Ethnic/Racial Comparisons in Strategies Parents Use to Cope with Food Insecurity: A Systematic Review of Published Research.

Food insecurity in US affects African Americans, Hispanic, and American Indians disproportionately compared to Caucasians. Ethnicity/race may influence the strategies parents use to reduce the effects of food insecurity. The purpose of this review is to compare coping strategies for food insecurity used by parents of different ethnicities/race as reported in published literature. A systematic search on PubMed and Embase yielded 983 studies, of which 13 studies met inclusion criteria and were reviewed. All groups used public and private assistance, social networks, nutrition related, and financial-related strategies. The limited evidence suggests that there are differences in how parents of different ethnicities/race apply these coping strategies. Current evidence is insufficient to confidently determine the extent of these differences. This review is a starting point for exploration of cultural differences in how parents of various ethnicities/race cope with food insecurity and identifies specific areas for further research.

Medication costs associated with early initiation of antiretroviral therapy.

The START Study randomly assigned 4685 persons with CD4+ counts >500 to either immediate treatment (2326 persons) or a group (2359) that had treatment delayed until the CD4+ count was <350 or clinical judgment dictated treatment. The average time in the study was three years. The immediate group (IG) had 42 serious clinical events and the delayed group (DG) had 96. Policy considerations for adopting these results should consider the cost of medications for early treatment, which is the purpose of this article. Cost of early treatment was estimated by assuming the delayed treatment group had been treated for the three-year average course of the study. However, 48% of the DG received ART before the study's end, so that portion of the group's time on ART was reduced to 1.5 years. Average wholesale prices in the United States of the five recommended ART regimens were discounted by 50% to reflect actual pricing. An average medication cost for the five regimens of $20,000 per person year was used. The three-year cost was $107,580,000 for the 52% who would have been treated for three years and for the 48% treated for an average of 1.5 years. The cost per clinical event avoided was $1,992,222. Formulae are provided that will allow the reader to adjust these results to reflect local prices and volumes. Additional factors to be considered should include the cost savings from avoiding serious clinical events, reduction in transmission of HIV for those being treated early in the infection and the issues associated with long-term adherence for those receiving ART at >500 CD4 counts.

Physicians' and nurses' thoughts and concerns about introducing neonatal male circumcision in Thailand: a qualitative study.

BACKGROUND: Neonatal male circumcision (NMC) is an alternative approach to adult male circumcision for HIV prevention. Recent studies found that NMC was rarely performed in Thailand and that most Thai health professionals did not recognize that NMC could reduce the risk of HIV infection and would not want NMC services in their hospitals. This study explored the thoughts and concerns of Thai government health staff regarding the introduction of NMC in government health facilities as a public health measure. METHODS: In-depth interviews with physicians, nurses and physician administrators from four different levels of government hospitals in four provinces representing 4 regions of Thailand were conducted after provision of education regarding the benefits and risks of NMC. Interviews were audio recorded and analyzed using Atlas.ti software to develop themes. RESULTS: Six themes emerged from the data of 42 respondents: understanding of the benefits of NMC; risks of NMC; need for a pilot project; need for staff training and hospital readiness; need for parental/family education; and need for public awareness educational campaign. Major concerns included possible medical complications of NMC, infringement of child rights, and lack of understanding from staff and parents. The respondents emphasized the need for a clear policy, proper training of staff, financial and equipment support, and piloting NMC rollout before this measure could be fully implemented. CONCLUSIONS: Thai health professionals who took part in this study expressed several concerns if NMC had to be performed in their health care facilities. There is significant preparation that needs to be done before NMC can be introduced in the country.

When to consider acute HIV infection in the differential diagnosis.

Patients presenting with fever, pharyngitis, and lymphadenopathy are likely to have mononucleosis; however, patients with acute HIV infection may present with similar symptoms. Acute HIV infection should be considered as a differential diagnosis if test results for mononucleosis are negative. This article describes when to order HIV testing and discusses the importance of early intervention for acute HIV infection.

Thai health care provider knowledge of neonatal male circumcision in reducing transmission of HIV and other STIs.

BACKGROUND: Male circumcision (MC) reduces the risk of female-to-male transmission of HIV and other sexually transmitted infections (STIs). MC has not been practiced as a disease prevention measure in Thailand probably because of low recognition of its benefits among stakeholders. Neonatal male circumcision (NMC) is simpler, safer and cheaper than adult MC. This study aimed to assess Thai health care provider knowledge of benefits implementing NMC in Thailand. METHODS: Multi-stage sampling identified 16 government hospitals to represent various hospital sizes and regions of the country. Researchers administered a fixed choice questionnaire, developed by the research team based on a previous study, to physician administrators, practicing physicians, and nurses whose jobs involved NMC clinical procedures or oversight. The participants reviewed printed educational materials on the benefits of NMC during questionnaire completion. Data were analyzed using descriptive statistics, chi square tests, odds ratios, and logistic regression. RESULTS: One hundred thirty-three individuals participated in this quantitative study. Only 38% of the participants agreed that NMC reduced the risk of sexual transmission of HIV while 65% indicated that they knew that NMC prevented STIs. Most participants recognized the benefits of NMC on hygiene (96%) as well as cancer prevention (74%). Major concerns raised were potential trauma to the child, child rights and safety of NMC. After reviewing written information about the benefits of NMC, 59% of the participants agreed that NMC should be offered in their hospital. Physicians and nurses who had previous experience with circumcising patients of all ages were more reluctant to have NMC performed in their hospital. CONCLUSIONS: A clear policy advocating NMC, thorough preparation of health facilities, and staff training are needed before NMC could be used in Thailand as prevention strategy for HIV and other STIs.

ATTITUDES AND BEHAVIOR AMONG RURAL THAI ADOLESCENTS REGARDING SEXUAL INTERCOURSE.

Early initiation of sexual intercourse has been associated with negative consequences, such as higher rates of unwanted pregnancy and HIV infection. This study examined the attitudes and behavior of rural Thai adolescent students aged 16 to 20 years from northern Thailand regarding sexual intercourse. Differences between participants who previously had sexual intercourse and those who had not were explored. Those who had not previously had sexual intercourse were asked about the reasons why they had not had sex, their future plans for having sex and their dating experiences. More than 70% of participants stated they had not previously had sexual intercourse but one third of this group reported engaging in other sexual behavior. There were significant differences by gender, religion, ethnicity, and household income between those who had previously had sex and those who had not. Among those who had not previously had sexual intercourse, concern for their parents' feelings was the most common reason for delaying intercourse. About two-thirds of this group had plans not to have sexual intercourse until after marriage; nearly half of them reported currently having a boyfriend/girlfriend. Interventions aimed at delaying sexual intercourse should involve adolescents in their design and include their attitudes for delaying intercourse. Because of many gender differences seen in our study, interventions should be designed differently for males and females in rural northern Thailand.

Verifying quantitative stigma and medication adherence scales using qualitative methods among Thai youth living with HIV/AIDS.

HIV/AIDS-related stigma has been linked to poor adherence resulting in drug resistance and the failure to control HIV. This study used both quantitative and qualitative methods to examine stigma and its relationship to adherence in 30 HIV-infected Thai youth aged 14 to 21 years. Stigma was measured using the HIV stigma scale and its 4 subscales, and adherence was measured using a visual analog scale. Stigma and adherence were also examined by in-depth interviews. The interviews were to determine whether verbal responses would match the scale's results. The mean score of stigma perception from the overall scale and its 4 subscales ranged from 2.14 to 2.45 on a scale of 1 to 4, indicating moderate levels of stigma. The mean adherence score was .74. The stigma scale and its subscales did not correlate with the adherence. Totally, 17 of the respondents were interviewed. Contrary to the quantitative results, the interviewees reported that the stigma led to poor adherence because the fear of disclosure often caused them to miss medication doses. The differences between the quantitative and the qualitative results highlight the importance of validating psychometric scales when they are translated and used in other cultures.

Measurement issues in using pharmacy records to calculate adherence to antiretroviral drugs.

BACKGROUND: Researchers often use pharmacy records to calculate adherence to antiretrovirals. Variability in the findings may be due to inconsistent methods of calculating adherence. OBJECTIVE: Determine the impact on adherence rates of 6 different calculations that include accounting for whether filled antiretroviral prescriptions were picked up and whether the patient had medications at the start of the observation period. METHODS: Fifty-six patients of a public care system, who had ordered, but failed to pick up, antiretroviral prescriptions from the clinic pharmacy at least once from September thru December, were identified using an electronic pharmacy database. Their adherence during the 4 months was calculated using refilled doses and picked up doses as a percent of prescribed doses. The effect on the calculation of adherence of medications in the patients' possession from August was examined. RESULTS: When medications in the patients' possession from August were considered in calculating adherence, the rate was 54% based on the prescription refill date and 33.4% based on the prescription pick-up date. If medications in the patients' possession at the beginning of the observation period were ignored, adherence based on refill was 48.9% and 28.1% based on pick-up. If the start date for calculating adherence was the date of the first refill or pick-up during the first month of the observation period, adherence rates were 56.2% and 41%, respectively. CONCLUSIONS: This study demonstrated that 6 different methods of calculating adherence from pharmacy records yielded adherence rates of 28.1% to 56.2%. Studies using pharmacy records should specify how adherence is calculated.

A nursing intervention to enhance the self-care capacity of nondisclosed persons living with HIV in Thailand.

Significant numbers of nondisclosed persons living with HIV (NPLWH) who are aware of their status do not enter care and must rely on their own abilities to maintain their health. This study shows how these individuals can be reached through nongovernmental organizations and assisted to improve their self-care capacity through an intensive nursing intervention. NPLWH in Chiang Mai, Thailand, were assessed using a 31-item self-care capacity questionnaire (range = 0-62) at baseline and monthly for 6 months. The nursing intervention used reflective questioning to assist PLWH to find ways to improve their self-care capacity. At baseline, the mean self-care capacity score was 31.4. After 3 months of intervention, the score increased to 54 and was maintained at this level for the next 3 months. This study demonstrates that nurses can reach out to NPLWH who are not in care and help to improve self-care capacity.

Readiness, trust, and adherence: a clinical perspective.

OBJECTIVE: This paper examines the scientific bases for the recommendations on readiness, trust, and adherence that were contained in 5 HIV treatment guidelines. METHODS: The authors reviewed the treatment guidelines of 5 internationally recognized expert panels, and 5 review articles on readiness, trust, and adherence to determine the evidence for the guidelines' recommendations. These review articles were assessed to determine whether they contained: 1) a definition of the concept, 2) a measure that predicted outcomes, or 3) evidence that a replicable intervention altered outcomes. RESULTS: There is no good definition, measure, or evidence that readiness predicts adherence. There were no interventions that improved readiness in a clinically useful way. There was no good definition or measure of trust, nor was there evidence that patient trust predicts adherence or that interventions improve trust. It is not clear whether trust is a cause or an effect of clinical outcomes. There is agreement that adherence is defined as taking medications as prescribed. Six measures of adherence were found, and several studies showed that they correlated poorly when applied to the same sample of patients. Adherence interventions have had some success but are poorly described and idiosyncratic such that it is difficult to replicate them in other settings. CONCLUSION: Research on readiness and trust are unlikely to yield useful results. Systematic, long term research on clinician-based adherence interventions must be done. A life-long process such as adherence to antiretroviral treatment is unlikely to be understood without having a long-term study of a cohort of patients taking these medications.

HIV positive but not in care: a follow-up study from Thailand.

Twenty-two persons in Northern Thailand who knew of their HIV positivity but were not in care were identified. They had significant medical, economic, behavioral, and family problems. A nurse researcher carried out a 6-month intervention with them to (1) assess whether they would remain in contact with the researcher for 6 months and (2) assess whether they would make positive changes in their lives. All 22 participants remained in contact for 6 months. A 5-step intervention process resulted in substantial improvements in their lives. Eleven patients entered care. Five needed immediate antiretroviral therapy (ART) and improved their CD4 counts. Six others established primary care relationships for non-HIV care. Twelve obtained legal, full-, or part-time employment. Eight disclosed to family members. Nine participants and/or family members entered counseling. Twelve persons publicly disclosed themselves. Twelve reported reducing or stopping substance abuse. Of 4 sex workers, 2 ceased engaging in that work.

The effects of self-management education for school-age children on asthma morbidity: a systematic review.

The effects of asthma self-management education for school-age children on number of school days missed, emergency department visits and hospital admissions were evaluated through a systematic review of the published research. A total of 9 studies on asthma education programs that were conducted in schools by school nurses and health educators and targeted children 5-18 years of age were reviewed. The studies were all published between 1998 and 2009. The school-based asthma education programs delivered interventions in multiple sessions over short consecutive time periods of about a month to a month and a half. Follow-up data were collected in varying intervals from 1 month to 1 year postinterventions. Results indicated that a decrease in school days missed can be expected from such programs. The data regarding emergency department visits and hospital admissions was less definitive.

Readiness: the state of the science (or the lack thereof).

HIV treatment guidelines state that patients' readiness should be assessed before initiating highly active antiretroviral therapy (HAART) to assure adherence. None of the guidelines provide a way to measure readiness. Therefore, this article sought to review the literature on readiness to determine if there was a viable predictor of adherence. Twenty-seven articles were reviewed. Nine described studies that examined the relationship between a measure of readiness and HAART adherence. No readiness measure demonstrated clinical utility as a predictor of adherence. Study flaws included small sample sizes (only one study >100 patients), short follow-up periods (all ≤1 year and six were ≤5 months, four ≤1 month), measures of readiness that related poorly to adherence, and inconsistent adherence measures (eight different measures were used by the researchers). Neither the guidelines nor the literature will help clinicians judge who should initiate HAART and who should delay treatment.

Nurses' intentions to respond to bioterrorism and other infectious disease emergencies.

Although nurses historically have responded to natural disasters, little is known about nurses' intentions to respond during bioterrorism and other infectious disease emergencies where they and their families may be at risk. To investigate that question, we surveyed nurses following their participation in a class on bioterrorism. Participants (N = 292) completed a Personal/Professional Profile (PPP), Test of Bioterrorism Knowledge (BT Knowledge), and an Intention to Respond (IR) instrument. IR was measured by participants' scores on their likelihood to care for patients (0 = extremely unlikely, 10 = extremely likely) for each of 10 infectious disease scenarios reflecting different infection risk. We calculated scores for each scenario, totaled them, and examined the total IR related to the participant's PPP and scores on BT Knowledge. Additionally, we examined participants' written comments explaining the reasons for their IR. Total IR scores ranged from 8-100 (mean and median of 70). The IR was higher in scenarios where the infection risk was lower. Overall IR scores were positively related to BT Knowledge and having had previous emergency and disaster experience. Those less likely to respond had dependent children and more years in nursing. Results indicate that nurses differentiated risks associated with different infectious disease situations and may decide to respond during a real emergency based on such information. Implications for nursing administrators and nursing educators are discussed.

Patient readiness to adhere to HAART.

OBJECTIVES: To determine 1) whether patients' statements of readiness to take HAART predicted adherence and 2) whether previous experience with HAART enabled patients to better predict adherence. METHOD: Thirty-nine patients (24 naïve to HAART and 15 reinitiating HAART after a hiatus of >6 months) indicated readiness to take HAART on a Likert scale and a visual analog scale (VAS). Adherence was measured by prescription renewals. RESULTS: Participants were 72% male; 62% African/American; 23% Anglo-White, and 13% Hispanic. Patients considered themselves quite ready to initiate therapy on both scales. Adherence for 5 months ranged from 24% to 100%; mean = 68%; median = 78%. Adherence was not associated with readiness as measured by the Likert scale (F = .15, p = .86) or the VAS (r = -.078, p = .64). VAS readiness scores did not correlate with adherence for naïve (r = -.16; p = .47) or experienced (r = .09; p = .76) patients. CONCLUSIONS: Patients' statements of readiness to take HAART do not predict their adherence.

Known to be positive but not in care: a pilot study from Thailand.

This study was designed to describe persons with HIV/ AIDS (PWHAs) in Thailand who have not disclosed their HIV status to the government HIV clinics to receive medical care. Objectives were to (1) demonstrate a way to access these persons, and (2) describe their characteristics, HIV status, reasons for nondisclosure, and problems related to their self-care. Two nongovernmental organizations (NGOs) serving the nonmedical needs of PWHAs were used. In all, 22 PWHAs participated. Approximately 80% have known their HIV status for more than 1 year and 30% for more than 5 years. Almost 60% currently used recreational drugs. Reasons for not disclosing their HIV status included that they were still healthy (81.8%) and worried about stigma (77.3%). Two thirds will disclose when a serious problem occurs. This study demonstrates that this population can be accessed and studied through NGOs and that this population differs slightly from PWHAs in Thailand studied at initiation of medical care.

Antibiotic resistance in Staphylococcus aureus-containing cutaneous abscesses of patients with HIV.

PURPOSE: The aim of this study was to document the resistance patterns found in exudates from cutaneous abscesses of HIV-infected persons. BASIC PROCEDURES: Patient records were reviewed on 93 culture and sensitivity tests performed on exudates taken from incised and drained abscesses of HIV-infected persons. MAIN FINDINGS: Of the specimens, 84.6% were Staphylococcus aureus. Of these, 93.5% were penicillin resistant, 87% oxacillin resistant, 84.4% cephazolin resistant, 84.4% erythromycin resistant, 52.2% ciprofloxacin resistant, and 15.6% tetracycline resistant. Fifty-eight specimens were tested for clindamycin with 29.3% found resistant; 85.7% were methicillin-resistant S aureus (MRSA) (defined as resistant to both penicillin G and oxacillin). All specimens were resistant to multiple antibiotics including antimicrobials that might be considered for use in MRSA. No specimens were resistant to trimethoprim-sulfamethoxazole, rifampin, or vancomycin. CONCLUSIONS: Empiric antimicrobial therapy of HIV-infected persons with cutaneous abscesses must be tailored to the high frequency of antimicrobial drug resistance including MRSA in this population.

Bioterrorism: class A agents and their potential presentations in immunocompromised patients.

A bioterrorism attack would be particularly challenging for medical professionals caring for patients with cancer who often have weakened immune systems. Knowledge of the class A agents and the potential variable presentations in immunocompromised patients is key to early recognition of an outbreak and prompt reporting. The purpose of this article is to present the class A agents: Bacillus anthracis (anthrax), botulinum toxin (botulism), variola virus (smallpox), Yersinia pestis (pneumonic plague), and Francisella tularensis (tularemia). The variable signs and symptoms that may be present in immunocompromised patients with cancer will be discussed with a focus on assessment and early recognition of an outbreak. The availability of vaccines and the implications for patients with cancer receiving these vaccines also will be discussed.

Assessment of readiness to initiate antiretroviral therapy.

PURPOSE: An important factor in adherence to antiretroviral therapy (ART) is the patient's commitment to follow the regimen, which suggests that therapy should be initiated only when the patient is ready to make such a commitment. Because there has been no research on patient readiness for ART, this study was undertaken to investigate factors that influence the decision of an HIV-positive person to seek medical care and to initiate ART. METHOD: The investigators surveyed 83 HIV-infected patients on ART. Participants completed a questionnaire that obtained information on the length of time from when they learned of their HIV-positive status to when they sought medical care, the length of time from when they learned of their HIV-positive status to when they were ready to initiate therapy, and psychological and social factors thought to be associated with readiness. RESULTS: Respondents had a mean age of 37 years, 71% were male, and 65% were African American. Only 42% said they sought medical care immediately upon learning their HIV diagnosis. Fifty percent were ready to initiate therapy immediately upon learning their diagnosis, and 25% were ready within 1 year. Sixty-four percent of respondents experienced barriers that interfered with therapy initiation. Although 98% of respondents experienced at least one emotional response to HIV diagnosis, less than 25% of respondents thought that their responses interfered with readiness. However, five emotional responses demonstrated an association with readiness through chi-square analysis. CONCLUSION: Further research is needed to explain the relationships among emotional responses to HIV diagnosis, readiness to initiate ART, and adherence.