HIV Care in Asian and Pacific Islanders in Kansas.

A complex cultural dynamic within the Asian and Pacific Islander (APIs) population contributes to barriers in HIV care. This qualitative narrative study investigated how awareness, resource accessibility, and cultural taboo impact HIV care in APIs in Kansas. Eleven HIV-infected API patients were interviewed. Two evaluators independently completed a qualitative themes analysis. Important themes impacting HIV care included lack of awareness, sex as a taboo topic, and misconceptions about HIV infection. These factors create a closed community regarding HIV prevention and care. Clinicians must be aware of these barriers and provide specific culturally sensitive information and care to this population.

Principles for Patient and Family Partnership in Care: An American College of Physicians Position Paper.

In this position paper, the American College of Physicians (ACP) examines the rationale for patient and family partnership in care and reviews outcomes associated with this concept, including greater adherence to care plans, improved satisfaction, and lower costs. The paper also explores and acknowledges challenges associated with implementing patient- and family-centered models of care. On the basis of a comprehensive literature review and a multistakeholder vetting process, the ACP's Patient Partnership in Healthcare Committee developed a set of principles that form the foundation for authentic patient and family partnership in care. The principles position patients in their rightful place at the center of care while acknowledging the importance of partnership between the care team and patient in improving health care and reducing harm. The principles state that patients and families should be treated with dignity and respect, be active partners in all aspects of their care, contribute to the development and improvement of health care systems, and be partners in the education of health care professionals. This paper also recommends ways to implement these principles in daily practice.

Residents Perceive Limited Education on Family Planning and Contraception for Patients with Severe and Persistent Mental Illness.

OBJECTIVE: The primary goal of this study was to assess perceived adequacy of training by residents from multiple specialties on contraceptive prescribing and family planning for patients with severe and persistent mental illness (SPMI). Secondary goals included the following: (1) explore resident knowledge, attitudes, and behavior towards patients with SPMI and (2) identify barriers to meeting the reproductive health needs of patients with SPMI. METHODS: The target population was 44,237 residents from four medical specialties. Participants were from a stratified, self-selected sample. Program coordinators were asked to forward a survey link to residents. Consenting residents were provided access to a questionnaire via a secure, web-based application (REDCap). The survey assessed resident education on the reproductive health needs of patients with SPMI and included demographics (age, gender, year of residency, and specialty), perceived adequacy of training, knowledge, and attitudes, and barriers regarding contraception and family planning. Responses were summarized with frequency and compared by medical specialty. RESULTS: A total of 768 residents consented: 49% female, 20% male, and 31% did not indicate their gender; 19% were first year residents, 21% second year residents, 21% third year residents, 8% fourth year residents, and 30% did not indicate their year of training. By specialty, 30.6% of residents were from family medicine programs (n = 235), 10.8% were from internal medicine programs (n = 83), 18.1% were from OBGYN programs (n = 139), and 10.4% were from psychiatry programs (n = 80); 231 (30.1%) did not indicate specialty. Regarding training, 60% of residents disagreed or strongly disagreed that they had proper training on prescribing contraceptives for patients with SPMI (363 of 599). Sixty two percent of residents disagreed or strongly disagreed that they had proper training about family planning for patients with SPMI (368/599). Over 83% of residents surveyed (405/486) would prescribe contraception for patients with SPMI if they had adequate training. CONCLUSIONS: Results indicate the need for curricular change on the reproductive health needs of patients with SPMI.

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 Preliminary Study of the Attitudes and Barriers of Family Physicians to Prescribing HIV Preexposure Prophylaxis.

INTRODUCTION: Attitudes of individuals who provide HIV care towards prescribing Preexposure Prophylaxis (PrEP) to at-risk populations have been studied, but few studies indicate if family physicians would be willing to prescribe PrEP as most family physicians do not specialize in HIV medicine. Few data exist on the perceived barriers preventing family physicians from prescribing PrEP. The purpose of this project was to assess the attitudes and perceived barriers of family physicians in Kansas towards prescribing PrEP to high risk patient populations. METHODS: This study was a descriptive, observational, and cross-sectional survey of family physicians who respond to email surveys issued through the Family Medicine Research and Data Information Office (FM RADIO). RESULTS: Fifty-three percent of family physicians take a sexual history on new patients less than frequently, and only 35% frequently ask about the use of safe sex practices. Only 29% frequently ask if the patient has sex with men, women, or both. Seventy-six percent of respondents would be willing to prescribe PrEP to men who have sex with men, and an equal percentage would be willing to prescribe to heterosexually active men and women who are at substantial risk of acquiring HIV. While 59% of participants agreed that PrEP belongs in the primary care domain of treatment, 71% agreed that they had limited or no knowledge of PrEP guidelines. CONCLUSIONS: This preliminary study indicated a need for increased family physician screening of new patients for high risk sexual behaviors who would be eligible for PrEP. The limited knowledge of PrEP guidelines and its use in clinical practice are significant limiting factors to increasing prescribing practices in the family medicine community rather than a perceived ethical dilemma of prescribing PrEP to men who have sex with men. As a result, an increase in continuing medical education about PrEP could significantly increase its prescribing in the family medicine community.

Cost-Effectiveness of Single- Versus Generic Multiple-Tablet Regimens for Treatment of HIV-1 Infection in the United States.

BACKGROUND: The possibility of incorporating generics into combination antiretroviral therapy and breaking apart once-daily single-tablet regimens (STRs), may result in less efficacious medications and/or more complex regimens with the expectation of marked monetary savings. A modeling approach that assesses the merits of such policies in terms of lifelong costs and health outcomes using adherence and effectiveness data from real-world U.S. settings. METHODS: A comprehensive computer-based microsimulation model was developed to assess the lifetime health (life expectancy and quality adjusted life-years--QALYs) and economic outcomes in HIV-1 infected patients initiating STRs compared with multiple-table regimens including generic medications where possible (gMTRs). The STRs considered included tenofovir disoproxil fumarate/emtricitabine and efavirenz or rilpivirine or elvitegravir/cobicistat. gMTRs substitutions included each counterpart to STRs, including generic lamivudine for emtricitabine and generic versus branded efavirenz. RESULTS: Life expectancy is estimated to be 1.301 years higher (discounted 0.619 QALY gain) in HIV-1 patients initiating a single-tablet regimen in comparison to a generic-based multiple-table regimen. STRs were associated with an average increment of $26,547.43 per patient in medication and $1,824.09 in other medical costs due to longer survival which were partially offset by higher inpatients costs ($12,035.61) with gMTRs treatment. Overall, STRs presented incremental lifetime costs of $16,335.91 compared with gMTRs, resulting in an incremental cost-effectiveness ratio of $26,383.82 per QALY gained. CONCLUSIONS: STRs continue to represent good value for money under contemporary cost-effectiveness thresholds despite substantial price reductions of generic medications in the U. S.

Real-world medication persistence with single versus multiple tablet regimens for HIV-1 treatment.

INTRODUCTION: Adherence to antiretroviral (ARV) treatment for HIV-1 is crucial to achieving optimal clinical outcomes. Simplification of regimens with once-daily single-tablet regimens (STRs) can improve adherence compared to multi-tablet regimens (MTRs). This study compared real-world persistence (a proxy for treatment effectiveness and adherence) between HIV-1 infected patients receiving STRs versus MTRs. MATERIALS AND METHODS: Adult HIV-1 infected patients starting their first observed ARV regimen (with at least six prior months of no ARV treatment) were identified in the MarketScan claims database (10/2008-03/2014). Persistence was measured as the time from the index regimen start date to the end of the first 90-day gap between fills for any ARV in the index regimen, or to the start date of an ARV not in the index regimen. Persistence was described using Kaplan-Meier curves and compared using log-rank tests, and Cox proportional hazards models adjusted for age, gender, insurance type, region, employment status, Charlson Comorbidity Index, other comorbidities, hospitalizations, emergency room visits and office visits. STRs were further stratified by regimen. RESULTS: A total of 3257 patients (37%) initiated MTRs, and 5484 (63%) initiated STRs, including 4409 on efavirenz (EFV)/tenofovir (TDF)/emtricitabine (FTC), 484 on rilpivirine (RPV)/TDF/FTC, and 591 on elvitegravir (EVG)/cobicistat (COBI)/TDF/FTC. Median persistence was 45.0 months for STRs versus 15.2 months for MTRs (P<0.001; Figure 1). Median persistence was not reached for RPV/TDF/FTC or EVG/COBI/TDF/FTC; 31 months after RPV/TDF/FTC approval for the treatment of HIV-1 infection, more than 65% of patients who started on it remained persistent, and 19 months after EVG/COBI/TDF/FTC approval, more than 72% of patients who started on it remained persistent. Compared with MTRs, STRs had an approximately 50% lower hazard of discontinuation (adjusted hazard ratio [HR]=0.54, 95% CI 0.50-0.58). EVG/COBI/TDF/FTC and RPV/TDF/FTC had significantly longer unadjusted and adjusted persistence compared with EFV/TDF/FTC (Figure 2, Table 1). CONCLUSIONS: Among HIV-1 infected patients, the use of STRs was associated with longer regimen persistence compared with MTRs. Among STRs, EVG/COBI/TDF/FTC and RPV/TDF/FTC were associated with significantly longer persistence than EFV/TDF/FTC.

Prevalence of communication disorders in HIV-infected adults.

Few adult patients with HIV/AIDS are evaluated for communication disorders. A broad inventory of the communication disorders was obtained in a convenience sample of 82 adult HIV/AIDS patients who presented for medical appointments. Each participant underwent a head and neck exam and a communications skills evaluation. Speech, language, and cognition were assessed using a 10-item test battery. A 14-item hearing test battery was conducted in a separate session. The primary outcomes were the presence and degree of communication disorders. Head and neck exams revealed 40% with ear-related issues. Only 2 participants showed normal findings on all 24 communication skills assessments. Four demonstrated normal findings on all speech-language-cognitive assessments, whereas 8 had normal findings on the complete hearing test battery. A relatively high prevalence of cognitive and language deficits and central auditory disturbances were found. Clinicians must recognize the potential for communication deficits even in a relatively healthy patient with HIV.

Screening, monitoring, and treatment of stage 1 to 3 chronic kidney disease: A clinical practice guideline from the American College of Physicians.

DESCRIPTION: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the screening, monitoring, and treatment of adults with stage 1 to 3 chronic kidney disease. METHODS: This guideline is based on a systematic evidence review evaluating the published literature on this topic from 1985 through November 2011 that was identified by using MEDLINE and the Cochrane Database of Systematic Reviews. Searches were limited to English-language publications. The clinical outcomes evaluated for this guideline included all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, chronic heart failure, composite vascular outcomes, composite renal outcomes, end-stage renal disease, quality of life, physical function, and activities of daily living. This guideline grades the evidence and recommendations by using ACP's clinical practice guidelines grading system. RECOMMENDATION 1: ACP recommends against screening for chronic kidney disease in asymptomatic adults without risk factors for chronic kidney disease. (Grade: weak recommendation, low-quality evidence) RECOMMENDATION 2: ACP recommends against testing for proteinuria in adults with or without diabetes who are currently taking an angiotensin-converting enzyme inhibitor or an angiotensin II-receptor blocker. (Grade: weak recommendation, low-quality evidence) RECOMMENDATION 3: ACP recommends that clinicians select pharmacologic therapy that includes either an angiotensin-converting enzyme inhibitor (moderate-quality evidence) or an angiotensin II-receptor blocker (high-quality evidence) in patients with hypertension and stage 1 to 3 chronic kidney disease. (Grade: strong recommendation) RECOMMENDATION 4: ACP recommends that clinicians choose statin therapy to manage elevated low-density lipoprotein in patients with stage 1 to 3 chronic kidney disease. (Grade: strong recommendation, moderate-quality evidence).

Screening for colorectal cancer: a guidance statement from the American College of Physicians.

DESCRIPTION: Colorectal cancer is the second leading cause of cancer-related deaths for men and women in the United States. The American College of Physicians (ACP) developed this guidance statement for clinicians by assessing the current guidelines developed by other organizations on screening for colorectal cancer. When multiple guidelines are available on a topic or when existing guidelines conflict, ACP believes that it is more valuable to provide clinicians with a rigorous review of the available guidelines rather than develop a new guideline on the same topic. METHODS: The authors searched the National Guideline Clearinghouse to identify guidelines developed in the United States. Four guidelines met the inclusion criteria: a joint guideline developed by the American Cancer Society, the U.S. Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology and individual guidelines developed by the Institute for Clinical Systems Improvement, the U.S. Preventive Services Task Force, and the American College of Radiology. GUIDANCE STATEMENT 1: ACP recommends that clinicians perform individualized assessment of risk for colorectal cancer in all adults. GUIDANCE STATEMENT 2: ACP recommends that clinicians screen for colorectal cancer in average-risk adults starting at the age of 50 years and in high-risk adults starting at the age of 40 years or 10 years younger than the age at which the youngest affected relative was diagnosed with colorectal cancer. GUIDANCE STATEMENT 3: ACP recommends using a stool-based test, flexible sigmoidoscopy, or optical colonoscopy as a screening test in patients who are at average risk. ACP recommends using optical colonoscopy as a screening test in patients who are at high risk. Clinicians should select the test based on the benefits and harms of the screening test, availability of the screening test, and patient preferences. GUIDANCE STATEMENT 4: ACP recommends that clinicians stop screening for colorectal cancer in adults over the age of 75 years or in adults with a life expectancy of less than 10 years.

Oral pharmacologic treatment of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians.

DESCRIPTION: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the comparative effectiveness and safety of type 2 diabetes medications. METHODS: This guideline is based on a systematic evidence review evaluating literature published on this topic from 1966 through April 2010 that was identified by using MEDLINE (updated through December 2010), EMBASE, and the Cochrane Central Register of Controlled Trials. Searches were limited to English-language publications. The clinical outcomes evaluated for this guideline included all-cause mortality, cardiovascular morbidity and mortality, cerebrovascular morbidity, neuropathy, nephropathy, and retinopathy. This guideline grades the evidence and recommendations by using the American College of Physicians clinical practice guidelines grading system. RECOMMENDATION 1: ACP recommends that clinicians add oral pharmacologic therapy in patients diagnosed with type 2 diabetes when lifestyle modifications, including diet, exercise, and weight loss, have failed to adequately improve hyperglycemia (Grade: strong recommendation; high-quality evidence). RECOMMENDATION 2: ACP recommends that clinicians prescribe monotherapy with metformin for initial pharmacologic therapy to treat most patients with type 2 diabetes (Grade: strong recommendation; high-quality evidence). RECOMMENDATION 3: ACP recommends that clinicians add a second agent to metformin to treat patients with persistent hyperglycemia when lifestyle modifications and monotherapy with metformin fail to control hyperglycemia (Grade: strong recommendation; high-quality evidence).

Silence is not golden: invisible Latinas living with HIV in the Midwest.

This qualitative study was conducted to better understand the health needs and concerns of immigrant HIV-infected Latinas residing in the Midwest United States. Individual interviews (n = 18) were conducted in Spanish with Latinas in Kansas, Oklahoma and Missouri. Women were at different stages of acceptance about their HIV diagnosis and four common themes emerged from the data: pregnancy as a death sentence, HIV is taboo, God as their only resource, and living in isolation. Silence was an over-arching theme present throughout all the narratives and many women had never shared their stories about HIV with anyone. Depressive symptoms and suicidal ideation were common. These findings have implications for strategies to address the HIV prevention and HIV-related healthcare needs of this population of women. Results from this study further suggest that efforts are needed to break the silence surrounding HIV and to reduce HIV-related stigma in smaller Midwestern Hispanic communities.

Metabolic complications of antiretroviral therapy.

HIV-infected patients receiving long-term antiretroviral treatment experience a number of metabolic abnormalities, including lipid abnormalities, dysregulation of glucose metabolism, body-fat redistribution, mitochondrial abnormalities, and bone abnormalities, as well as the sequelae of these disorders. These complications can be severe and life threatening, disrupt adherence to antiretroviral therapy, limit options in therapy, and profoundly affect quality of life. Risk for such complications should be considered in selection of antiretroviral therapy, and patients should be monitored for the occurrence of abnormalities and changes in risk factors. This article summarizes a presentation by Donna E. Sweet, MD, on the metabolic complications of long-term antiretroviral therapy at the IAS-USA course in New York in March 2005.

Initial Antiretroviral Therapy: When and With What to Begin.

At the International AIDS Society-USA course in Denver in May 2002, Donna E. Sweet, MD, discussed issues related to the ongoing question of when to initiate antiretroviral therapy in HIV-infected individuals and factors in selecting an initial drug regimen. Current treatment guidelines offer some consensus on the question of timing. Selection of the initial therapy focuses on the choice between regimens based on nucleoside reverse transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, or protease inhibitors.