approximately, 93.7% of the participants defined diarrhea as either soft or watery; 34.2% defined frequency as more than three times per day, but 64.2% said that it would have to be more than three times per day to mention it to a provider. PLWH continue to experience diarrhea warranting assessment and discussions between the PLWH and the provider.

GSK2818713, a Novel Biphenylene Scaffold-Based Hepatitis C NS5A Replication Complex Inhibitor with Broad Genotype Coverage

Pan-genotype NS5A inhibitors underpin hugely successful hepatitis C virus (HCV) therapy. The discovery of GSK2818713 (13), a nonstructural protein 5A (NS5A) HCV inhibitor characterized by a significantly improved genotype coverage relative to first-generation NS5A inhibitor daclatasvir (DCV), is detailed herein. The SAR analysis revealed cooperative potency effects of the biphenylene, bicyclic pyrrolidine (Aoc), and methyl-threonine structural motifs. Relative to DCV, 13 improved activity against genotype 1a (gt1a) and gt1b NS5A variants as well as HCV chimeric replicons containing NS5A fragments from genotypes 2-6. Long-term treatment of subgenomic replicons with 13 potently and durably decreased HCV RNA levels for gt1a, gt2a, and gt3a. These properties, suitable pharmacokinetics, and the lack of cross-resistance resulted in the selection of 13 as a preclinical candidate.

Medication costs associated with early initiation of antiretroviral therapy

The START Study randomly assigned 4685 persons with CD4+ counts >500 to either immediate treatment (2326 persons) or a group (2359) that had treatment delayed until the CD4+ count was <350 or clinical judgment dictated treatment. The average time in the study was three years. The immediate group (IG) had 42 serious clinical events and the delayed group (DG) had 96. Policy considerations for adopting these results should consider the cost of medications for early treatment, which is the purpose of this article. Cost of early treatment was estimated by assuming the delayed treatment group had been treated for the three-year average course of the study. However, 48% of the DG received ART before the study's end, so that portion of the group's time on ART was reduced to 1.5 years. Average wholesale prices in the United States of the five recommended ART regimens were discounted by 50% to reflect actual pricing. An average medication cost for the five regimens of $20,000 per person year was used. The three-year cost was $107,580,000 for the 52% who would have been treated for three years and for the 48% treated for an average of 1.5 years. The cost per clinical event avoided was $1,992,222. Formulae are provided that will allow the reader to adjust these results to reflect local prices and volumes. Additional factors to be considered should include the cost savings from avoiding serious clinical events, reduction in transmission of HIV for those being treated early in the infection and the issues associated with long-term adherence for those receiving ART at >500 CD4 counts.

Physicians' and nurses' thoughts and concerns about introducing neonatal male circumcision in Thailand: a qualitative study

BACKGROUND

Neonatal male circumcision (NMC) is an alternative approach to adult male circumcision for HIV prevention. Recent studies found that NMC was rarely performed in Thailand and that most Thai health professionals did not recognize that NMC could reduce the risk of HIV infection and would not want NMC services in their hospitals. This study explored the thoughts and concerns of Thai government health staff regarding the introduction of NMC in government health facilities as a public health measure.

METHODS

In-depth interviews with physicians, nurses and physician administrators from four different levels of government hospitals in four provinces representing 4 regions of Thailand were conducted after provision of education regarding the benefits and risks of NMC. Interviews were audio recorded and analyzed using Atlas.ti software to develop themes.

RESULTS

Six themes emerged from the data of 42 respondents: understanding of the benefits of NMC; risks of NMC; need for a pilot project; need for staff training and hospital readiness; need for parental/family education; and need for public awareness educational campaign. Major concerns included possible medical complications of NMC, infringement of child rights, and lack of understanding from staff and parents. The respondents emphasized the need for a clear policy, proper training of staff, financial and equipment support, and piloting NMC rollout before this measure could be fully implemented.

CONCLUSIONS

Thai health professionals who took part in this study expressed several concerns if NMC had to be performed in their health care facilities. There is significant preparation that needs to be done before NMC can be introduced in the country.

Re-engagement in HIV Care: A Clinical and Public Health Priority

As many as 40-50% of persons living with HIV (PLWH) who once were in HIV care are no longer in care. It is estimated that these individuals account for over 60% of HIV transmissions. So, preventing the leaving of care and re-engaging PLWH with care are crucial if the HIV epidemic is to be brought under control. Clinicians can improve retention by keeping in close contact with patients. Governmental public health agencies have great expertise in finding and engaging in care persons with sexually transmitted infections. This expertise can be used to re-engage PLWH with HIV care, but it can only be utilized if the agencies know that someone is out of care. Data on who has left care are in the hands of HIV providers. This requires a close working relationship between HIV providers and public health agencies.

The Influence of Trust in Physicians and Trust in the Healthcare System on Linkage, Retention, and Adherence to HIV Care

Lack of trust by the patient in the physicians or the healthcare system has been associated with poorer health outcomes. The present study was designed to determine if trust in physicians and the healthcare system among persons newly diagnosed with HIV infection was predictive of patients' subsequent linkage, retention, and adherence to HIV care. 178 newly diagnosed HIV infected patients were administered the trust-in-physicians and trust-in-healthcare system scales. Median trust-in-physicians and trust-in-healthcare system scores were compared for all the mentioned subsequent linkage, retention, and adherence to HIV care. Univariate logistic regression using the trust-in-physician scale confirmed significant association with retention in care (p = 0.04), which persisted in multivariate analyses (p = 0.04). No significant association was found between trust-in-physicians and linkage to care or adherence to antiretroviral therapy. Trust in the healthcare system was not associated with any of the outcomes. Patients with higher trust in physicians were more likely to be retained in HIV care. Trust at diagnosis may not be a barrier to better clinical outcomes, either because trust changes based on subsequent interactions, or because trust is not a determining feature. Interventions to improve retention in care could include improving trust in physicians or target persons with low trust in physicians.

Effect of an Empowerment Intervention on Antiretroviral Drug Adherence in Thai Youth

A pilot study was conducted to determine effects of an empowerment intervention on antiretroviral therapy (ART) adherence among Thai youth living with HIV/AIDS. It compared two groups of 23 young persons (15-24 years) who receive ART from AIDS clinics at two community hospitals. One hospital's patients served as the experimental group, and the other as a control group. The experimental groups attended five sessions that empowered them to take control of their own health. The control group received the standard of care. The data were analyzed using descriptive statistics and Chi-square statistics. Before the empowerment, no one from the experimental group or the control group had ART adherence ≥ 95%. After the intervention, the 82.6% of the experimental group had ≥ 95% adherence compared to the control group, which had 21.7% adherence (p < .0001). The empowerment intervention resulted in a significant increase in ART adherence among Thai youth.

ATTITUDES AND BEHAVIOR AMONG RURAL THAI ADOLESCENTS REGARDING SEXUAL INTERCOURSE

Early initiation of sexual intercourse has been associated with negative consequences, such as higher rates of unwanted pregnancy and HIV infection. This study examined the attitudes and behavior of rural Thai adolescent students aged 16 to 20 years from northern Thailand regarding sexual intercourse. Differences between participants who previously had sexual intercourse and those who had not were explored. Those who had not previously had sexual intercourse were asked about the reasons why they had not had sex, their future plans for having sex and their dating experiences. More than 70% of participants stated they had not previously had sexual intercourse but one third of this group reported engaging in other sexual behavior. There were significant differences by gender, religion, ethnicity, and household income between those who had previously had sex and those who had not. Among those who had not previously had sexual intercourse, concern for their parents' feelings was the most common reason for delaying intercourse. About two-thirds of this group had plans not to have sexual intercourse until after marriage; nearly half of them reported currently having a boyfriend/girlfriend. Interventions aimed at delaying sexual intercourse should involve adolescents in their design and include their attitudes for delaying intercourse. Because of many gender differences seen in our study, interventions should be designed differently for males and females in rural northern Thailand.

Effects of Internet-based instruction on HIV-prevention knowledge and practices among men who have sex with men

HIV infection is increasing among men who have sex with men. In this study, the effects of Internet-based instruction on HIV-prevention knowledge were evaluated. The sample consisted of 162 men-who-have-sex-with-men volunteers in Thailand. The research instruments included a demographic data questionnaire, a knowledge test, and an HIV preventive practice questionnaire. The participants completed these instruments upon entry to the study and four months later. After entry to the study, the participants were given access to a previously-developed Internet-based instruction on HIV risk behaviors. Data were analyzed using descriptive statistics and paired t-test. After accessing the Internet-based instruction, the average score of HIV-prevention knowledge among the sample increased significantly, from 11.17 to 15.09 (maximum score of 20 points). The average score of practicing HIV prevention among the sample increased significantly, from 62.94 to 76.51 (maximum score of 99 points). This study demonstrated that Internet-based instruction was effective in improving HIV-prevention knowledge and practices among men who have sex with men. This suggests that Internet-based instruction could be developed for use in other countries and evaluated in a similar way.

Computed tomography in patients with abdominal pain and diarrhoea: does the benefit outweigh the drawbacks?

The role of computed tomography (CT) in the evaluation of abdominal pain is well established. However, concern exists in regard to procedure-related radiation levels, contrast-medium toxicity and costs. We sought to determine whether the use of abdominal CT caused major changes in the management of patients who had abdominal pain and diarrhoea. We reviewed all abdominal CT examinations that were performed at our hospital from October through December 2010. We selected 574 scans that had been performed in patients who presented with or without diarrhoea. We examined the selected medical records to determine whether the CT scan changed patients' management. A scan was considered to be management changing if a decisive intervention occurred on the basis of the scan results. Among 124 scans in patients with diarrhoea and 450 scans in patients without diarrhoea, the scan results changed management in 13 of the patients with diarrhoea (11%) and in 233 of those without diarrhoea (52%) (P < 0.001). When management changed, the changes resulted from findings unrelated to diarrhoea. Despite its defined role in the assessment of abdominal pain, CT of patients that also had diarrhoea seldom caused a major change in management. The probability of CT causing such a change does not outweigh the cost, radiation risk or potential for contrast-induced nephropathy.

Discovery of epigenetic regulator I-BET762: lead optimization to afford a clinical candidate inhibitor of the BET bromodomains

The bromo and extra C-terminal domain (BET) family of bromodomains are involved in binding epigenetic marks on histone proteins, more specifically acetylated lysine residues. This paper describes the discovery and structure-activity relationships (SAR) of potent benzodiazepine inhibitors that disrupt the function of the BET family of bromodomains (BRD2, BRD3, and BRD4). This work has yielded a potent, selective compound I-BET762 that is now under evaluation in a phase I/II clinical trial for nuclear protein in testis (NUT) midline carcinoma and other cancers.

Counseling about the HPV vaccine: desexualize, educate, and advocate

Information is provided for clinicians who treat adolescents and adult women to use when counseling patients about human papillomavirus (HPV) vaccine. A literature search was done to determine: (1) reasons for refusal of the vaccine, including cost and concerns that immunization against HPV will lead to promiscuity; (2) potential for non-sexual transmission of HPV; (3) non-genital locations of HPV; (4) non-genital cancers associated with HPV. Vaccines for Children Program and the Affordable Care Act eliminate many costs.Neither biological nor behavioral evidence supports the idea that sexual behavior changes after immunization. HPV is transmitted from person to person by non-sexual routes including mother to child at birth and apparently by touch after birth. HPV is persistent in the environment, including medical environments. It has been found on apparently sterilized instruments used in vaginal exams. Pathogenic HPV has been recovered from breast tissue, sinonasal areas, and nipples as well as from hair follicles on arms, legs, scalps, eyebrows, and pubic hair. Pathogenic HPV was found in 6.5% of the oral cavities of a random sample of Americans. HPV is known to cause anal and oral cancers. It has also been associated with skin cancers, breast tumors, and prostate cancers. It is not known if the vaccine is protective against these cancers, but it is useful to educate about these other routes of transmission and non-genital HPV linked cancers so that patients/parents do not just focus on the sexual nature of the human papillomavirus.

Measurement issues in using pharmacy records to calculate adherence to antiretroviral drugs

BACKGROUND

Researchers often use pharmacy records to calculate adherence to antiretrovirals. Variability in the findings may be due to inconsistent methods of calculating adherence.

OBJECTIVE

Determine the impact on adherence rates of 6 different calculations that include accounting for whether filled antiretroviral prescriptions were picked up and whether the patient had medications at the start of the observation period.

METHODS

Fifty-six patients of a public care system, who had ordered, but failed to pick up, antiretroviral prescriptions from the clinic pharmacy at least once from September thru December, were identified using an electronic pharmacy database. Their adherence during the 4 months was calculated using refilled doses and picked up doses as a percent of prescribed doses. The effect on the calculation of adherence of medications in the patients' possession from August was examined.

RESULTS

When medications in the patients' possession from August were considered in calculating adherence, the rate was 54% based on the prescription refill date and 33.4% based on the prescription pick-up date. If medications in the patients' possession at the beginning of the observation period were ignored, adherence based on refill was 48.9% and 28.1% based on pick-up. If the start date for calculating adherence was the date of the first refill or pick-up during the first month of the observation period, adherence rates were 56.2% and 41%, respectively.

CONCLUSIONS

This study demonstrated that 6 different methods of calculating adherence from pharmacy records yielded adherence rates of 28.1% to 56.2%. Studies using pharmacy records should specify how adherence is calculated.

Factors Related to Sexual Self-Efficacy among Thai Youth Living with HIV/AIDS

Studies of sexual behavior among HIV-infected Thai youth show conflicting results due to the different ages of the respondents. This study examined the relationships between sexual self-efficacy and risk behaviors among 92 HIV-positive Thai youth aged 14 to 21 years. A questionnaire previously validated in Thailand measured sexual self-efficacy. There were low levels of sexual activity with 13 respondents having sex in the last 6 months. The sexual self-efficacy scales were inversely related to the risk behaviors of having sex, having multiple partners, and drinking alcohol in the last 6 months. The scores of the sexual self-efficacy scale and its subscales were significantly lower in those aged 17 to 21 than in 14 to 16. Sexual risk behaviors were significantly higher in those aged 17 to 21 than in 14 to 16. These findings suggest that interventions to increase sexual self-efficacy should be emphasized as HIV-infected Thai youth reach late adolescence.

Capability of Thailand to implement newborn male circumcision: a nation-wide survey

This study was designed to gain baseline information on the capability of the hospitals of Thailand to provide newborn male circumcision (NC) and on the opinions of health-care personnel towards NC. Two questionnaires were sent to every hospital in Thailand that might have obstetrical services. One questionnaire requested information about the degree to which NC was provided by the hospital. The second questionnaire targeted health-care providers' opinions about NC. The response rate was 55.1% (747/1355). Of the 562 hospitals that had deliveries in 2010, 8.2% (46) provided at least one NC. Thirty-eight percent (35/92) of private hospitals and 2.3% (11/470) of government hospitals provided the service. The primary reason for performing NC was parental request (82.6%). Some providers (31.3%) said that NC was easy to perform and 39.1% thought NC was safe. Most respondents (91.8%) stated that physicians should perform the procedure instead of nurses, and choices about undergoing NC should be left to parents (55.0%). NC was rarely performed in government hospitals, and its staffs seemed to not recognize the health benefits of NC. A massive education program for health-care providers would be necessary before implementing a national program for NC. More information on the opinions of health authorities, health-care personnel and parents as well as cost-effectiveness studies are needed before a proper policy can be implemented.

Using cost as a consideration for antiretroviral regimen selection: an example using average wholesale prices

Funding for the AIDS Drug Assistance Program (ADAP) has lagged behind the number of persons needing antiretroviral therapy, leading to waiting lists and reduction of needed treatments and services. This paper demonstrates a method of providing more treatment for the same amount of money by selecting clinically equivalent, but lower-cost drug regimens. Average wholesale prices (AWPs) were used to calculate the annual costs of preferred, alternative, and acceptable regimens. The cost of each regimen was divided into $1,000,000 to determine how many patients could be treated per $1,000,000 that an ADAP had to spend. AWPs for preferred regimens ranged from $25,318 to 35,645 per year. For alternative regimens, the range of annual AWPs was $22,002-$32,335. The range for the acceptable regimens was $19,031-$31,543. The range of person treated per $1,000,000 per year was from 28 to 52. Funding shortages will lead ADAPs to resort to waiting lists or other means of denying appropriate care unless alternative approaches to treatment are sought. Cost conscious selection of regimens where there is no harm to individual patients is one alternative approach. Medical conditions that allow exceptions to lower-cost-based regimens must be developed with the assistance of clinicians.

Verifying quantitative stigma and medication adherence scales using qualitative methods among Thai youth living with HIV/AIDS

HIV/AIDS-related stigma has been linked to poor adherence resulting in drug resistance and the failure to control HIV. This study used both quantitative and qualitative methods to examine stigma and its relationship to adherence in 30 HIV-infected Thai youth aged 14 to 21 years. Stigma was measured using the HIV stigma scale and its 4 subscales, and adherence was measured using a visual analog scale. Stigma and adherence were also examined by in-depth interviews. The interviews were to determine whether verbal responses would match the scale's results. The mean score of stigma perception from the overall scale and its 4 subscales ranged from 2.14 to 2.45 on a scale of 1 to 4, indicating moderate levels of stigma. The mean adherence score was .74. The stigma scale and its subscales did not correlate with the adherence. Totally, 17 of the respondents were interviewed. Contrary to the quantitative results, the interviewees reported that the stigma led to poor adherence because the fear of disclosure often caused them to miss medication doses. The differences between the quantitative and the qualitative results highlight the importance of validating psychometric scales when they are translated and used in other cultures.

The role of trust in delayed HIV diagnosis in a diverse, urban population

Delayed diagnosis of HIV infection is a common problem. We hypothesized that persons with less trust in physicians and in the healthcare system would be diagnosed with lower CD4 cell counts than persons with more trust because they would delay seeking healthcare. From January 2006 to October 2007, 171 newly diagnosed HIV-infected persons, not yet in HIV primary care, were recruited from HIV testing sites in Houston, Texas, that primarily serve the under- and un-insured. The participants completed instruments measuring trust in physicians and trust in the healthcare system. Initial CD4 cell counts were obtained from medical record review. Mean trust scores for participants with CD4 cell counts ≥200 cells/mm(3) were compared with scores from participants with CD4 cell counts <200 cells/mm(3). We found that 51% of the cohort was diagnosed with a CD4 cell count <200 cells/mm(3). Neither trust in physicians nor trust in the healthcare system was an independent predictor of delayed diagnosis of HIV infection. In multivariate analysis, men who have sex with men and injection drug users were more likely to have early HIV diagnosis. Race/ethnicity was the only variable statistically significantly predictive of trust in physicians and in the healthcare system. Hispanics had the highest trust scores, followed by Blacks and Whites. Low trust is likely not a barrier to timely diagnosis of HIV infection.

Developing a web site for human immunodeficiency virus prevention in a middle income country: a pilot study from Thailand

The Internet has often been used to reach men who have sex with men (MSMs) in developed countries. However, its use has not been as widespread in middle income countries because of a perceived lack of access to the web by residents of these countries. However, over half of the Internet users in the world now live in middle income countries. This article describes the development of web-based human immunodeficiency virus (HIV) prevention program that can serve as a model for middle income countries. Thai nursing faculty worked with MSMs to create and evaluate a Web site that provided HIV prevention messages directed toward MSMs. The steps for creating the site are described. Forty-one MSMs used the site and provided feedback to the site developers. The group was young (median=19 years), low income (median income was ∼170 US$ per month). The users demonstrated that they had access to the Internet and that they could utilize the site. They also reported moderate-to-high levels of satisfaction with site design, content, ease of use, information obtained, and benefits obtained from using the site. A previous article in the Thai language also showed that they reduced risk behaviors. They also made many useful suggestions for improving the content of the site. In conclusion, the study showed that the combination of nurses and MSMs from a middle income country could develop a usable HIV prevention Web site that instructed and changed behavior.

Why Thailand should consider promoting neonatal circumcision?

Male circumcision (MC) has been proven to reduce the risk of HIV transmission. The WHO and UNAIDS jointly recommend the international community consider MC as an HIV prevention measure. MC reduces the risk of acquiring other sexually transmitted infections (STIs) among men, urinary tract infections among children and penile cancer. Lowering the prevalence of STIs in men may reduce the incidence of STIs among women. High levels of adult MC are difficult to achieve in cultures where it has not been customary. Adult MC is associated with a high prevalence of post-operative complications. Neonatal male circumcision (NC) is simpler, safer, and cheaper. Higher coverage with MC can be achieved through NC. Thailand is a good country to promoting NC for the following reasons: most HIV infections are contracted through heterosexual transmission, there is a low MC rate, most newborn deliveries occur in hospitals, there is a relatively strong health care infrastructure and Thailand has well developed HIV care services. Issues of concern regarding promoting NC include length of time before seeing benefits, cost effectiveness of the intervention, the burden to the health care delivery system and concerns about children's rights. NC is an efficacious HIV prevention strategy that should be considered by those involved in HIV/AIDS prevention planning in Thailand. Further studies are needed to determine whether NC should be promoted in Thailand.

Readiness, trust, and adherence: a clinical perspective

OBJECTIVE

This paper examines the scientific bases for the recommendations on readiness, trust, and adherence that were contained in 5 HIV treatment guidelines.

METHODS

The authors reviewed the treatment guidelines of 5 internationally recognized expert panels, and 5 review articles on readiness, trust, and adherence to determine the evidence for the guidelines' recommendations. These review articles were assessed to determine whether they contained: 1) a definition of the concept, 2) a measure that predicted outcomes, or 3) evidence that a replicable intervention altered outcomes.

RESULTS

There is no good definition, measure, or evidence that readiness predicts adherence. There were no interventions that improved readiness in a clinically useful way. There was no good definition or measure of trust, nor was there evidence that patient trust predicts adherence or that interventions improve trust. It is not clear whether trust is a cause or an effect of clinical outcomes. There is agreement that adherence is defined as taking medications as prescribed. Six measures of adherence were found, and several studies showed that they correlated poorly when applied to the same sample of patients. Adherence interventions have had some success but are poorly described and idiosyncratic such that it is difficult to replicate them in other settings.

CONCLUSION

Research on readiness and trust are unlikely to yield useful results. Systematic, long term research on clinician-based adherence interventions must be done. A life-long process such as adherence to antiretroviral treatment is unlikely to be understood without having a long-term study of a cohort of patients taking these medications.

HIV Positive But Not in Care

Twenty-two persons in Northern Thailand who knew of their HIV positivity but were not in care were identified. They had significant medical, economic, behavioral, and family problems. A nurse researcher carried out a 6-month intervention with them to (1) assess whether they would remain in contact with the researcher for 6 months and (2) assess whether they would make positive changes in their lives. All 22 participants remained in contact for 6 months. A 5-step intervention process resulted in substantial improvements in their lives. Eleven patients entered care. Five needed immediate antiretroviral therapy (ART) and improved their CD4 counts. Six others established primary care relationships for non-HIV care. Twelve obtained legal, full-, or part-time employment. Eight disclosed to family members. Nine participants and/or family members entered counseling. Twelve persons publicly disclosed themselves. Twelve reported reducing or stopping substance abuse. Of 4 sex workers, 2 ceased engaging in that work.

Readiness: the state of the science (or the lack thereof)

HIV treatment guidelines state that patients' readiness should be assessed before initiating highly active antiretroviral therapy (HAART) to assure adherence. None of the guidelines provide a way to measure readiness. Therefore, this article sought to review the literature on readiness to determine if there was a viable predictor of adherence. Twenty-seven articles were reviewed. Nine described studies that examined the relationship between a measure of readiness and HAART adherence. No readiness measure demonstrated clinical utility as a predictor of adherence. Study flaws included small sample sizes (only one study >100 patients), short follow-up periods (all ≤1 year and six were ≤5 months, four ≤1 month), measures of readiness that related poorly to adherence, and inconsistent adherence measures (eight different measures were used by the researchers). Neither the guidelines nor the literature will help clinicians judge who should initiate HAART and who should delay treatment.

Influence of trust on HIV diagnosis and care practices: a literature review

Delays in accessing HIV health care and failure to adhere to providers' advice are common. Patient trust is critical to an individual's willingness to seek care and follow the physician's advice. Conversely, patient distrust can diminish the patient's health status. The trust literature is reviewed in an attempt to determine its effect on HIV care. In the HIV literature reviewed, greater trust in health care providers was associated with improved accessing of and remaining in care. Interventions to enhance patient trust have been tested, with no changes in the levels of trust being found. Few studies were rigorous enough to assess causality or temporal relation. It is not clear whether there is a causal association between patient trust and HIV health care outcomes. As these relationships are better understood, interventions can be designed to increase health-promoting behaviors.

Novel macrocyclic HCV NS3 protease inhibitors derived from α-amino cyclic boronates

A novel series of P2-P4 macrocyclic HCV NS3/4A protease inhibitors with α-amino cyclic boronates as warheads at the P1 site was designed and synthesized. When compared to their linear analogs, these macrocyclic inhibitors exhibited a remarkable improvement in cell-based replicon activities, with compounds 9a and 9e reaching sub-micromolar potency in replicon assay. The SAR around α-amino cyclic boronates clearly established the influence of ring size, chirality and of the substitution pattern. Furthermore, X-ray structure of the co-crystal of inhibitor 9a and NS3 protease revealed that Ser-139 in the enzyme active site traps boron in the warhead region of 9a, thus establishing its mode of action.

An effective, low-cost approach to implementing HIV/AIDS education programs in low literacy populations: an example from rural Haiti

The HIV/AIDS pandemic disproportionately afflicts regions of the world that have minimal access to formal schooling and low literacy rates. Health educational interventions are difficult to evaluate efficiently in these settings because standard approaches such as written questionnaires cannot easily be employed. Here, we describe a novel method of rapidly assessing health interventions among large groups that does not require the ability to read or write. We tested this evaluation tool within the context of a community-based HIV/AIDS drama education program in a low-literate region of rural Haiti. The evaluation was simple, easy to use, and confirmed substantial improvements in knowledge after the intervention. The tool also provided information that helped alter the intervention to improve educational outcomes in subsequent productions of the drama. This evaluation method can be utilized for very little cost, and may be replicated in resource-poor, non-literate settings throughout the developing world.

Patient Readiness to Adhere to HAART

Objectives: to determine 1) whether patients’ statements of readiness to take HAART predicted adherence and 2) whether previous experience with HAART enabled patients to better predict adherence. Method: Thirty-nine patients (24 naïve to HAART and 15 reinitiating HAART after a hiatus of >6 months) indicated readiness to take HAART on a Likert scale and a visual analog scale (VAS). Adherence was measured by prescription renewals. Results: Participants were 72% male; 62% African/American; 23% Anglo-White, and 13% Hispanic. Patients considered themselves quite ready to initiate therapy on both scales. Adherence for 5 months ranged from 24% to 100%; mean = 68%; median = 78%. Adherence was not associated with readiness as measured by the Likert scale (F = .15, p = .86) or the VAS (r = -.078, p = .64). VAS readiness scores did not correlate with adherence for naïve (r = -.16; p = .47) or experienced (r = .09; p = .76) patients. Conclusions: Patients’ statements of readiness to take HAART do not predict their adherence.

Sociocultural dimensions of HIV/AIDS among Middle Eastern immigrants in the US: bridging culture with HIV/AIDS programmes

The population of Middle Eastern immigrants in the US has been increasing dramatically over the past 30 years, growing from 200,000 in 1970 to 1.5 million in 2000. These immigrants and their descendants constitute an important new population of interest for public health and other social programmes. With this addition to the cultural diversity of American society, it is important for healthcare programmes to be responsive to the unique cultural needs of those of Middle Eastern origin and to include them in healthcare curricula. This need is particularly imperative for human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) intervention programmes, where the reduction of risky behaviours is essential to controlling the epidemic. When Middle Easterners emigrate to the US they must adjust to the American culture, which leads to preservation of some aspects of their culture and adjustment of behaviors to match American customs. This article aims to present sociocultural factors of HIV risk behaviours that are specific to Middle Eastern culture. The article also provides recommendations for HIV/AIDS-culturally appropriate intervention programmes.

Known to Be Positive But Not in Care: A Pilot Study From Thailand

This study was designed to describe persons with HIV/ AIDS (PWHAs) in Thailand who have not disclosed their HIV status to the government HIV clinics to receive medical care. Objectives were to (1) demonstrate a way to access these persons, and (2) describe their characteristics, HIV status, reasons for nondisclosure, and problems related to their self-care. Two nongovernmental organizations (NGOs) serving the nonmedical needs of PWHAs were used. In all, 22 PWHAs participated. Approximately 80% have known their HIV status for more than 1 year and 30% for more than 5 years. Almost 60% currently used recreational drugs. Reasons for not disclosing their HIV status included that they were still healthy (81.8%) and worried about stigma (77.3%). Two thirds will disclose when a serious problem occurs. This study demonstrates that this population can be accessed and studied through NGOs and that this population differs slightly from PWHAs in Thailand studied at initiation of medical care.

Antibiotic resistance in Staphylococcus aureus-containing cutaneous abscesses of patients with HIV

PURPOSE

The aim of this study was to document the resistance patterns found in exudates from cutaneous abscesses of HIV-infected persons.

BASIC PROCEDURES

Patient records were reviewed on 93 culture and sensitivity tests performed on exudates taken from incised and drained abscesses of HIV-infected persons.

MAIN FINDINGS

Of the specimens, 84.6% were Staphylococcus aureus. Of these, 93.5% were penicillin resistant, 87% oxacillin resistant, 84.4% cephazolin resistant, 84.4% erythromycin resistant, 52.2% ciprofloxacin resistant, and 15.6% tetracycline resistant. Fifty-eight specimens were tested for clindamycin with 29.3% found resistant; 85.7% were methicillin-resistant S aureus (MRSA) (defined as resistant to both penicillin G and oxacillin). All specimens were resistant to multiple antibiotics including antimicrobials that might be considered for use in MRSA. No specimens were resistant to trimethoprim-sulfamethoxazole, rifampin, or vancomycin.

CONCLUSIONS

Empiric antimicrobial therapy of HIV-infected persons with cutaneous abscesses must be tailored to the high frequency of antimicrobial drug resistance including MRSA in this population.

Knowledge and attitudes of Pakistani medical students towards HIV-positive and/or AIDS patients

As the incidence of HIV increases, one of the major steps in preventing a widespread epidemic is to make certain that medical students are prepared to recognize and treat HIV infections and their related conditions, and to counsel patients about avoiding risks that might lead to infections. This cross-sectional study assessed the knowledge level of 357 medical students and their attitudes about AIDS and HIV enrolled in a Medical College in Karachi, Pakistan. Only 6% of the students had complete knowledge on symptoms of HIV/AIDS and 7% of the students had complete knowledge on the modes of transmission of HIV. Statistical analysis of demographic factors affecting knowledge was done. Linear regression and Maentel-Haenszel tests showed that older and clinical students were more knowledgeable of symptoms and modes of transmission of HIV/AIDS. Ten attitudes were correlated with knowledge and none of these showed an association. These results on knowledge indicate that education about HIV/AIDS should be incorporated in the curriculum and interventions must be taken by public health professionals to avoid poor treatment outcomes.

Social and behavioral determinants of consistent condom use among female commercial sex workers in Ghana

This study investigated the social and behavioral predictors of consistent condom use among female commercial sex workers (FCSWs) in Ghana. Four hundred fifty street commercial sex workers were interviewed in Accra, Kumasi and Techiman. The level of condom education was very low (14%); however consistent condom use (all the time) with clients was relatively high (49.6%). Two hundred seventy-seven of the participants did not use condoms all the time.

Cost to achieve an undetectable viral load using recommended antiretroviral regimens

PURPOSE

The April 2005 Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents recommended 9 regimens to be combined with 2 nucleoside reverse transcriptase inhibitors (NRTIs). These regimens are effective in lowering viral load but are expensive. This study aimed to determine the cost for each regimen to achieve an undetectable viral load.

METHOD

52 clinical trials were reviewed. The outcome measure was cost per undetectable patient, C/PU, where C = cost of a drug, and PU = percent of patients with undetectable viral loads.

RESULTS

For 30 weeks, cost per undetectable (<400 copies/mL) ranged from 4,416 dollars (efavirenz) to 23,110 dollars (nelfinavir); for 42 weeks, the range was 5,729 dollars (efavirenz) to 24,071 dollars (indinavir/ritonavir); for 60 weeks, it ranged from 9,535 dollars (efavirenz) to 26,829 dollars (fosamprenavir); and for 84 weeks, it ranged from 12,203 dollars (efavirenz) to 22,960 dollars (nelfinavir). For <50 copies/mL, at 30 weeks the range was from 7,140 dollars (efavirenz) to 17,548 dollars (atazanavir); for 42 weeks, it ranged from 9,849 dollars (lopinavir/ritonavir) to 13,181 dollars (nelfinavir); for 60 weeks, it ranged from 8,702 dollars (nevirapine) to 36,034 dollars (atazanavir); and for 84 weeks, it ranged from 15,660 dollars (efavirenz) to 29,177 dollars (indinavir/ritonavir).

CONCLUSION

Efavirenz's low price and high effectiveness make it the least expensive means of achieving an undetectable viral load.

A retrospective study to determine the impact of medical- and lifestyle-based contraindications to a prescribed HAART regimen on clinical outcomes and adherence

OBJECTIVE

To determine whether patients who are prescribed a highly active antiretroviral therapy regimen, that minimizes medical and lifestyle contraindications, will be better able to adhere to their drug regimens and will have better clinical outcomes, than patients who do not have such a regimen.

METHODS

A retrospective chart review of patients' prescription renewals and changes in viral load and CD4(+) count and a comparison of these changes with patients' self-identified contraindications. Contraindications were identified by a questionnaire with 35 questions relating to medical history/concurrently prescribed medication and 16 questions on lifestyle. Main outcome measures are adherence assessed by prescription renewals, change in plasma HIV-1 RNA viral loads, and change in CD4(+) T-lymphocyte counts. Logistic and linear regression and student t-test were used to identify associations between outcome measurements and number of contraindications.

RESULTS

A total of 203 patients (72% male, 74% African-American, 7% Hispanic) completed the questionnaire. Seventy-four per cent of the patients had at least one medical/drug contraindication and 78% had at least one lifestyle contraindication. Increases in CD4 counts were reduced by an average of 13 cells/mm(3) (P = 0.033) for each medical/drug contraindication and viral load decreases was significant even with one medical contraindication vs. none (P = 0.042). Patients with fewer lifestyle contraindications were more likely to have at least a 1 log drop in viral load (P = 0.036). For each increase in the number of contraindications, there was a corresponding 2% decrease in the rate of adherence (P = 0.048).

CONCLUSIONS

The results suggest that using a patient administered questionnaire it is possible to identify contraindications in prescribed regimens that impact on adherence and on treatment effects on viral load and CD4 counts.

Symptom exacerbation and adherence to antiretroviral therapy during the menstrual cycle: a pilot study

Our objective is to investigate the relationship between drug and menstrual cycle symptoms in HIV+ women receiving antiretroviral therapy (HAART). Interviews were done for 12 weeks with 54 HIV+ women receiving HAART. Patients were asked if they experienced any of 28 symptoms associated with HAART and the menstrual cycle and about HAART adherence. Weeks were divided into menstrual weeks (MWs), premenstrual weeks (PWs), and other weeks. Women reported more bloating (P = .02) and cramps (P = .001) during MWs. Skin problems (P = .08) and breast tenderness (P = .03) were experienced during PWs. Feeling tired/loss of energy (P = .05), joint pain (P = .02), and chills (P = .03) were higher in non-MW/PWs. Women were slightly less adherent during the MWs (89%) than PWs (94%) and other weeks (93%). Feeling sad or depressed (P = .01) was associated with nonadherence. Experiencing certain symptoms associated with both the menstrual cycle and HAART drugs was related with nonadherence.

The population effectiveness of highly active antiretroviral therapy: Are good drugs good enough?

Despite the success of highly active antiretroviral therapy (HAART) at reducing mortality from HIV infection, there is evidence that it is not reaching the all of the population that needs it, even in the developed world. To be maximally effective at the population level, all persons with HIV infection must be diagnosed; those persons with an indication for HAART must enter care, must receive HAART, and then must adhere to appointments and, finally, HAART itself. There is considerable evidence that significant portions of the population infected with HIV have not completed all of these steps of HIV care even in the developed world. Although new medications to treat HIV are certainly needed, significant improvements in viral, immunologic, and clinical outcomes could be achieved from improving timely diagnosis, access to HAART, and adherence to appointments, as well as adherence to HAART.

Patients referred to an urban HIV clinic frequently fail to establish care: factors predicting failure

To measure the success with which patients newly entering outpatient care establish regular care, and assess whether race/ethnicity was a predictive factor, we conducted a medical record review of new patients seen 20 April 1998 to 31 December 1998 at The Thomas Street Clinic, a county clinic for uninsured persons. Patients were considered 'not established' if they never saw a physician in the 6 months after intake (the 'initial period'), 'poorly established' if seen but a > 6-month gap in care began in the initial period, and 'established' if there were no such gaps. Of 404 patients, 11% were 'not established', 37% 'poorly established', and 53% 'established'. Injection drug use as HIV risk factor (IDU), admitted current alcohol and drug use, age < 35 years, and CD4 count > or = 200 cells/mm(3) were most common in the 'not established' group and least common in the 'established' group. In multivariate ordinal logistic regression, difficulty establishing care was associated with IDU, admitted current alcohol use, and admitted former drug use. Age > 35 years was protective. Half the indigent patients entering care in this single-site study fail to establish regular care. Substance use and younger age are predictors of failure to establish care.

Clinical, sociodemographic, and local system factors associated with a hospital death among cancer patients

OBJECTIVE

The study was conducted to examine factors associated with hospital deaths among a group of cancer patients.

PATIENTS AND METHODS

A retrospective chart review of the M. D. Anderson Cancer Center Tumor Registry was conducted. Participants were all adult cancer patients, residents of the State of Texas diagnosed and treated since January 1, 1990, and who died during the years 1999 and 2000. The study outcome was the site of death.

MAIN RESULTS

The inclusion criteria were met by 866 patients of whom 504 (58%) died in a hospital. The group included 489 (56%) men. A number of 641 (74%) were White, 104 (12%) Hispanic, 92 (11%) Black, and 29 (3%) of other origin. The majority, 501 (58%), had been diagnosed with stage IV disease, and the median survival time was 14 months. Multivariate logistic regression analysis showed patients diagnosed with hematologic cancers to be significantly more likely (p<0.001) of dying in hospitals, odds ratio [OR 2.88] and confidence interval [95% CI 1.79-4.63], women diagnosed with breast and gynecological cancers were significantly less likely (p=0.03) of dying at hospitals odds ratio [OR 0.64] and confidence interval [95% CI 0.42-0.96], when compared with patients diagnosed with other cancers. Lower household income per zip code of residency was marginally associated (p=0.06) with hospital deaths.

CONCLUSIONS

The study identified groups of cancer patients at risk of hospital death. These results should account when planning the allocation of hospital palliative care services as well as when informing policy decisions about health care financing and delivery of these services.

Diagnosis of non-dental conditions. Carotid artery calcifications on panoramic radiographs identify patients at risk for stroke

BACKGROUND

The oral and maxillofacial manifestations of some occult systemic disorders may be identified during the provision of dental care. Medical conditions so identified should be referred to a physician for confirmation by appropriate test and indicated therapy. Atherosclerosis at the bifurcation of the carotid artery is a common cause of stroke, and, when such lesions are calcified, they may easily be identified on a panoramic radiograph since the carotid bifurcation lies within the field of a properly performed X-ray.

LITERATURE REVIEWED

To examine the degree to which this finding is recognized by the dental community, the authors conducted a PubMed review to find publications that detailed the identification of carotid artery calcifications on panoramic radiographs.

RESULTS

Between 1981-2003, there were 39 peer-reviewed dental manuscripts and 29 pertinent abstracts reporting the observation of incidental carotid calcifications visible on routine panoramic radiographs. These studies documented a 3% to 5% prevalence of carotid artery calcifications in the general dental population, with higher percentages occurring in patients having medical illnesses associated with advanced atherosclerosis.

PRACTICE IMPLICATIONS

The widespread recognition that calcifications seen in the region of the carotid bifurcation can identify a population at increased risk of stroke supports the practice of routinely examining this area during review of panoramic radiographs. Since a panoramic radiograph is often obtained for dental reasons, in many instances, further examination of the area of the carotid bifurcation is essentially cost-free, and can serve to prolong lives and bring significant savings in overall health care costs by assisting in the prevention of critical events such as strokes.

Medical Treatment of Women and Adherence to HIV Guidelines at an Urban University-Staffed Public Clinic

BACKGROUND

HIV-related morbidity and mortality have declined in recent years in the United States. Relative to their male counterparts, however, HIV-infected women tend to have less reduced morbidity and mortality. The purpose of this study was to investigate if the reported small decreases in HIV-related morbidity and mortality in women could be due to their receiving a lesser standard of care from public health clinics.

METHODS

One hundred sixteen female and 131 male patients who were diagnosed with HIV infection were drawn consecutively from a county-owned health clinical database in Houston, Texas. Physicians from the two local medical schools staffed the clinic. Information on patients' demographic characteristics, screening tests, clinical care, and prophylaxis care was abstracted for comparison.

RESULTS AND CONCLUSIONS

The data showed that there were no statistically significant sex-based differences in getting access to antiretroviral treatment or for prophylaxis of opportunistic infections in the clinic. Sex-based differences, however, were found in the initial CD4 cell count and HIV load. Women had higher CD4 cell counts and HIV RNA levels at the initial stage and during the time of treatment.

Use of bDNA testing in the immunologically nonresponding patient who has a low or undetectable viral load by RT-PCR testing

BACKGROUND

Studies have shown that reverse transcription-polymerase chain reaction (RT-PCR) technology underquantifies viral loads in patients with non-B clades of HIV-1. Testing with bDNA technology gave higher viral loads in these subtypes. A study was conducted to determine whether virologically responding patients on HAART who were not immunologically responding would have higher viral loads using bDNA technology and whether these differences were due to non-B clades.

METHOD

Forty-eight patients receiving HAART for more than 6 months who were having inappropriate immunologic responses in spite of undetectable or very low viral loads determined by RT-PCR (<3000 copies by Roche Amplicor 1.0) were studied. These patients had bDNA viral loads performed. All patients who had bDNA viral loads equivalent to >3000 by RT-PCR had clade and genotypic studies performed.

RESULTS

Fifteen patients had viral loads by bDNA that were equivalent to >3000 copies by RT-PCR. Four of these were found to have non-B clades (one D clade and three AG clade). The D clade patient had multidrug resistance; none of the AG clade patients had resistance. Of the remaining 11 patients, virus could not be recovered from 2 and 9 had a B clade. Six of these nine had genotypic resistance to HAART drugs.

CONCLUSION

bDNA testing may be useful in the immunologically nonresponding patient.

A collaborative program between a school of public health and a local health department to increase HIV testing of pregnant women

OBJECTIVE

This study evaluates the effectiveness of a continuing medical education (CME) program that sought to increase HIV testing of women attending maternity clinics of the City of Houston Department of Health and Human Services (HDHHS). The CME program consisted of 14 training sessions given in 1995, 1996, 1997, 1999, and 2000. Educational objectives included increasing patient knowledge of HIV perinatal testing, increasing patient appreciation of the importance of HIV testing, and developing staff skills in educating and counseling women to accept HIV testing during pregnancy.

METHODS

The CME program was based on assessment of clinician learning needs and an algorithm of the testing process, both jointly developed by faculty from the University of Texas Health Science Center at Houston School of Public Health and HDHHS personnel. The algorithm was also used to assess the care delivered. The CME was evaluated by examining changes in the percentage of women tested in the maternity clinics.

RESULTS

In 1995, the year before the education program, 5.7% of women seen in the maternity clinics were tested for HIV. After the program began, testing rates rose to 64.2% in 1996, 65.5% in 1997, and 43.3% in 1998. Given the decline in testing in 1998, additional CME sessions were conducted in 1999-2000. The rate of testing rose to 62.3% in 1999 and 76.5% in 2000.

CONCLUSION

Cooperative planning between university and health department personnel can create CME programs that alter provider behaviors and service delivery patterns to increase HIV testing. Outcomes need to be regularly monitored, however, to determine the need for maintenance or performance reinforcement.

Clinical experience with human immunodeficiency virus-infected older patients in the era of effective antiretroviral therapy

New therapies for human immunodeficiency virus (HIV)-infected patients suggest the need to examine whether these therapies are as effective in older patients as in younger patients. Fifty-two patients aged >/=50 years were compared with 52 patients aged <50 years for changes in CD4(+) counts, viral loads, opportunistic disease, hospitalizations, drug side effects, and death. No differences were found, except for higher rates of candidiasis in younger patients. Antiretroviral therapy seems to be equally effective in older and younger patients.