Antiretroviral Prescription and Viral Suppression in a Representative Sample of HIV-Infected Persons in Care in 4 Large Metropolitan Areas of the United States, Medical Monitoring Project, 2011-2013.

BACKGROUND: Comparisons of antiretroviral therapy (ART) prescription and viral suppression among people in HIV care across US metropolitan areas are limited. Medical Monitoring Project, 2011-2013, data were used to describe and compare associations between sociodemographics and ART prescription and viral suppression for persons receiving HIV care. SETTING: Chicago, Los Angeles County (LAC), Philadelphia, and San Francisco in the United States. METHODS: Bivariate and multivariable methods were used. RESULTS: The proportion of patients prescribed ART (91%-93%) and virally suppressed (79%-88%) was consistent although more persons were virally suppressed in San Francisco compared with the other areas, and a smaller proportion was virally suppressed in Philadelphia compared with Chicago. In the combined cohort, persons aged 30-49 years were less likely than persons 50+ (adjusted prevalence ratio (aPR) -0.97, confidence interval (CI): 0.94 to 0.99); persons reporting non-injection drug use were less likely than non-users (aPR = 0.94, CI: 0.90 to 0.98); and Hispanics were more likely than whites (aPR - 1.04, CI: 1.01 to 1.08) to be prescribed ART. Blacks (aPR = 0.93; CI: 0.87 to 0.99) and homeless persons (aPR = 0.87; CI: 0.80 to 0.95) were less likely to be virally suppressed in the combined cohort. In LAC, persons aged 30-49 years were less likely than those 50+ to be prescribed ART (aPR = 0.94, CI: 0.90 to 0.98). Younger persons (18-29) (aPR = 0.77; CI: 0.60 to 0.99) and persons with less than a high school education (aPR = 0.80; CI: 0.67 to 0.95) in Philadelphia, blacks (aPR = 0.90; CI: 0.83 to 0.99) and men who have sex with women only (aPR = 0.89; CI: 0.80 to 0.99) in Chicago, and homeless individuals in LAC (aPR = 0.80; CI: 0.67 to 0.94) were less likely to be virally suppressed. CONCLUSION: Data highlight the need to increase ART prescription to achieve viral suppression among younger persons, noninjection drug users, blacks, and homeless persons in US metropolitan areas and underscores the importance of region-specific strategies for affected subgroups.

Regional differences among HIV patients in care: California medical monitoring project sites, 2007-2008.

INTRODUCTION: The Medical Monitoring Project (MMP) is a national, multi-site population-based supplemental HIV/AIDS surveillance project of persons receiving HIV/AIDS care. We compared California MMP data by region. Demographic characteristics, medical care experiences, HIV treatment, clinical care outcomes, and need for support services are described. METHODS: HIV-infected patients 18 years or older were randomly selected from medical care facilities. In person structured interviews from 2007 - 2008 were used to assess sociodemographic characteristics, self-reported clinical outcomes, and need for supportive services. Pearson chi-squared, Fisher's exact and Kruskal-Wallis p-values were calculated to compare regional differences. RESULTS: Between 2007 and 2008, 899 people were interviewed: 329 (37%) in San Francisco (SF), 333 (37%) in Los Angeles (LA) and 237 (26%) in other California counties. Significant regional sociodemographic differences were found. Care received and clinical outcomes for patients in MMP were positive and few regional differences were identified. HIV case management (36%), mental health counseling (35%), and dental services (29%) were the supportive services patients most frequently needed. Unmet needs for supportive services were low overall. Significant differences by region in needed and unmet need services were identified. DISCUSSION: The majority of MMP respondents reported standard of care CD4 and viral load monitoring, high treatment use, undetectable HIV viral loads and CD4 counts indicative of good immune function and treatment efficacy. Information from MMP can be used by planning councils, policymakers, and HIV care providers to improve access to care and prevention. Identifying regional differences can facilitate sharing of best practices among health jurisdictions.

Barriers and unmet need for supportive services for HIV patients in care in Los Angeles County, California.

Abstract HIV-infected patients frequently experience depression, drug use, and unstable housing but are often unable to access supportive services to manage these challenges. Data on barriers to needed supportive services are critical to improving patient access. Data from the Medical Monitoring Project (MMP), a national supplemental surveillance system for HIV-infected persons in care, was used to examine barriers to support service use and factors associated with need and unmet need for services. Interview data for 333 patients in care in 2007 and 2008 in Los Angeles County (LAC) showed that 71% (n=236) reported needing at least one supportive service and of these, 35% (n=83) reported at least one unmet need for services (46% Latino; 25% white; 83% male; 92% 30+; 77% gay/bisexual; 40% response rate). The main reasons that supportive services were not accessed included lack of information (47%; do not know where to go or who to call); an agency barrier (33%; system too confusing, wait list too long); or a financial/practical barrier (18%; too expensive, transportation problems). In a logistic regression that included all participants (n=333), African Americans (OR=3.1, 95% CI: 1.1-8.7) and those with incomes less than $10,000 were more likely to have service needs (odds ratio [OR]=3.5; 95% confidence interval [CI]: 1.3-9.3). Among those with at least one service need (n=236), those who were gay or bisexual were more likely to report at least one unmet service need (OR=2.8; 95% CI: 1.3-6.1). Disparities were found for need and unmet need for supportive services by race/ethnicity; income and sexual orientation. The reported reasons that services were not obtained suggest needed improvements in information dissemination on availability and location of HIV support services and more streamlined delivery of services.

Factors associated with late HIV testing for Latinos diagnosed with AIDS in Los Angeles.

Latinos are more likely to test late for HIV infection compared to other racial/ethnic groups in the United States. A population-based interview study was used to examine factors associated with late HIV testing for Latinos diagnosed with AIDS in Los Angeles County (LAC) to develop more effective HIV testing outreach strategies. Latinos testing for HIV within one year of an AIDS diagnosis were considered as late testers, while those diagnosed with AIDS more than one year after an HIV diagnosis were defined as non-late testers. After adjusting for age, education, country of birth, and injection drug use in a logistic regression analysis, completion of the interview in Spanish was the main factor associated with late testing (adjusted Odds Ratio (AOR) = 2.9, 95% Confidence Intervals (CIs): 1.4, 6.0). Latinos testing late for HIV were also more likely to test due to illness (p<0.0001) and less likely to test as part of a clinical screening (p<0.0001). Late testers were more likely to receive their first positive HIV test as a hospital inpatient (p<0.0001) and less likely to test positive at a community health center or public clinic (p=0.05). To accomplish widespread and timely HIV testing for Latinos in LAC, Spanish-language social marketing campaigns are needed and Spanish-speaking patients should be offered HIV testing in all clinical settings.

Cervical cancer survivorship in a population based sample.

OBJECTIVE: Though cervical cancer is preventable, this cancer nonetheless poses serious mortality and morbidity threats to American women and women globally. The purpose of this study is to utilize a multidimensional framework to assess Health-related Quality of Life (HRQOL) and its salient predictors among a population based sample of cervical cancer survivors. METHODS: A cross-sectional design was used with a population-based sample ascertained from the California Cancer Surveillance Program. Descriptive, bivariate and multivariate regression analyses were conducted. RESULTS: Participants were 560 cervical cancer survivors: English-speaking Latina- (n=88), Spanish-speaking Latina- (n=199) and European- (n=273) Americans. The greatest concerns were documented for family/social and emotional well-being, and body image and sexual health. In general, Latina-Americans reported poorer overall HRQOL, functional, emotional, and social/family wellbeing compared to European-Americans. Differences in HRQOL persisted by ethnic/language group after controlling for covariates. Radiation, comorbidity, role limitations, perceived health status, psychological wellbeing, body image, sexual impact, doctor-patient relationship, and social support were significant predictors of overall HRQOL. The regression model explained 58% of the variance in predicting HRQOL. CONCLUSION: These cervical cancer survivors reported poor to moderate HRQOL with persistent psychosocial challenges. Our findings indicate that lower SES, monolingual Latinas are at greatest risk for poor HRQOL outcomes. Clinicians should pay attention to their patients' socio-ecological context as a risk factor for poorer outcomes; and provide early referrals to resources that are low cost and culturally and linguistically appropriate.

Measuring quality of life among cervical cancer survivors: preliminary assessment of instrumentation validity in a cross-cultural study.

BACKGROUND: With growing interest in cross-cultural and multicultural cancer-related quality of life studies, the need to assess reliability and validity of quality of life measures for linguistically and culturally diverse cancer survivors is pressing. METHODS: Reliability and validity of the English and Spanish versions of the Functional Assessment of Cancer Therapy (FACT)-G subscales were tested with a sample of English-speaking European American (n = 273) and ethnic minority American (n = 194), and Spanish-speaking Latina (n = 199) cervical cancer survivors in the U.S. RESULTS: Reliability coefficients (Cronbach's alpha) were 0.76 or higher across ethnic/linguistic groups except for the emotional wellbeing subscale among Spanish-speaking Latinas (alpha = 0.64). Factor analyses demonstrated overall measurement equivalence across groups with some ethnic/linguistic variations: there were greater differences between linguistic groups than between ethnic groups. Additionally, the scale's factor structure was less satisfactory for Spanish-speaking Latinas. The subscales had good concurrent validity with appropriate subscales of the Short Form (SF)-12 and Rand/SF-36 General Health subscale (Pearson's r 0.53-0.66), suggesting each subscale was assessing its intended construct. CONCLUSION: The overall psychometric properties of the FACT-G were cross-culturally equivalent. However, more validation studies are needed for non-English speaking populations particularly with emotional wellbeing. In addition, disaggregated analyses on linguistic groups are recommended unless cross-cultural equivalence is established.

Examining predictive models of HRQOL in a population-based, multiethnic sample of women with breast carcinoma.

BACKGROUND: This study examined health related quality of life (HRQOL) and its predictors among African-, Asian-, Latina-, and European American breast cancer survivors (BCS) using a socio-ecologically and culturally contextual theoretical model of HRQOL. METHODS: We employed a case-control, cross sectional design with a population-based sample from the California Cancer Registry. Descriptive, bivariate, and multivariate regression analyses were conducted. RESULTS: The sample included 703 BCS: 135 (19%) African-, 206 (29%) Asian-, 183 (26%) Latina-, and 179 (26%) European Americans. Latinas reported the lowest HRQOL (p < 0.0001). The final regression model explained 70% of variance in HRQOL. Years since diagnosis, number of comorbidities, role limitation, emotional wellbeing, quality of doctor-patient relationship, social support, and life stress are significant HRQOL determinants. Exploratory regression analyses indicate ethnic differences in significant predictors for HRQOL. CONCLUSIONS: HRQOL among this multiethnic sample ranged from fair to good. Bivariate analysis suggests that ethnic differences in HRQOL exist. However, regression analyses demonstrated that socio-ecological factors in conjunction with medical characteristics are more salient to HRQOL outcomes, and that ethnic group membership may be a proxy for socio-ecological context. Furthermore, the influence of ethnicity, culture, and social-ecology are complex; research with large, population-based samples are necessary to disentangle the impact of contextual factors on HRQOL.

Survivorship: a qualitative investigation of Latinas diagnosed with cervical cancer.

Latinas experience high rates of cervical cancer (CCA) in the U.S. This health-related quality of life (HRQOL) qualitative study was conducted with key informant and focus groups (N = 26). The results indicate that overall Latinas experience persistent concerns: Physical challenges including pain, and bladder, bowel, and sexual health problems; medical care barriers (e.g., difficulties accessing quality care, poor patient-physician relationship); functional issues including employment difficulties; and personal concerns including family and relationship burdens. Spiritual, familial, and cultural factors promote coping and well-being but may delay care seeking. In summary, Latinas diagnosed with CCA face a burdensome survivorship experience. Increases in medical and psychosocial services are greatly needed for Latinas to improve cancer outcomes including HRQOL.

Breast cancer among Asian Americans: is acculturation related to health-related quality of life?

PURPOSE/OBJECTIVES: To examine the association of acculturation with health-related quality of life (HRQOL) among Asian American breast cancer survivors. DESIGN: Cross-sectional. SETTING: Analysis of an Asian American subsample of breast cancer survivors from a larger multiethnic study. SAMPLE: 206 Asian Americans, including Chinese, Filipinos, Koreans, and Japanese. Most were diagnosed with early-stage breast cancer (stage 0-II) and were an average of 54 years old. METHODS: Participants completed a mailed questionnaire or answered a telephone survey in English, Mandarin, or Korean. HRQOL was measured using the Functional Assessment of Cancer Therapy Breast Version 4. Acculturation was measured using an eight-item scale adapted from Marin's Short Acculturation Scale. MAIN RESEARCH VARIABLES: HRQOL, acculturation, health insurance, life stress, and social support. FINDINGS: Acculturation was significantly associated with HRQOL when demographic, medical, socioecologic, and healthcare access factors were controlled. However, the significant association between acculturation and HRQOL disappeared when Asian subgroup membership was considered. Subgroup differences in HRQOL remained after controlling for covariates, with Korean Americans reporting lower HRQOL than the other Asian American subgroups. CONCLUSIONS: The absence of a significant association between acculturation and HRQOL in the final model is likely a result of the strong association between acculturation and Asian American subgroup membership. The results suggest that the correlation between acculturation and HRQOL is not an effect of having health insurance, life stress, and social support. IMPLICATIONS FOR NURSING: Closer attention is needed regarding acculturation level; Asian American subgroup differences, including language capacity; and socioecologic characteristics in nursing practice and research.

Understanding the breast cancer experience of Latina women.

Qualitative interviews were used to investigate the impact of breast cancer among Latina survivors. The findings revealed that Latina survivors were optimistic about their health, utilized cultural and religious recovery practices; and seemed to accept their diagnosis, fears and suffering as part of their personal journey. The survivors' narrative identified spirituality as central to their recovery and coping. Extended family and friends were the primary sources of support. Common issues were the impact of cancer on medical care problems, work concerns, the meaning of cancer, family well-being, emotional well-being, body image, and sexual health. Latina survivors, particularly those who are poor and speak limited English, often have inadequate insurance, receive unsatisfactory medical care, and experience poor physician-patient communication and relationship. These problems are directly related to health-care system factors as well as socio-ecological and language issues. In addition, many Latina survivors have inadequate resources and inaccurate beliefs that may affect their health care (e.g., delay, lack of follow-up), and overall quality of life. Results will inform a quantitative study with a larger sample of Latina breast cancer survivors.

The impact of cervical cancer and dysplasia: a qualitative, multiethnic study.

STUDY PURPOSE: Cervical cancer (CCA) remains a health challenge nationally and globally. In the US, more than 12,000 women are diagnosed each year with invasive cervical cancer and more than 220,000 are living with a history of this diagnosis (ACS, 2003). This qualitative study aims to examine health related quality of life (HRQOL) from a culturally consistent framework. METHODS: Key-informant interviews (N = 23) and focus group interviews (N = 51) were conducted with a multiethnic sample of cervical cancer survivors (CCS) recruited from hospitals and clinics. ANALYSES AND RESULTS: Content and theme analyses were conducted. Findings indicate that cultural and family factors often promote coping and well-being, but may foster delay in care seeking and self-deprecation, particularly among Latina and Asian CCS. Faith in God was relied on for comfort, strength and healing by many survivors, especially the African Americans and Latinas. Overall, our participants reported moderate HRQOL. However, persistent concerns included treatment side-effects; difficulties accessing quality care; inadequate health insurance, barriers to good physician-patient relationship such as language and doctors' time constraints; insufficient knowledge about CCA due to limited information from medical staff; lack of control over treatments; social support, family well-being, functional and work issues; and sexuality and relationship concerns. Socioeconomic status, ethnicity, cultural beliefs and practices, age and family support dictated the level of cancer-related burden. CONCLUSION: Invasive CCA is primarily a cancer of women who are economically disenfranchised. Women with a CCA diagnosis are disproportionately challenged by lack of resources including quality, affordable health care and psychosocial services. CCS experience persistent medical, psychological, social, and relational concerns. Information concerning CCS is needed, particularly in Spanish, Vietnamese and Korean. There is an urgent need for further research to understand the risk factors, and the social and cultural mediators of cancer-related HRQOL for CCS.

Breast cancer survivorship in a multiethnic sample: challenges in recruitment and measurement.

BACKGROUND: The inclusion of ethnic minorities in cancer-related studies continues to be an important concern for researchers. In this article, the authors present 1) a brief discussion of recruitment and measurement challenges in conducting multiethnic survivorship research, and 2) recruitment outcomes and sample characteristics for a health-related quality-of-life study with a multiethnic sample of breast cancer survivors (BCS). METHODS: A case-control, cross-sectional design with mixed sampling methods was used. The Contextual Model for Recruitment and Enrollment of Diverse Samples was used to guide the protocol. BCS were recruited from the California Cancer Surveillance Program, from hospital registries, and from community agencies. Participation rates, demographic factors, and medical factors were compared. The reliability of standard measures by ethnicity was assessed. RESULTS: Seven hundred three women participated, including 135 African-American women (19%), 206 Asian-American women (29%), 183 Latino-American women (26%), and 179 European-American women (26%). Participation was influenced by ethnicity, age, and site of recruitment. Overall, African Americans were least likely to participate, and European Americans most likely to participate. African Americans and Asian Americans were more likely to refuse, European Americans and Latino Americans were more likely to agree to participate, and European Americans and Asian Americans were most likely to complete the survey after consenting. Measures possessed moderate to excellent reliability (0.64-0.91). CONCLUSIONS: Despite important recruitment and measurement challenges, this study obtained acceptable participation rates and good internal consistency of the measures. The results demonstrate the utility of a culturally responsive approach to health disparities research.

Understanding the breast cancer experience of women: a qualitative study of African American, Asian American, Latina and Caucasian cancer survivors.

Breast cancer is the most common form of cancer in American women across most ethnic groups. Although the psychosocial impact of breast cancer is being studied, there is little information on women from diverse ethnic and socioeconomic backgrounds. We conducted a qualitative study with breast cancer survivors (BCS) of various ethnicities. A total of 102 BCS participated in focus group interviews (24 African Americans, 34 Asians, 26 Latinas and 18 Caucasians); 20 health professionals participated in key informant interviews. Important ethnic differences in type of treatment were noted, Asians and Latinas were more likely to receive mastectomies and African American BCS were least likely to receive adjuvant therapies, including radiation and chemotherapy. These BCS enjoyed a fairly good overall health-related quality of life (HRQOL) with some persistent concerns. The prevailing concerns among all women included overall health, moderate physical concerns, cancer recurrence or metastases, psychosocial concerns related to worry about children and burdening the family, and body image and sexual health concerns. Additional challenges included: lack of knowledge about breast cancer; medical care issues such as insurance, cost and amount of time spent with physician; cultural sensitivity of providers, language barriers, cultural factors related to beliefs about illness, gender role and family obligations (e.g. self-sacrifice). These BCS, particularly the women of color, voiced that their spiritual beliefs and practices are central to their coping. This study accomplishes two goals; it adds to the sparse literature concerning the psychosocial sequelae of breast cancer among women of color, and it increases our knowledge of specific cultural influences (e.g. dietary practices, coping) and socio-ecological factors on HRQOL. More importantly, the study addressed areas that have not been studied before, specifically, an in-depth study on BCS QOL comparing multiple ethnic groups in the US. The results of this investigation will provide preliminary information to survivors and health-care providers about the impact of culture and socio-ecological contexts on survivorship. Among women of all major ethnic groups, breast cancer is the most common form of cancer and the second leading cause of cancer death (American Cancer Society (ACS), 2002). In 2002, over 203,000 women in the United States will be diagnosed with breast cancer (ACS, 2002). Ethnic disparities exist for cancer stage, diagnosis, survival, morbidity and mortality. In general, ethnic minority women are diagnosed with more advanced disease and experience greater morbidity and mortality (Haynes & Smedley, 1999; Miller et al., 1996; Ries et al., 2000; Shinagawa, 2000). In general, increases in survival rates have prompted greater interest in the quality of life (QOL) of breast cancer survivors (BCS) over the past two decades. Additionally, the QOL of cancer survivors from diverse ethnic, cultural and socioeconomic backgrounds is an emerging priority area for studies on survivorship research and clinical care (Haynes and Smedley, 1999; National Cancer Institute (NCI), 2002; President's Cancer Panel, 2000).

Understanding the breast cancer experience of Asian American women.

Breast cancer is the most common form of cancer in women and affects women across all ethnic groups. Although the psychosocial impact of breast cancer is being studied, there is little information on ethnic minorities. To better understand the breast cancer experience of Asian American women, we conducted key informant and focus group interviews. Six professionals participated in the key informant interviews. A total of 34 Asian American breast cancer survivors participated in focus group interviews, including Korean (n=10), Chinese (n=11), and a mixed Asian group (n=13). The common themes identified in this series of qualitative studies included: lack of knowledge about breast cancer; medical care issues such as cost and amount of time spent with physician; cultural factors related to beliefs about illness, gender role and family obligations (e.g. self-sacrifice) and language barriers; the importance of spirituality; and psychosocial concerns related to worry about children, burdening the family, body image and sexual health concerns. A primary source of support and coping for Asian American women with breast cancer was their spiritual beliefs. The results from this qualitative study have been used to prepare a survey instrument to examine these issues in a larger sample of Asian American women.