Interprofessional Education: An Innovative Approach to Increase the Human Immunodeficiency Virus Workforce.

Ending the human immunodeficiency virus (HIV) epidemic relies on a robust clinical workforce. The Southeast AIDS Education and Training Center's interprofessional education program is a novel approach to increasing the interest and ability of early health professional learners to provide high-quality, comprehensive, person-first care for people with HIV. Key Points: Interprofessional education (IPE) focusing on multidisciplinary care for people with HIV can serve as a novel way to increase the HIV workforce. This brief report describes the IPE program of the Southeast AIDS Education and Training Center.

Trends in Recommended Screening and Monitoring Tests for Users of HIV Pre-Exposure Prophylaxis Before and During the COVID-19 Pandemic.

Introduction: To ensure the health and safety of persons taking pre-exposure prophylaxis to prevent HIV infection, the 2017 Centers for Disease Control and Prevention guidelines recommended initial and follow-up laboratory testing. We assessed the trends in adherence rates to recommended laboratory testing among pre-exposure prophylaxis users and identified factors associated with HIV testing among pre-exposure prophylaxis users from 2016 to 2020 and also examined rate changes during the COVID-19 pandemic in 2020. Methods: We conducted a retrospective cohort study assessing the rates and trends of recommended laboratory testing among commercially insured pre-exposure prophylaxis users from 2016 to 2020, using the MarketScan database. We examined the proportion of pre-exposure prophylaxis users adhering to the following initial and follow-up laboratory testing: (1) HIV, creatinine clearance, hepatitis B virus, hepatitis C virus, and sexually transmitted infections (chlamydia/gonorrhea and syphilis) within 7 days before pre-exposure prophylaxis initiation; (2) HIV 90 days after initiation; and (3) HIV, creatinine clearance, and sexually transmitted infections 180 days after pre-exposure prophylaxis initiation. We used general linear models to examine trends and multivariable logistic regression to identify predictors of ≥1 HIV test within 180 days after index pre-exposure prophylaxis. Results: We identified 19,581 new pre-exposure prophylaxis users. Most were male (96%) and aged 18-34 years (55%). Adherence rates to recommended testing increased from 2016 through 2019 (e.g., 9.0%-13.6% for all initial screening tests 7 days before initiation, 42.1%-44.6% for HIV testing 90 days after initiation, 33.8%-40.6% for all follow-up tests within 180 days after initiation), but all rates decreased during the COVID-19 pandemic (12.4%, 33.6%, and 31.6%, respectively). Younger age (aged 13-17 years: AOR=0.44, 95% CI=0.28, 0.71) and ages 18-34 years (AOR=0.80, 95% CI=0.74, 0.86) were associated with a significantly lower likelihood of getting an HIV test within 180 days after initiation than ages 35-44 years, and female sex (AOR=0.64, 95% CI=0.55, 0.74) were associated with a significantly lower likelihood than male sex. Pre-exposure prophylaxis users with a history of sexually transmitted infections had a higher likelihood (AOR=1.27, 95% CI=1.16, 1.40) of getting tested than those without. Conclusions: Initial screening and follow-up testing rates were lower than those recommended by the Centers for Disease Control and Prevention. Public health efforts are needed to ensure that patients have access to needed laboratory testing during pandemics or natural disasters and to educate patients and clinicians about the importance of screening and monitoring tests to ensure the safety and health of pre-exposure prophylaxis users.

Automated Sexual History and Self-Collection of Extragenital Chlamydia and Gonorrhea Improve Detection of Bacterial Sexually Transmitted Infections in People with HIV.

With consistently rising rates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) since 2014, the need for increased screening, testing, and treatment of bacterial sexually transmitted infections (STIs) in people at risk is clear. In this study, people with HIV were asked to complete a comprehensive audio computer-assisted self-interview sexual history at routine clinic-based laboratory visits every 3-6 months. The sexual health screening resulted in an automated summary of recommended bacterial STI tests. Self-collection of recommended extragenital CT/GC specimens was implemented to decrease the need for a provider to collect the specimen(s) and to give more control to the client. In total, extragenital CT/GC testing returned a 7.3% (n = 11) test positivity for CT and/or GC, with the highest test positivity of 14% (n = 7) among rectal swabs and 4% (n = 4) for pharyngeal swabs. Urogenital testing for combined CT/GC returned a 4.8% (n = 11) test positivity. All participants with extragenital CT/GC who underwent simultaneous urine testing returned discordant laboratory results, with urine collected at the same clinic visit resulting as negative. In addition, 7 of 11 (63.6%) of the positive extragenital GC/CT cases were asymptomatic. Therefore, extragenital site-specific testing was essential in appropriately diagnosing and treating CT and GC among participants. When extragenital STI testing was recommended, participants needing extragenital CT/GC specimens primarily chose self-collection after a brief demonstration. Error rates between self- versus provider-collected samples did not differ, and participants provided positive feedback on the intervention and self-collection process in satisfaction surveys taken at the end of each visit.

Pasteurella Cerebral Mycotic Aneurysm: A Case Report and Review of the Literature.

Pasteurella species (spp.) are pleomorphic, Gram-negative, facultatively anaerobic bacilli commonly found in the upper respiratory tract and oral cavities of wild and domesticated animals such as dogs and cats. Pasteurella spp. infections in humans are typically caused by animal bites or scratches, or other inadvertent exposure of an open skin lesion to oral secretions of the animal. While skin and soft tissue infections are relatively common, respiratory infections, endocarditis, osteomyelitis, meningitis, and mycotic aneurysms have also been documented. To date, nine cases of mycotic aneurysms caused by Pasteurella spp. have been reported. However, only one of those cases has involved a cerebral mycotic aneurysm, and it had a fatal outcome. This report describes a successfully managed Pasteurella cerebral mycotic aneurysm that had occurred as a complication of underlying mitral valve endocarditis.

Single-Tablet Combination Therapy for HIV Infection in Pregnancy.

Advances in the management of human immunodeficiency virus infection during pregnancy have led to improved maternal health and significant declines in rates of mother-to-child transmission of human immunodeficiency virus. A critical contributor to this success has been the development of better tolerated, safer, and more convenient antiretroviral medication regimens. Today, 12 fixed-dose, single-tablet combination antiretroviral regimens are available in the United States. These regimens are commonly used in nonpregnant individuals. However, because of altered pharmacokinetics of many drugs during pregnancy and concerns regarding short- and long-term fetal safety, few of these regimens are appropriate for routine use in pregnancy.

The association between symptoms of generalized anxiety disorder and appointment adherence, overnight hospitalization, and emergency department/urgent care visits among adults living with HIV enrolled in care.

This study examined the association between generalized anxiety disorder (GAD) symptoms and healthcare utilization (HCU) among 801 people living with HIV (PLWH). Participants recruited from community health centers in Florida completed questionnaires assessing demographics, substance use, symptoms of GAD and depression, and HCU. Adjusted binary and multinomial logistic regressions assessed the association between moderate-severe GAD symptoms and past 6-month missed HIV-care appointments, overnight hospitalization, and emergency department (ED)/urgent care visits. Participants reporting moderate-severe GAD symptoms had a greater odds of missing an HIV-care appointment (AOR 2.03, 95% CI 1.28-3.24, p = 0.003), spending 2 (AOR 4.35, 95% CI 2.18-8.69, p < 0.001) or 3+ (AOR 2.79, 95% CI 1.20-6.45, p = 0.016) nights in the hospital, and visiting an ED/urgent care facility 2 (AOR 2.63, 95% CI 1.39-4.96, p = 0.003) or 3+ (AOR 2.59, 95% CI 1.27-5.26 p = 0.008) times compared to participants reporting none-mild anxiety. Depression was associated with fewer ED/urgent care visits and overnight hospitalizations, while no association was found with missed primary care appointments. The role of anxiety in illness management remains understudied among PLWH. Anxiety identification and the development of interventions for anxiety among PLWH may have important consequences for healthcare cost saving, patient retention in care, and HIV-disease management.

Differences in Selected HIV Care Continuum Outcomes Among People Residing in Rural, Urban, and Metropolitan Areas-28 US Jurisdictions.

PURPOSE: The HIV care continuum is used to monitor success in HIV diagnosis and treatment among persons living with HIV in the United States. Significant differences exist along the HIV care continuum between subpopulations of people living with HIV; however, differences that may exist between residents of rural and nonrural areas have not been reported. METHODS: We analyzed the Centers for Disease Control and Prevention's National HIV Surveillance System data on adults and adolescents (≥13 years) with HIV diagnosed in 28 jurisdictions with complete reporting of HIV-related lab results. Lab data were used to assess linkage to care (≥1 CD4 or viral load test ≤3 months of diagnosis), retention in care (≥2 CD4 and/or viral load tests ≥3 months apart), and viral suppression (viral load <200 copies/mL) among persons living with HIV. Residence at diagnosis was grouped into rural (<50,000 population), urban (50,000-499,999 population), and metropolitan (≥500,000 population) categories for statistical comparison. Prevalence ratios and 95% CI were calculated to assess significant differences in linkage, retention, and viral suppression. FINDINGS: Although greater linkage to care was found for rural residents (84.3%) compared to urban residents (83.3%) and metropolitan residents (81.9%), significantly lower levels of retention in care and viral suppression were found for residents of rural (46.2% and 50.0%, respectively) and urban (50.2% and 47.2%) areas compared to residents of metropolitan areas (54.5% and 50.8%). CONCLUSIONS: Interventions are needed to increase retention in care and viral suppression among people with HIV in nonmetropolitan areas of the United States.

A HAART-Breaking Review of Alternative Antiretroviral Administration: Practical Considerations with Crushing and Enteral Tube Scenarios.

Selection of an appropriate antiretroviral regimen for the patient infected with human immunodeficiency virus can be challenging, as various considerations must be taken into account including viral resistance mutations, patient comorbidities, drug interactions, and the potential for drug-related adverse effects and toxicities. Treatment is further complicated when a clinical scenario arises requiring an alteration in the dosage form. Factors ranging from dysphagia to administration through an enteral feeding tube can affect decisions regarding antiretroviral dosage forms. Limited pharmacokinetic data exist regarding the alteration of antiretroviral medications from their original form. Bioavailability may vary substantially between dosage forms, which can lead to unpredictable drug concentrations. Supratherapeutic or subtherapeutic antiretroviral drug concentrations can result in increased toxicity, virologic failure, or the emergence of drug resistance. We performed a systematic literature search to review the available antiretroviral literature on the modification of solid dosage forms as well as alternative routes of administration of oral antiretroviral agents and their application to clinical practice.

An in-depth analysis of medication errors in hospitalized patients with HIV.

BACKGROUND: It is well recognized that medication errors occur and can affect success in treating patients with HIV/AIDS. However, little information is available describing the prevalence, nature, and causes of medication errors. OBJECTIVE: To determine the incidence of combination antiretroviral therapy (ART)- and opportunistic infection (OI)-related medication errors and describe the nature and cause(s) of errors to guide future interventions. METHODS: A daily antiretroviral utilization report was used to identify adults who were receiving ART and had been admitted to a tertiary care teaching hospital during 2 consecutive months in 2005. Patients' charts, medication profiles, and medication administration records were reviewed for medication errors such as improper dosing, interactions, drug omissions, and missing doses. Once identified, etiology and cause were further investigated through provider interviews. An interdisciplinary team reviewed each case to establish validity of the error, severity, and cause. RESULTS: Sixty-nine combined ART- and OI-related medication errors were identified in 20 of 26 (77%) evaluated patients, with 2.7 medication errors per patient. Fifty-four percent of the errors occurred within the first 24 hours after admission. Inadequate medication reconciliation on admission caused 21 of 37 (57%) admission-related errors. The most prevalent error types included missing doses (20%), underdosing (13%), overdosing (13%), therapy omission (13%), and drug-drug interaction (12%). The primary cause of errors was provider lack of knowledge. CONCLUSIONS: Prospective investigation of medication errors provided in-depth insight into the diverse nature of HIV-related medication errors, risk factors, and potential preventive strategies. System changes such as hard stops in the clinical decision support software and improved medication reconciliation training, and changes in cart-fill time could prevent specific types of errors. Further studies are warranted to evaluate the impact of various strategies for preventing medication errors in the HIV population.

Apparent sialadenopathy of the sublingual glands after general anesthesia with placement of laryngeal mask airway.

Sialadenopathy, inflammation of the salivary glands, is a rare anesthetic complication. This case conference describes a patient who developed sialadenopathy of the sublingual glands after placement of a laryngeal mask airway during a brief surgical procedure. The patient's history is detailed, the surgical and anesthetic procedures are described, and a discussion follows, which describes the different causes of this inflammatory process. In the comment, the physiology of the salivary gland is described in detail.