Perceived barriers to receiving HIV services in groups of traditionally underserved individuals: empirical models.

Persons living with HIV/AIDS face many issues that make them highly vulnerable to a number of health and social problems. As the demographics of the epidemic have shifted in recent years, many members of traditionally underserved groups have encountered barriers to entering the services system. This article uses data from seven national demonstration projects funded to enroll persons with HIV/AIDS who tend to "fall through the cracks" and help them access needed services. Data on the initial perceptions of the participants about barriers to accessing services were related to 17 indicators of traditionally underserved status including demographic characteristics and behavioral variables using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Through the modeling methods, the groups most likely to experience a large number of barriers to service participation are identified. Having children needing care is particularly predictive of the level of barriers to care.

Unmet needs in groups of traditionally underserved individuals with HIV/AIDS: empirical models.

Over the course of the HIV epidemic, the demographics of the populations of affected individuals have changed. Groups that traditionally have been underserved in systems of care have a number of unmet service needs. This article presents results based on data from 478 patients in five national demonstration projects which were funded to enroll individuals from traditionally underserved groups and to help them access services using different strategies. The participants in these programs had a high level of unmet need prior to enrolling in care. Data on client service needs were related to 17 indicators of traditionally underserved status including demographic characteristics and risk behaviors, using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Crack cocaine users with HIV/AIDS were more likely than other patient groups to have unmet service needs. Patients who were homeless or in precarious housing also were vulnerable. Results are discussed in terms of designing and evaluating innovative service models to close these service gaps.

Finding the underserved: directions for HIV care in the future.

The demographic, behavior, and background characteristics of 4,804 participants in 17 national demonstration projects for HIV medical and/or psychosocial support services were coded for an index of "service need" or possible under-representation in the traditional healthcare system. Fifteen items were coded including status as a person of color, lack of private insurance, unemployment/disability, problem drinking, crack cocaine use, heroin use, other illicit drug use, less than 12 years of education, criminal justice system involvement, children requiring care while the patient receives services, sex work, being the sex partner of an injection drug user, unstable housing, primary language not English, and age less than 21 or over 55 years. Most (87.7%) of the program participants had four or more of these factors present. Through CHAID modeling, those groups with the highest levels of service need and vulnerability were identified. These data suggest that these projects, designed to attract and serve individuals potentially underrepresented in the health services system, had in fact achieved that goal. Implications of the changing demographics of the HIV epidemic for the health service delivery system are discussed.

Do characteristics of HIV/AIDS education and training affect perceived training quality? Lessons from the evaluation of seven projects.

Initial and continuing HIV/AIDS education and training has been a critical way to bring the nation's health providers up to date on emerging developments and approaches. This study reports cross-cutting findings from seven HIV/AIDS education and training projects. Trainers described over 600 training sessions from these projects in terms of their structural characteristics and design elements, while trainees described these sessions on several dimensions related to training quality. Training characteristics were compared to trainee assessments of training quality. Using a decision-tree analytic approach for major training attributes, considerable support emerged for links between training characteristics and perceived quality of the HIV/AIDS training experience. More favorable quality ratings were associated with certain projects, the training setting, the types of trainees served by the training, the intended training impact, discussion of special populations, and training methods involving interactive learning. With increased knowledge regarding how these educational experiences relate to the ways they are perceived and processed, more targeted approaches to training design on HIV/AIDS can be developed.

Trainee characteristics and perceptions of HIV/AIDS training quality.

HIV/AIDS education and training have played a vital role in keeping health providers up to date on emerging developments and approaches. This study reports findings from seven HIV/AIDS education and training projects. Participants in more than 600 training sessions described themselves, their professional background, and their general reasons for taking the training. Immediately following the training, they also rated the quality of their educational experience along several dimensions. Trainee characteristics were related to assessments of training quality, using a regression decision-tree analytic approach. Although effect sizes were generally small, quality ratings of the HIV/AIDS training experiences were associated with certain projects, basic trainee demographic characteristics, professional background, and experience in the HIV field. Greater understanding about participant characteristics can provide clues about how these training experiences are perceived and processed and may inform decision making about instructional HIV/AIDS curricula.

Effects of HIV/AIDS education and training on patient care and provider practices: a cross-cutting evaluation.

Initial and continuing training in HIV/AIDS service provision is a critical way to enable the nation's health providers to use state-of-the-art developments and perspectives. Typically, the efficacy of HIV/AIDS training programs is evaluated using assessments administered to trainees immediately following the training. This study reports cross-cutting findings from telephone interviews conducted with 218 trainees an average of 8 months after training. Long-term training effects are examined in three domains: (a) general perspectives on HIV/AIDS; (b) health care provider service provision; and (c) changes in procedures and operations at the health care system level. The findings show the different ways that the training experience had long-term positive and observable effects in these three domains. In some cases, background characteristics and job positions predicted the specific type of reported training effects. The pattern of results suggests ways in which training methods can be targeted to specific audiences.

Typology of quality of life experiences among persons living with HIV.

This article develops a typology of 2,038 participants in 13 innovative HIV/AIDS treatment model service demonstration projects targeted to traditionally underserved populations. The typology is based on self-reported health-related quality of life levels. Eight clusters were identified that classify HIV/AIDS patients based on their reported health-related quality of life. Participants were clustered based on their overall levels of quality of life, as well as by deficits in specific areas of functioning such as energy level, physical impairment, and role impairment. However, factor analysis suggests that health-related quality of life as perceived by the HIV-positive participants is best represented as a single underlying dimension and an ordering of the types shows that they are consistently related, in the same order, to several criterion measures of impairment. The results suggest that a general categorization of patients with HIV in terms of quality of life is more meaningful than an assessment of the relative areas of impairment. Since the impairment ratings were also self-reported, analyses relating quality of life clusters to actual symptom levels and healthcare utilization are needed. Implications for the assessment of health-related quality of life and the evaluation of service delivery programs for persons living with HIV are discussed.

Service needs and factors related to quality of life at time of service enrollment among persons living with HIV.

This article explores the relationships of HIV risk factors, service needs, and vulnerabilities to health-related quality of life in a sample of 1,371 participants newly enrolled into 13 innovative HIV/AIDS treatment model service demonstration projects. These projects targeted services to traditionally underserved populations. Eight distinct quality of life clusters of HIV patients were used in this analysis along with patient self-identified risk factors. The quality of life clusters were based on patient self-reported quality of life dimensions. The eight clusters were differentiated based on relative strengths and weaknesses in physical functioning, energy levels, and social functioning. Data on patient need-vulnerability factors and demographic characteristics were related to these eight clusters using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Through this method, the characteristics most likely to be associated with higher and lower levels of quality of life at the time of enrollment into services were identified. The results provide further support that quality of life assessment is a useful clinical tool for monitoring patient progress.

Systems change resulting from HIV/AIDS education and training. A cross-cutting evaluation of nine innovative projects.

An evaluation of nine diverse HIV/AIDS training programs assessed the degree to which the programs produced changes in the ways that health care systems deliver HIV/AIDS care. Participants were interviewed an average of 8 months following completion of training and asked for specific examples of a resulting change in their health care system. More than half of the trainees gave at least one example of a systems change. The examples included the way patient referrals are made, the manner in which agency collaborations are organized, and the way care is delivered.

Children with special health-care needs in Texas.

A comprehensive system for the delivery of care to children with special healthcare needs and to their families has been developed by the department of pediatrics of The University of Texas Health Science Center at San Antonio. A description of the structure and operations of this system is presented and offered as a model for the state of Texas.

The effects of cyclosporine and dexamethasone on an alveolar macrophage cell line (NR8383).

Lung infections are a major source of morbidity and mortality in recipients of lung transplants. Prominent among the pathogens that cause pneumonias in these subjects are gram-negative bacilli, particularly Pseudomonas strains. One important reason that bacteria infect the lungs of these patients is that pulmonary defenses are impaired by the drugs used to prevent transplant rejection. Using a rat alveolar macrophage cell line (NR8383), we measured the effects of exposure (24 hr) to cyclosporine and dexamethasone (DEX) on the ability of these cells to (1) kill Pseudomonas aeruginosa (Pa); (2) produce H2O2; and (3) release tumor necrosis factor. We found that the bactericidal activity against unopsonized or opsonized Pa of NR8383 cells was unaltered by CsA (0.1, 0.5, or 1 micrograms/ml), DEX (10(-6) M), or CsA + DEX (0.5 micrograms/ml + 10(-6) M, respectively). Likewise, LPS-induced TNF release, and zymosan A and Pa-induced H2O2 production were unaltered by CsA (0.1 or 1 microgram/ml). In contrast, H2O2 production and TNF release were decreased by about 50% and 90%, respectively, by DEX exposure (10(-6) M). Thus, while DEX but not CsA decreased TNF release and H2O2 production in NR8383 cells, bactericidal activity against Pa was unaffected. One explanation for these results is that decreases in TNF or H2O2 of the magnitude we observed do not impair bactericidal activity against Pa; however, an alternative explanation is that Pa are killed by NR8383 cells through other mechanisms. Interpretation of these results must take into consideration the fact that macrophages from different species and tissues may respond differently to various stimuli.

Pneumocystis carinii induces an oxidative burst in alveolar macrophages.

There is evidence that alveolar macrophages (AM) play a role in the clearing of Pneumocystis carinii from the lungs. To investigate the mechanisms involved in this process, we studied in vitro the induction of an oxidative burst by P. carinii in a cell line of macrophages (NR8383) and AM from normal rats. P. carinii was added to macrophage monolayers (10(6) cells), and the H2O2 produced after 4 h of incubation was measured. Both NR8383 macrophages and normal rat AM produced H2O2 in response to P. carinii cysts and trophozoites isolated from dexamethasone-treated rats, although the amount of H2O2 induced in AM from normal rats was larger. NR8383 macrophages bound and phagocytized both P. carinii cysts and trophozoites and produced increasing amounts of H2O2 as a dose-related response to cysts and trophozoites. Opsonization of P. carinii with normal rat serum increased H2O2 production by both types of macrophages; this enhancement was decreased, but not abolished, when the serum was first depleted of complement by heat treatment. These findings demonstrate that NR8383 macrophages and normal rat AM produce an oxidative burst in response to P. carinii and that this response is enhanced by complement.

Role of the zymolyase-sensitive cyst wall of Pneumocystis carinii in the oxidative burst of macrophages.

Alveolar macrophages are thought to participate in clearing Pneumocystis carinii (Pc) from the lungs. We have recently demonstrated that Pc cysts and trophozoites induce an oxidative burst in a cell line of rat alveolar macrophages (NR8383). In order to investigate the mechanism of this response, we examined the effect that disruption of the Pc cyst wall with zymolyase had on the cyst's ability to elicit H2O2 from NR8383 macrophages and correlated these results with the electron microscopic appearance of the cyst wall.

A continuous alveolar macrophage cell line: comparisons with freshly derived alveolar macrophages.

Responses of a recently developed rat alveolar macrophage cell (NR8383.1) line were compared to those of freshly derived alveolar macrophages in vitro. Marked inter- and intraspecies heterogeneity in levels of phagocytosis of unopsonized Pseudomonas aeruginosa or zymosan was noted among freshly derived alveolar macrophages from rats, rabbits, and baboons. In contrast, phagocytic responses of alveolar macrophage cell line were predictable and highly reproducible. Similar results were obtained in measuring oxidative burst, as indicated by the production of H2O2 and luminol-enhanced chemiluminescence. Responses were again highly variable in freshly derived alveolar macrophages stimulated with zymosan or phorbol myristic acetate; moreover, freshly derived alveolar macrophages exhibited a wide range of chemiluminescence activity in unstimulated cultures. Results strongly suggest that data derived from the continuous alveolar macrophage culture NR8383.1 can be extrapolated to freshly derived alveolar macrophages of various species, and in many experiments will be useful in avoiding the significant animal-to-animal variance observed among freshly derived cell preparations.

Resistance of mucoid Pseudomonas aeruginosa to nonopsonic phagocytosis by alveolar macrophages in vitro.

A unique, recently described rat alveolar macrophage cell line (NR8383) was used to study the interaction of the pulmonary immune system with a mucoid cystic fibrosis isolate of Pseudomonas aeruginosa (SRM-3), its nonmucoid revertant (SRM-3R), and a non-cystic fibrosis isolate (PAO-1). Strain SRM-3 was cultivated in a chemostat system to allow maintenance of an entirely mucoid population. The alveolar macrophage response to the mucoid and nonmucoid strains of P. aeruginosa was determined by visually quantitating phagocytosis in acridine orange-stained monolayers and measuring the induction of an oxidative burst as indicated by chemiluminescence and H2O2 production. In all experiments, fewer than 2% of the NR8383 cells engulfed the mucoid SRM-3 isolate, while SRM-3R and PAO-1 were phagocytized by 15 and 41%, respectively. Opsonization by normal serum (complement) provided minimal phagocytic enhancement of these strains, whereas specific anti-P. aeruginosa antibody slightly elevated phagocytic responses to strains with nonmucoid phenotypes while providing a sevenfold increase in uptake of SRM-3. Chemiluminescent and H2O2 responses were comparable with the levels of phagocytosis observed, with very little or no response to the mucoid strain SRM-3. The data indicate that the strains with mucoid phenotypes are refractile to ingestion and that studies which describe ingestion of mucoid strains were likely measuring ingestion of revertants. Alginic acid (2 mg/ml) was found to inhibit stimulation of macrophage response to the opsonized and unopsonized nonmucoid strain PAO-1.

From growth factor dependence to growth factor responsiveness: the genesis of an alveolar macrophage cell line.

A rat pulmonary alveolar macrophage (PAM) cell line (NR8383) was initiated in culture in the presence of a gerbil lung cell conditioned medium (GLCM), and has been propagated continuously for over 36 mo. When examined at different times throughout this in vitro period, NR8383 exhibited characteristics typical of macrophages: (a) Zymosan ingestion was seen in 90 to 98% of the cells examined; (b) Pseudomonas aeruginosa phagocytosis in 50 to 80%; (c) Nonspecific esterase activity in greater than 95%. During the first 6 mo., the PAM replicated with doubling times approximating 15 to 20 d. Throughout this period, GLCM dependence was evident. After 27 wk in vitro, NR8383 replication increased markedly, and within 2 wk, the doubling time was less than 48 h. NR8383 was readily monitored by [3H]thymidine (TdR) blastogenesis assay. In the presence of GLCM uptake of [3H]TdR was fivefold greater than in control cultures. Adherence and growth kinetics were effectively controlled by modulation of GLCM or serum content in culture medium. It was demonstrated that PAM growth factor(s) is ubiquitous, not species-specific, and under certain conditions may be derived from "endogenous" sources of persisting non-PAM populations within the parent, uncloned line NR8383. Cloned progeny remain devoid of non-PAM "feeder" cells, but retain macrophage properties, including interleukin-1 secretion, Fc receptors, and H2O2 production.

Systolic pressure amplification in pedal arteries in children.

Sphygmomanometric indirect blood pressure readings on the arm were compared to direct blood pressure readings from the radial and pedal arteries in pediatric patients. The direct systolic pressure in the pedal arteries was significantly (p less than 0.001) greater (25.1 +/- 12.3 mm Hg) than the indirect arm systolic pressure. The direct systolic pressure from the radial artery was identical to the indirect systolic arm pressure. Although there were no statistical differences between direct and indirect diastolic pressures, correlations for diastolic pressures were relatively poor. These data indicate that (1) there is a significant and unpredictable amplification of systolic pressure in the pedal arteries which may result in erroneous diagnosis of hypertension or jeopardize early detection of circulatory shock, (2) indirect blood pressure measurement with the recommended cuff width (125% of arm diameter or 40% of arm circumference) accurately reflects direct systolic pressure in the radial artery, and (3) indirect blood pressure measurement gives a relatively poor prediction of direct diastolic pressures.

Reflex stimulation of tracheal mucus gland secretion by gastric irritation in cats.

Our aim was to determine whether flow from the submucosal glands of the trachea is reflexly regulated by sensory stimuli from the stomach in the cat, and, if such a gastropulmonary reflex exists, what sensory and motor pathways are important. We found that mechanical stimulation of the gastric mucosa increased submucosal gland secretions from 7.9 +/- 0.7 to 17.4 +/- 1.7 nl/min (mean +/- SE, P less than 0.001). This effect was prevented reversibly by cooling both abdominal vagus nerves to -3 degrees C before stimulation and was restored by rewarming the nerves. The effect was prevented irreversibly by cutting both abdominal vagus nerves and was then mimicked by electrically stimulating the central cut end of one of the nerves. This increase in secretions caused by electrical stimulation of the nerve was prevented by administration of atropine sulfate before stimulation. We conclude that stimuli from the stomach reflexly affect the rate of submucosal gland secretion. The sensory limb of this reflex lies in the abdominal vagus nerves, and the motor pathways are mediated by cholinergic muscarinic receptors.

Micropipette measurement of airway submucosal gland secretion: laryngeal reflex.

We used our microcollection technique to study the effect of mechanical stimulationof the larynx on tracheobrochial gland secretion. The basal secretory rate of 8 glands in 5 cats rose from 18.6 +/- 2.0 nl/min (mean +/- SE) to a maximum of 47.8 +/- 4.0 nl/min within 1 min of mechanical stimulationof the laryngeal mucosa(p < 0.005) and returned to prestimulation levels within 4 to 5 min after cessation of the stimulus. The effect of laryngeal stimulation on gland secretion was prevented by cooling both cerevical vagi to - 3 degrees C before and during stimulation, and was restored by warming both vagito 37 degrees C before stimulaltion. Atropine sulfate (0.5 mg/kg given intravaenously) also prevented the secretory response to laryngeal stimulation. Transsection of the sensory nerves to the larynx blocked this response as well. Electrical stimulation (7 V, 20 Hz, 15 s) of the central end of the cut superior layyngeal nerve increased the rate of secretion of 6 glands in 5 cats from 10.0 +/- 2.0 nl/min to 26.0 +/- 3.0 nl/min (p < 0.01); atropine also prevented this effect.

Micropipette measurement of airway submucosal gland secretion. Autonomic effects.

We describe a micropipette method for obtaining secretions from single submucosal gland ducts in vivo in cat tracheas. The secretory rate of 65 glands sampled under basal conditions in 16 animals varied from 3 to 30 nl/min (mean +/- SE, 9.05 +/- 0.60 nl/min) and varied 2 to 3-fold among glands sampled within an animal. Sequential samples collected from individual ducts during a 10-min period were highly repeatable (correlation coefficient, 0.96) and were remarkably constant for as long as 4 h. Vagal cooling decreased the secretory rate by a mean of 39% (n = 11, p less than 0.05). Stimulation of the cervical vagus nerves increased flow from 8.3 +/- 0.7 to 16.4 +/- 0.8 nl/min (n = 15, p less than 0.01), an effect that was abolished by intravenous injection of 0.5 mg of atropine sulfate/kg of body weight or by cooling of the vagus nerves, but not by 0.08 mg of phentolamine/kg given intravenously. Intravenous injection of 0.3 mg of phenylephrine/kg of body weight increased flow from 8.6 +/- 0.6 to 18.9 +/- 1.1 nl/min (n = 20, p less than 0.001), an effect that was prevented by phentolamine, but not by atropine. We conclude that cholinergic and alpha-adrenergic stimulation increases fluid secretion from feline submucosal glands.