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Objectives: The COVID-19 pandemic demonstrated how vaccination decisions are influenced by misinformation, disinformation, and social pressures, leading to varied and inequitable uptake rates. In this study, we examined how COVID-19 vaccine messages received via social networks were associated with vaccine uptake in rural Alabama., Methods: From November 2021 through March 2022, we collected 700 responses to a telephone survey administered in 4 rural Alabama counties. We asked respondents to indicate whether certain social relationships (eg, family, businesses) tried to influence them to (1) obtain or (2) avoid a COVID-19 vaccine. We used χ 2 tests, Kruskal-Wallis tests, Mantel-Haenszel χ 2 tests, and Fisher exact tests to examine the associations between vaccination status and survey responses., Results: Respondents in majority-African American counties were significantly more likely than those in majority-White counties to have received ≥1 dose of COVID-19 vaccine (89.8% vs 72.3%; P  < .001). Respondents who received ≥1 dose had a significantly higher mean age than those who had not (58.0 vs 39.0 years; P  < .001). Respondents who were encouraged to get vaccinated by religious leaders were more likely to have received ≥1 dose ( P  = .001), and those who were encouraged to avoid vaccination by family ( P  = .007), friends ( P  = .02), coworkers ( P  = .003), and health care providers ( P  < .001) were less likely to have received ≥1 dose. Respondents with more interpersonal relationships that encouraged them to avoid vaccination were more likely to be unvaccinated ( P  < .001)., Conclusions: Interpersonal relationships and demographic characteristics appeared to be important in COVID-19 vaccine decision-making in rural Alabama. Further research needs to identify how to facilitate vaccine-positive interpersonal relationships, such as peer mentoring and trusted messenger interventions., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

People living with HIV are disproportionately affected by depression, anxiety, and substance use which impede engagement with HIV treatment services and can increase risks of HIV-related morbidity and mortality. Capturing timely, accurate patient data at point of care is recommended to inform clinical decision-making and retain patients on the HIV care continuum. Currently, there is limited use of validated screening tools for substance use and mental health at the point of care in HIV clinics, even though people with HIV (PWH) have a high prevalence of these comorbidities. Even fewer clinics screen in a manner that encourages disclosure of stigmatized substance use, depression, and anxiety. Electronic patient-reported outcomes (ePROs) are an evidence-based modality to overcome such limitations by eliciting responses directly from patients via tablet, smartphone, or computer. To date, there is limited consensus on how to implement ePROs into non-academic settings and enhance uptake. Our team sought to address this gap by examining the implementation of ePROs, previously implemented in an academic clinic, to enhance screening and treatment of mental health (MH) and substance use at five Ryan White HIV/AIDS Program-funded clinics in Alabama. The ePROs were delivered through a multi-component intervention titled HIV + Service delivery and Telemedicine through Effective Patient Reported Outcomes (+STEP), which also provides targeted training to frontline clinicians, and resources for MH and substance use treatment for PWH without access to care. The objective of this study is to provide an implementation blueprint that can be tested and utilized in other HIV clinics to integrate ePROs and increase evidence-based screening for depression, anxiety, and substance use among PWH, as well as outline lessons learned from implementation to date. The findings from this study provide practical steps and advice based on our experience in implementing electronic patient-reported outcomes in HIV clinics in the US Deep South., Competing Interests: EE reports honorarium from Gilead for participating in the HIV Re-engagement working group and from PRIME, DKBMed, and IAS-USA for developing HIV continuing education content. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Gagnon et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Black cisgender women (CGW) are disproportionately impacted by the human immunodeficiency virus (HIV) epidemic in the United States. Black women account for 57% of the total new diagnoses among CGW. In addition, Black CGW women are 9 times more likely to be diagnosed with HIV than their White counterparts., Methods: We conducted surveys (September 2019-March 2020) and collected information on sociodemographics, HIV/preexposure prophylaxis (PrEP) knowledge, HIV/PrEP stigma, sexual practices, and other factors identified as PrEP barriers among Black CGW (n = 795). This cross-sectional study used logistic regression models to assess intrapersonal, interpersonal, and structural factors among individuals willing to use PrEP versus individuals unwilling or unsure to use PrEP., Results: Our study population had a mean age of 37 years, predominantly lived in urban areas (65%), had stable housing (96.7%), and had private insurance/Medicare (78.2%). Overall, 29.6% reported willingness to use PrEP, 35.6% reported unwillingness to use PrEP, and 34.8% were unsure of PrEP use. The multivariable analysis showed that, compared with individuals reporting unwillingness/unsure to PrEP use, those reporting willingness to PrEP use were younger (adjusted odds ratio [AOR; 95% confidence interval {CI}], 0.97 [0.96-0.99]), had lower odds of intimate partner violence (AOR [95% CI], 0.87 [0.78-0.98), and had higher odds of organizational religiosity (AOR [95% CI], 1.10 [1.01-1.20]), HIV knowledge (AOR [95% CI], 1.08 [1.03-1.13]), and perceived need for PrEP (AOR [95% CI], 6.38 [3.36-12.11])., Conclusions: Preexposure prophylaxis willingness among Black CGW was impacted by individual-level, interpersonal, and structural factors. Improving PrEP willingness and uptake among Black CGW will require multilevel interventions., Competing Interests: Conflict of Interest and Sources of Funding: L.E. serves as an investigator on a Merck pharmaceuticals research grant. The remaining authors have no conflict of interest to disclose., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: The syndemic of mental health (MH) and substance use disorders (SUDs) is common among persons living with HIV and jeopardizes HIV treatment adherence, engagement in care, and viral load suppression. Electronic patient-reported outcomes (ePROs), completed through tablet or computer, and telemedicine are evidence- and technology-based interventions that have been used to successfully increase screening and treatment, respectively, a model that holds promise for persons living with HIV. To date, there is limited guidance on implementing ePROs and telemedicine into HIV clinical practice even though it is well known that these evidence-based tools improve diagnosis and access to care., Objective: To address this, we aim to conduct a multicomponent intervention for persons living with HIV, including the delivery of HIV services and telemedicine through effective ePROs (+STEP), to increase screening and treatment of MH and SUD in Ryan White HIV/AIDS Program (RWHAP)-funded clinics in Alabama., Methods: Through this intervention, we will conduct a readiness, acceptability, and accessibility assessment and implement +STEP to improve the diagnosis and treatment of MH and SUD at RWHAP clinics in Alabama. To describe implementation strategies that address barriers to the uptake of +STEP in RWHAP clinics, we will conduct qualitative interviews in years 1 (early implementation), 2 (scale up), and 4 (maintenance) with patients and key staff to evaluate barriers, facilitators, and implementation strategies. Our Results will enable us to modify strategies to enhance +STEP penetration over time and inform the implementation blueprint, which we will develop for both RWHAP clinics in Alabama and future sites. We will assess the impact of implementing +STEP on diagnoses, referrals, and health care use related to MH, SUD, and HIV by comparing clinical outcomes from patients receiving these interventions (ePROs and telemedicine) with historical controls., Results: The first study site began implementation in April 2022. A total of 2 additional sites have initiated ePROs. Final results are expected in 2026. The results of this study will provide a foundation for future research expanding access to ePROs for improved diagnosis linked to telemedicine access to accelerate patients along the continuum of care from MH and SUD diagnosis to treatment., Conclusions: Achieving the end of the HIV epidemic in the United States necessitates programs that accelerate movement across the MH and SUD care continuum from diagnosis to treatment for persons living with HIV. Scaling these services represents a path toward improved treatment outcomes with both individual health and population-level prevention benefits of sustained HIV viral suppression in the era of undetectable=untransmittable (U=U). This study will address this evidence gap through the evaluation of the implementation of +STEP to establish the necessary systems and processes to screen, identify, and better treat substance use and MH for people living with HIV., International Registered Report Identifier (irrid): DERR1-10.2196/40470., (©Kelly W Gagnon, Stefan Baral, Dustin Long, Alfredo L Guzman, Bernadette Johnson, Greer Burkholder, James Willig, Michael Mugavero, Margaret Baldwin, Susanne Fogger, Thomas Creger, Karen Cropsey, Ellen Eaton. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 15.08.2023.)

The emergence of the COVID-19 pandemic necessitated rapid expansion of telehealth as part of healthcare delivery. This study compared HIV-related no-shows by visit type (in-person; video; telephone) during the COVID-19 pandemic (April 2020-September 2021) from the Data for Care Alabama project. Using all primary care provider visits, each visit's outcome was categorized as no-show or arrived. A logistic regression model using generalized estimating equations accounting for repeat measures in individuals and within sites calculated odds ratios (OR) and their accompanying 95% confidence interval (CI) for no-shows by visit modality. The multivariable models adjusted for sociodemographic factors. In-person versus telephone visits [OR (95% CI) 1.64 (1.48-1.82)] and in-person versus video visits [OR (95% CI) 1.53 (1.25-1.85)] had higher odds of being a no-show. In-person versus telephone and video no-shows were significantly higher. This may suggest success of telehealth visits as a method for HIV care delivery even beyond COVID-19., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Understanding the impact of caregiving responsibilities on women in medicine is crucial for ensuring a healthy and intact workforce, as caregiving responsibilities have the potential to affect the careers of women in health care along the entire pipeline, from students and trainees to physicians, physician-scientists, and biomedical researchers., (©Katherine A Meese, Laurence M Boitet, Katherine L Sweeney, Lauren Nassetta, Michael Mugavero, Bertha Hidalgo, Rebecca Reamey, David A Rogers. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 14.06.2023.)

We compared retention in care outcomes between a pre-COVID-19 (Apr19-Mar20) and an early-COVID-19 (Apr20-Mar21) period to determine whether the pandemic had a significant impact on these outcomes and assessed the role of patient sociodemographics in both periods in individuals enrolled in the Data for Care Alabama project (n = 6461). Using scheduled HIV primary care provider visits, we calculated a kept-visit measure and a missed-visit measure and compared them among the pre-COVID-19 and early-COVID-19 periods. We used logistic regression models to calculated odds ratios (OR) and accompanying 95% confidence intervals (CI). Overall, individuals had lowers odds of high visit constancy [OR (95% CI): 0.85 (0.79, 0.92)] and higher odds of no-shows [OR (95% CI): 1.27 (1.19, 1.35)] during the early-COVID-19 period. Compared to white patients, Black patients were more likely to miss an appointment and transgender people versus cisgender women had lower visit constancy in the early-COVID-19 period., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Engaging people living with HIV who report substance use (PLWH-SU) in care is essential to HIV medical management and prevention of new HIV infections. Factors associated with poor engagement in HIV care include a combination of syndemic psychosocial factors, mental and physical comorbidities, and structural barriers to healthcare utilization. Patient navigation (PN) is designed to reduce barriers to care, but its effectiveness among PLWH-SU remains unclear. We analyzed data from NIDA Clinical Trials Network's CTN-0049, a three-arm randomized controlled trial testing the effect of a 6-month PN with and without contingency management (CM), on engagement in HIV care and viral suppression among PLWH-SU ( n = 801). Latent profile analysis was used to identify subgroups of individuals' experiences to 23 barriers to care. The effects of PN on engagement in care and viral suppression were compared across latent profiles. Three latent profiles of barriers to care were identified. The results revealed that PN interventions are likely to be most effective for PLWH-SU with fewer, less severe healthcare barriers. Special attention should be given to individuals with a history of abuse, intimate partner violence, and discrimination, as they may be less likely to benefit from PN alone and require additional interventions.

Introduction: Ending the HIV Epidemic initiatives provide a unique opportunity to use implementation scientific methods to guide implementation of evidence-based practices and evaluate their effectiveness in real-word settings to improve HIV inequities. This report demonstrates our use of Implementation Mapping (IM) to engage participating county health departments, AIDS services organizations, and community-based organizations in the development of a data dashboard to track the PrEP care continuum for the state of Alabama, an Ending the HIV Epidemic hotspot., Methods: Our project is guided by an overarching Implementation Research Logic Model and by the tenets of IM, a 5-step approach to support researchers and community partners in the systematic selection, development, and/or tailoring of implementation strategies to increase program adoption, implementation, and sustainability., Results: Step 1, the needs assessment, established baseline data elements for a PrEP care continuum for participating community-based organizations, AIDS services organizations, and the state health department as well as investigated their desire for data visualization and willingness to share data to inform initiatives to improve PrEP access. Step 2 identified adaptability, relative advantage, and complexity as determinants of intervention adoption. Based on findings from steps 1 and 2, the investigators and community partners determined to move forward with development of a data dashboard. Step 3 identified the following implementation strategies to support a dashboard, including development of educational materials, synchronous and asynchronous training, technical assistance, and improved record systems., Discussion: Using IM supports community-engaged researchers in designing strategies to end the epidemic that are context-specific and more impactful in real-word settings., Competing Interests: L.E. is currently receiving a grant (MK8591-022) from Merck, has consulted for Black AIDS Institute, and is a speaker for MedIQ who provide CME. The remaining authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Pre-exposure prophylaxis for HIV (PrEP) is an effective yet underutilized biomedical tool for adolescents and young adults' (AYA) HIV prevention due to barriers such as PrEP adherence. We assessed HIV prevention knowledge, attitudes and beliefs from adults who self-identified as a primary support person to an AYA., Methods: We surveyed AYA primary support persons at an academic hospital. Univariate and multivariate regression analyses were completed to identify factors associated with the belief AYAs engaging in HIV-associated behaviors should use PrEP and willingness to support AYAs on PrEP., Results: 200 primary support persons completed the survey. Participants were predominately female (77%) and black (56%). Nearly all primary support persons believed AYAs engaging in HIV-associated behaviors should take PrEP (94%) and 98% would support an AYA taking PrEP via transportation to appointments, assistance with refilling prescriptions, medication reminders, or encouragement., Conclusions: Primary support persons are willing to support AYAs using PrEP., Competing Interests: The authors have declared that no competing interests exist.

Background: With potent antiretroviral therapy and simplified regimens, people living with HIV (PWH) are achieving near-normal lifespans but not necessarily a normal health span or healthy aging. PWH have a higher than expected risk of developing a number of non-AIDS comorbidities, coinfections, and complications (CCC), often against a background of stigma, poverty, and isolation., Setting: To gain a better understanding of research needs for HIV-associated CCC, the NIH convened a 2-day workshop (HIV-associated CCC, or HIV ACTION)., Methods: A cross-institute NIH planning committee identified 6 key research areas: epidemiology and population research, pathogenesis and basic science research, clinical research, implementation science research, syndemics research and international research in low and middle income countries. Investigators were selected to lead working groups (WGs) to assess the state-of-the-art and identify 3-5 priority areas in each field before the workshop. A 2-day program at the NIH was developed which included presentations by invited experts and WG members., Results: Over 400 participants attended the workshop. After general and individual WG discussions, the most pressing gaps, questions, or proposed action items were identified. Priority lists of pressing research issues were presented by cochairs of each WG. A detailed report is posted at the NHLBI website. This article reports the streamlined priority list and a summary of WG discussions to inform investigators of current priorities in the field., Conclusion: Collaborative efforts of many disciplines are needed to improve the health and wellbeing of PWH. Several common themes emerged across WG representing potential priorities for investigators and recommendations for the NIH.

Despite the issuance of evidence-based and evidence-informed guidelines to improve engagement in HIV care and adherence-related outcomes, few studies have assessed contemporary adherence or engagement support practices of HIV care providers in US clinics. As a result, the standard of HIV care in the US and globally remains poorly understood. This programmatic assessment approach aimed to identify the strengths and gaps in the current standard of HIV care from the perspective of HIV care providers. A self-administered Standard of Care measure was developed and delivered through Qualtrics to HIV care providers at four different HIV care sites as a part of a multisite intervention study to improve engagement in HIV care and ART adherence. Providers were asked to provide demographic and clinic specific information, identify practices/strategies applied during typical initial visits with HIV-positive patients and visits prior to and at ART initiation, as well as their perceptions of patient behaviors and adequacy of HIV care services at their clinics. Of the 75 surveys which were completed, the majority of respondents were physicians, and on average, providers have worked in HIV care for 13.5 years. Across the sites, 91% of the providers' patient panels consist of HIV-positive patients, the majority of whom are virally suppressed and 1/5 are considered "out of care." Few resources were routinely available to providers by other staff related to monitoring patient adherence and engagement in care. During typical initial visits with HIV positive patients, the majority of providers report discussing topics focused on behavioral/life contexts such as sexual partnerships, sexual orientation, disclosure, and other sources of social support. Nearly all providers emphasize the importance of adherence to treatment recommendations and nearly 90% discuss outcomes of good adherence and managing common side effects during ART start visits. Overall, providers do not report often implementing practices to improve retention in care. Survey results point to opportunities to enhance engagement in HIV care and improve ART adherence through systematic data monitoring and increased collaboration across providers and other clinic staff, specifically when identifying patients defined as "in need" or "out of care." Trial Registration: Clinicaltrials.gov NCT01900236.

Purpose: To assess sampling bias in national viral suppression (VS) estimates derived from the Medical Monitoring Project (MMP) resulting from use of an abbreviated (four-month) annual sampling period. We aimed to improve VS estimates using cohort data from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) and a novel cohort-adjustment method., Methods: Using full calendar years of NA-ACCORD data, we assessed timing of HIV care attendance (inside vs. exclusively outside MMP's four-month sampling period), VS status at last test (<200 vs. ≥200 copies/mL), and associated demographics. These external estimates were used to standardize MMP to NA-ACCORD data with multivariable regression models of care attendance and VS, yielding adjusted 2009-2013 VS estimates with 95% confidence intervals., Results: Weighted percentages of VS among persons in HIV care were 67% in 2009 and 77% in 2013. These estimates are slightly lower than previously published MMP estimates (72% and 80% in 2009 and 2013, respectively). The number of persons receiving HIV care was previously underestimated by 20%, because patients receiving care exclusively outside the MMP sampling period did not contribute toward the weighted population estimate., Conclusions: Careful examination of national surveillance estimates using data triangulation and novel methodologies can improve the robustness of VS estimates., (Published by Elsevier Inc.)

Background: The effect of depressive symptoms on progression through the human immunodeficiency virus (HIV) treatment cascade is poorly characterized., Methods: We included participants from the Centers for AIDS Research Network of Integrated Clinic Systems cohort who were antiretroviral therapy (ART) naive, had at least 1 viral load and HIV appointment measure after ART initiation, and a depressive symptom measure within 6 months of ART initiation. Recent depressive symptoms were measured using the Patient Health Questionnaire-9 (PHQ-9) and categorized using a validated cut point (PHQ-9 ≥10). We followed participants from ART initiation through the first of the following events: loss to follow-up (>12 months with no HIV appointment), death, administrative censoring (2011-2014), or 5 years of follow-up. We used log binomial models with generalized estimating equations to estimate associations between recent depressive symptoms and having a detectable viral load (≥75 copies/mL) or missing an HIV visit over time., Results: We included 1057 HIV-infected adults who contributed 2424 person-years. At ART initiation, 30% of participants reported depressive symptoms. In multivariable analysis, recent depressive symptoms increased the risk of having a detectable viral load (risk ratio [RR], 1.28; 95% confidence interval [CI], 1.07, 1.53) over time. The association between depressive symptoms and missing an HIV visit (RR, 1.20; 95% CI, 1.05, 1.36) moved to the null after adjustment for preexisting mental health conditions (RR, 1.00; 95% CI, 0.85, 1.18)., Conclusions: Recent depressive symptoms are a risk factor for unsuppressed viral load, while preexisting mental health conditions may influence HIV appointment adherence.

Depressive symptoms vary in severity and chronicity. We used group-based trajectory models to describe trajectories of depressive symptoms (measured using the Patient Health Questionnaire-9) and predictors of trajectory group membership among 1493 HIV-infected men (84%) and 292 HIV-infected women (16%). At baseline, 29% of women and 26% of men had depressive symptoms. Over a median of 30 months of follow-up, we identified four depressive symptom trajectories for women (labeled "low" [experienced by 56% of women], "mild/moderate" [24%], "improving" [14%], and "severe" [6%]) and five for men ("low" [61%], "mild/moderate" [14%], "rebounding" [5%], "improving" [13%], and "severe" [7%]). Baseline antidepressant prescription, panic symptoms, and prior mental health diagnoses were associated with more severe or dynamic depressive symptom trajectories. Nearly a quarter of participants experienced some depressive symptoms, highlighting the need for improved depression management. Addressing more severe or dynamic depressive symptom trajectories may require interventions that additionally address mental health comorbidities.

The objective of this review is to consider how existing human immunodeficiency virus (HIV) infrastructure may be leveraged to inform and improve hepatitis C virus (HCV) treatment efforts in the HIV-HCV coinfected population. Current gaps in HCV care relevant to the care continuum are reviewed. Successes in HIV treatment are then applied to the HCV treatment model for coinfected patients. Finally, the authors give examples of HCV treatment strategies for coinfected patients in both domestic and international settings., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Achieving and sustaining high levels of adherence to medication regimens is essential to improving health outcomes, but continues to be a challenge for a sizable proportion of patients. Decades of research suggests that medication adherence is determined by a complex constellation of factors. Social-behavioral science research has focused on creating frameworks that identify which contextual, personal, social, or drug-related factors appear to most influence adherence. Comprehensive models of adherence propose specific structural relationships between these factors that can be used to plan for, implement, and monitor programs that seek to optimize adherence. The use of social-behavioral models offers multiple advantages in both practice and research environments; however, the breadth and depth of these models can deter many from engaging in this important exercise. To promote the use of social-behavioral frameworks and models of adherence, we provide a brief overview of the advantages in using a social-behavioral lens in adherence work, a sampling of models used in HIV medication adherence research that have high generalizability to other conditions, and practical guidance for grounding adherence promotion strategies in evidence informed by social-behavioral science research.

Objectives: Institutions participating in the Medicare Bundled Payments for Care Improvement (BPCI) initiative invest significantly in efforts to reduce readmissions and costs for patients who are included in the program. Eligibility for the BPCI initiative is determined by diagnosis-related group (DRG) classification. The implications of this methodology for chronic diseases are not known. We hypothesized that patients included in a BPCI initiative for chronic obstructive pulmonary disease (COPD) would have less severe illness and decreased hospital utilization compared with those excluded from the bundled payment initiative., Study Design: Retrospective observational study., Methods: We sought to determine the clinical characteristics and outcomes of Medicare patients admitted to the University of Alabama at Birmingham Hospital with acute exacerbations of COPD between 2012 and 2014 who were included and excluded in a BPCI initiative. Patients were included in the analysis if they were discharged with a COPD DRG or with a non-COPD DRG but with an International Classification of Diseases, Ninth Revision code for COPD exacerbation., Results: Six hundred and ninety-eight unique patients were discharged for an acute exacerbation of COPD; 239 (34.2%) were not classified into a COPD DRG and thus were excluded from the BPCI initiative. These patients were more likely to have intensive care unit (ICU) admissions (63.2% vs 4.4%, respectively; P <.001) and require noninvasive (46.9% vs 6.5%; P <.001) and invasive mechanical ventilation (41.4% vs 0.7%; P <.001) during their hospitalization than those in the initiative. They also had a longer ICU length of stay (5.2 vs 1.8 days; P = .011), longer hospital length of stay (10.3 days vs 3.9 days; P <.001), higher in-hospital mortality (14.6% vs 0.7%; P <.001), and greater hospitalization costs (median = $13,677 [interquartile range = $7489-$23,054] vs $4281 [$2718-$6537]; P <.001)., Conclusions: The use of DRGs to identify patients with COPD for inclusion in the BPCI initiative led to the exclusion of more than one-third of patients with acute exacerbations who had more severe illness and worse outcomes and who may benefit most from the additional interventions provided by the initiative., Competing Interests: Author Disclosures: The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Background: Although the increasing number of recommended immunizations is essential for patients infected with human immunodeficiency virus (HIV), the potentially uncompensated costs of expanded immunizations will present significant challenges for clinics and health systems serving HIV-infected patients., Methods: We estimated costs of providing Gardasil, Prevnar, and Zostavax to eligible patients at a US Ryan White Part C academically affiliated HIV clinic in 2013. Clinic expenditures were calculated using vaccine price and administrative fees. Revenue was calculated using insurance reimbursement data for vaccination and administration. Three scenarios were used: 100% uptake of vaccines, adjusted uptake based on published rates, and adjusted reimbursement according to pre-Affordable Care Act (ACA) insurance status., Results: 2887 patients (27% Medicare, 13% Alabama Medicaid, 26% Commercial, 34% Uninsured), received care with wide variation in immunization reimbursement ($0 to $210) by insurance and vaccine. The net yield (revenue minus expenditure) was calculated for each vaccine. Prevnar was most costly: annual net yield of -$60 691. Provision of all 3 vaccines would lead to a net yield of -$97 122. Adjusting for reduced uptake led to annual clinic losses of $44 119. Using pre-ACA reimbursement for immunization of the uninsured led to reduced clinic losses (-$62 326), attributable to reimbursement via Ryan White funds., Conclusions: A cost analysis of 3 vaccines shows great variation in insurance coverage, with potential losses of almost $100 000 for one HIV clinic if eligible patients received vaccinations in one calendar year. Adequate, cost neutral reimbursement should be instituted if medical providers and health systems are to achieve Advisory Committee on Immunization Practices immunization recommendations for both HIV positive and negative adults., (© The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Background: Retaining HIV patients in medical care promotes access to antiretroviral therapy, viral load suppression, and reduced HIV transmission to partners. We estimate the programmatic costs of a US multisite randomized controlled trial of an intervention to retain HIV patients in care., Methods: Six academically affiliated HIV clinics randomized patients to intervention (enhanced personal contact with patients across time coupled with basic HIV education) and control [standard of care (SOC)] arms. Retention in care was defined as 4-month visit constancy, that is, at least 1 primary care visit in each 4-month interval over a 12-month period. We used microcosting methods to collect unit costs and measure the quantity of resources used to implement the intervention in each clinic. All fixed and variable labor and nonlabor costs of the intervention were included., Results: Visit constancy was achieved by 45.7% (280/613) of patients in the SOC arm and by 55.8% (343/615) of patients in the intervention arm, representing an increase of 63 patients (relative improvement 22.1%; 95% confidence interval: 9% to 36%; P < 0.01). The total annual cost of the intervention at the 6 clinics was $241,565, the average cost per patient was $393, and the estimated cost per additional patient retained in care beyond SOC was $3834., Conclusions: Our analyses showed that a retention in care intervention consisting of enhanced personal contact coupled with basic HIV education may be delivered at fairly low cost. These results provide useful information for guiding decisions about planning or scaling-up retention in care interventions for HIV-infected patients.

HIV infection and initiation of antiretroviral therapy (ART) have been consistently associated with decreased bone mineral density (BMD), with growing evidence linking HIV to an increased risk of fracture. This is especially concerning with the expanding number of older persons living with HIV. Interestingly, recent data suggest that HIV-infected children and youth fail to achieve peak BMD, possibly increasing their lifetime risk of fracture. Elucidating the causes of the bone changes in HIV-positive persons is challenging because of the multifactorial nature of bone disease in HIV, including contribution of the virus, immunosuppression, ART toxicity, and traditional osteoporosis risk factors, such as age, lower weight, tobacco, and alcohol use. Thus, practitioners must recognize the risk of low BMD and fractures and appropriately screen patients for osteoporosis if risk factors exist. If fractures do occur or elevated fracture risk is detected through screening, treatment with bisphosphonate medications appears safe and effective in the HIV+population.

Effective human immunodeficiency virus (HIV) care in the modern antiretroviral therapy (ART) era requires early entry into and retention in care. Early initiation and adherence to ART therapy improves outcomes. Many evidence-based tools and behavioral interventions are available to optimize adherence to care and ART and can be implemented in clinical settings. Monitoring care engagement and ART adherence creates the opportunity to intervene and prevent virologic failure or loss to follow up. Special HIV-infected populations, such as pregnant and mentally ill patients, require enhanced surveillance and care., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Despite widespread use in HIV and hepatitis B virus (HBV) infection, the effectiveness of tenofovir (TDF) has not been studied extensively outside of small cohorts of coinfected patients with HBV-HIV. We examined the effect of prior lamivudine (3TC) treatment and other factors on HBV DNA suppression with TDF in a multisite clinical cohort of coinfected patients., Methods: We studied all patients enrolled in the Centers for AIDS Research Network of Integrated Clinical Systems cohort from 1996 to 2011 who had chronic HBV and HIV infection, initiated a TDF-based regimen continued for ≥ 3 months and had on-treatment HBV DNA measurements. We used Kaplan-Meier curves and Cox-proportional hazards to estimate time to suppression (HBV DNA level <200 IU/mL or <1000 copies/mL) by selected covariates., Results: Among 397 coinfected patients on TDF, 91% were also on emtricitabine or 3TC concurrently, 92% of those tested were hepatitis B e antigen positive, 196 (49%) had prior 3TC exposure; 192 (48%) achieved HBV DNA suppression over a median of 28 months (interquartile range: 13-71). Median time to HBV DNA suppression was 17 months for those who were 3TC-naive and 50 months for those who were 3TC exposed. After controlling for other factors, prior 3TC exposure, baseline HBV DNA level >10,000 IU/mL, and lower nadir CD4 count were independently associated with decreased likelihood of HBV DNA suppression on TDF., Conclusions: These results emphasize the role of prior 3TC exposure and immune response on delayed HBV suppression on TDF.

Background: Low back pain is a common cause of chronic pain in human immunodeficiency virus (HIV)-infected patients. The American College of Physicians and American Pain Society guidelines for diagnostic imaging in low back pain are difficult to apply to patients with chronic illnesses like HIV who may have risk factors for cancer or compression fractures, but whether imaging all such patients for low back pain improves outcomes is unknown., Objective: Our objective was to describe patients referred to a chronic pain-focused HIV/palliative care clinic (HPCC) with back pain and their associated lumbar spine imaging findings., Methods: We conducted a retrospective chart review of patients at a palliative care clinic that sees patients with HIV, most of whom have chronic pain. Charts with a diagnosis of low back pain were cross-referenced with an imaging database and any magnetic resonance imaging (MRI) of the lumbar spine with or without contrast were identified., Results: Seventy-six of 137 patients referred to the HPCC were found to have back pain. These patients were mainly young (median age 45, interquartile range 40-51) with well-controlled HIV. Twenty-two (29%) of these patients had an MRI of the lumbar spine, and 11 (50%) of these warranted follow-up, most of whom had degenerative disc disease, including four with findings concerning for malignancy., Discussion: This is the first study to explore the role of spinal imaging in HIV-infected patients. In our study, four patients had findings concerning for malignancy. These findings suggest that spinal imaging should be considered in the work up of HIV-infected patients with moderate to severe back pain., (Wiley Periodicals, Inc.)

We demonstrate an interdependent relationship between sexual behavior and church attendance on timing of human immunodeficiency virus (HIV) diagnosis and presentation for care. Men who have sex with men (MSM) and who attend church are more likely to present with lower CD4(+) T-lymphocyte counts than MSM who do not attend church.

Introduction: PLHIV have higher rates of smoking and lower motivation to quit smoking; thus to impact smoking rates, cessation interventions need to be acceptable to a wider range of PLHIV smokers as well as feasible to implement in a busy clinical setting. The purpose of this study was to evaluate the acceptability, feasibility, and effects of a Screening, Brief Intervention, and Referral for Treatment (SBIRT) model in an HIV/AIDS clinic among a sample of PLHIV., Methods: PLHIV smokers (N=40) were randomized at baseline, irrespective of their self-reported discrete smoking cessation motivation status, to receive either 8-weeks of combination nicotine replacement therapy (NRT) in conjunction with brief counseling (SBIRT framework) (n=23) or usual care (n=17). Smoking outcome measures included cigarettes smoked per day, nicotine dependence, smoking urge, and smoking withdrawal symptoms., Results: The SBIRT intervention appeared to be acceptable and feasible, and produced medium to large reductions in cigarettes smoked per day, physical nicotine dependence, smoking urge, and smoking withdrawal symptoms, even for smokers not ready to quit within 6months., Conclusions: Findings provide preliminary support for the integration of an SBIRT model in an HIV/AIDS clinic setting to screen and provide active treatment to all smokers, regardless of readiness to quit smoking. Given the high prevalence and incredible health burden of continued smoking in this population, identifying brief and effective interventions that are easily translated into clinical practice represents an enormous challenge that if met, will yield significant improvements to overall patient outcomes., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

The recommendation for the frequency for routine clinical monitoring of persons with well-controlled HIV infection is based on evidence that relies on observed rather than intended follow-up intervals. We sought to determine if the scheduled follow-up interval is associated with subsequent virologic failure. Participants in this 6-clinic retrospective cohort study had an index clinic visit in 2008 and HIV viral load (VL) ≤400 c/mL. Univariate and multivariate tests evaluated if scheduling the next follow-up appointment at 3, 4, or 6 months predicted VL >400 c/mL at 12 months (VF). Among 2171 participants, 66%, 26%, and 8% were scheduled next follow-up visits at 3, 4, and 6 months, respectively. With missing 12-month VL considered VF, 25%, 25%, and 24% of persons scheduled at 3, 4, and 6 months had VF, respectively (p=0.95). Excluding persons with missing 12-month VL, 7.1%, 5.7%, and 4.5% had VF, respectively (p=0.35). Multivariable models yielded nonsignificant odds of VF by scheduled follow-up interval both when missing 12-month VL were considered VF and when persons with missing 12-month VL were excluded. We conclude that clinicians are able to make safe decisions extending follow-up intervals in persons with viral suppression, at least in the short-term.

Persistency is the time from initiation to discontinuation of therapy. Previous research has described factors that affect the persistency of initial antiretroviral therapy (ART); however, the impact of persistency on clinical outcomes is unknown. A retrospective study was conducted of treatment-naive HIV patients initiating ART between January 1, 2000 and December 31, 2010 at an academic medical center. Descriptive statistics and Cox proportional hazards regression models with persistency as a time-varying covariate were fit for (1) immunologic failure (subsequent CD4 lower than initial CD4); (2) development of an opportunistic infection (OI) or malignancy; and (3) mortality. Analyses were repeated with an interaction term of persistency (per 180 days) and time (before and after 1 year of ART). Among 879 patients who started ART, the mean age was 38 years (±10) and most patients were racial/ethnic minority (59%), males (80%), and with baseline CD4 <200 cells/mm(3) (52%). There were 100 deaths, 94 OIs/malignancy, and 183 immunologic failures; the mean persistency=723 days. In multivariable modeling, increased persistency decreased the overall and long-term hazard for immunologic failure (0.84 per 180 additional days; 0.70-1.00; 0.045). Increased persistency exhibited a potential trend toward decreased hazard for the occurrence of OI/malignancy (0.91; 0.80-1.03; 0.124) overall and after 1 year. Persistency exhibited a trend toward less risk of mortality in the first year of ART (0.42; 0.17-1.06; 0.067). In this study of the relationship between initial ART persistency and clinical outcomes, increased persistency was associated with a decreased hazard for the development of immunologic failure, a trend toward a decreased hazard for OI/malignancy, and a trend toward a decreased risk of first year mortality. Given these findings, the relationship between persistency and clinical outcomes merits further study.

Background: Retention in care is key to improving HIV outcomes. The goal of this study was to describe 'churn' in patterns of entry, exit, and retention in HIV care in the United States and Canada., Methods: Adults contributing ≥1 CD4 count or HIV-1 RNA (HIV-lab) from 2000 to 2008 in North American AIDS Cohort Collaboration on Research and Design clinical cohorts were included. Incomplete retention was defined as lack of 2 HIV-laboratories (≥90 days apart) within 12 months, summarized by calendar year. Beta-binomial regression models were used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI) of factors associated with incomplete retention., Results: Among 61,438 participants, 15,360 (25%) with incomplete retention significantly differed in univariate analyses (P < 0.001) from 46,078 (75%) consistently retained by age, race/ethnicity, HIV risk, CD4, antiretroviral therapy use, and country of care (United States vs. Canada). From 2000 to 2004, females (OR = 0.82, CI: 0.70 to 0.95), older individuals (OR = 0.78, CI: 0.74 to 0.83 per 10 years), and antiretroviral therapy users (OR = 0.61, CI: 0.54 to 0.68 vs. all others) were less likely to have incomplete retention, whereas black individuals (OR = 1.31, CI: 1.16 to 1.49, vs. white), those with injection drug use HIV risk (OR = 1.68, CI: 1.49 to 1.89, vs. noninjection drug use), and those in care longer (OR = 1.09, CI: 1.07 to 1.11 per year) were more likely to have incomplete retention. Results from 2005 to 2008 were similar., Discussion: From 2000 to 2008, 75% of the North American AIDS Cohort Collaboration on Research and Design population was consistently retained in care with 25% experiencing some changes in status or churn. In addition to the programmatic and policy implications, the findings of this study identify patient groups who may benefit from focused retention efforts.

Purpose: A lower daily pill burden may improve adherence to antiretroviral treatment (ART) and clinical outcomes in patients with human immunodeficiency virus (HIV). This study assessed differences in adherence using the number of pills taken per day, and evaluated how adherence correlated with hospitalization., Methodology: Commercially insured patients in the LifeLink database with an HIV diagnosis (International Classification of Diseases, 9th Revision, Clinical Modification code 042.xx) between 6/1/2006 and 12/31/2008 and receipt of a complete ART regimen were selected for inclusion. Patients were grouped according to their daily pill count and remained on ART for at least 60 days. Outcomes included adherence and rates of hospitalization. Adherence was measured as the proportion of days between the start and end of the regimen in which the patient maintained supply of all initiated ART components. Logistic regressions assessed the relationship between pills per day, adherence, and hospitalization, controlling for demographics, comorbidities, and ART-naïve (vs. experienced) status., Results: 7,073 patients met the study inclusion criteria, and 33.4%, 5.8%, and 60.8% received an ART regimen comprising one, two, or three or more pills per day, respectively. Regression analysis showed patients receiving a single pill per day were significantly more likely to reach a 95% adherence threshold versus patients receiving three or more pills per day (odds ratio [OR] = 1.59; P<0.001). Regardless of the number of pills received per day, patients were over 40% less likely to have a hospitalization if they were adherent to therapy (OR = 0.57; P<0.001). Patients receiving a single pill per day were 24% less likely to have a hospitalization versus patients receiving three or more pills per day (OR = 0.76; P = 0.003)., Conclusions: ART consisting of a single pill per day was associated with significantly better adherence and lower risk of hospitalization in patients with HIV compared to patients receiving three or more pills per day.

Through this qualitative study we explored the patient/provider relationships of rural HIV-infected women. Thirty-nine women from rural Alabama were recruited to participate in one of four focus groups. The focus groups were audiorecorded, and the participants were asked to complete surveys measuring patient/provider trust. The verbatim-transcribed audio recordings were analyzed using content analysis. The participants' descriptions of their relationships with health care providers were represented by three major thematic categories: caring, informative, and competent. These findings provide a foundation for further research on the role of patient/provider relationships in the health outcomes of HIV disease in rural, resource-poor settings.

Purpose: We provide detailed instructions for analyzing patient-reported outcome (PRO) data collected with an existing (legacy) instrument so that scores can be calibrated to the PRO Measurement Information System (PROMIS) metric. This calibration facilitates migration to computerized adaptive test (CAT) PROMIS data collection, while facilitating research using historical legacy data alongside new PROMIS data., Methods: A cross-sectional convenience sample (n = 2,178) from the Universities of Washington and Alabama at Birmingham HIV clinics completed the PROMIS short form and Patient Health Questionnaire (PHQ-9) depression symptom measures between August 2008 and December 2009. We calibrated the tests using item response theory. We compared measurement precision of the PHQ-9, the PROMIS short form, and simulated PROMIS CAT., Results: Dimensionality analyses confirmed the PHQ-9 could be calibrated to the PROMIS metric. We provide code used to score the PHQ-9 on the PROMIS metric. The mean standard errors of measurement were 0.49 for the PHQ-9, 0.35 for the PROMIS short form, and 0.37, 0.28, and 0.27 for 3-, 8-, and 9-item-simulated CATs., Conclusions: The strategy described here facilitated migration from a fixed-format legacy scale to PROMIS CAT administration and may be useful in other settings.

A history of traumatic and/or stressful experiences is prevalent among HIV-infected individuals and has been consistently associated with poorer health outcomes. However, little is known about incident stressful experiences and the factors that predict these experiences among HIV-infected individuals. Data from a longitudinal study of 611 HIV-infected individuals in the Southeastern USA were used to examine the frequency and types of incident stress reported in a 27-month period and to determine predictors associated with three incident stress measures (all stressful events, severe stressful events, and traumatic events such as physical assault). Incident stressful experiences frequently occurred among study participants, as 91% reported at least one stressful experience (median=3.5 experiences) and 10% of study participants reported traumatic stress in any given nine-month reporting period. Financial stressors were the most frequently reported by study participants. Greater emotional distress, substance use, and a higher number of baseline stressful experiences were significantly associated with reporting a greater number of incident stressful experiences and any traumatic experiences. Study results indicate that efforts are needed to identify individuals at risk for traumatic events and/or substantial stressors and to address the factors, including mental health and substance abuse, that contribute to these experiences.

Nurses and nurse practitioners require information on the health problems faced by aging HIV-infected adults. In this descriptive, cross-sectional study, we reviewed the electronic medical records of 1,478 adult patients seen in an HIV clinic between May 2006 and August 2007 to examine patterns of comorbidities, and immunological and clinical characteristics across each decade of life. With increasing age, patients were found to have lower HIV viral loads, more prescribed medications, and a higher prevalence of comorbid conditions, including coronary artery disease, hypertension, hypercholesterolemia, hypogonadism, erectile dysfunction, diabetes, peripheral neuropathy, hepatitis C, esophageal gastric reflux disease, and renal disease. Fortunately, with increasing age, patients were also more likely to have public or private health insurance and tended to be more compliant to medical appointments. With growing interest in aging with HIV, this study highlights the vastly different comorbidity profiles across decades of life, calling into question what constitutes "older" with HIV., (Copyright © 2011 Association of Nurses in AIDS Care. Published by Elsevier Inc. All rights reserved.)

Despite the wide availability of effective treatments for HIV disease, many HIV-infected individuals are not in care, and HIV-infected women, particularly those residing in resource-poor areas, may have greater difficulty accessing HIV care than men. The purpose of this research was to explore perceived barriers to care experienced by HIV-infected women living in the Deep South region of the United States. Qualitative research methods were used to generate in-depth descriptions of women's experiences in accessing HIV care. Participants (N = 40) were recruited from 4 community-based HIV service organizations to participate in focus groups. Sessions lasted approximately 2 hours and were audio recorded. Verbatim transcripts, demographic data, and observational notes were subjected to content analysis strategies that coded the data into categories. Five categories of barriers to HIV care were identified as follows: personal, social, financial, geographic/transportation, and health system barriers. Implications of the findings for future research and practice are discussed in this study., (Copyright © 2010 Association of Nurses in AIDS Care. Published by Elsevier Inc. All rights reserved.)

Retention in HIV medical care has been recognized as critical for long-term favorable clinical outcomes among HIV-positive patients. However, relatively little is known about specific factors related to HIV medical care adherence among HIV-positive women in rural areas in the United States, where the epidemic is rapidly growing among minorities and women. The objective of the current study was to assess barriers and facilitators to HIV clinic visit adherence among HIV-positive women in the rural southeastern region of the United States. Forty HIV-positive women were recruited from four outpatient clinics providing services to HIV-positive patients residing in 23 predominately rural counties in Alabama. Four focus groups were conducted ranging from 5 to 16 participants each. Content analysis was used to analyze and interpret the data. Data coding and sorting was conducted using QRS NVivo 8 software. Participants were predominately African American (92.3%) ranging in age from 29 to 69 years (mean = 46.1 years). On average, participants reported living with HIV for 8.8 years. Factors that impacted participants' ability to maintain clinic visit appointments included personal, contextual, and community/environmental factors that included: patient/provider relationships, family support, access to transportation, organizational infrastructure of the health care facility visited and perceived HIV stigma within their communities. The current study highlights the myriad of retention-in-care barriers faced by HIV-positive women living in rural areas in the southeastern United States. Innovative multilevel interventions that address these factors are sorely needed to increase long-term retention-in-care among HIV-positive women residing in rural areas.

Background: Among HIV-infected patients, hepatitis C virus (HCV) coinfection is associated with lower cholesterol levels, but it remains unclear how it affects cardiovascular outcomes., Methods: We performed logistic regression to evaluate acute myocardial infarction (AMI) and cerebrovascular disease (CVD) events by HCV status among HIV-infected US veterans in the highly active antiretroviral therapy (HAART) era (1996-2004). We then performed survival analyses to evaluate incident AMI and CVD, exploring antiretroviral therapy (ART) as a time-dependent variable., Results: A total of 19 424 HIV-infected patients [31.6% of whom were HCV-coinfected (HIV/HCV)] contributed 76 376 patient-years of follow-up. HCV coinfection was associated with lower rates of hypercholesterolaemia (18.0% in HIV/HCV vs. 30.7% in HIV-only patients; P<0.001), but higher rates of hypertension (43.8%vs. 35.6%; P<0.0001), type 2 diabetes mellitus (16.2%vs. 11.1%; P<0.0001) and smoking (36.7%vs. 24.7%; P=0.009). Rates of AMI and CVD were significantly higher among HIV/HCV than HIV-only patients: 4.19 vs. 3.36 events/1000 patient-years, respectively (P<0.001), for AMI; and 12.47 vs. 11.12 events/1000 patient-years, respectively (P<0.001), for CVD. When analyses were controlled for diabetes mellitus, hypertension, age and duration of ART, hazard ratios (HRs) among those with HIV/HCV (vs. HIV only) were 1.25 [95% confidence interval (CI) 0.98-1.61; P=0.072] for AMI and 1.20 (CI 1.04-1.38; P=0.013) for CVD. Hypertension (HR 2.05; P<0.001), greater age (HR 1.79; P<0.001) and longer duration (cumulative years) of antiretroviral use (HR 1.12; P=0.0411) were also associated with increased risk of AMI in the adjusted model., Conclusions: In the HAART era, HCV coinfection was associated with a significantly increased risk of CVD and a trend towards an increased risk of AMI among HIV-infected patients.

Background: Although antiretroviral therapy has the ability to fully restore a normal CD4(+) cell count (>500 cells/mm(3)) in most patients, it is not yet clear whether all patients can achieve normalization of their CD4(+) cell count, in part because no study has followed up patients for >7 years., Methods: Three hundred sixty-six patients from 5 clinical cohorts who maintained a plasma human immunodeficiency virus (HIV) RNA level 1000 copies/mL for at least 4 years after initiation of antiretroviral therapy were included. Changes in CD4(+) cell count were evaluated using mixed-effects modeling, spline-smoothing regression, and Kaplan-Meier techniques., Results: The majority (83%) of the patients were men. The median CD4(+) cell count at the time of therapy initiation was 201 cells/mm(3) (interquartile range, 72-344 cells/mm(3)), and the median age was 47 years. The median follow-up period was 7.5 years (interquartile range, 5.5-9.7 years). CD4(+) cell counts continued to increase throughout the follow-up period, albeit slowly after year 4. Although almost all patients (95%) who started therapy with a CD4(+) cell count 300 cells/mm(3) were able to attain a CD4(+) cell count 500 cells/mm(3), 44% of patients who started therapy with a CD4(+) cell count <100 cells/mm(3) and 25% of patients who started therapy with a CD4(+) cell count of 100-200 cells/mm(3) were unable to achieve a CD4(+) cell count >500 cells/mm(3) over a mean duration of follow-up of 7.5 years; many did not reach this threshold by year 10. Twenty-four percent of individuals with a CD4(+) cell count <500 cells/mm(3) at year 4 had evidence of a CD4(+) cell count plateau after year 4. The frequency of detectable viremia ("blips") after year 4 was not associated with the magnitude of the CD4(+) cell count change., Conclusions: A substantial proportion of patients who delay therapy until their CD4(+) cell count decreases to <200 cells/mm(3) do not achieve a normal CD4(+) cell count, even after a decade of otherwise effective antiretroviral therapy. Although the majority of patients have evidence of slow increases in their CD4(+) cell count over time, many do not. These individuals may have an elevated risk of non-AIDS-related morbidity and mortality.

Among HIV-infected persons, high-level adherence to antiretroviral medications (>90%-95%) is associated with improved immunologic, virologic, and clinical outcomes, and is necessary to prevent the emergence of viral resistance. This study examines whether lifetime traumatic events including physical and sexual abuse, are associated with antiretroviral nonadherence. We present a cross-sectional analysis of the Coping with HIV/AIDS in the Southeast (CHASE) Study, analyzing data from the enrollment interview and medical records of study subjects. The CHASE Study is a prospective cohort study of consecutively sampled HIV-infected subjects from infectious diseases clinics in five southern states; Alabama, Georgia, Louisiana, North Carolina, and South Carolina. Four hundred seventy-four (78%) of the 611 CHASE study subjects reported being treated with antiretroviral medications at enrollment and are included in this analysis. Nonadherence was defined as the patient's self-report of missing any doses of their antiretroviral medications over the previous 7 days. Among study subjects, 54% reported a history of physical and/or sexual abuse, 91% reported at least one lifetime traumatic event, and 24% reported nonadherence with their antiretrovirals. In multivariable logistic regression analysis, the number of categories of lifetime traumatic events (p = 0.03), the Addiction Severity Index (ASI) alcohol score (p = 0.02), and being uninsured (p = 0.04) were associated with antiretroviral nonadherence. The finding that lifetime traumatic events are associated with antiretroviral nonadherence, particularly among those who have been traumatized in multiple ways, highlights the complex and often persisting manifestations of such trauma and calls for further investigation.

In the present study, we examined how the arterial insulin level alters the alpha-cell response to a fall in plasma glucose in the conscious overnight fasted dog. Each study consisted of an equilibration (-140 to -40 min), a control (-40 to 0 min), and a test period (0 to 180 min), during which BAY R 3401 (10 mg/kg), a glycogen phosphorylase inhibitor, was administered orally to decrease glucose output in each of four groups (n = 5). In group 1, saline was infused. In group 2, insulin was infused peripherally (3.6 pmol. kg(- 1). min(-1)), and the arterial plasma glucose level was clamped to the level seen in group 1. In group 3, saline was infused, and euglycemia was maintained. In group 4, insulin (3.6 pmol. kg(-1). min(-1)) was given, and euglycemia was maintained by glucose infusion. In group 1, drug administration decreased the arterial plasma glucose level (mmol/l) from 5.8 +/- 0.2 (basal) to 5.2 +/- 0.3 and 4.4 +/- 0.3 by 30 and 90 min, respectively (P < 0.01). Arterial plasma insulin levels (pmol/l) and the hepatic portal-arterial difference in plasma insulin (pmol/l) decreased (P < 0.01) from 78 +/- 18 and 90 +/- 24 to 24 +/- 6 and 12 +/- 6 over the first 30 min of the test period. The arterial glucagon levels (ng/l) and the hepatic portal-arterial difference in plasma glucagon (ng/l) rose from 43 +/- 5 and 5 +/- 2 to 51 +/- 5 and 10 +/- 5 by 30 min (P < 0.05) and to 79 +/- 16 and 31 +/- 15 (P < 0.05) by 90 min, respectively. In group 2, in response to insulin infusion, arterial insulin (pmol/l) was elevated from 48 +/- 6 to 132 +/- 6 to an average of 156 +/- 6. The hepatic portal-arterial difference in plasma insulin was eliminated, indicating a complete inhibition of endogenous insulin release. The arterial glucagon level (ng/l) and the hepatic portal-arterial difference in plasma glucagon (ng/l) did not rise significantly (40 +/- 5 and 7 +/- 4 at basal, 44 +/- 4 and 9 +/- 4 at 90 min, and 44 +/- 8 and 15 +/- 7 at 180 min). In group 3, when euglycemia was maintained, the insulin and glucagon levels and the hepatic portal-arterial difference remained constant. In group 4, the arterial plasma glucose level remained basal (5.9 +/- 1.1 mmol/l) throughout, whereas insulin infusion increased the arterial insulin level to an average of 138 +/- 6 pmol/l. The hepatic portal-arterial difference in plasma insulin was again eliminated. Arterial glucagon level (ng/l) and the hepatic portal-arterial difference in plasma glucagon (ng/l) did not change significantly (43 +/- 2 and 9 +/- 2 at basal, 39 +/- 3 and 9 +/- 2 at 90 min, and 37 +/- 3 and 7 +/- 2 at 180 min). Thus, a difference of approximately 120 pmol/l in arterial insulin completely abolished the response of the alpha-cell to mild hypoglycemia.