HIV Primary Care Patients Research Articles

1851. ID Fellow Quality Improvement Project Shows Gains in Oral Health Exams for People with HIV

Abstract Background Oral Health is important in people with HIV and remains an important HRSA performance measure. This HRSA measure is the percentage of people with HIV who had an oral health exam by a dentist in the performance year out of the people who had a medical visit in that same year. Our clinic is unique in that it has a Ryan White funded dental clinic with 3 full-time dentists on site. The percentage of patients receiving an oral health exam had decreased in recent years due to shutdowns and fear during the COVID-19 pandemic as well as the vaccine and testing requirements implemented for safety. Methods A quality improvement project was designed by an infectious diseases fellow to improve the number of patients receiving an oral health exam. The project was multipronged. The first step was educating the HIV providers about how to place a referral to the HIV dental clinic. The second was placing educational posters in each exam room to educate the patients about the importance of oral health and encourage them to ask for a referral. The last was giving each patient a questionnaire when they checked in for their visit. Each patient filled in the date of their last oral health exam, where it was received, and willingness to be referred for an oral health exam if not examined in the past 12 months. The questionnaires were collected by the provider and served as a reminder to refer. Our goal was a 40% improvement over our baseline, which was 23% in 2020 (goal >32.2%). The intervention began in September of 2022. Results In 2019, 31% of our HIV primary care patients were seen in the attached dental clinic, this dropped to 23% in 2020 and 24% in 2021. In the three months prior to our intervention, 38% of patients were referred, and 286 patients had an oral health exam; during the intervention 56%(n=388) of patients were referred, and 329 had an oral health exam. In 2022, 33% of HIV primary care patients were seen in the attached dental clinic, showing an increase despite only three months of the intervention. Conclusion Early results indicate an increase in the referrals and an oral health exams with this quality improvement intervention. Outcomes were limited by significant no shows and confounded by removal of COVID vaccine and testing requirements. Disclosures All Authors: No reported disclosures

Factors associated with hazardous alcohol use and motivation to reduce drinking among HIV primary care patients: Baseline findings from the Health & Motivation study

BackgroundLimited primary care-based research has examined hazardous drinking risk factors and motivation to reduce use in persons with HIV (PWH). MethodsWe computed prevalence ratios (PR) for factors associated with recent (<30 days) hazardous alcohol use (i.e., 4+/5+ drinks in a single day for women/men), elevated Alcohol Use Disorders Identification Test (AUDIT) scores, and importance and confidence (1–10 Likert scales) to reduce drinking among PWH in primary care. ResultsOf 614 participants, 48% reported recent hazardous drinking and 12% reported high alcohol use severity (i.e., AUDIT zone 3 or higher). Factors associated with greater alcohol severity included moderate/severe anxiety (PR: 2.07; 95% CI: 1.18, 3.63), tobacco use (PR: 1.79; 1.11, 2.88), and other substance use (PR: 1.72; 1.04, 2.83). Factors associated with lower alcohol severity included age 50–59 years (PR: 0.46; 0.22, 2.00) compared with age 20–39 years, and having some college/college degree (PR: 0.61; 0.38, 0.97) compared with ≤high school. Factors associated with greater importance to reduce drinking (scores >5) included: moderate/severe depression (PR: 1.43; 1.03, 2.00) and other substance use (PR: 1.49; 1.11, 2.01). Lower importance was associated with incomes above $50,000 (PR: 0.65; 0.46, 0.91) and marijuana use (PR: 0.65; 0.49, 0.87). HIV-specific factors (e.g., CD4 and HIV RNA levels) were not associated with alcohol outcomes. ConclusionsThis study identified modifiable participant characteristics associated with alcohol outcomes in PWH, including anxiety and depression severity, tobacco use, and other substance use.

A Cross-Sectional Study of Depressive Symptoms and Risky Alcohol Use Behaviors Among HIV Primary Care Patients in New York City.

An association between problem drinking and depression among HIV-infected individuals has been previously demonstrated; however, which specific risky drinking behaviors are associated with higher levels of depression has not yet been investigated. Using an adult sample of HIV-infected primary care patients (78% male, 94% Black or Hispanic), we investigated whether depressive symptoms are associated with various risky drinking behaviors. Participants were administered the Beck Depression Inventory-II to assess depressive symptoms, and the Alcohol Use Disorders and Associated Disabilities Interview Schedule-IV to evaluate alcohol involvement. Participants with depressive symptoms (26%) were at higher risk for alcohol dependence [adjusted odds ratio (AOR) 3.8; 95% CI 2.0-7.2], regular binge drinking (AOR 2.0; 95% CI 1.1-3.8), and regular daytime drinking (AOR 2.1; 95% CI 1.2-3.8), in comparison with their non-depressed counterparts. Because both depression and unhealthy drinking negatively affect medication adherence and clinical outcomes, a better understanding of the association between depression and certain risky drinking behaviors among HIV-infected individuals is vital to improving their care and prognoses.

Reducing non-injection drug use in HIV primary care: A randomized trial of brief motivational interviewing, with and without HealthCall, a technology-based enhancement

AimsIn HIV-infected individuals, non-injection drug use (NIDU) compromises many health outcomes. In HIV primary care, the efficacy of brief motivational interviewing (MI) to reduce NIDU is unknown, and drug users may need greater intervention. We designed an enhancement to MI, HealthCall (HC), for daily patient self-monitoring calls to an interactive voice response (IVR) phone system, and provided participants with periodic personalized feedback. To reduce NIDU among HIV primary care patients, we compared the efficacy of MI+HealthCall to MI-only and an educational control condition. DesignParticipants age >18 with >4days of NIDU during the prior 30days were recruited from large urban HIV primary care clinics. Of the 240 participants, 83 were randomly assigned to control, 77 to MI-only, and 80 to MI+HC. Counselors provided educational control, MI-only or MI+HC at baseline. At 30 and 60days (end-of-treatment), counselors briefly discussed drug use, moods and health behaviors, using HealthCall-generated graphs with MI+HC patients. Primary outcomes (last 30days) were number of days used primary drug (NumDU), and total quantity of primary drug used (dollar amount spent; QuantU), derived from the Time-Line Follow-Back. FindingsAcross all groups, at end-of-treatment, frequency and quantity of NIDU decreased, with significantly greater reductions in the MI-Only group. A twelve-month post-treatment follow-up indicated sustained benefits of MI+HC and MI-only relative to control. ConclusionsBrief interventions can be successfully used to reduce non-injection drug use in HIV primary care. IVR-based technology may not be sufficiently engaging to be effective. Future studies should investigate mobile technology to deliver a more engaging version of HealthCall to diverse substance abusing populations.

Statin Use With the ATP III Guidelines Compared to the 2013 ACC/AHA Guidelines in HIV Primary Care Patients

Background: The 2013 Cholesterol Guidelines include a new atherosclerotic cardiovascular disease (ASCVD) risk calculator that determines the 10-year risk of coronary heart disease and/or stroke. The applicability of this calculator and its predecessor, the Framingham risk score (FRS) in Adult Treatment Panel (ATP) III, has been limited in patients with HIV. The objective of this study was to compare the risk scores of ASCVD and FRS in the initiation of statin therapy in patients with HIV. Methods: We conducted a retrospective chart review of patients with HIV on statin therapy from October 1, 2013, to April 1, 2014. Data collection included patient demographics, pertinent laboratory test results, and medication list. The primary end point evaluated the level of agreement between the guidelines. Results: Of 155 patients who met the inclusion criteria, 116 were treated similarly with both guidelines. This showed a moderate level of agreement (P < .001). Forty-eight of 86 patients requiring statins were placed on the correct intensity statin using the 2013 guidelines. Regardless of which guideline, a majority of patients required statin therapy. Conclusion: A moderate agreement was found between both guidelines in terms of statin use when applied to an HIV patient population. Based on the 2013 guidelines and taking into account drug interactions with antiretrovirals, 44.2% of the patients were treated with an incorrect statin intensity.

Contrasting trajectories of intervention-related self-monitoring in HIV primary care patients

Contrasting trajectories of intervention-related self-monitoring in HIV primary care patients

Post-treatment drinking among HIV patients: Relationship to pre-treatment marijuana and cocaine use

BackgroundFor individuals with HIV, heavy drinking can pose serious threats to health. Some interventions are effective at reducing drinking in this population, but many HIV-infected heavy drinkers also use marijuana or cocaine. Although these drugs have predicted poor alcohol outcomes in other treatment studies, whether this occurs among HIV patients who drink heavily is unknown. MethodsParticipants were binge-drinking HIV primary care patients (N=254) enrolled in a randomized trial of three brief drinking interventions over 60 days that varied in intensity. We investigated the relationship of baseline past-year drug use (marijuana-only, cocaine-only, both, neither) to end-of-treatment drinking quantity and frequency. We also evaluated whether the relationship between intervention type and end-of-treatment drinking varied by baseline drug use. Final models incorporated control for patients’ demographic and HIV characteristics. ResultsIn final models, drinking frequency at the end of treatment did not vary by baseline drug use, but drinking quantity did (X2[3]=13.87, p<0.01), with individuals using cocaine-only drinking significantly more per occasion (B=0.32, p<0.01). Baseline drug use also interacted with intervention condition in predicting end-of-treatment drinking quantity (X2[6]=13.98, p<0.05), but not frequency, with the largest discrepancies in end-of-treatment drinks per drinking day by intervention intensity among cocaine-only patients. ConclusionsIn general, HIV patients using cocaine evidenced the highest levels of drinking after alcohol intervention. However, these individuals also evidenced the most pronounced differences in end-of-treatment drinking by intervention intensity. These results suggest the importance of more intensive intervention for individuals using alcohol and cocaine.

Agreement between timeline follow-back (TLFB) and Audio Computer-Assisted Self Interview (A-CASI) in HIV primary care patients: Assessment of days used primary drug

Agreement between timeline follow-back (TLFB) and Audio Computer-Assisted Self Interview (A-CASI) in HIV primary care patients: Assessment of days used primary drug

Perceived medical risks of drinking, alcohol consumption, and hepatitis C status among heavily drinking HIV primary care patients.

Heavy drinking poses significant risks to the health and survival of individuals infected with HIV, particularly those coinfected with hepatitis C virus (HCV). However, little is known about patients' perceptions of these risks, and whether these perceptions relate to their alcohol consumption. A sample of 254 heavily drinking HIV primary care patients (78% male; 94.5% minority; 31.8% with HCV) reported on their perceptions of the medical risks of drinking and on their alcohol consumption prior to participation in a drinking-reduction intervention trial. In the HIV-infected sample as a whole, 62.9% reported that they had a medical problem made worse by drinking, and 64.3% reported restricting drinking to avoid future medical problems. Although patients coinfected with HIV/HCV reported greater efforts to restrict drinking to avoid future medical problems (adjusted odds ratio=1.94), their reported drinking quantity and frequency did not differ from that of HIV mono-infected patients. Awareness of medical risk was not associated with drinking level. Effort to restrict drinking to avoid medical risk was associated with lower drinking quantity, frequency, and binge frequency (ps<0.05), but the association with binge frequency was specific to patients without HCV. Over one-third of HIV patients are unaware of the medical risks of drinking, and do not restrict use, suggesting the need for intervention in this group. Patients coinfected with HIV/HCV may report more effort to restrict drinking, but their reported drinking quantity and frequency suggest that they are actually drinking just as heavily as HIV mono-infected patients. Awareness of medical risk was unrelated to drinking, which suggests the need for interventions consisting of more than simple education. However, reported effort to restrict drinking did predict less drinking, suggesting the importance of patient commitment and initiative in change.

Reasons for limiting drinking in an HIV primary care sample.

Heavy drinking among individuals with HIV is associated with major health concerns (liver disease, medication nonadherence, immune functioning), but little is known about cognitive-motivational factors involved in alcohol consumption in this population, particularly reasons for limiting drinking. Urban HIV primary care patients (N = 254; 78.0% male; 94.5% African American or Hispanic) in a randomized trial of brief drinking-reduction interventions reported on reasons for limiting drinking, alcohol consumption, and alcohol dependence symptoms prior to intervention. Exploratory factor analysis indicated 3 main domains of reasons for limiting drinking: social reasons (e.g., responsibility to family), lifestyle reasons (e.g., religious/moral reasons), and impairment concerns (e.g., hangovers). These factors evidenced good internal consistency (αs = 0.76 to 0.86). Higher scores on social reasons for limiting drinking were associated with lower typical quantity, maximum quantity, and binge frequency (ps < 0.01), and higher scores on lifestyle reasons were associated with lower maximum quantity, binge frequency, and intoxication frequency (ps < 0.01). In contrast, higher scores on impairment concerns were associated with more frequent drinking and intoxication, and higher risk of alcohol dependence (ps < 0.05), likely because dependent drinkers are more familiar with alcohol-induced impairment. The current study is the first to explore reasons for limiting drinking among individuals with HIV and how these reasons relate to alcohol involvement. This study yields a scale that can be used to assess reasons for limiting drinking among HIV-positive drinkers and provides information that can be used to enhance interventions with this population. Discussing social and lifestyle reasons for limiting drinking among less extreme drinkers may support and validate these patients' efforts to limit engagement in heavy drinking; discussion of impairment reasons for limiting drinking may be a way to engage dependent drinkers in efforts to decrease their alcohol consumption.

Drinking motives as prospective predictors of outcome in an intervention trial with heavily drinking HIV patients

BackgroundHeavy alcohol consumption in HIV patients is an increasing health concern. Applying the drinking motivational model to HIV primary care patients, drinking motives (drinking to cope with negative affect, for social facilitation, and in response to social pressure) were associated with alcohol consumption at a baseline interview. However, whether these motives predict continued heavy drinking or alcohol dependence in this population is unknown. MethodsParticipants were 254 heavy-drinking urban HIV primary care patients (78.0% male; 94.5% African American or Hispanic) participating in a randomized trial of brief drinking-reduction interventions. Drinking motive scales, as well as measures of alcohol consumption and alcohol dependence, were administered at baseline. Consumption and dependence measures were re-administered at the end of treatment two months later. Regression analyses tested whether baseline drinking motive scale scores predicted continued heavy drinking and alcohol dependence status at the end of treatment, and whether motives interacted with treatment condition. ResultsBaseline drinking to cope with negative affect predicted continued heavy drinking (p<0.05) and alcohol dependence, the latter in both in the full sample (adjusted odds ratio [AOR]=2.14) and among those with baseline dependence (AOR=2.52). Motives did not interact with treatment condition in predicting alcohol outcomes. ConclusionsDrinking to cope with negative affect may identify HIV patients needing targeted intervention to reduce drinking, and may inform development of more effective interventions addressing ways other than heavy drinking to cope with negative affect.

Drinking Motives Among HIV Primary Care Patients

Heavy drinking among individuals with HIV is associated with poor medication adherence and other health problems. Understanding reasons for drinking (drinking motives) in this population is therefore important and could inform intervention. Using concepts of drinking motives from previous alcohol research, we assessed these motives and drinking in 254 HIV-positive primary care patients (78.0 % male; 94.5 % African American or Hispanic) prior to their participation in an alcohol intervention trial. Three motives had good factor structure and internal consistency: "drinking to cope with negative affect", "drinking for social facilitation" (both associated with heavier drinking), and "drinking due to social pressure" (associated with less drinking). Drinking motives may provide important content for alcohol intervention; clinical trials could indicate whether inclusion of such content improves intervention efficacy. Discussing motives in session could help providers assist clients in better managing psychological and social aspects of their lives without reliance on alcohol.

Reducing heavy drinking in HIV primary care: a randomized trial of brief intervention, with and without technological enhancement

In HIV-infected individuals, heavy drinking compromises survival. In HIV primary care, the efficacy of brief motivational interviewing (MI) to reduce drinking is unknown, alcohol-dependent patients may need greater intervention and resources are limited. Using interactive voice response (IVR) technology, HealthCall was designed to enhance MI via daily patient self-monitoring calls to an automated telephone system with personalized feedback. We tested the efficacy of MI-only and MI+HealthCall for drinking reduction among HIV primary care patients. Parallel random assignment to control (n = 88), MI-only (n = 82) or MI+HealthCall (n = 88). Counselors provided advice/education (control) or MI (MI-only or MI+HealthCall) at baseline. At 30 and 60 days (end-of-treatment), counselors briefly discussed drinking with patients, using HealthCall graphs with MI+HealthCall patients. Large urban HIV primary care clinic. Patients consuming ≥4 drinks at least once in prior 30 days. Using time-line follow-back, primary outcome was number of drinks per drinking day, last 30 days. End-of-treatment number of drinks per drinking day (NumDD) means were 4.75, 3.94 and 3.58 in control, MI-only and MI+HealthCall, respectively (overall model χ(2) , d.f. = 9.11,2, P = 0.01). For contrasts of NumDD, P = 0.01 for MI+HealthCall versus control; P = 0.07 for MI-only versus control; and P = 0.24 for MI+HealthCall versus MI-only. Secondary analysis indicated no intervention effects on NumDD among non-alcohol-dependent patients. However, for contrasts of NumDD among alcohol-dependent patients, P < 0.01 for MI+HealthCall versus control; P = 0.09 for MI-only versus control; and P = 0.03 for MI+HealthCall versus MI-only. By 12-month follow-up, although NumDD remained lower among alcohol-dependent patients in MI+HealthCall than others, effects were no longer significant. For alcohol-dependent HIV patients, enhancing MI with HealthCall may offer additional benefit, without extensive additional staff involvement.

Identifying Drivers of Overall Satisfaction in Patients Receiving HIV Primary Care: A Cross-Sectional Study

ObjectiveThis study seeks to understand the drivers of overall patient satisfaction in a predominantly low-income, ethnic-minority population of HIV primary care patients. The study’s primary aims were to determine 1) the component experiences which contribute to patients’ evaluations of their overall satisfaction with care received, and 2) the relative contribution of each component experience in explaining patients’ evaluation of overall satisfaction.MethodsWe conducted a cross-sectional study of 489 adult patients receiving HIV primary care at two clinics in Houston, Texas, from January 13–April 21, 2011. The participation rate among eligible patients was 94%. The survey included 15 questions about various components of the care experience, 4 questions about the provider experience and 3 questions about overall care. To ensure that the survey was appropriately tailored to our clinic population and the list of component experiences reflected all aspects of the care experience salient to patients, we conducted in-depth interviews with key providers and clinic staff and pre-tested the survey instrument with patients.ResultsPatients’ evaluation of their provider correlated the strongest with their overall satisfaction (standardized β = 0.445, p<0.001) and accounted for almost half of the explained variance. Access and availability, like clinic hours and ease of calling the clinic, also correlated with overall satisfaction, but less strongly. Wait time and parking, despite receiving low patient ratings, did not correlate with overall satisfaction.ConclusionsThe patient-provider relationship far exceeds other component experiences of care in its association with overall satisfaction. Our study suggests that interventions to improve overall patient satisfaction should focus on improving patients’ evaluation of their provider.

Dental Anxiety and the Use of Oral Health Services among People Attending Two HIV Primary Care Clinics in Miami

We examined factors associated with dental anxiety among a sample of HIV primary care patients and investigated the independent association of dental anxiety with oral health care. Cross-sectional data were collected in 2010 from 444 patients attending two HIV primary care clinics in Miami-Dade County, Florida. Corah Dental Anxiety Scores and use of oral health-care services were obtained from all HIV-positive patients in the survey. The prevalence of moderate to severe dental anxiety in this sample was 37.8%, while 7.9% of the sample was characterized with severe dental anxiety. The adjusted odds of having severe dental anxiety were 3.962 times greater for females than for males (95% confidence interval [CI] 1.688, 9.130). After controlling for age, ethnicity, gender, education, access to dental care, and HIV primary clinic experience, participants with severe dental anxiety had 69.3% lower adjusted odds of using oral health-care services within the past 12 months (vs. longer than 12 months ago) compared with participants with less-than-severe dental anxiety (adjusted odds ratio = 0.307, 95% CI 0.127, 0.742). A sizable number of patients living with HIV have anxiety associated with obtaining needed dental care. Routine screening for dental anxiety and counseling to reduce dental anxiety are supported by this study as a means of addressing the impact of dental anxiety on the use of oral health services among HIV-positive individuals.

HealthCall: Technology-based extension of motivational interviewing to reduce non-injection drug use in HIV primary care patients – a pilot study

To reduce non-injection drug use (NIDU) among HIV primary care patients, more than a single brief intervention may be needed, but clinic resources are often too limited for extended interventions. To extend brief motivational interviewing (MI) to reduce NIDU, we designed and conducted a pilot study of “HealthCall,” consisting of brief (1–3 minutes) daily patient calls reporting NIDU and health behaviors to a telephone-based interactive voice response (IVR) system, which provided data for subsequent personalized feedback. Urban HIV adult clinic patients reporting ≥4 days of NIDU in the previous month were randomized to two groups: MI-only (n=20) and MI+HealthCall (n=20). At 30 and 60 days, patients were assessed and briefly discussed their NIDU behaviors with their counselors. The outcome was the number of days patients used their primary drug in the prior 30 days. Medical marijuana issues precluded HealthCall with patients whose primary substance was marijuana (n=7); excluding these, 33 remained, of whom 28 patients (MI-only n=17; MI+HealthCall n=11) provided post-treatment data for analysis. Time significantly predicted reduction in “days used” in both groups (p<0.0001). At 60 days, between-group differences approached trend level, with an effect size of 0.62 favoring the MI+HealthCall arm. This pilot study suggests that HealthCall is feasible and acceptable to patients in resource-limited HIV primary care settings and can extend patient involvement in brief intervention with little additional staff time. A larger efficacy trial of HealthCall for NIDU-reduction in such settings is warranted.

A low-cost, sustainable intervention for drinking reduction in the HIV primary care setting

Excess drinking poses multiple substantial health risks to HIV-infected individuals. However, no published intervention studies have focused on drinking reduction as the main outcome in HIV primary care patients. An intervention in this setting must place minimal demands on pressured staff and resources. This pilot study tested such an intervention, which consisted of brief Motivational Interviewing (MI) and HealthCall, an automated daily telephone self-monitoring system based on Interactive Voice Response (IVR), designed to extend and enhance the effects of brief MI. Thirty-one patients entered the study, received a 30-minute MI and were instructed in daily use of the IVR system. They received graphical feedback on their daily drinking from the HealthCall database after 30 days. A statistically significant decrease in drinking was found over time, both as reported in daily IVR calls (β = − 0.01, se 0.01, p=.03) and in follow-up interviews (β = − 0.04, se 0.12, p=.02) at 60 days. The proportion of daily calls made supported the feasibility of the intervention. The results indicate that HealthCall is acceptable to a disadvantaged HIV patient population, and preliminary data support the efficacy of this intervention in reducing harmful drinking among HIV primary care patients.