PrEP patient attitudes, beliefs and perceived barriers surrounding HPV vaccination: a qualitative study of semistructured interviews with PrEP patients in primary care clinics in Kansas and Missouri.

OBJECTIVES: Men who have sex with men who use pre-exposure prophylaxis (PrEP) have not traditionally been targets for human papillomavirus (HPV) vaccine programmes, despite their high risk for HPV-related cancers and HPV vaccine being approved by the U.S. Food and Drug Administration (FDA) for people up to age 45. The objective of this study was to assess attitudes and barriers towards HPV vaccine for adult PrEP users in the primary care context. METHODS: Semistructured phone interviews of 16 primary care patients taking PrEP in the Kansas City metropolitan area were conducted, with interviews assessing HPV vaccination status, and attitudes, beliefs and perceived barriers surrounding HPV vaccine. Interview notes were open-coded by student authors, and themes were generated through code review and consensus. Data were then analysed using thematic analysis. RESULTS: The results showed that most patients believed that preventative health was important and felt the HPV vaccine was important. Most patients were open to vaccination if recommended by their primary care physician and covered by insurance. Most participants believed HPV infection to be far worse in women, and there were gaps in knowledge surrounding HPV and its effects in men. CONCLUSIONS: While more research is needed to better understand facilitators of a linkage between PrEP and HPV vaccine in clinical settings for groups at high risk for HPV-related cancers, getting primary care providers involved in educating high-risk patients about the importance of HPV vaccination and actively recommending the vaccine to those patients has the potential to prevent HPV-related cancers.

Health Literacy and Medication Adherence Among Patients Treated in a Free Health Clinic: A Pilot Study.

BACKGROUND: A patient's health literacy is not routinely assessed during visits with a health care provider. Since low health literacy is a risk factor for poor health outcomes, assessing health literacy should be considered as part of the standard medical workup. OBJECTIVES: To evaluate the health literacy levels and medication adherence of patients treated by pharmacists in both the general medicine and the chronic care clinics at an urban free health clinic. METHODS: Eligible patients from the free health clinic completed the Rapid Estimate of Adult Literacy in Medicine (REALM), a health literacy measurement tool, during their clinic visit in 2011. Medication adherence was self-reported by the patients. RESULTS: A total of 100 patients participated (mean age = 48). The majority of participants were female (56%) and white (55%). Most (64%) of the patients scored at a high school reading level according to REALM. Only 21% of participants read at a seventh- to eighth-grade level. Overall medication adherence rate was 73%. Forgetting to take medication was the most popular reason given for nonadherence. CONCLUSION: Disease state and adherence were significantly related in patients with HIV/AIDS and hypertension. Patient's ethnicity was significantly associated with literacy levels (P < .05). Although patients' literacy levels were not significantly associated with self-reported adherence in this population, availability of a patient's baseline health literacy level as a part of the medical record may help clinicians to individualize their interaction based on the patient's health literacy level in order to achieve better health outcomes, including improved medication adherence, especially for underserved populations.

Simplification to Stribild vs continuation of RTV-boosted DRV with FTC and TDF in virologically suppressed HIV adults: a STRATEGY-PI subgroup analysis.

INTRODUCTION: Simplification to Stribild (STB) was statistically superior to continuation of a ritonavir-boosted protease inhibitor (PI+RTV) with emtricitabine and tenofovir DF (FTC/TDF) at week (W) 48 in virologically suppressed HIV adults (1). We report the W48 efficacy and safety of STB versus RTV-boosted darunavir (DRV) with FTC/TDF in suppressed subjects. MATERIAL AND METHODS: Virologically suppressed subjects on PI+RTV with FTC/TDF regimens for ≥6 months were randomized (2:1) to switch to STB vs continue their PI regimen. Eligibility criteria included no documented resistance to FTC and TDF, no history of virologic failure and eGFR ≥70 mL/min. The primary endpoint was the proportion of subjects in the modified ITT population who maintained HIV-1 RNA <50 copies(c)/mL at W48 by FDA snapshot algorithm (12% non-inferiority margin). Subgroup analysis by PI use (DRV [173], atazanavir [174], lopinavir [72], Other PI [13]) at screening was pre-specified. RESULTS: Four hundred twenty-nine subjects were randomized and treated (mITT set). In the DRV subgroup, 113 switched to STB; 60 continued a RTV-boosted DRV with FTC/TDF. At W48, 95% STB versus 92% DRV maintained HIV-1 RNA <50 c/mL. No emergent resistance was detected in either group. Median increases from baseline in CD4 count at week 48 (cells/µL): 28 STB versus 29 DRV (p=0.81). Discontinuations due to adverse events were 3% STB versus 2% DRV; one case of isolated decrease in eGFR in the DRV group and no cases of proximal renal tubulopathy in either group. There were statistically significant decreases in the frequency of diarrhoea reported on the HIV Symptom Index at week 4 to week 48 compared to baseline after switching to STB. There was a greater but non-progressive decrease from baseline in eGFR in the STB vs DRV group; median changes (mL/min) at week 48: -8.5 vs -0.6, consistent with the known cobicistat inhibition of renal creatinine secretion. Switch to STB was associated with a higher treatment ease (convenience, flexibility, demand, lifestyle, understanding) score (range: -15 to 15) at week 4 (median: 12 vs 9; p=0.006) and week 24 (median: 13 vs 8; p=0.001). CONCLUSIONS: In this small group of virologically suppressed subjects, simplification to STB versus continuation of a RTV-boosted DRV with FTC/TDF was safe, well-tolerated, and associated with a high rate of virologic suppression at week 48. There was more treatment ease with STB use.

Expanding the role of a pharmacist as a sexually transmitted infection provider in the setting of an urban free health clinic.

BACKGROUND: This study was designed to explore patient perceptions of sexually transmitted infection (STI) screening and treatment provided by a pharmacist in an urban free health clinic. With health care reform on the horizon, the role of a pharmacist is quickly evolving, making it necessary for pharmacists to sharpen their clinical skills to accurately serve their patients. One in 4 American adolescents is infected with an STI, placing pharmacists in a position to help decrease STI transmission and complications. METHODS: To assess patient attitudes toward pharmacists as STI providers, a convenience sample of patients who presented to an urban free health clinic in 2009 for STI testing were given a confidential survey of 12 statements relating to STI testing and the acceptability of a pharmacist-provider. RESULTS: Patients expressed overwhelming support of a pharmacist as their STI treatment provider (79.9%). The services they were comfortable with a pharmacist performing included running a urine screen (95.1%), performing a physical examination (81.1%), treating STIs (98.2%), and discussing STI test results (93.9%). Patients also approved of pharmacists working under a collaborative practice agreement with a physician (97.6%). CONCLUSIONS: Acceptance by patients of a pharmacist-provider for STI screening may lead to the adoption of pharmacists as providers in STI screening clinics. This would decrease barriers to treatment (eg, stigma and lack of access), increase accessibility to care, and greatly improve the identification of those infected with STIs, ultimately leading to a decrease in the spread and long-term sequelae of untreated STIs.

Genital, oral, and anal human papillomavirus infection in men who have sex with men.

Even though the incidence of anal cancer among men who have sex with men (MSM) is higher than the incidence of cervical cancer among women, few MSM are identified as high-risk patients in primary care or have received vaccination for human papillomavirus (HPV), the most common sexually transmitted infection worldwide, with 6.2 million new infections each year. The authors review the current literature on diagnosis and basic management of genital, oral, and anal HPV infection. Early diagnosis and treatment of patients with HPV infection is important because this infection causes patients substantial distress even in its benign manifestations. It has also been implicated in a host of cancers, including oral, cervical, penile, and anal cancers and is an independent risk factor for the development of human immunodeficiency virus infection. The incidence of HPV infection drops in women older than 30 years but remains high for MSM in all age ranges. For all of these reasons, physicians should routinely assess the sexual practices of all male patients, especially MSM, and educate them on the HPV infection risks, diagnosis, and treatment options. Physicians can have a significant impact in the primary prevention of HPV by routinely offering HPV vaccination to male patients younger than 26 years.

Patients' attitudes about rapid oral HIV screening in an urban, free dental clinic.

The 2006 Centers for Disease Control recommendations for routine HIV screening in all health care settings could include dental clinics an important testing venue. However, little is known about patients' attitudes regarding the routine use of rapid oral HIV screening at an urban free dental clinic. This pilot study seeks to evaluate the patient perspective on rapid HIV screening in this setting. In June 2007, patients at a free dental clinic in Kansas City, Missouri, were provided an attitude assessment survey prior to their dental visit. This dental clinic serves a diverse patient population consisting of approximately 37% white, 47% black, 6% Hispanic, 4% Asian, and 1% Native American uninsured patients. Results were analyzed for acceptance of testing and potential barriers. Of the 150 respondents, 73% reported they would be willing to take a free rapid HIV screening test during their dental visit. Overall, 91% of Hispanics, 79% of Caucasians, and 73% of African American patients reported they would be willing to be screened. Patients with a history of multiple prior screening tests for HIV were more likely to agree to oral rapid HIV screening in the dental clinic. The majority (62%) reported that it did not matter who provided them with the screening result, although some (37%) preferred their dentist above any other provider. Low self-perception of risk (37%) and having already received screening elsewhere (24%) were the main reasons for not accepting a free, rapid HIV screening. Overall, dental clinic patients widely accepted the offer of rapid oral HIV screening. Rapid HIV screening in the dental clinic setting is a viable option to increase the number of individuals who know their HIV status.

Implementing rapid HIV testing in outreach and community settings: results from an advancing HIV prevention demonstration project conducted in seven U.S. cities.

OBJECTIVES: The goals of this project were to assess the feasibility of conducting rapid human immunodeficiency virus (HIV) testing in outreach and community settings to increase knowledge of HIV serostatus among groups disproportionately affected by HIV and to identify effective nonclinical venues for recruiting people in the targeted populations. METHODS: Community-based organizations (CBOs) in seven U.S. cities conducted rapid HIV testing in outreach and community settings, including public parks, homeless shelters, and bars. People with reactive preliminary positive test results received confirmatory testing, and people confirmed to be HIV-positive were referred to health-care and prevention services. RESULTS: A total of 23,900 people received rapid HIV testing. Of the 267 people (1.1%) with newly diagnosed HIV infection, 75% received their confirmatory test results and 64% were referred to care. Seventy-six percent were from racial/ethnic minority groups, and 58% identified themselves as men who have sex with men, 72% of whom reported having multiple sex partners in the past year. Venues with the highest proportion of new HIV diagnoses were bathhouses, social service organizations, and needle-exchange programs. The acceptance rate for testing was 60% among sites collecting this information. CONCLUSIONS: Findings from this demonstration project indicate that offering rapid HIV testing in outreach and community settings is a feasible approach for reaching members of minority groups and people at high risk for HIV infection. The project identified venues that would be important to target and offered lessons that could be used by other CBOs to design and implement similar programs in the future.