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Generalized Anxiety Disorder (GAD) presents a significant personal and societal burden and is associated with chronic medical comorbidities and markedly lower quality of life. Effective treatments exist, less than half of individuals with lifetime GAD will ever seek psychotherapeutic or pharmacological treatment. A thorough understanding of the factors that influence treatment seeking for GAD is warranted. The present study investigates the correlates of GAD treatment seeking, using data from the National Epidemiological Survey on Alcohol and Related Disorders-III (NESARC-III), which assessed for psychiatric disorders using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-5 Version (AUDADIS-5). A series of logistic regressions were run to identify demographic, diagnostic, and symptom-level correlates of treatment seeking in those meeting DSM-5 diagnostic criteria for GAD. Comorbid depression, panic disorder, and PTSD were all uniquely associated with higher rates of GAD-related treatment seeking. Additionally, several accompanying anxiety symptoms were also uniquely predicted treatment seeking, including fatigue, panic attacks, reassurance-seeking, and interpersonal avoidance. Findings underscore the multi-factorial nature of treatment seeking behavior in GAD and highlight the need for further research to fully understand these relationships and devise effective strategies to improve treatment seeking in this population., Competing Interests: Declaration of Competing Interest JZ, TP, and JC have no conflicts of interest to report., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Individuals elevated in distress intolerance (DI) may engage in dysfunctional behavioral strategies to cope with their distress. One behavioral strategy that may be related to DI is appearance related safety behavior (ARSB; i.e., maladaptive behavior that seeks to mitigate the feared consequences of the negative evaluation of appearance). We examined the relationship between DI and ARSBs in two separate samples of women. In Study 1 (N = 91), we found in an unselected sample that ARSBs were robustly associated with DI cross-sectionally while accounting for symptoms of depression and body dysmorphia. Further, greater ARSBs predicted increases in DI longitudinally. In Study 2, among a clinical sample of women with elevated appearance concerns (N = 94), we examined the experimental effect of reducing ARSBs compared to a self-monitoring control. Relative to control, instructions to reduce ARSBs led to lower DI, but this effect was only found for individuals low in baseline DI. Overall, we found preliminary evidence that ARSBs may be a salient factor in contributing to and maintaining DI; and SB fading may be a helpful strategy for reducing DI. We discuss these findings in the context of existing literature and provide directions for future research., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Problematic anger is linked with multiple adverse smoking outcomes, including cigarette dependence, heavy smoking, and cessation failure. A smoking cessation intervention that directly targets anger and its maintenance factors may increase rates of smoking cessation. We examined the efficacy of an interpretation bias modification for hostility (IBM-H) to facilitate smoking cessation in smokers with elevated trait anger. Participants were 100 daily smokers (mean age = 38, 62% female, 55% white) with elevated anger were randomly assigned to eight computerized sessions of either IBM-H or a health and relaxation video control condition (HRVC). Participants in both conditions attempted to quit at mid-treatment. Measures of hostility, anger, and smoking were administered at pre-, mid-, post-treatment, as well as at up to three-month follow-up. Compared to HRVC, IBM-H led to greater reductions in hostile interpretation bias, both at posttreatment and follow-up. IBM-H also led to statistically significant reductions in hostility only at posttreatment, and trait anger only at three-month follow-up. Both conditions experienced reductions in smoking, although they did not differ in quit success. We discuss these findings in the context of literature on anger and smoking cessation and provide directions for future research., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: Individuals who experience gambling harms report that sustained recovery involves changing both gambling behaviors and psychological symptoms, as well as building a meaningful life. However, there is limited understanding about the effect of cognitive behavioral (CB) techniques on psychological symptoms and quality of life. The purpose of the present study was to examine the effect of CB techniques for gambling-related harms on broader recovery outcomes such as psychological symptoms and quality of life., Method: A systematic article search was conducted to identify randomized controlled trials of CB techniques with nonactive and minimal treatment control groups that assessed psychological symptoms or quality of life as outcomes. Random-effects meta-analysis was used to examine the effect of CB techniques relative to nonactive and minimal treatment control groups., Results: A total of nine studies representing 658 participants were included. Eight studies reported outcomes on depression and anxiety, three on substance use, and six on quality of life. CB techniques significantly reduced anxiety ( g = -0.44) and depression ( g = -0.35) at posttreatment, but not substance use. CB techniques also significantly increased quality of life at posttreatment ( g = 0.40). There was a large amount of heterogeneity suggesting the magnitude of effects could vary significantly in future randomized trials., Conclusions: Future studies should examine the longitudinal associations between gambling harms, psychological symptoms, and quality of life and to assess whether changes in gambling harms throughout treatment precede or are a consequence of changes in psychological symptoms and quality of life. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Aims: To measure the effect of cognitive-behavioral techniques (CBTs) on gambling disorder severity and gambling behavior at post-treatment and follow-up., Method: Seven databases and two clinical trial registries were searched to identify peer-reviewed studies and unpublished studies of randomized controlled trials. The Cochrane Risk of Bias tool assessed risk of bias in the included studies. A random effect meta-analysis with robust variance estimation was conducted to measure the effect of CBTs relative to minimally treated or no treatment control groups., Results: Twenty-nine studies representing 3991 participants were identified. CBTs significantly reduced gambling disorder severity (g = -1.14, 95% CI = -1.68, -0.60, 95% prediction interval [PI] = -2.97, 0.69), gambling frequency (g = -0.54, 95% CI = -0.80, -0.27, 95% PI = -1.48, 0.40) and gambling intensity (g = -0.32, 95% CI = -0.51, -0.13, 95% PI = -0.76, 0.12) at post-treatment relative to control. CBTs had no significant effect on follow-up outcomes. Analyses supported the presence of publication bias and high heterogeneity in effect size estimates., Conclusions: Cognitive-behavioral techniques are a promising treatment for reducing gambling disorder and gambling behavior; however, the effect of cognitive-behavioral techniques on gambling disorder severity and gambling frequency and intensity at post-treatment is overestimated, and cognitive-behavioral techniques may not be reliably efficacious for all individuals seeking treatment for problem gambling and gambling disorder., (© 2023 Society for the Study of Addiction.)

Cannabis use disorder (CUD) and frequency of use are highly related to social anxiety disorder (SAD). With updates to diagnostic criteria of psychiatric disorders and recent changes in cannabis laws, the present study sought to explore the relationships between cannabis use, CUD, and social anxiety in a large nationally representative sample of individuals with lifetime (N = 1255) and past-year SAD (N = 980). Notably, we found that at the symptom level, at least weekly cannabis use was significantly related to fear or avoidance of social situations interfering with relationships in both samples. Weekly + cannabis use and CUD were significantly associated with lifetime SAD symptom severity, but only weekly + cannabis use was related to SAD severity in the past-year sample. We also found that weekly + cannabis use but not CUD was related to greater odds of seeking treatment for SAD and suicide attempt history. Overall, these data provide an updated examination of cannabis use and SAD using DSM-5 criteria and a large nationally representative sample and also highlight the importance of weekly + cannabis use as a marker of severity and suicide risk in individuals with SAD., Competing Interests: Declaration of competing interest We have no conflicts of interest or funding information to disclose., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Introduction: Tuberculosis (TB) causes one-third of HIV-related deaths worldwide, making TB preventive treatment (TPT) a critical element of HIV programmes. Approximately 16% of people living with HIV (PLHIV) on antiretrovirals in Zimbabwe are enrolled in the Fast Track (FT) differentiated service delivery model, which includes multi-month dispensing of antiretrovirals and quarterly health facility (HF) visits. We assessed the feasibility and acceptability of utilizing FT to deliver 3HP (3 months of once-weekly rifapentine and isoniazid) for TPT by aligning TPT and HIV visits, providing multi-month dispensing of 3HP, and using phone-based monitoring and adherence support., Methods: We recruited a purposive sample of 50 PLHIV enrolled in FT at a high-volume HF in urban Zimbabwe. At enrolment, participants provided written informed consent, completed a baseline survey, and received counselling, education and a 3-month supply of 3HP. A study nurse mentor called participants at weeks 2, 4 and 8 to monitor and support adherence and side effects. When participants returned for their routine 3-month FT visit, they completed another survey, and study staff conducted a structured medical record review. In-depth interviews were conducted with providers who participated in the pilot., Results: Participants were enrolled between April and June 2021 and followed through September 2021. Median age = 32 years (IQR 24,41), 50% female, median time in FT 1.8 years (IQR 0.8,2.7). Forty-eight participants (96%) completed 3HP in 13 weeks; one completed in 16 weeks, and one stopped due to jaundice. Most participants (94%) reported "always" or "almost always" taking 3HP correctly. All reported they were very satisfied with the counselling, education, support and quality of care they received from providers and FT service efficiency. Almost all (98%) said they would recommend it to other PLHIV. Challenges reported included pill burden (12%) and tolerability (24%), but none had difficulty with phone-based counselling or wished for additional HF-based visits., Discussion: Using FT to deliver 3HP was feasible and acceptable. Some reported tolerability challenges but 98% completed 3HP, and all appreciated the efficiency of aligning TPT and HIV HF visits, multi-month dispensing and phone-based counselling., Conclusions: Scaling up this approach could expand TPT coverage in Zimbabwe., (© 2023 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Background: Multi-month dispensing (MMD) of antiretroviral therapy (ART) is an integral component of differentiated HIV service delivery for people living with HIV (PLHIV). Although many countries have scaled up ART dispensing to 3-month intervals, Ethiopia was the first African country to implement six-month dispensing (6-MMD) at scale, introducing its Appointment Spacing Model (ASM) for people doing well on ART in 2017. As of June 2021, 51.4% (n = 215,101) of PLHIV on ART aged ≥ 15 years had enrolled in ASM. Since little is known about the benefits and challenges of ASM perceived by Ethiopian clients and their healthcare workers (HCWs), we explored how the ASM was being implemented in Ethiopia's Oromia region in September 2019., Methods: Using a parallel convergent mixed-methods study design, we conducted 6 focus groups with ASM-eligible enrolled clients, 6 with ASM-eligible non-enrolled clients, and 22 in-depth interviews with HCWs. Data were audio-recorded, transcribed and translated into English. We used thematic analysis, initially coding deductively, followed by inductive coding of themes that emerged from the data, and compared the perspectives of ASM-enrolled and non-enrolled clients and their HCWs., Results: Participants enrolled in ASM and HCWs perceived client-level ASM benefits to include time and cost-savings, fewer work disruptions, reduced stigma due to fewer clinic visits, better medication adherence and improved overall health. Perceived health system-level benefits included improved quality of care, decongested facilities, reduced provider workloads, and improved record-keeping. Although non-enrolled participants anticipated many of the same benefits, their reasons for non-enrollment included medication storage challenges, concerns over less frequent health monitoring, and increased stress due to the large quantities of medicines dispensed. Enrolled participants and HCWs identified similar challenges, including client misunderstandings about ASM and initial ART stock-outs., Conclusions: ASM with 6-MMD was perceived to have marked benefits for clients and health systems. Clients enrolled in the ASM and their HCWs had positive experiences with the model, including perceived improvements in efficiency, quality and convenience of HIV treatment services. The concerns of non-ASM enrolled participants suggest the need for enhanced client education about the model and more discreet and efficiently packaged ART and highlight that ASM is not ideal for all clients., (© 2023. The Author(s).)

Background: Digital mental health interventions, such as 2-way and asynchronous messaging therapy, are a growing part of the mental health care treatment ecosystem, yet little is known about how users engage with these interventions over the course of their treatment journeys. User engagement, or client behaviors and therapeutic relationships that facilitate positive treatment outcomes, is a necessary condition for the effectiveness of any digital treatment. Developing a better understanding of the factors that impact user engagement can impact the overall effectiveness of digital psychotherapy. Mapping the user experience in digital therapy may be facilitated by integrating theories from several fields. Specifically, health science's Health Action Process Approach and human-computer interaction's Lived Informatics Model may be usefully synthesized with relational constructs from psychotherapy process-outcome research to identify the determinants of engagement in digital messaging therapy., Objective: This study aims to capture insights into digital therapy users' engagement patterns through a qualitative analysis of focus group sessions. We aimed to synthesize emergent intrapersonal and relational determinants of engagement into an integrative framework of engagement in digital therapy., Methods: A total of 24 focus group participants were recruited to participate in 1 of 5 synchronous focus group sessions held between October and November 2021. Participant responses were coded by 2 researchers using thematic analysis., Results: Coders identified 10 relevant constructs and 24 subconstructs that can collectively account for users' engagement and experience trajectories in the context of digital therapy. Although users' engagement trajectories in digital therapy varied widely, they were principally informed by intrapsychic factors (eg, self-efficacy and outcome expectancy), interpersonal factors (eg, the therapeutic alliance and its rupture), and external factors (eg, treatment costs and social support). These constructs were organized into a proposed Integrative Engagement Model of Digital Psychotherapy. Notably, every participant in the focus groups indicated that their ability to connect with their therapist was among the most important factors that were considered in continuing or terminating treatment., Conclusions: Engagement in messaging therapy may be usefully approached through an interdisciplinary lens, linking constructs from health science, human-computer interaction studies, and clinical science in an integrative engagement framework. Taken together, our results suggest that users may not view the digital psychotherapy platform itself as a treatment so much as a means of gaining access to a helping provider, that is, users did not see themselves as engaging with a platform but instead viewed their experience as a healing relationship. The findings of this study suggest that a better understanding of user engagement is crucial for enhancing the effectiveness of digital mental health interventions, and future research should continue to explore the underlying factors that contribute to engagement in digital mental health interventions., Trial Registration: ClinicalTrials.gov NCT04507360; https://clinicaltrials.gov/ct2/show/NCT04507360., (©James M Zech, Morgan Johnson, Michael D Pullmann, Thomas D Hull, Tim Althoff, Sean A Munson, Nicole Fridling, Boris Litvin, Jerilyn Wu, Patricia A Areán. Originally published in JMIR Formative Research (https://formative.jmir.org), 26.04.2023.)

Introduction: Maternal antiretroviral therapy (ART) with viral suppression prior to conception, during pregnancy and throughout the breastfeeding period accompanied by infant postnatal prophylaxis (PNP) forms the foundation of current approaches to preventing vertical HIV transmission. Unfortunately, infants continue to acquire HIV infections, with half of these infections occurring during breastfeeding. A consultative meeting of stakeholders was held to review the current state of PNP globally, including the implementation of WHO PNP guidelines in different settings and identifying the key factors affecting PNP uptake and impact, with an aim to optimize future innovative strategies., Discussion: WHO PNP guidelines have been widely implemented with adaptations to the programme context. Some programmes with low rates of antenatal care attendance, maternal HIV testing, maternal ART coverage and viral load testing capacity have opted against risk-stratification and provide an enhanced PNP regimen for all infants exposed to HIV, while other programmes provide infant daily nevirapine antiretroviral (ARV) prophylaxis for an extended duration to cover transmission risk throughout the breastfeeding period. A simplified risk stratification approach may be more relevant for high-performing vertical transmission prevention programmes, while a simplified non-risk stratified approach may be more appropriate for sub-optimally performing programmes given implementation challenges. In settings with concentrated epidemics, where the epidemic is often driven by key populations, infants who are found to be exposed to HIV should be considered at high risk for HIV acquisition. All settings could benefit from newer technologies that promote retention during pregnancy and throughout the breastfeeding period. There are several challenges in enhanced and extended PNP implementation, including ARV stockouts, lack of appropriate formulations, lack of guidance on alternative ARV options for prophylaxis, poor adherence, poor documentation, inconsistent infant feeding practices and in inadequate retention throughout the duration of breastfeeding., Conclusions: Tailoring PNP strategies to a programmatic context may improve access, adherence, retention and HIV-free outcomes of infants exposed to HIV. Newer ARV options and technologies that enable simplification of regimens, non-toxic potent agents and convenient administration, including longer-acting formulations, should be prioritized to optimize the effect of PNP in the prevention of vertical HIV transmission., (© 2023 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Introduction: In 2018, South Africa's National Department of Health provided additional resources for ward-based primary healthcare outreach teams (OT) with support from the U.S. President's Emergency Plan for AIDS Relief. The intervention package included a new training curriculum, enhanced staffing, revised management and supervisory structures, and more intensive monitoring and evaluation (M&E). The goal was to strengthen OT and their impact on both primary healthcare and HIV-specific services. We conducted a process evaluation of this intervention package during its second year and examined implementation successes and challenges., Methods: We conducted a mixed-methods evaluation at 20 purposively selected facilities in Bojanala and City of Tshwane districts, including surveys with 222 community health workers (CHWs) and outreach team leaders (OTLs); key informant interviews and online surveys with 28 policy and program stakeholders; 70 in-depth interviews with health facility staff; 20 focus group discussions with 194 CHWs; 20 structured health facility assessments; directly-observed time-motion studies; and review of program documents., Results: Most participants highlighted the hiring and training of CHWs and OTLs as a key implementation success because this had partially alleviated staffing shortages and helped clarify CHWs' and OTLs' responsibilities and supervisory structures. The new monitoring tools were welcomed for their potential to improve data collection and program tracking. However, participants highlighted many program challenges: short-lived gains in CHWs' knowledge and skills due to lack of ongoing training and mentoring; insufficient integration of OT into health facility management structures; persistent shortages of equipment, supplies, transportation, and workspace for CHWs; and insufficient remuneration for staff., Conclusion: Strengthening and expanding CHW programs, such as OT, requires intensive support and continuous investments. To sustain improvements in training, supervision, and job satisfaction, CHWs must be equipped with needed resources, provided with ongoing supportive supervision, and strengthened by optimized program management, monitoring and processes., Competing Interests: The authors have declared that no competing interests exist.

Background: While message-based therapy has been shown to be effective in treating a range of mood disorders, it is critical to ensure that providers are meeting a consistently high standard of care over this medium. One recently developed measure of messaging quality-The Facilitative Interpersonal Skills Task for Text (FIS-T)-provides estimates of therapists' demonstrated ability to convey psychotherapy's common factors (e.g., hopefulness, warmth, persuasiveness) over text. However, the FIS-T's scoring procedure relies on trained human coders to manually code responses, thereby rendering the FIS-T an unscalable quality control tool for large messaging therapy platforms., Objective: In the present study, researchers developed two algorithms to automatically score therapist performance on the FIS-T task., Methods: The FIS-T was administered to 978 messaging therapists, whose responses were then manually scored by a trained team of raters. Two machine learning algorithms were then trained on task-taker messages and coder scores: a support vector regressor (SVR) and a transformer-based neural network (DistilBERT)., Results: The DistilBERT model had superior performance on the prediction task while providing a distribution of ratings that was more closely aligned with those of human raters, versus SVR. Specifically, the DistilBERT model was able to explain 58.8% of the variance ( R 2  = 0.588) in human-derived ratings and realized a prediction mean absolute error of 0.134 on a 1-5 scale., Conclusions: Algorithms can be effectively used to ensure that digital providers meet a consistently high standard of interactions in the course of messaging therapy. Natural language processing can be applied to develop new quality assurance systems in message-based digital psychotherapy., Competing Interests: JZ, RS, and TDH are employed by Talkspace, Inc. VKF was employed by Talkspace, Inc., (© 2022 Zech, Steele, Foley and Hull.)

Introduction: Historical approaches to clinical development of novel therapeutics for treatment and prevention of HIV have led to unacceptable delays in the generation of data to support optimal antiretroviral drug use in pregnancy. Over the last 5 years, multiple stakeholders have voiced their concerns around the exclusion of pregnant women from drug trials, and some progress has been made to consolidate principles and forge consensus. Building on ongoing efforts, the World Health Organization (WHO) and the International Maternal Paediatric Adolescent AIDS Clinical Trials Network (IMPAACT) convened a technical consultation designed to move the discussion from theory to practice., Discussion: Accelerating the inclusion of pregnant women in pre-licensure clinical trials, with a goal to have pharmacokinetics (PK) and preliminary safety data for all new HIV agents in pregnancy available at the time of drug approval, requires: (1) performing non-clinical developmental and reproductive toxicology studies early in drug development for all new HIV agents; (2) recognizing and acting on the central role of women of childbearing potential affected by HIV through the research being conducted and the dissemination of associated results; (3) enrolling pregnant women in studies to specifically determine pregnancy PK and preliminary safety, as soon as late non-clinical studies are completed with no negative signals, for all new HIV agents that have demonstrated preliminary evidence of safety and efficacy from phase 2 trials; (4) investigating adverse pregnancy and birth outcomes through dedicated pregnancy safety studies for all new priority HIV agents; and (5) expanding active surveillance of drug safety in pregnancy for rare events, such as birth defects. Strategic actions to pursue include developing tools and resources to support designing and implementing studies among pregnant and breastfeeding women, identifying and promoting modifications of the regulatory framework that are supportive of systematic ethical investigation of new drugs in pregnancy, coordinating surveillance efforts, mobilizing key stakeholders and promoting transparency and accountability for all involved., Conclusions: With more than 19 million women living with HIV worldwide, ensuring greater inclusion of pregnant women in research on novel therapeutics is a priority to support drug optimization and effective introduction of innovations for treatment and prevention of HIV., (© 2022 World Health Organization; licensed by IAS.)

Introduction: Women who are pregnant or who could become pregnant experience delayed access to or underinformed use of important new antiretroviral (ARV) drugs because of traditional drug development processes that ostensibly aim to reduce potential harm but effectively fail to ensure that timely information about safe and effective use in pregnancy is available., Discussion: The World Health Organization and International Maternal, Pediatric, Adolescent Antiretroviral Clinical Trials Network convened a year-long workshop on "Approaches to Enhance and Accelerate Study of New Drugs for HIV and Associated Infections in Pregnant Women." Workshop participants were tasked with defining key principles and optimal approaches to including pregnant women in pre- and post-licensure trials in order to accelerate the availability of pharmacokinetic and safety data for new ARV agents in pregnancy. ARV efficacy in pregnancy and ARV efficacy for prevention of vertical transmission can be extrapolated from proof of efficacy in non-pregnant adults, provided that drug levels in pregnancy are similar. However, short-term safety and pharmacokinetics must be studied directly in pregnant women and should be conducted and included in initial licensure for all new ARVs. Accelerating the timeline for completion of pre-clinical studies is essential for pregnancy short-term safety and pharmacokinetic studies to be safely completed by the time a drug is licensed. Composite key pregnancy, birth and neonatal outcomes are critical for drugs expected to have broad use, and studies should be initiated at or soon after drug licensure. Teratogenicity risk cannot be feasibly assessed before drug licensure and will depend on robust post-marketing surveillance systems. With some modifications, these principles will apply to ARVs used for prevention, two-drug regimens, long-acting ARVs and ARVs administered through novel delivery systems., Conclusions: Implementation of the proposed principles and framework will enhance and accelerate the study of new ARVs in pregnancy, resulting in more timely, equitable and informed access to new ARVs for pregnant women., (© 2022 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

As Zimbabwe expands tuberculosis preventive treatment (TPT) for people living with HIV (PLHIV), the Ministry of Health and Child Care is considering making TPT more accessible to PLHIV via less-intensive differentiated service delivery models such as Community ART Refill Groups (CARGs). We designed a study to assess the feasibility and acceptability of integrating TPT into CARGs among key stakeholders, including CARG members, in Zimbabwe. We conducted 45 key informant interviews (KII) with policy makers, implementers, and CARG leaders; 16 focus group discussions (FGD) with 136 PLHIV in CARGs; and structured observations of 8 CARG meetings. KII and FGD were conducted in English and Shona. CARG observations were conducted using a structured checklist and time-motion data capture. Ninety six percent of participants supported TPT integration into CARGs and preferred multi-month TPT dispensing aligned with ART dispensing schedules. Participants noted that the existing CARG support systems could be used for TB symptom screening and TPT adherence monitoring/support. Other perceived advantages included convenience for PLHIV and decreased health facility provider workloads. Participants expressed concerns about possible medication stockouts and limited knowledge about TPT among CARG leaders but were confident that CARGs could effectively provide community-based TPT education, adherence monitoring/support, and TB symptom screening provided that CARG leaders received appropriate training and supervision. These results are consistent with findings from pilot projects in other African countries that are scaling up both differentiated service delivery for HIV and TPT and suggest that designing contextually appropriate approaches to integrating TPT into less-intensive HIV treatment models is an effective way to reach people who are established on ART but who may have missed out on access to TPT.

One potential reason that low-value care remains persistent is variation in recommendations created to deter it. A better understanding of key features, and how they differ across a range of recommendations, can offer insight about improvement opportunities. To address this knowledge gap, the authors described 3 features using a broad set of consensus Choosing Wisely recommendations: underlying rationales (ie, avoidance of waste and/or harm), types of services targeted, and types of supportive evidence used. The minority of recommendations were accompanied by rationales invoking waste (36%), harm (17%), and both (40%); 7% of recommendations were accompanied by no rationales. The most commonly targeted service type was diagnostic imaging (31%), while the least commonly targeted service type was clinical referrals/consults (1%). Most recommendations (50%) utilized guidelines as sources. These findings highlight several opportunities to modify low-value care recommendations in order to ultimately strengthen efforts to reduce low-value care., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Differentiated service delivery holds great promise for streamlining the delivery of health services for HIV. This study used a discrete choice experiment to assess preferences for differentiated HIV treatment delivery model characteristics among 500 virally suppressed adults on antiretroviral therapy in Harare, Zimbabwe. Treatment model characteristics included location, consultation type, healthcare worker cadre, operation times, visit frequency and duration, and cost. A mixed effects logit model was used for parameter estimates to identify potential preference heterogeneity among participants, and interaction effects were estimated for sex and age as potential sources of divergence in preferences. Results indicated that participants preferred health facility-based services, less frequent visits, individual consultations, shorter waiting times, lower cost and, delivered by respectful and understanding healthcare workers. Some preference heterogeneity was found, particularly for location of service delivery and group vs. individual models; however, this was not fully explained by sex and age characteristics of participants. In urban areas, facility-based models, such as the Fast Track model requiring less frequent clinic visits, are likely to better align with patient preferences than some of the other community-based or group models that have been implemented. As Zimbabwe scales up differentiated treatment models for stable patients, a clear understanding of patient preferences can help in designing services that will ensure optimal utilization and improve the efficiency of service delivery.

Introduction: Zimbabwe is scaling up HIV differentiated service delivery (DSD) to improve treatment outcomes and health system efficiencies. Shifting stable patients into less-intensive DSD models is a high priority in order to accommodate the large numbers of newly-diagnosed people living with HIV (PLHIV) needing treatment and to provide healthcare workers with the time and space needed to treat people with advanced HIV disease. DSD is also seen as a way to improve service quality and enhance retention in care. National guidelines support five differentiated antiretroviral treatment models (DART) for stable HIV-positive adults, but little is known about patient preferences, a critical element needed to guide DART scale-up and ensure person-centered care. We designed a mixed-methods study to explore treatment preferences of PLHIV in urban Zimbabwe., Methods: The study was conducted in Harare, and included 35 health care worker (HCW) key informant interviews (KII); 8 focus group discussions (FGD) with 54 PLHIV; a discrete choice experiment (DCE) in which 500 adult DART-eligible PLHIV selected their preferences for health facility (HF) vs. community location, individual vs. group meetings, provider cadre and attitude, clinic operation times, visit frequency, visit duration and cost to patient; and a survey with the 500 DCE participants exploring DART knowledge and preferences., Results: Patient preferences were consistent in the FGDs, DCE and survey. Participants strongly preferred respectful HCWs, HF-based services, individual DART models, and less costly services. Patients also preferred less frequent visits and shorter wait times. They were indifferent to variations in HCW cadre and distances from home to HF. These preferences were mostly homogenous, with only minor differences between male vs. female and older vs. younger patients. HCWs in the KII correctly characterized facility-based individual models as the one most favored by patients; HCWs also preferred this model, which they felt decongested HFs and reduced their workload., Conclusions: DART-eligible PLHIV in Harare found it relatively easy to access HFs, and preferred attributes associated with facility-based individual models. Prioritizing these for scale-up in urban areas may be the most efficient way to sustain positive patient outcomes and increase health system performance., Competing Interests: The authors have declared that no competing interests exist.

Context: Hospitalized patients with advanced cancer often face complex, preference-sensitive decisions. How clinicians and patients engage in shared decision-making during goals-of-care discussions is not well understood., Objective: The objective of this study was to explore decision-making by patients and clinicians during inpatient goals-of-care discussions., Methods: This is a qualitative study of audio-recorded goals-of-care discussions between hospitalized patients with advanced cancer and their clinicians. Grounded theory was used to analyze transcripts., Results: Sixty-two patients participated in goals-of-care discussions with 51 unique clinicians. Nearly half of patients (n = 30) were female and their mean age was 60.1 years (SD = 12.7). A palliative care attending or fellow was present in 58 of the 62 discussions. Decisions centered on three topics: 1) disease-modifying treatments; 2) hospice; and 3) code status. Clinicians' approach to decision-making included the following stages: "information exchange," "deliberation," "making a patient-centered recommendation," and "wrap-up: decisional status." Successful completion of each stage varied by the type of decision. When discussing code status, clinicians missed opportunities to engage patients in information exchange and to wrap up decisional status. By contrast, clinicians discussing disease-modifying treatments and hospice failed to integrate patient preferences. Clinicians also missed opportunities to make patient-centered recommendations when discussing treatment decisions., Conclusion: Clinicians missed opportunities to facilitate shared decision-making regarding goals of care, and these missed opportunities differed by type of decision being discussed. Opportunities for clinician communication training include engagement in collaborative deliberation with patients and making patient-centered recommendations in situations of high medical uncertainty., (Copyright © 2019. Published by Elsevier Inc.)

Genetic test use in oncology is growing, yet providers' experiences with evolving testing norms and their implications for patient care remain under-explored. In interviews with oncologists and cancer genetics professionals, 22 key informants described the increasing importance of germline results for therapeutic decision-making, preference for ordering tests directly rather than referring, and rapid adoption of cancer gene panels for testing. Implications for informed consent, result interpretation, and patient management were identified. These results suggest concerns raised by the transition of genetic test delivery from cancer genetics professionals to oncologists that must be addressed in practice guidelines and provider training.

Objectives: We describe the evaluation of a system to create hospital progress notes using voice and electronic health record integration to determine if note timeliness, quality, and physician satisfaction are improved., Materials and Methods: We conducted a randomized controlled trial to measure effects of this new method of writing inpatient progress notes, which evolved over time, on important outcomes., Results: Intervention subjects created 709 notes and control subjects created 1143 notes. When adjusting for clustering by provider and secular trends, there was no significant difference between the intervention and control groups in the time between when patients were seen on rounds and when progress notes were viewable by others (95% confidence interval -106.9 to 12.2 min). There were no significant differences in physician satisfaction or note quality between intervention and control., Discussion: Though we did not find support for the superiority of this system (Voice-Generated Enhanced Electronic Note System [VGEENS]) for our 3 primary outcomes, if notes are created using voice during or soon after rounds they are available within 10 min. Shortcomings that likely influenced subject satisfaction include the early state of our VGEENS and the short interval for system development before the randomized trial began., Conclusion: VGEENS permits voice dictation on rounds to create progress notes and can reduce delay in note availability and may reduce dependence on copy/paste within notes. Timing of dictation determines when notes are available. Capturing notes in near-real-time has potential to apply NLP and decision support sooner than when notes are typed later in the day, and to improve note accuracy., (© The Author(s) 2018. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Importance: Clinician miscommunication contributes to an estimated 250 000 deaths in US hospitals per year. Efforts to standardize handoff communication may reduce errors and improve patient safety., Objective: To determine the effect of a standardized handoff curriculum, UW-IPASS, on interclinician communication and patient outcomes., Design, Setting, and Participants: This cluster randomized stepped-wedge randomized clinical trial was conducted from October 2015 to May 2016 at 8 medical and surgical intensive care units at 2 hospital systems within an academic tertiary referral center. Participants included residents, fellows, advance-practice clinicians, and attending physicians (n = 106 clinicians, with 1488 handoff events over 8 months) and data were collected from daily text message-based surveys and patient medical records., Exposures: The UW-IPASS standardized handoff curriculum., Main Outcomes and Measures: The primary aim was to assess the effect of the UW-IPASS handoff curriculum on perceived adequacy of interclinician communication. Patient days of mechanical ventilation, intensive care unit length of stay, reintubations within 24 hours, and order workflow patterns were also analyzed. Mixed-effects logistic regression was used to compute odds ratios and confidence intervals with adjustment for location, time period, and clinician., Results: A total of 63 residents and advance practice clinicians, 13 fellows, and 30 attending physicians participated in the study. During the control period, clinicians reported being unprepared for their shift because of a poor-quality handoff in 35 of 343 handoffs (10.2%), while UW-IPASS-period residents reported being unprepared in 53 of 740 handoffs (7.2%) (odds ratio, 0.19; 95% CI, 0.03-0.74; P = .03). Compared with the control phase, the perceived duration of handoffs among clinicians using UW-IPASS was unchanged (+5.5 minutes; 95% CI, 0.34-9.39; P = .30). Early morning order entry decreased from 106 per 100 patient-days in the control phase to 78 per 100 patient-days in the intervention period (-28 orders; 95% CI, -55 to -4; P = .04). Overall, UW-IPASS was not associated with any changes in intensive care unit length of stay, duration of mechanical ventilation, or the number of reintubations., Conclusions and Relevance: The UW-IPASS standardized handoff curriculum was perceived to improve intensive care provider preparedness and workflow. IPASS-based curricula represent an important step forward in communication standardization efforts and may help reduce communication errors and omissions., Trial Registration: isrctn.org Identifier: ISRCTN14209509.