Care For HIV Patients Research Articles

The Pharmacy Only Visit Care Model (POV) and its Effects on the Quality of Care of HIV Patients in Uganda. A Case Study of Mulago National Referral Hospital HIV Clinic. Clients

The Pharmacy Only Visit Care Model (POV) and its Effects on the Quality of Care of HIV Patients in Uganda. A Case Study of Mulago National Referral Hospital HIV Clinic. Clients

Retaining HIV Patients in Care: The Role of Initial Patient Care Experiences.

Cross-sectional studies have shown an association between better patient experiences and health outcomes. However, the direction of causality remains unclear. Our prospective study seeks to determine whether better initial patient experiences predict subsequent retention in HIV care. We enrolled patients new to an HIV clinic in Houston, Texas, from August 26, 2013 to November 18, 2013. The patients' overall experience with the HIV provider was based on six items; overall experience with the HIV clinic was based on five items. We measured subsequent retention over the first 6months and entire first year of HIV care. Analyses included 140 patients. Sixty-one percent were non-Hispanic black, 41% were diagnosed with HIV within the last 3months, and 36% had a CD4 cell count <200. Thirty three percent were totally satisfied with their initial HIV provider experience and 32% were totally satisfied with their initial HIV clinic experience. Retention was 68% over the first 6months and 51% over the first year. Satisfaction with the HIV provider at the initial visit significantly predicted 6-month retention in care (aOR=3.56, p=0.006). Similar results were found for satisfaction with the HIV clinic (aOR=4.67, p=0.002). Neither of the patient experience measures at the initial visit predicted 12-month retention. Patients with better initial care experiences have significantly greater retention in HIV care. The effect of better initial care experiences was limited in duration. Consistently improving patient care experiences, not onlyat baseline butalsoon subsequent visits, may be a way to increase retention in HIV care.

Toward a comprehensive care of HIV patients: finding a strategy to detect depression in a Spanish HIV cohort

ABSTRACTDepression is a common but frequently undiagnosed feature in individuals with HIV infection. To find a strategy to detect depression in a non-specialized clinical setting, the overall performance of the Hospital Anxiety and Depression Scale (HADS) and the depression identification questions proposed by the European AIDS Clinical Society (EACS) guidelines were assessed in a descriptive cross-sectional study of 113 patients with HIV infection. The clinician asked the two screening questions that were proposed under the EACS guidelines and requested patients to complete the HADS. A psychiatrist or psychologist administered semi-structured clinical interviews to yield psychiatric diagnoses of depression (gold standard). A receiver operating characteristic (ROC) analysis for the HADS-Depression (HADS-D) subscale indicated that the best sensitivity and specificity were obtained between the cut-off points of 5 and 8, and the ROC curve for the HADS-Total (HADS-T) indicated that the best cut-off points were between 12 and 14. There were no statistically significant differences in the correlations of the EACS (considering positive responses to one [A] or both questions [B]), the HADS-D ≥ 8 or the HADS-T ≥ 12 with the gold standard. The study concludes that both approaches (the two EACS questions and the HADS-D subscale) are appropriate depression-screening methods in HIV population. We believe that using the EACS-B and the HADS-D subscale in a two-step approach allows for rapid, assumable and accurate clinical diagnosis in non-psychiatric hospital settings.

SMSaúde: Evaluating Mobile Phone Text Reminders to Improve Retention in HIV Care for Patients on Antiretroviral Therapy in Mozambique.

We evaluated whether regular mobile phone text reminders improved patients' retention in antiretroviral therapy (ART) care in Mozambique. SMSaúde was a randomized control trial of HIV-infected patients on ART who received regular text message reminder vs. standard of care at 3 public health facilities in Maputo Province, Mozambique. The primary outcome was retention in HIV care. Between November 2011 and March 2012, 830 eligible HIV-infected patients on ART were randomized 1:1 to the text reminder intervention or standard of care. We used Kaplan-Meier estimators and log-rank tests to compare proportions of patients who received SMS reminders who were retained in HIV care compared to the control group who received standard of care. Post hoc analyses were performed using Cox proportional hazards models stratified by urban/rural facility and when initiated ART (≤3 months vs. >3 months). Hazard ratios and confidence intervals (CIs) are reported. Analysis was with intention to treat. Patients who received text messages had lower attrition from HIV care at 12 months, though the difference was nonsignificant (RR: 0.68, 95% CI: 0.41 to 1.13). Among urban patients, text messages improved retention in HIV care (RR: 0.54, 95% CI: 0.31 to 0.95). Intervention patients newly initiated on ART (<3 months) had lower attrition than control patients (HR: 0.54; 95% CI: 0.23 to 0.91), especially urban newly initiated patients (HR: 0.20, 95% CI: 0.06 to 0.64). Text messages had no effect on retention among rural patients. Text messages did not improve retention in HIV care for all patients on ART but improved retention in care of urban patients and those who recently started ART and received text reminders compared with standard of care.

Is utilization of health services for HIV patients equal by socioeconomic status? Evidence from the Basque country

IntroductionAccess to ART and health services is guaranteed under universal coverage to improve life expectancy and quality of life for HIV patients. However, it remains unknown whether patients of different socioeconomic background equally use different types of health services.MethodsWe use one-year (2010–2011) data on individual healthcare utilization and expenditures for the total population (N = 2262698) of the Basque Country. We observe the prevalence of HIV and use OLS regressions to estimate the impact on health utilization of demographic, socioeconomic characteristics, and health status in such patients.ResultsHIV prevalence per 1000 individuals is greater the lower the socioeconomic status (0.784 for highest; 2.135 for lowest), for males (1.616) versus females (0.729), and for middle-age groups (26–45 and 46–65). Health expenditures are 11826€ greater for HIV patients than for others, but with differences by socioeconomic group derived from a different mix of services utilization (total cost of 13058€ for poorest, 14960€ for richest). Controlling for health status and demographic variables, poor HIV patients consume more on pharmaceuticals; rich in specialists and hospital care. Therefore, there is inequity in health services utilization by socioeconomic groups.ConclusionsEquity in health provision for HIV patients represents a challenge even if access to treatment is guaranteed. Lack of information in poorer individuals might lead to under-provision while richer individuals might demand over-provision. We recommend establishing accurate clinical guidelines with the appropriate mix of health provision by validated need for all socioeconomic groups; promoting educational programs so that patients demand the appropriate mix of services, and stimulating integrated care for HIV patients with multiple chronic conditions.

HIV and/or AIDS-related deaths and modifiable risk factors: A descriptive study of medical admissions at Oshakati Intermediate Hospital in Northern Namibia.

BackgroundHigh rates of HIV infection have decreased life expectancy in many African countries. Regardless of worldwide efforts to escalate treatment, care and prevention strategies, the number of deaths due to AIDS-related disorders is still high. Local healthcare workers suspect that there are modifiable factors in the care of HIV and/or AIDS patients which can be identified and improved.AimTo describe the HIV and/or AIDS-related causes of adult mortality and identify modifiable factors amongst patients admitted to Oshakati Intermediate Hospital, northern Namibia.MethodsData was extracted retrospectively and coded using the modified CoDe protocol for AIDS. Modifiable factors relating to the patient, health system or clinical care were identified using a standardised data collection tool.ResultsA total of 177 HIV and/or AIDS patients were identified, 94 (53.1%) were male and 120 (68%) had a CD4 count of less than 200 cells/mL. The common HIV-related causes of death were tuberculosis (25.9%), renal failure (15.8%), Pneumocystis jirovecii pneumonia (11.3%), cryptococcal meningitis (9%), HIV wasting syndrome (7.9%) and AIDS-defining malignancy (7.9%). The analysis revealed 281 modifiable factors; patient-related factors were the most common (153 [54.4%]), followed by health system factors (97 [34.5%]) and healthcare personnel factors (31 [11%]).ConclusionOur findings have highlighted the challenges in overall HIV and/or AIDS inpatient care and surrounding primary care facilities. The identification of specific modifiable factors can be used to reduce mortality by providing training as well as rational monitoring, planning and resource allocation.

Retention in Care of Adult HIV Patients Initiating Antiretroviral Therapy in Tigray, Ethiopia: A Prospective Observational Cohort Study.

IntroductionAlthough Ethiopia has been scaling up the antiretroviral therapy (ART) services, low retention in care of patients remains one of the main obstacles to treatment success. We report data on retention in care and its associated determinants in Tigray, Ethiopia.MethodsWe used data from the CASA project, a prospective observational and multi-site study of a cohort of HIV-infected patients who initiated ART for the first time in Tigray. Four participating health facilities (HFs) located in the South of Tigray were considered for this study. Patients were followed for one year after ART initiation. The main outcome measure was represented by the current retention in care, defined as the proportion of patients who were alive and receiving ART at the same HF one year after ART initiation. Patients who started ART between January 1, 2013 and December 31, 2013 were included in this analysis. Patients were followed for one year after ART initiation. The determinants of retention were analysed using univariate and multivariate Cox Proportional Hazards model with robust sandwich estimates to account for within HF correlation.ResultsThe four participating HFs in Tigray were able to retain overall 85.1% of their patients after one year from starting ART. Loss to follow-up (5.5%) and transfers to other HF (6.6) were the main determinant of attrition. A multivariate analysis shows that the factors significantly associated with retention were the type of HF, gender and active TB. Alamata health center was the HF with the highest attrition rate (HR 2.99, 95% CI: 2.77–3.23). Active TB (HR 1.72, 95% CI: 1.23–2.41) and gender (HR 1.64, 95% CI: 1.10–2.56) were also significantly associated with attrition.ConclusionsAlthough Ethiopia has significantly improved access to the ART program, achieving and maintaining a satisfactory long-term retention rate is a future goal. This is difficult because of different retention rates among HFs. Moreover specific interventions should be directed to people of different sex to improve retention in care in male population.

Ryan White–Funded Facilities Improve Services and Outcomes for Poor Patients with HIV Infection

When the Ryan White CARE Act was enacted in 1990, HIV infection was uniformly fatal. Now, with appropriate management, HIV-infected people can enjoy long lives. But because HIV infection disproportionately affects individuals with less access to care, including racial/ethnic minorities, the poor, and the uninsured, many do not benefit from recent treatment gains. Using Medical Monitoring Project data, investigators evaluated the characteristics and outcomes of a probability sample of 8038 HIV patients in care in the U.S. in 2009 and 2011 and the 989 facilities serving them. …

L’infection par le VIH : une maladie chronique redéfinissant la collaboration entre généralistes et spécialistes. Obstacles et opportunités

With the development of antiretroviral therapy, Human Immunodeficiency Virus [HIV) infection has become a chronic disease. In order to develop an efficient response to this new challenge, there is a need for closer collaboration between specialized units and general practitioners. This article identifies the opportunities for and the barriers to this collaboration. Semi-structured interviews were conducted with patients living with HIV, general practitioners working in multidisciplinary group practice using the capitation system and infectiologists from one Belgian urban area. Interviews focused one xperiences and expectations in relation to diagnosis, follow-up and collaboration between general practitioners and infectiologists. Overall, infectiologists and general practitioners aspire to improved communication and collaboration. There are overlaps between general practitioner's and infectiologist's field of action. The general practitioner's intervention is sometimes restricted to common uncomplicated or psychosocial problems, in the context of unplanned and short contacts.Infectiologists prefer to focus on HIV problems, leaving general practitioners to take care of these patients' other health problems. The patient may be an obstacle to greater involvement of general practitioners due to fear of stigmatization from his family and social circle or lack of confidence in the general practitioner's skills. This research underlines the difficulties and gaps in the care of HIV patients and provides preliminary explanations for the lack of active cooperation between general practitioners and infectiologists. Overlaps between the areas of professional skills can result in uncovered aspects of care, which can have a negative impact on patients, but also on general practitioners and infectiologists. Collaboration between general practitioners and infectiologists should be based on a concerted decision, with clear allocation of tasks, taking into account the patient's expectations.

Medication Adherence Clubs: a potential solution to managing large numbers of stable patients with multiple chronic diseases in informal settlements.

ObjectivesTo assess the care of hypertension, diabetes mellitus and/or HIV patients enrolled into Medication Adherence Clubs (MACs).MethodsRetrospective descriptive study was carried out using routinely collected programme data from a primary healthcare clinic at informal settlement in Nairobi, Kenya. All patients enrolled into MACs were selected for the study. MACs are nurse‐facilitated mixed groups of 25–35 stable hypertension, diabetes mellitus and/or HIV patients who met quarterly to confirm their clinical stability, have brief health discussions and receive medication. Clinical officer reviewed MACs yearly, when a patient developed complications or no longer met stable criteria.ResultsA total of 1432 patients were enrolled into 47 clubs with 109 sessions conducted between August 2013 and August 2014. There were 1020 (71%) HIV and 412 (29%) non‐communicable disease patients. Among those with NCD, 352 (85%) had hypertension and 60 (15%) had DM, while 12 had HIV concurrent with hypertension. A total of 2208 consultations were offloaded from regular clinic. During MAC attendance, blood pressure, weight and laboratory testing were completed correctly in 98–99% of consultations. Only 43 (2%) consultations required referral for clinical officer review before their routine yearly appointment. Loss to follow‐up from the MACs was 3.5%.ConclusionsThis study demonstrates the feasibility and early efficacy of MACs for mixed chronic disease in a resource‐limited setting. It supports burden reduction and flexibility of regular clinical review for stable patients. Further assessment regarding long‐term outcomes of this model should be completed to increase confidence for deployment in similar contexts.

Time above 1500 copies: a viral load measure for assessing transmission risk of HIV-positive patients in care.

We examined HIV transmission potential of patients in care by analyzing the amount of person-time spent above a viral load threshold that increases risk for transmission. Observational cohort and supplemental data. The cohort included HIV patients who received care at six HIV clinics in the United States, from 1 April 2009 to 31 March 2013, and had two or more viral load tests during this interval. Person-time (in days) above a viral load of 1500 copies/ml out of the total observation time was determined by inspecting consecutive pairs of viral load results and the time intervals between those pairs. The person-time rate ratios comparing demographic and clinical subgroups were estimated with Poisson regression. The cohort included 14 532 patients observed for a median of 1073 days with a median of nine viral load records. Ninety percent of the patients had been prescribed antiretroviral therapy. On average, viral load exceeded 1500 copies/ml during 23% of the patients' observation time (average of 84 days per year, per patient). Percentage of person-time above the threshold was higher among patients who had more than a fourth of their viral load pairs exceeding a 6-month interval (34% of observation time), patients not on antiretroviral therapy (58% of time), new/re-engaging patients (34% of time), patients 16-39 years of age (32% of time), and patients of black race (26% of time). HIV patients in care spent an average of nearly a quarter of their time with viral loads above 1500 copies/ml, higher among some subgroups, placing them at risk for potentially transmitting HIV to others.

Perspectives of key stakeholders regarding task shifting of care for HIV patients in Mozambique: a qualitative interview-based study with Ministry of Health leaders, clinicians, and donors.

BackgroundTask shifting is a common strategy to deliver antiretroviral therapy (ART) in resource-limited settings and is safe and effective if implemented appropriately. Consensus among stakeholders is necessary to formulate clear national policies that maintain high-quality care. We sought to understand key stakeholders’ opinions regarding task shifting of HIV care in Mozambique and to characterize which specific tasks stakeholders considered appropriate for specific cadres of health workers.MethodsNational and provincial Ministry of Health leaders, representatives from donor and non-governmental organizations (NGOs), and clinicians providing HIV care were intentionally selected to represent diverse viewpoints. Using open- and closed-ended questions, interviewees were asked about their general support of task shifting, its potential advantages and disadvantages, and whether each of seven cadres of non-physician health workers should perform each of eight tasks related to ART provision. Responses were tallied overall and stratified by current job category. Interviews were conducted between November 2007 and June 2008.ResultsOf 62 stakeholders interviewed, 44% held leadership positions in the Ministry of Health, 44% were clinicians providing HIV care, and 13% were donors or employed by NGOs; 89% held a medical degree. Stakeholders were highly supportive of physician assistants performing simple ART-related tasks and unanimous in opposing community health workers providing any ART-related services. The most commonly cited motives to implement task shifting were to increase ART access, decrease physician workload, and decrease patient wait time, whereas chief concerns included reduced quality of care and poor training and supervision. Support for task shifting was higher among clinicians than policy and programme leaders for three specific task/cadre combinations: general mid-level nurses to initiate ART in adults (supported by 75% of clinicians vs. 41% of non-clinicians) and in pregnant women (75% vs. 34%, respectively) and physician assistants to change ART regimens in adults (43% vs. 24%, respectively).ConclusionsStakeholders agreed on some ART-related task delegation to lower health worker cadres. Clinicians were more likely to support task shifting than policy and programme leaders, perhaps motivated by their front-line experiences. Harmonizing policy and programme managers’ views with those of clinicians will be important to formulate and implement clear policy.Electronic supplementary materialThe online version of this article (doi:10.1186/s12960-015-0009-3) contains supplementary material, which is available to authorized users.

Estimating the cost of increasing retention in care for HIV-infected patients: results of the CDC/HRSA retention in care trial.

Retaining HIV patients in medical care promotes access to antiretroviral therapy, viral load suppression, and reduced HIV transmission to partners. We estimate the programmatic costs of a US multisite randomized controlled trial of an intervention to retain HIV patients in care. Six academically affiliated HIV clinics randomized patients to intervention (enhanced personal contact with patients across time coupled with basic HIV education) and control [standard of care (SOC)] arms. Retention in care was defined as 4-month visit constancy, that is, at least 1 primary care visit in each 4-month interval over a 12-month period. We used microcosting methods to collect unit costs and measure the quantity of resources used to implement the intervention in each clinic. All fixed and variable labor and nonlabor costs of the intervention were included. Visit constancy was achieved by 45.7% (280/613) of patients in the SOC arm and by 55.8% (343/615) of patients in the intervention arm, representing an increase of 63 patients (relative improvement 22.1%; 95% confidence interval: 9% to 36%; P < 0.01). The total annual cost of the intervention at the 6 clinics was $241,565, the average cost per patient was $393, and the estimated cost per additional patient retained in care beyond SOC was $3834. Our analyses showed that a retention in care intervention consisting of enhanced personal contact coupled with basic HIV education may be delivered at fairly low cost. These results provide useful information for guiding decisions about planning or scaling-up retention in care interventions for HIV-infected patients.

Adherence to Appointments for Comprehensive Primary Care of HIV Patients With Substance Use Disorders

One of the critical issues in HIV patients with substance use disorders is engagement in care. The authors measured engagement as adherence to comprehensive primary care that included primary routine care, mental health, sick call, research clinic visits, and laboratory visits in 189 HIV patients of an urban clinic in the southern United States. Substance users were highly engaged in care, but adherence to primary routine care and mental health appointments declined over time. While this finding warrants further scrutiny, social services should be aware of substance users' engagement in all aspects of primary care and provide support to facilitate it.

Intervention to retain HIV patients in care "fairly low cost"

Intervention to retain HIV patients in care "fairly low cost"

Nutritional care protocol proposal for patients living with HIV without antiretroviral therapy, treated at the center of diagnostic references of San Martín de Quillota Hospital, Chile

The nutritional care for HIV patients in Chile is a challenge for public health due to the absence of ministerial guidelines to ensure standardized and timely nutritional care that helps to enhance immunity and delay immunological failure from a preventive approach. To design a proposal of protocol for nutritional care to optimize the nutritional management in a group of patients living with HIV. The design considered an initial diagnosis (patients and nutritional care characterization in a secondary public health service) to identify local needs, which was complemented with bibliographical precedents. Protocol content was validated by expert opinion, using a Likert questionnaire evaluating three variables: format, protocol's plan of nutritional care, and content quality. The proposed protocol consists of flowcharts care, nutritional care procedures and educational material. The validation process involved five experts, according to whom more time for patient care should be assigned, integration of the multidisciplinary team should be consider in the flowcharts and in short term reliability and applicability of the protocol should be assessed. This proposal is the first document oriented to nutritional management of outpatient with HIV from the early stages of the disease in Chile. Studies are needed to measure the impact of nutritional intervention in patients with HIV without antiretroviral therapy.

Better adherence to pre-antiretroviral therapy guidelines after implementing an electronic medical record system in rural Kenyan HIV clinics: a multicenter pre–post study

SUMMARYIntroductionThe monitoring of pre-antiretroviral therapy (pre-ART) is a key indicator of HIV quality of care. This study investigated the association of an electronic medical record system (EMR) with adherence to pre-ART guidelines in rural HIV clinics in Kenya.MethodsA retrospective study was carried out to assess the quality of pre-ART care using three indicators: (1) the performance of a baseline CD4 test, (2) time from enrollment in care to first CD4 test, and (3) time from baseline CD4 to second CD4 test. A comparison of these indicators was made pre and post the introduction of an EMR system in 17 rural HIV clinics.ResultsA total of 18 523 patients were receiving pre-ART care, of whom 38.8% in the paper group had had at least one CD4 test compared to 53.4% in the EMR group (p < 0.001). The adjusted odds of performing a CD4 test in clinics using an EMR was 1.59 (95% confidence interval 1.49–1.69). The median time from enrolment into HIV care to first CD4 test was 1.40 months (interquartile range (IQR) 0.47–4.87) for paper vs. 0.93 months (IQR 0.43–3.37) for EMR. The median time from baseline to first CD4 follow-up was 7.5 months (IQR 5.97–10.73) for paper and 6.53 months (IQR 5.57–7.87) for EMR.ConclusionThe use of the EMR system was associated with better compliance to HIV guidelines for pre-ART care. EMRs have a potential positive impact on quality of care for HIV patients in resource-constrained settings.

English

BACKGROUND AND OBJECTIVES: Cardiovascular autonomic nervous dysfunction has been demonstrated to severely debilitate HIV infected patients, namely by postural hypotension and syncopes It has important implication in health care of HIV patients. METHODS: 50 patients (25 HIV +ve without AIDS and 25 HIV+ with AIDS) who fulfilled the inclusion and exclusion criteria and 50 healthy matched controls were enrolled in the study. Autonomic function was assessed by batteries of autonomic function tests. RESULTS: In the present study 16% of HIV +ve with the AIDS had abnormal autonomic dysfunction and 4% of HIV positive without AIDS had abnormal autonomic dysfunction. Abnormalities in autonomic function occurred at all levels of CD4 counts. More number of abnormal results was found below 200 CD4 range. But the difference was not statistically significant. CONCLUSION: Cardiac autonomic nervous dysfunction is a common and relevant clinical problem it is significantly affected in both HIV positive without AIDS and HIV positive with AIDS groups. It may provide an alternative explanation for symptoms commonly observed in HIV infected individuals such as bowel and bladder dysfunction, impotence, syncope and sweating abnormalities.

Satisfaction of HIV patients with pharmaceutical services in South Eastern Nigerian hospitals.

Pharmacists play an important role in the care of HIV patients especially by providing pharmaceutical care. Thus it is imperative to assess the experience and satisfaction of HIV patients with the pharmaceutical services they receive as this will ensure that quality care is provided. The objective of this study was to assess HIV-infected patients' satisfaction with pharmaceutical services provided in South-Eastern Nigeria's HIV/AIDS clinics. A secondary aim was to repeat the validation process in order to confirm the initial validation of 'Patient Satisfaction with Pharmaceutical Service' (PSPS) questionnaire. The survey was conducted in six HIV/AIDS clinics in South-Eastern Nigeria. Multi-stage sampling technique was used to select the clinics. The level of satisfaction of the participants was determined. Variance in satisfaction score among the different demographic variables was also assessed. Re-validation techniques employed include factor analysis, reliability test, and construct validity. Results The response rate was 81.85 % (1,637 patients). With the exception of item 12 which examined provision of written information by pharmacists, the average score obtained in the survey was high. Most of the average scores ranged from 4 to 5, signifying that responses ranged from agree to strongly agree. Re-validation of the PSPS questionnaire revealed the same result obtained in the original validation exercise. HIV patients were highly satisfied with services rendered by the pharmacists in South-Eastern HIV clinics in Nigeria and PSPS proved to be a reliable and valid instrument for measuring satisfaction of HIV patients with pharmaceutical services.

Disparities in care for HIV patients with lung cancer.

e17566 Background: HIV patients with lung cancer appear to have an increased incidence and an overall shorter survival than HIV negative patients. Issues such as compliance with established guidelines, second and third line therapies and molecular testing have not been investigated thoroughly. Methods: We conducted a retrospective review at our institution from 2002-2013 analyzing patients with lung cancer and HIV. Frequency of molecular testing, second and third line therapy, CD4 count, HIV viral load, and survival data were included. Results: Eighteen patients were included for analysis. The median age at diagnosis was 49. Only one patient received EGFR testing; none received ALK testing. Second line and third line therapies were not offered to any patients with stage IV cancers. 64% of the patients with stage III or IV were either not treated or received palliative radiation only. 50% were immune suppressed with CD4 count 15,000 at time of lung cancer diagnosis. The media...