The Impact of Youth-Friendly Structures of Care on Retention among HIV-Infected Youth

Limited data exist on how structures of care impact retention among youth living with HIV (YLHIV). We describe the availability of youth-friendly structures of care within HIV Research Network (HIVRN) clinics and examine their association with retention in HIV care. Data from 680 15- to 24-year-old YLHIV receiving care at 7 adult and 5 pediatric clinics in 2011 were included in the analysis. 

The primary outcome was retention in care, defined as completing ≥2 primary HIV care visits ≥90 days apart in a 12-month period. Sites were surveyed to assess the availability of clinic structures defined a priori as 'youth-friendly'. Univariate and multivariable logistic regression models assessed structures associated with retention in care. 

Among 680 YLHIV, 85% were retained. Nearly half (48%) of the 680 YLHIV attended clinics with youth-friendly waiting areas, 36% attended clinics with evening hours, 73% attended clinics with adolescent health-trained providers, 87% could email or text message providers, and 73% could schedule a routine appointment within 2 weeks. Adjusting for demographic and clinical factors, YLHIV were more likely to be retained in care at clinics with a youth-friendly waiting area, evening clinic hours, and providers with adolescent health training. 

Youth-friendly structures of care impact retention in care among YLHIV. Further investigations are needed to determine how to effectively implement youth-friendly strategies across clinical settings where YLHIV receive care.

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By:  Lee L1, Yehia BR2, Gaur AH3, Rutstein R4, Gebo K5, Keruly JC5, Moore RD5, Nijhawan AE6, Agwu AL5.

• 1 Divisions of General Pediatrics and Adolescent Medicine, Johns Hopkins School of Medicine , Baltimore, Maryland.
• 2 Department of Infectious Diseases, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.
• 3 Department of Infectious Diseases, St. Jude Children's Research Hospital , Memphis, Tennessee.
• 4 Division of General Pediatrics, Children's Hospital of Philadelphia , Philadelphia, Pennsylvania.
• 5 Divisions of Infectious Diseases, Johns Hopkins School of Medicine , Baltimore, Maryland.
• 6 Department of Internal Medicine, University of Texas Southwestern Medical Center , Dallas, Texas. 
• AIDS Patient Care STDS. 2016 Apr;30(4):170-7. doi: 10.1089/apc.2015.0263. Epub 2016 Mar 16.

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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 6 months 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 3 months, 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 6 months 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 only at baseline and but also on subsequent visits, may be a way to increase retention in HIV care.

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By:  Dang BN1,2,3,4, Westbrook RA5, Hartman CM6,7, Giordano TP6,7,8,9.

• 1VA Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Houston, TX, USA. bndang@bcm.edu.
• 2Michael E. DeBakey Veterans Affairs Medical Center (152), 2002 Holcombe Blvd, Houston, TX, 77030, USA. bndang@bcm.edu.
• 3Department of Medicine, Baylor College of Medicine, Houston, TX, USA. bndang@bcm.edu.
• 4Harris Health System, Houston, TX, USA. bndang@bcm.edu.
• 5Jesse H. Jones Graduate School of Business, Rice University, Houston, TX, USA.
• 6VA Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Houston, TX, USA.
• 7Michael E. DeBakey Veterans Affairs Medical Center (152), 2002 Holcombe Blvd, Houston, TX, 77030, USA.
• 8Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
• 9Harris Health System, Houston, TX, USA. 
• AIDS Behav. 2016 Feb 24

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A Risk Score to Identify HIV-Infected Women Most Likely to Become Lost to Follow-Up in the Postpartum Period

Access to lifelong combination antiretroviral therapy (cART) is expanding among HIV-infected pregnant and breastfeeding women throughout sub-Saharan Africa (SSA). For this strategy to meaningfully improve maternal HIV outcomes, retention in HIV care is essential. 

We developed a risk score to identify women with high likelihood of loss to follow-up (LTFU) at 6 months postpartum from HIV care, using data from public health facilities in Lusaka, Zambia. LTFU was defined as not presenting for HIV care within 60 days of the last scheduled appointment. We used logistic regression to assess demographic, obstetric and HIV predictors of LTFU and to develop a simple risk score. Sensitivity and specificity were assessed at each risk score cut-point. 

Among 2029 pregnant women initiating cART between 2009 and 2011, 507 (25%) were LTFU by 6 months postpartum. Parity, education, employment status, WHO clinical stage, duration of cART during pregnancy and number of antenatal care visits were associated with LTFU (p-value < .10). A risk score cut-point of 11 (42nd percentile) had 85% sensitivity (95% CI 82%, 88%) and 22% specificity (95% CI 20%, 24%) to detect women LTFU and would exclude 20% of women from a retention intervention. A risk score cut-point of 18 (69th percentile) identified the 23% of women with the highest probability of LTFU and had sensitivity 32% (95% CI 28%, 36%) and specificity 80% (95% CI 78%, 82%). 

A risk score approach may be useful to triage a subset of women most likely to be LTFU for targeted retention interventions.

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By:  Bengtson AM1, Chibwesha CJ2, Westreich D1, Mubiana-Mbewe M3, Chi BH2,3, Miller WC1,4, Mapani M2, Pence BW1, Musonda P5, Stringer JS2, Pettifor A1.

• 1 Department of Epidemiology , University of North Carolina , Chapel Hill , NC , USA.
• 2 Department of Obstetrics and Gynecology , University of North Carolina , Chapel Hill , NC , USA.
• 3 Centre for Infectious Disease Research , Zambia , Africa.
• 4 Department of Medicine , University of North Carolina , Chapel Hill , NC , USA.
• 5 Department of Public Health, University of Zambia School of Medicine , Lusaka , Zambia , Africa. 
• AIDS Care. 2016 Feb 17:1-11

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Correlates of Nine-Month Retention following Interim Buprenorphine-Naloxone Treatment in Opioid Dependence: A Pilot Study

Interim medication-only treatment has been suggested for the initiation of opioid maintenance treatment (OMT) in opioid-dependent subjects, but this rarely has been studied using buprenorphine instead of methadone. Following a pilot trial assessing interim buprenorphine-naloxone treatment in order to facilitate transfer into OMT, we here aimed to study retention, and potential correlates of retention, in full-scale treatment. Thirty-six patients successfully referred from a waiting list through an interim treatment phase were followed for nine months in OMT. Baseline characteristics, as well as urine analyses during the interim phase and during full-scale OMT, were studied as potential correlates of retention. The nine-month retention in OMT was 83 percent (n = 30). While interim-phase urine samples positive for benzodiazepines did not significantly predict dropout from full-scale OMT (p = 0.09), urine samples positive for benzodiazepines within full-scale OMT were significantly associated with dropout (p < 0.01), in contrast to other substances and baseline characteristics. Retention remained high through nine months in this pilot study sample of patients referred through buprenorphine-naloxone interim treatment, but use of benzodiazepines is problematic, and the present data suggest that it may be associated with treatment dropout.

…The use of benzodiazepines during interim treatment and during full-scale OMT was the only variable associated with dropout in the present study. Although the number of dropouts in this pilot study was low, urines positive for benzodiazepines in the interim condition tended to be associated with a negative outcome once referred to the full-scale program but did not reach statistical significance (p = 0.09). However, significantly, a negative outcome in full-scale OMT was associated with the use of benzodiazepines within that OMT treatment setting, which was not the case for any other substance, suggesting that benzodiazepines may play a major role in the clinical picture of patients with a negative treatment course in opioid dependence.

The seemingly negative association between retention and benzodiazepine use during treatment of opioid dependence may require further attention in research and in clinical practice. In the present study, at baseline, the frequency of use of benzodiazepines was comparable to that of the main drug of these primarily opioid-dependent subjects. In contrast to the high rates of continued benzodiazepine use, urine samples positive for opiates were very infrequent in the full-scale OMT phase, markedly lower than in many other studies [35,36], and opioid-positive urines were not associated with dropout in OMT. The role of benzodiazepines in the present results, compared to the role of opioids, strengthens the impression that polydrug use, particularly including the use of benzodiazepines, may present a potentially even larger challenge in the treatment of severe opioid dependence than the actual primary opioid-related disorder.

Patients with a high level of benzodiazepine use could represent a group with more complicated psychiatric problems and more severe substance-related problems [29, 37]. In the present study, patients dropping out of treatment did not report more use of benzodiazepines during the last 30 days prior to study start, but still, this type of substance use was associated with a negative outcome once in full-scale treatment. It cannot be excluded that intake of benzodiazepines actually increases when the intake of illicit opioids decreases in treatment, at least in a subset of individuals…

Full article at:   http://goo.gl/7QXGbu

By:  A. Håkansson, 1 , 2 , * C. Widinghoff, 1 , 2 T. Abrahamsson, 1 , 2 and C. Gedeon 1 , 3

¹Department of Clinical Sciences Lund, Division of Psychiatry, Lund University, 221 85 Lund, Sweden

²Malmö Addiction Center, Department of Psychiatry, 205 02 Malmö, Skane Region, Sweden

³Solstenen Outpatient Unit for Opiate Maintenance Treatment, Östra Mårtensgatan 15, 223 61 Lund, Sweden

*A. Håkansson: Email: es.ul.dem@nossnakah.c_sredna

Academic Editor: Dennis M. Donovan

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Factors Associated with Retention among Non-Perinatally HIV-Infected Youth in the HIV Research Network

BACKGROUND:

The transmission of human immunodeficiency virus (HIV) among youth through high-risk behaviors continues to increase. Retention in Care is associated with positive clinical outcomes and a decrease in HIV transmission risk behaviors. We evaluated the clinical and demographic characteristics of non-perinatally HIV (nPHIV)-infected youth associated with retention 1 year after initiating care and in the 2 years thereafter. We also assessed the impact retention in year 1 had on retention in years 2 and 3.

METHODS:

This was a retrospective analysis of treatment-naive nPHIV-infected 12- to 24-year-old youth presenting for care in 16 US HIV clinical sites within the HIV Research Network between 2002 and 2008. Multivariate logistic regression identified factors associated with retention.

RESULTS:

Of 1160 nPHIV-infected youth, 44.6% were retained in care during the first year, and 22.4% were retained in all 3 years. Retention in the first year was associated with starting antiretroviral therapy in the first year (adjusted odds ratio [AOR], 3.47 [95% confidence interval (CI), 2.57-4.67]), Hispanic ethnicity (AOR, 1.66 [95% CI, 1.08-2.56]), men who have sex with men (AOR, 1.59 [95% CI, 1.07-2.36]), and receiving care at a pediatric site (AOR, 5.37 [95% CI, 3.20-9.01]). Retention in years 2 and 3 was associated with being retained 1 year after initiating care (AOR, 7.44 [95% CI, 5.11-10.83]).

CONCLUSION:

A high proportion of newly enrolled nPHIV-infected youth were not retained for 1 year, and only 1 in 4 were retained for 3 years. Patients who were Hispanic, were men who have sex with men, or were seen at pediatric clinics were more likely to be retained in care. Interventions that target those at risk of being lost to follow up are essential for this high-risk population.

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By:  Farmer C1, Yehia BR2, Fleishman JA3, Rutstein R4, Mathews WC5, Nijhawan A6, Moore RD7, Gebo KA8, Agwu AL9; HIV Research Network.

• 1Johns Hopkins School of Medicine, Baltimore, Maryland.
• 2Division of Infectious Diseases, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia.
• 3Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, Maryland.
• 4Division of General Pediatrics, Children's Hospital of Philadelphia, Pennsylvania.
• 5Department of Clinical Medicine, University of California San Diego Medical Center.
• 6Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas.
• 7Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
• 8Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
• 9Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland. 
• J Pediatric Infect Dis Soc. 2016 Mar;5(1):39-46. doi: 10.1093/jpids/piu102. Epub 2014 Oct 19.

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People Living with HIV Travel Farther to Access Healthcare: A Population-Based Geographic Analysis from Rural Uganda

INTRODUCTION:

The availability of specialized HIV services is limited in rural areas of sub-Saharan Africa where the need is the greatest. Where HIV services are available, people living with HIV (PLHIV) must overcome large geographic, economic and social barriers to access healthcare. The objective of this study was to understand the unique barriers PLHIV face when accessing healthcare compared with those not living with HIV in a rural area of sub-Saharan Africa with limited availability of healthcare infrastructure.

METHODS:

We conducted a population-based cross-sectional study of 447 heads of household on Bugala Island, Uganda. Multiple linear regression models were used to compare travel time, cost and distance to access healthcare, and log binomial models were used to test for associations between HIV status and access to nearby health services.

RESULTS:

PLHIV traveled an additional 1.9 km to access healthcare compared with those not living with HIV, and they were 56% less likely to access healthcare at the nearest health facility to their residence, so long as that facility lacked antiretroviral therapy (ART) services. We found no evidence that PLHIV traveled further for care if the nearest facility supplies ART services. Among those who reported uptake of care at one of two facilities on the island that provides ART (81% of PLHIV and 68% of HIV-negative individuals), PLHIV tended to seek care at a higher tiered facility that provides ART, even when this facility was not their closest facility (30% of PLHIV traveled further than the closest ART facility compared with 16% of HIV-negative individuals), and traveled an additional 2.2 km to access that facility, relative to HIV-negative individuals. Among PLHIV, residential distance was associated with access to facilities providing ART, comparing residential distances of 3-5 km to 0-2 km

CONCLUSIONS:

PLHIV travel longer distances for care, a phenomenon that may be driven by both the limited availability of specialized HIV services and preference for higher tiered facilities.

Below:  Spatial distribution of 447 heads of household and seven official health facilities surveyed (ART services indicated) on the northern portion of Bugala Island, Uganda

Full article at:   http://goo.gl/WqDS0O

By:  Akullian AN1, Mukose A2, Levine GA3, Babigumira JB4.

• 1Institute for Disease Modeling, Bellevue, WA, USA; aakullian@intven.com.
• 2Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
• 3Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle, WA, USA.
• 4Global Medicines Program, Department of Global Health, University of Washington, Seattle, WA, USA. 
• J Int AIDS Soc. 2016 Feb 10;19(1):20171. doi: 10.7448/IAS.19.1.20171. eCollection 2016

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Qualitative Analysis of Programmatic Initiatives to Text Patients with Mobile Devices in Resource-Limited Health Systems

Background

Text messaging is an affordable, ubiquitous, and expanding mobile communication technology. However, safety net health systems in the United States that provide more care to uninsured and low-income patients may face additional financial and infrastructural challenges in utilizing this technology. Formative evaluations of texting implementation experiences are limited. We interviewed safety net health systems piloting texting initiatives to study facilitators and barriers to real-world implementation.

Methods

We conducted telephone interviews with various stakeholders who volunteered from each of the eight California-based safety net systems that received external funding to pilot a texting-based program of their choosing to serve a primary care need. We developed a semi-structured interview guide based partly on the Consolidated Framework for Implementation Research (CFIR), which encompasses several domains: the intervention, individuals involved, contextual factors, and implementation process. We inductively and deductively (using CFIR) coded transcripts, and categorized themes into facilitators and barriers.

Results

We performed eight interviews (one interview per pilot site). Five sites had no prior texting experience. Sites applied texting for programs related to medication adherence and monitoring, appointment reminders, care coordination, and health education and promotion. No site texted patient-identifying health information, and most sites manually obtained informed consent from each participating patient. Facilitators of implementation included perceived enthusiasm from patients, staff and management belief that texting is patient-centered, and the early identification of potential barriers through peer collaboration among grantees. Navigating government regulations that protect patient privacy and guide the handling of protected health information emerged as a crucial barrier. A related technical challenge in five sites was the labor-intensive tracking and documenting of texting communications due to an inability to integrate texting platforms with electronic health records.

Conclusions

Despite enthusiasm for the texting programs from the involved individuals and organizations, inadequate data management capabilities and unclear privacy and security regulations for mobile health technology slowed the initial implementation and limited the clinical use of texting in the safety net and scope of pilots. Future implementation work and research should investigate how different texting platform and intervention designs affect efficacy, as well as explore issues that may affect sustainability and the scalability.

Full article at:   http://goo.gl/SAsnqs

By:  Sachin K. Garg, Courtney R. Lyles, Sara Ackerman, Margaret A. Handley, Dean Schillinger, Gato Gourley, Veenu Aulakh, and Urmimala Sarkar

Division of General Internal Medicine and Center for Vulnerable Populations at San Francisco General Hospital, University of California, San Francisco (UCSF), San Francisco, USA

Department of Social and Behavior Sciences, UCSF, San Francisco, USA

Center for Care Innovations, Oakland, USA

Department of Epidemiology and Biostatistics, UCSF, San Francisco, USA

Sachin K. Garg, Phone: (415) 353-7900, Email: ude.fscu@grag.nihcas.

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Maintaining the continuity of HIV-care records for patients transferring care between centers: Challenges, workloads, needs and risks

With improved life expectancy, the medical records of HIV-infected patients are likely to be transferred repeatedly between HIV caregivers. The challenges, and risk for introducing medical error from incomplete record transfers are poorly understood. 

We measured number of requests for record transfer, the workload incurred, and explore, using genotypic antiretroviral resistance testing results (GART), the potential risk of incomplete records. Using retrospective database and chart review, we examined all patients followed at the Southern Alberta Clinic between 1 January 2004 and 1 January 2015, and determined how many patients transferred care into and out our program, the associated requests and the workload for record transfer. Using a complete record of all GART tests, the potential importance of absent historic records in current treatment decisions was analyzed. 

The annual churn rate was 22 ± 3.4%. We received requests for only 70% of patient records who had left our care. Median time for receipt of incoming medical records was 28 days; average clerical time for processing data was 2 hours/record. Of all GART results, 25% exhibited resistance. Of 111 patients with potentially misleading GART results (i.e., documented historical resistance not visible on more recent GART), 34 (30.6%) had moved in from elsewhere. Rigorous maintenance of the continuity of the HIV record is not universally practiced. 

Resources, costs and logistic challenges as well as a lack of appreciation of risks clearly shown by GART testing, may be relevant barriers. Addressing such issues is pressing as aging and transfers of care are increasingly common.

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By:  Gill MJ1,2,3, Ody M1, Lynch T1,4, Jessiman-Perreault L1, Krentz HB1,2.

• 1 Southern Alberta HIV Clinic, Alberta Health Services , Calgary , Canada.
• 2 Department of Medicine , University of Calgary , Calgary , Alberta , Canada.
• 3 Department of Microbiology , Immunology, and Infectious Diseases, University of Calgary , Calgary , Canada.
• 4 Department of Pathology and Laboratory Medicine , University of Calgary , Calgary , Canada.
• AIDS Care. 2016 Feb 1:1-6. 

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Conditional Cash Transfers & Uptake Of & Retention in Prevention of Mother-To-Child HIV Transmission Care

BACKGROUND:

Novel strategies are needed to increase retention in and uptake of prevention of mother-to-child HIV transmission (PMTCT) services in sub-Saharan Africa. We aimed to determine whether small, increasing cash payments, which were conditional on attendance at scheduled clinic visits and receipt of proposed services can increase the proportions of HIV-infected pregnant women who accept available PMTCT services and remain in care.

METHODS:

In this randomised controlled trial, we recruited newly diagnosed HIV-infected women, who were 32 or less weeks pregnant, from 89 antenatal care clinics in Kinshasa, Democratic Republic of Congo, and randomly assigned (1:1) them to either the intervention group or the control group using computer-based randomisation with varying block sizes of four, six, and eight. The intervention group received compensation on the condition that they attended scheduled clinic visits and accepted offered PMTCT services (US$5, plus US$1 increment at every subsequent visit), whereas the control group received usual care. Outcomes assessed included retention in care at 6 weeks' post partum and uptake of PMTCT services, measured by attendance of all scheduled clinic visits and acceptance of proposed services up to 6 weeks' post partum. Analyses were by intention to treat. This trial is registered with ClinicalTrials.org, number NCT01838005.

FINDINGS:

Between April 18, 2013, and Aug 30, 2014, 612 potential participants were identified, 545 were screened, and 433 were enrolled and randomly assigned; 217 to the control group and 216 to the intervention group. At 6 weeks' post partum, 174 participants in the intervention group (81%) and 157 in the control group (72%) were retained in care (risk ratio [RR] 1·11; 95% CI 1·00-1·24). 146 participants in the intervention group (68%) and 116 in the control group (54%) attended all clinic visits and accepted proposed services (RR 1·26; 95% CI 1·08-1·48). Results were similar after adjustment for marital status, age, and education.

INTERPRETATION:

Among women with newly diagnosed HIV, small, incremental cash incentives resulted in increased retention along the PMTCT cascade and uptake of available services. The cost-effectiveness of these incentives and their effect on HIV-free survival warrant further investigation.

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By:  Yotebieng M1, Thirumurthy H2, Moracco KE3, Kawende B4, Chalachala JL4, Wenzi LK4, Ravelomanana NL5, Edmonds A5, Thompson D5, Okitolonda EW4,Behets F6.

• 1The Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH, USA; The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA. Electronic address: yotebieng.2@osu.edu.
• 2The University of North Carolina at Chapel Hill, Department of Health Policy and Management, Chapel Hill, NC, USA.
• 3The University of North Carolina at Chapel Hill, Department of Health Behavior, Chapel Hill, NC, USA.
• 4The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo.
• 5The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA.
• 6The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA; The University of North Carolina at Chapel Hill, Department of Social Medicine, Chapel Hill, NC, USA. 
• Lancet HIV. 2016 Feb;3(2):e85-93. doi: 10.1016/S2352-3018(15)00247-7.

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