Access, interest, and attitudes toward electronic communication for health care among patients in the medical safety net.

BACKGROUND: Electronic and internet-based tools for patient-provider communication are becoming the standard of care, but disparities exist in their adoption among patients. The reasons for these disparities are unclear, and few studies have looked at the potential communication technologies have to benefit vulnerable patient populations. OBJECTIVE: To characterize access to, interest in, and attitudes toward internet-based communication in an ethnically, economically, and linguistically diverse group of patients from a large urban safety net clinic network. DESIGN: Observational, cross-sectional study PARTICIPANTS: Adult patients (≥ 18 years) in six resource-limited community clinics in the San Francisco Department of Public Health (SFDPH) MAIN MEASURES: Current email use, interest in communicating electronically with health care professionals, barriers to and facilitators of electronic health-related communication, and demographic data-all self-reported via survey. KEY RESULTS: Sixty percent of patients used email, 71 % were interested in using electronic communication with health care providers, and 19 % reported currently using email informally with these providers for health care. Those already using any email were more likely to express interest in using it for health matters. Most patients agreed electronic communication would improve clinic efficiency and overall communication with clinicians. CONCLUSIONS: A significant majority of safety net patients currently use email, text messaging, and the internet, and they expressed an interest in using these tools for electronic communication with their medical providers. This interest is currently unmet within safety net clinics that do not offer a patient portal or secure messaging. Tools such as email encounters and electronic patient portals should be implemented and supported to a greater extent in resource-poor settings, but this will require tailoring these tools to patients' language, literacy level, and experience with communication technology.

Biological treatment of shrimp aquaculture wastewater using a sequencing batch reactor.

To improve the water quality in the shrimp aquaculture, a sequencing batch reactor (SBR) has been tested for the treatment of shrimp wastewater. A SBR is a variation of the activated sludge biological treatment process. This process uses multiple steps in the same tank to take the place of multiple tanks in a conventional treatment system. The SBR accomplishes equalization, aeration, and clarification in a timed sequence in a single reactor basin. This is achieved in a simple tank, through sequencing stages, which include fill, react, settle, decant, and idle. A laboratory scale SBR and a pilot scale SBR was successfully operated using shrimp aquaculture wastewater. The wastewater contained high concentration of carbon and nitrogen. By operating the reactor sequentially, viz, aerobic and anoxic modes, nitrification and denitrification were achieved as well as removal of carbon in a laboratory scale SBR. To be specific, the initial chemical oxygen demand (COD) concentration of 1,593 mg/l was reduced to 44 mg/l within 10 days of reactor operation. Ammonia in the sludge was nitrified within 3 days. The denitrification of nitrate was achieved by the anaerobic process and 99% removal of nitrate was observed. Based on the laboratory study, a pilot scale SBR was designed and operated to remove excess nitrogen in the shrimp wastewater. The results mimicked the laboratory scale SBR.

Prevalence and correlates of HIV testing in a multi-site sample of young men who have sex with men.

This study assessed HIV testing among 2,621 urban young men who have sex with men (YMSM). Of these, 77% were men of colour, 30% reported recent unprotected anal intercourse (UAI), 22% had never tested for HIV and 71% had not tested recently. Ever testing was associated with older age (OR=1.28), being employed (OR=1.34), exposure to more types of HIV preventions (linear trend p=0.02), sex with a main partner (OR=1.92), sex with a non-main partner (OR=1.36), UAI with a non-main partner (OR=0.53), UAI in the last three months (OR=1.32), knowing a comfortable place for testing (OR=5.44) and social support (OR=1.47). Rates of ever testing increased with behavioural risk with main partners; rates were lowest for men reporting high-risk with non-main partners. Recent testing was associated with greater numbers of HIV-prevention exposures (linear trend p = <0.001), sex with a main partner (OR=1.30), knowing a comfortable place for testing (OR=2.31) and social support (OR=1.23). Findings underscore the urgency of promoting testing among YMSM, point to components for the recruitment and retention of young MSM of colour in testing programmes and highlight the need for a theory-based approach to intervention development.

Retinoids and drugs of abuse: implications for neurological disease risk in human immunodeficiency virus type 1 infection.

Among injection drug users, human immunodeficiency virus (HIV) type 1 infection may be associated with an increased risk of nervous system disease. For HIV-infected drug users with vitamin A deficiency, the overall risk of HIV-related morbidity and mortality may also be higher. In previous studies, levels of retinol, retinol-binding protein, and transthyretin in samples from such individuals were examined and found to be lower than such levels in seronegative control subjects. Also, in studies using an activated mononuclear cell line, all-trans retinoic acid and 9-cis retinoic acid suppressed production of the tumor necrosis factor (TNF)-alpha and interferon (IFN)-gamma. However, simultaneous exposure of the cells to morphine at a concentration similar to that to which drug users are exposed resulted in increased production of these cytokines. Therefore, morphine may alter the immunomodulatory effects of retinoids, thereby potentially affecting the clinical outcome of studies involving retinoid administration to HIV-infected drug users and increasing the risk for the development of HIV-related complications, including neurological disease.

Is quality free? The relationship between cost and quality across 18 provider groups.

OBJECTIVE: To learn whether the healthcare costs for patients of various care delivery systems are associated with the quality of ambulatory care received. Despite intense interest in the cost and quality of healthcare delivery in the United States, there have been relatively few studies of the relationship between those measures, and none have addressed the relationship for integrated care delivery systems. STUDY DESIGN: Results of a retrospective analysis of claims records for overall costs of care for enrollees of 18 care delivery systems were compared with a variety of quality measures for each system. PATIENTS AND METHODS: We analyzed the yearly (1996-1998) claims records of 110,000 to 150,000 employees and dependents of member companies of an employer coalition in Minnesota that received all of their medical services from 18 care systems that had at least 1,000 employees and dependents. Overall case-mix and inflation-adjusted costs of care for enrollees of each care system were compared with 21 ambulatory care process-oriented quality indicators covering 3 chronic diseases and 5 preventive services. RESULTS: Regardless of whether the unit of analysis was the care system or the individual enrollee, there was no evidence of a consistent relationship between overall cost of care and quality on any measures. The little association there was tended to suggest that higher quality was provided by the lowest-cost care systems. CONCLUSION: Although additional confirmatory research is needed, this analysis of the quality-cost relationship provides some reassurance for those who question whether selecting lower-cost sources of medical care might have a negative effect on quality of care.

Characteristics of injection drug using parents who retain their children.

While it is known that injection drug users (IDUs) often have their children removed or place them voluntarily, little is known about factors associated with whether IDU parents live with their children. We identified a community sample of 391 IDU parents with at least one child under age 14 (index IDU parents). For these IDU parents, 62% did not have any of their children under age 14 living with them. We assessed whether certain health factors, risk related behaviors, social indicators, and active drug use were related to whether children of IDUs were living with the index IDU parent. IDU parents who were living with their children were overwhelmingly more likely to be female, more likely to have health insurance, and engage in no-risk or low-risk drug practices, as compared to moderate/high-risk practices. Additionally, HIV negative and HIV positive asymptomatic parents were about three times more likely to be living with their children than HIV positive parents with clinical symptoms commonly seen among those suffering from HIV-related illnesses. HIV-related clinical symptoms, rather than HIV status per se, seem to be associated with retention of children.

A seroprevalence study of viral hepatitis E infection in human immunodeficiency virus type 1 infected subjects in Malaysia.

Hepatitis E virus (HEV) is a RNA virus transmitted enterically. A study of anti-HEV antibodies in 145 human immunodeficiency virus type 1 (HIV-1) infected subjects found that 14.4% of them were reactive to anti-HEV antibodies. Anti-HEV IgG and anti-HEV IgM was detected in 10.3% and 4.1% of the subjects respectively. Prevalence of anti-HEV (either IgG or IgM) was similar across all adult ages (p = 0.154), between the three ethnic groups (p = 0.378), and across risk groups (p = 0.120). The results showed that HEV infection in subjects recruited in this study was most likely transmitted via faecal-route.

Improved antioxidant status among HIV-infected injecting drug users on potent antiretroviral therapy.

Low serum antioxidant levels in HIV-infected people have been attributed to altered metabolism associated with excess oxidative stress. We conducted a study to examine serum antioxidant levels in 175 HIV-positive and 210 HIV-negative injecting drug users (IDUs) in Baltimore, Maryland. At the time of data collection, 30 of the HIV-positive IDUs were receiving antiretroviral therapies (ART) including a protease inhibitor (PI), 43 ART without a PI, 22 monotherapies, and 80 not on any ART. Serum antioxidants examined included retinol, alpha-tocopherol and gamma-tocopherol, alpha-carotene and beta-carotene, lycopene, lutein/zeaxanthin, and beta-cryptoxanthin. Mean serum levels of lycopene and lutein/zeaxanthin were significantly lower in HIV-positive IDUs than HIV-negative IDUs. Contrary to the findings in other studies, however, levels of the remaining antioxidants in HIV-positive study subjects were not lower than in HIV-negative study subjects. In fact, serum alpha-tocopherol levels were significantly higher in HIV-positive IDUs than HIV-negative IDUs (medians = 744 microg/dl and 718 microg/dl, respectively; p = .04). Among HIV-positive study subjects, there were significant differences in antioxidant levels by ART regimen. In multivariate models adjusting for injecting drug use, dietary intake, supplement intake, gender, and alcohol intake, significant overall differences by ART regimen were observed for alpha-tocopherol, beta-carotene, and beta-cryptoxanthin. Serum levels of these three antioxidants were significantly higher in the PI group than in the other three ART groups combined (p = .0008, 0.02, and 0.02, respectively). These data provide indirect evidence of the effectiveness of PIs in lowering oxidative stress levels in HIV-positive IDUs.

Preventive intervention to reduce sexually transmitted infections: a field trial in the Royal Thai Army.

BACKGROUND: During 1991 through 1993, sexually transmitted infections among conscripts in the Royal Thai Army in the upper-northern provinces were common: human immunodeficiency virus (HIV) prevalence at induction was 12%, HIV incidence was 2.4% per year, and incidence of sexually transmitted diseases was 17% per year. We evaluated a behavioral intervention to reduce incident sexually transmitted infections among conscripts inducted into the Thai Army in 1993. METHODS: We developed a preventive intervention that addressed consistent condom use, reducing alcohol consumption and brothel patronage, and improving sexual negotiation and condom skills. Companies were assigned to 1 of 3 groups matched on military mission: 450 men were in the intervention group, 681 were in barracks at the same base but did not receive the intervention (diffusion group), and 414 were in distant camps (controls). Baseline HIV serological testing and behavioral interviews were conducted during basic training in 1993. The intervention was applied for 15 months, and men were followed up at 6-month intervals (with repeated HIV serological testing, sexually transmitted disease assessments, and behavioral interviews) through May 1995. RESULTS: Incident sexually transmitted diseases were 7 times less frequent among men assigned to the intervention than the combined controls (relative risk, 0.15; 95% confidence interval, 0.04-0.55), after adjusting for baseline risk factors (P<.005). There was no diffusion of the intervention to adjacent barracks. The intervention decreased incident HIV by 50% in the intervention group. CONCLUSION: Intensive interventions in structured institutions can successfully reduce risk in settings confronting expanding heterosexual HIV epidemics.

Needle-exchange attendance and health care utilization promote entry into detoxification.

This study was undertaken to identify factors associated with entry into detoxification among injection drug users (IDUs), and to assess the role of needle-exchange programs (NEPs) as a bridge to treatment. IDUs undergoing semiannual human immunodeficiency virus (HIV) tests and interviews were studied prospectively between 1994 and 1998, during which time an NEP was introduced in Baltimore. Logistic regression was used to identify independent predictors of entry into detoxification, stratifying by HIV serostatus. Of 1,490 IDUs, similar proportions of HIV-infected and uninfected IDUs entered detoxification (25% vs. 23%, respectively). After accounting for recent drug use, hospital admission was associated with four-fold increased odds of entering detoxification for HIV-seronegative subjects. Among HIV-infected subjects, hospital admission, outpatient medical care, and having health insurance independently increased the odds of entering detoxification. After accounting for these and other variables, needle-exchange attendance also was associated independently with entering detoxification for both HIV-infected (adjusted odds ratio [AOR] = 3.2) and uninfected IDUs (AOR = 1.4). However, among HIV-infected subjects, the increased odds of detoxification associated with needle exchange diminished significantly over time, concomitant with statewide reductions in detoxification admissions. These findings indicate that health care providers and NEPs represent an important bridge to drug abuse treatment for HIV-infected and uninfected IDUs. Creating and sustaining these linkages may facilitate entry into drug abuse treatment and serve the important public health goal of increasing the number of drug users in treatment.

Longitudinal human immunodeficiency virus type 1 load in the italian seroconversion study: correlates and temporal trends of virus load.

A prospective study of 149 human immunodeficiency virus type 1 (HIV-1) seroconverters was conducted to describe trends and correlates of HIV-1 load after seroconversion and over time. HIV-1 load was quantified from frozen sera by reverse transcriptase-polymerase chain reaction. High early virus load was associated with lower CD4 cell counts and male sex but not with age at seroconversion or injection drug use. Early virus load predicted progression to clinical AIDS and AIDS/<200 CD4 cells/microL. Virus load exhibited a decline of 52% by 18 months after seroconversion then increased 23% annually (95% confidence interval, 13%-33%). Men and those developing AIDS during follow-up had higher virus loads over the course of disease. Persons who developed AIDS had a steeper virus load slope than those who were AIDS-free (P=.01). In long-term follow-up, virus load exhibited a gradual and sustained increase over time. Virus load and annual increase are strong predictors of disease progression.

The effect of drug-injection behavior on genetic evolution of HIV-1.

The effect of injection-drug use on human immunodeficiency virus type 1 (HIV-1) env genetic evolution was examined in 15 seroconverting injection-drug users followed up for 4 years. After adjustment for non-drug-related independent variables significantly associated with genetic diversity (time since seroconversion and progressor status), injection frequency was positively and highly significantly associated with HIV-1 env genetic diversity (P=.003). The mutation rate in those who had injected at least once a day during the previous 6 months was estimated to be 62% greater than the rate in those who had not injected at all. If the positive effect of drug-injection frequency on env genetic diversity extends to the HIV-1 pol gene, the risk of emergence of resistance to antiretroviral drugs may be enhanced by increased drug-injection frequency, especially under the selection pressure of antiretroviral therapy.

Sex differences in longitudinal human immunodeficiency virus type 1 RNA levels among seroconverters.

Cross-sectional studies have demonstrated lower plasma human immunodeficiency virus type 1 (HIV-1) RNA virus levels (VLs) in women than in men, but it is unknown whether this sex difference is present at the time of seroconversion and throughout the course of infection. A nested case-control study was performed among HIV-1 seroconverters within a cohort of injection drug users. Plasma VL was determined longitudinally among both rapid progressors to AIDS (24 patients) and nonprogressors (47 controls). The initial median VL among female patients (n=10) was 14,918 copies/mL, compared with 148,354 copies/mL among male patients (n=14; P=.001); median plasma VL also tended to be lower among female (n=10) than among male controls (n=37; 11,917 vs. 61,311 copies/mL; P=.08). VL increased more rapidly over time in women than in men and subsequently converged in patients and controls, respectively. Understanding the mechanisms responsible for the sex difference in VL may provide insight into HIV-1 pathogenesis.

Evaluation of a rapid test for the detection of antibodies to human immunodeficiency virus type 1 and 2.

Hema-Strip HIV-1/2 is a one-step rapid test for the detection of anti-HIV-1/2 antibodies in whole blood. The test requires no expensive equipment and the results are available within 10-15 min. Using 72 known HIV-1 positive samples and 780 high-risk prisoners, the sensitivity and specificity of Hema-Strip HIV-1/2 was found to be comparable to microparticle enzyme immunoassay (MEIA). The data also indicated that Hema-Strip HIV-1/2 is an effective alternate testing system to conventional ELISA where the use of ELISA is not suitable and the result of the HIV testing is needed urgently.

Cell-associated infectious HIV-1 viral load as a predictor of clinical progression and survival among HIV-1 infected injection drug users and homosexual men.

Cell-associated infectious HIV-1 viral load was measured using semi-quantitative microculture techniques to determine its predictive capability for progression to AIDS or survival among HIV-1 infected injecting drug users (IDU) and homosexual men (HM). The authors followed 296 IDU and 240 HM from February 1992 through September 1995 for: (i) death, (ii) AIDS, and (iii) AIDS or bacterial infection. At baseline, viral load was quantified using microculture techniques to determine infectious units per million peripheral blood mononuclear cells (IUPM). Data were analyzed using standard statistical methods for survival analysis. Of the 536 total participants, 106 died (20%), and 98 of the 481 AIDS-free participants developed AIDS (20%). The relative hazard of AIDS for a viral load of > or = 100 IUPM, relative to a negative culture (0 IUPM), was 6.73 (95% CI: 2.23-20.3) after adjusting for risk group, initial CD4+ count, and other covariates. The adjusted relative hazard of death for a viral load of > or = 100 IUPM vs. 0 IUPM was 2.57 (95% CI: 0.97 6.80). Viral load predicted time to death within the < 200 cells/ul CD4+ stratum. The predictive value of viral load on HIV-1 progression did not vary by risk group. These data show that cell associated infectious HIV-1 viral load was significantly predictive of progression across risk groups for AIDS and death among those severely immune compromised.

Direct comparison of time to AIDS and infectious disease death between HIV seroconverter injection drug users in Italy and the United States: results from the ALIVE and ISS studies. AIDS Link to Intravenous Experiences. Italian Seroconversion Study.

OBJECTIVE: To compare the rate of HIV disease progression in a sample of polydrug injectors (AIDS Link to Intravenous Experiences [ALIVE] study) with that in a sample of predominantly opiate injectors (Italian Seroconversion Study [ISS]). DESIGN: Prospective cohort studies of HIV-positive individuals whose date of seroconversion (SC) is known with a good degree of precision. The ALIVE study involves a community-based cohort of injection drug users (IDU) in the United States and the ISS reports on a clinic-based cohort of seroconverters in Italy with different exposure modalities to HIV. METHODS: Data from the two cohorts were combined. The date of SC was estimated as the midpoint in time between the last negative and the first positive HIV test. Time-to-event (i.e., AIDS or death from an infectious disease) statistical methods were used. Relative hazards (RH) of progression to event were adjusted by age at SC, gender, and year of SC. RESULTS: Of the 1003 IDUs (251 from ALIVE and 752 from ISS), 226 progressed to AIDS, and 146 died after AIDS or from an infectious disease; of these, 10 were without an AIDS diagnosis. The two groups of IDUs differed in terms of age at SC (median, 35 years for ALIVE and 25 years for ISS), proportion of women (24% versus 31%), race (7.6% versus 100% white), and year of seroconversion (i.e., ISS participants seroconverted, on average, earlier than ALIVE participants). Although the univariate analysis suggested possible differences for progression to AIDS, or to death from infectious disease between cohorts, multivariate analyses that adjusted for age showed no significant differences by cohort, gender, race, or time of seroconversion. The median time to AIDS for 25-year-old persons was 12.3 years for ALIVE and 11.8 years for ISS; for 35-year-old persons, it was 8.5 and 8.2 years, respectively. These estimates were similar to those for non-IDUs observed in the ISS and to those from large cohort of homosexual men. CONCLUSION: Our results confirm the importance of accounting for age when considering the incubation period for HIV infection. Despite differences in drug use characteristics, the similar median times to AIDS, for each age, between the two cohorts of IDUs and between the IDUs and the non-IDUs suggest a negligible effect of injection drug use on HIV progression.

Comparison of two measures of human immunodeficiency virus (HIV) type 1 load in HIV risk groups.

Levels of viral burden were compared across risk group and gender populations among 485 human immunodeficiency virus type 1 (HIV-1)-infected participants consisting of 190 male injection drug users (IDUs), 92 female IDUs, and 203 homosexual men. Viral burden was quantified by a microculture technique to determine cell-associated infectious units per 10(6) peripheral blood mononuclear cells (IUPM) and by reverse transcriptase PCR (Amplicor) to determine plasma HIV RNA levels. Adjusting for CD4(+) cell count, females had a lower infectious HIV load than all males combined (0. 33 log10 lower; P = 0.004), and homosexual men had a 0.29 log10 higher infectious viral load than all IDUs combined (P = 0.001). For HIV RNA levels, females had lower levels than males (0.19 log10 lower; P = 0.04), but no differences were observed by risk group. After controlling for percent CD4(+) cells, no differences were found by risk group for either assay, but females still had a 0.25 log10 lower infectious viral load than males (P = 0.04) and a viral RNA load similar to that of males (P = 0.25). The correlation between infectious viral load and HIV RNA load was 0.58 overall, which did not differ by gender or risk group. Our data suggest that differences in viral load may exist by gender and that any differences observed by risk group are driven predominantly by gender or percent CD4(+) cell differences. These data also confirm a moderate correlation between cell-associated infectious viral load and plasma HIV RNA load, which appears to be similar by gender and across risk groups.

Sex differences in HIV-1 viral load and progression to AIDS.

BACKGROUND: Plasma HIV-1 RNA measurements are used for initiation of antiretroviral treatments. Whether the viral-load association with prognosis is similar in women and men is unknown. METHODS: We studied 812 specimens from 650 injection-drug users (IDUs) participating in a continuous observational study of patients based in a community clinic. HIV-1 load was measured by branched-chain DNA on samples from 527 IDUs from the baseline visit, and by reverse-transcriptase PCR and quantitative microculture on samples from 285 IDUs at a follow-up visit 3 years later. FNDINGS: Women had lower median viral-load measurements than men by branched-chain DNA (3365 vs 8907 copies/mL; p=0.001), reverse-transcriptase PCR (45416 vs 93130 copies/mL; p=0.02), and quantitative microculture (5 vs 8 infectious units per million peripheral blood mononuclear cells; p=0.015). This association remained even after adjustment for CD4 cell count, race, and drug use within the previous 6 months. Time to AIDS was statistically similar for men and women in a univariate proportional-hazards model and in a model adjusting for CD4 cell count. Proportional-hazards models showed that women with the same viral load as men had a 1.6-fold higher risk of AIDS (95% CI 1.10-2.32); or, equivalently, that women with half the viral load of men had a similar time to AIDS as men. INTERPRETATION: Although a biological mechanism remains unclear, these data suggest that current recommendations for HIV-1 viral-load thresholds to initiate antiretroviral therapy should be revised downwards for women.

Diversification of subtype E human immunodeficiency virus type 1 env in heterosexual seroconverters from Northern Thailand.

The C2-V3 region of the human immunodeficiency virus (HIV)-1 env was determined from 15 northern Thailand seroconverters between 1993 and 1995. Similar sequences were also determined from 18 seroconverting injection drug users in Baltimore. All seroconverters from northern Thailand were infected with subtype E HIV-1 on the basis of env sequences. Intersubject viral DNA distances increased from 2.3% in asymptomatic HIV-1-infected subjects characterized between 1990 and 1992 to 7.8% in these more recent seroconverters from Thailand. On the other hand, sequences from 18 seroconverters from Baltimore had a mean intersubject distance of 13.2%. The genetic diversity within HIV-1 subtype E in seroconverters in Thailand has increased significantly but is still less than that observed in HIV-1 from seroconverters in the United States, where the epidemic of HIV-1 infection is more mature. These results suggest that continued monitoring of the molecular epidemiology of HIV-1 infection in Thailand will be important for HIV vaccine development and evaluation.