Family medicine faculty development fellowships and the medically underserved.

OBJECTIVE: This study measured the prevalence of service in federally designated medically underserved communities (FD-MUC) by Title VII-funded, full-time faculty development fellowship alumni. METHODS: A two-stage survey of alumni of full-time, family medicine faculty development fellowships was completed. Alumni were dichotomized as serving in an FD-MUC or not. RESULTS: Of the 105 fellowship alumni identified, 81% (n = 85) responded; 42% (n = 36) were serving in an FD-MUC. Of alumni serving in an FD-MUC, the mean full-time equivalent service time was 73%. Of the demographic variables measured, only race was significantly associated with FD-MUC service, and minorities were more likely to practice in an FD-MUC. Respondents serving in FD-MUCs were more satisfied with their relationships with nonphysician health professionals, salary and income, and their role in making organizational and administrative decisions than those not serving in FD-MUCs. CONCLUSIONS: Title VII has the broad policy objective of increasing access to medical care by improving the supply and distribution of physicians and recruitment of minority health professionals. Alumni of faculty development programs have a high service rate in FD-MUCs, and minority alumni are significantly more likely to practice in these sites.

Low-molecular-weight heparin in outpatient treatment of DVT.

Patients with a diagnosis of acute deep venous thrombosis have traditionally been hospitalized and treated with unfractionated heparin followed by oral anticoagulation therapy. Several clinical trials have shown that low-molecular-weight heparin is at least as safe and effective as unfractionated heparin in the treatment of uncomplicated deep venous thrombosis. The use of low-molecular-weight heparin in an outpatient program for the management of deep venous thrombosis provides a treatment alternative to hospitalization in selected patients. Use of low-molecular-weight heparin on an outpatient basis requires coordination of care, laboratory monitoring, and patient education and participation in treatment. Overlapping the initiation of warfarin permits long-term anticoagulation. Advantages include a decreased incidence of heparin-induced thrombocytopenia and fewer episodes of bleeding complications. Future clinical trials evaluating the safety and efficacy of low-molecular-weight heparin in the treatment of complicated deep venous thrombosis will further define appropriate indications for use and strategies for outpatient management.

AIDS-Related malignancies.

Neoplasms are a common complication of HIV-infected individuals. The increased survival rates of those with HIV infection may allow the emergence of an increased number of cancers. The new therapeutic regimens may slow the rate of progression by partially restoring the integrity of the immune system.

Caregivers and HIV infection. Services and issues.

Because of the complexity of their illness, patients infected with HIV may require many services to facilitate the management of the disease. The primary care provider must understand and facilitate the services that are needed and needs to be familiar with the individuals responsible for the care of each patient. There are many stresses that have been identified in HIV caregiving, for informal caregivers and health care workers. These stresses are described, and suggestions for appropriate interventions are outlined.

Illustrations and implications of current models of HIV health service provision in rural areas.

Despite recent evidence of faster than average increases in HIV/AIDS cases in rural areas across the U.S., there is still a generally poor understanding of successful models of rural HIV/AIDS health-care delivery. Past research in rural Kentucky suggested several barriers to care resulting in most rural HIV-positive patients traveling from rural to urban areas for care. Patients sought urban areas for care for reasons including patient confidentiality, a perceived lack of expertise on the part of rural physicians in caring for HIV-positive patients, and outright referral from rural to urban areas. Case histories are used to illustrate a variety of models of care used by rural HIV-positive patients. These include splitting and sharing care between rural primary care physicians and urban medical specialists, as well as patients receiving all their care in urban areas. Implications of these models for quality of care are discussed.

Rural human immunodeficiency virus health service provision. Indications of rural-urban travel for care.

We studied the travel of rural individuals positive for human immunodeficiency virus (HIV) to urban areas for HIV diagnosis and for ambulatory and inpatient HIV-related health services. We surveyed all (N = 84) identified HIV-positive adults (aged 18 years or older) residing in rural central and eastern Kentucky. Sixty-three individuals completed the survey, for a response of 75%. Although 60 respondents (95%) were living in a rural area at 18 years of age, 23 (37%) of the survey sample lived in urban areas at the time of their initial HIV diagnosis. Of the respondents, 13 (21%) traveled from rural areas to urban areas for their initial diagnosis of HIV. Forty-seven respondents (74%) traveled outside their county for HIV-related ambulatory care, with 40 respondents (64%) traveling to an urban area. The mean travel time required to obtain care for those who traveled to an urban area was almost 2 hours. Primary reasons for travel for ambulatory care include confidentiality concerns, belief that their physician was not knowledgeable enough about HIV, and referral to an outside physician. Increased training of rural primary care physicians regarding the psychosocial and biomedical aspects of HIV is suggested.

Frequency of human immunodeficiency virus testing among rural US residents and why it is done.

OBJECTIVE: To examine the frequency with which rural residents' undergo human immunodeficiency virus (HIV) antibody testing and the reasons why. DESIGN: Data are from the 1991 National Health Interview Survey's supplemental questions on knowledge and attitudes about acquired immunodeficiency syndrome. SUBJECTS: The respondents were 42,725 adults (aged > or = 18 years), representing a nationwide sample of the civilian, noninstitutionalized population of the United States. Rural (n = 9903) and urban (n = 32,822) respondents were compared. RESULTS: Although 7.1% of rural and 7.9% of urban respondents are at high risk for contracting HIV (P = .06), 25.2% of rural and 33.0% of urban respondents had been tested for HIV (P = .001). Excluding blood donations, 10.7% of rural and 17.2% of urban respondents had been tested for HIV (P = .001). The primary reason between the two groups for not getting tested was a belief of being at low risk for contracting HIV. Rural respondents were less likely than urban respondents (6.6% vs 10.4%) (P = .001) to be tested for HIV in the next 12 months. Rural respondents were less informed about HIV risks than were urban respondents. Urban residence is a significant predictor of having had an HIV test even after controlling for actual risk status, perceived risk status, age, education, income, sex, perceived health status, and a scale of knowledge of acquired immunodeficiency syndrome risk factors (odds ratio, 1.54; 95% confidence interval, 1.37 to 1.73). CONCLUSIONS: Rural residents are less knowledgeable about HIV risk factors and are less likely to have been tested for HIV. With the increasing rates of infection in rural areas, specific and focused efforts for counseling and testing for HIV antibodies in rural areas might prevent and control HIV infection and acquired immunodeficiency syndrome.