Anish P. Mahajan

Stigma in the HIV/AIDS epidemic: A review of the literature and recommendations for the way forward

Although stigma is considered a major barrier to effective responses to the HIV/AIDS epidemic, stigma reduction efforts are relegated to the bottom of AIDS programme priorities. The complexity of HIV/AIDS-related stigma is often cited as a primary reason for the limited response to this pervasive phenomenon. In this paper, we systematically review the scientific literature on HIV/AIDS-related stigma to document the current state of research, identify gaps in the available evidence and highlight promising strategies to address stigma. We focus on the following key challenges: defining, measuring and reducing HIV/AIDS-related stigma as well as assessing the impact of stigma on the effectiveness of HIV prevention and treatment programmes. Based on the literature, we conclude by offering a set of recommendations that may represent important next steps in a multifaceted response to stigma in the HIV/AIDS epidemic.

Development and Psychometric Assessment of a Multidimensional Measure of Internalized HIV Stigma in a Sample of HIV-positive Adults

There is a need for a psychometrically sound measure of the stigma experienced by diverse persons living with HIV/AIDS (PLHA). The goal of this study was to develop and evaluate a multidimentional measure of internalized HIV stigma that captures stigma related to treatment and other aspects of the disease among sociodemographically diverse PLHA. We developed a 28-item measure of internalized HIV stigma composed of four scales based on previous qualitative work. Internal consistency reliability estimates in a sample of 202 PLHA was 0.93 for the overall measure, and exceeded 0.85 for three of the four stigma scales. Items discriminated well across scales, and correlations of the scales with shame, social support, and mental health supported construct validity. This measure should prove useful to investigators examining in the role of stigma in HIV treatment and health outcomes, and evaluating interventions designed to mitigate the impacts of stigma on PLHA.

Consistency of state statutes with the Centers for Disease Control and Prevention HIV testing recommendations for health care settings.

Timely HIV testing persists as a major public health challenge in the United States. Of the more than 1 million persons in the United States who are infected with HIV, 300000 are unaware of their HIV seropositivity (1). These persons tend to receive HIV testing late in the course of the disease (2) and unknowingly infect others, which accounts for most new HIV infections (3). Over the past decade, Centers for Disease Control and Prevention (CDC) recommendations have evolved from risk-assessmentbased testing to routine voluntary counseling and testing for all adults in all health care settings. Despite the revised guidelines, low HIV screening rates persist (4). According to providers, barriers to screening include the written informed consent process, time constraints of the patient encounter, and discomfort with discussing HIV risk behavior (5, 6). Patient-level barriers include low self-perceived risk and fear of stigmatization (7). Because of such barriers, missed opportunities for earlier diagnosis of HIV infection are common (8, 9). In September 2006, the CDC recommended a new paradigm for HIV testing: opt-out HIV screening for all patients in all health care settings (1). In the CDCs version of opt-out testing, the provider notifies the patient that HIV testing will be performed and offers the patient the opportunity to ask questions and to decline testing. In this paradigm, separate written consent and prevention counseling are not required for HIV testing. The target population for screening is all patients age 13 to 64 years who present to emergency departments, primary care, and other health care settings. Expanding on the 2001 recommendations for HIV testing of pregnant women (10), the 2006 recommendations specifically advocate opt-out screening, stipulating that HIV testing be included in the panel of routine prenatal screening tests. Although not without controversy (1114), the shift to opt-out screening is intended to expand HIV testing by destigmatizing the testing process and ameliorating provider- and patient-level barriers. Although these recommendations represent an opportunity to increase HIV screening, the potential for state laws to enable or obstruct implementation of the recommendations is not well understood. Existing literature on laws that relate to HIV testing provides a limited summary of the types of state laws that may conflict with routine HIV testing (15, 16) or focuses on federal law that may have ramifications for opt-out HIV testing (17). No state-by-state analysis of whether implementation of the CDC recommendations is consistent with state statutes has been published. Furthermore, the literature uses an inaccurately broad understanding of opt-out testing rather than the specific CDC recommendations for opt-out HIV screening. This has led to interpretive errors and the inaccurate generalization that state laws are incompatible with implementation of the recommendations. To offer policymakers and providers a comprehensive analysis, we performed a state-by-state review of all statutes pertaining to HIV testing and systematically assessed the compatibility of these laws with the new recommendations. We developed criteria for classifying state statutory frameworks as consistent, neutral, or inconsistent with the new recommendations and evaluated the implications for implementation of the recommendations in these various legal contexts. We examined HIV testing statutes during the 2 years after release of the 2006 CDC recommendations to capture new laws and legislative trends. Methods The 2006 CDC Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-care Settings (1) contain substantive changes to 3 components of the standard HIV testing process: consent for testing, pre- and posttest counseling, and method of offering screening to adults and pregnant women. To enable a detailed assessment of state law consistency with the CDC recommendations, we first recorded the key features of the recommendations within each of these components, including the specific, CDC-provided definitions of such terms as opt-out screening, informed consent, and HIV prevention counseling. We then systematically identified all state statutes pertaining to HIV testing in the 50 states and Washington, DC, by using the legal search engines LexisNexis and Westlaw (see Appendix for search strategy). We performed a systematic survey of laws at 6, 12, and 24 months after the September 2006 release of the recommendations. After the survey, we reviewed the statutes for their relevance to each of the 3 testing components addressed by the CDC recommendations. If we deemed a statute relevant, we assessed its language to determine the extent to which it permitted, obstructed, or was silent on the implementation of the testing component recommendation in question. We classified laws that permitted or promoted implementation as consistent with the testing component recommendation, laws that were barriers to implementation as inconsistent, and laws that were silent about or neither conformed to nor conflicted with the testing component recommendation as neutral. To summarize a states entire statutory framework, we developed criteria for classifying it as consistent, neutral, or inconsistent with the CDC recommendations. We classified a state statutory framework as consistent if any of its laws were consistent with either the consent, counseling, or prenatal provisions and it had no laws that were inconsistent with any of these provisions. We classified a statutory framework in which all laws were neutral on each of the 3 CDC provisions as neutral and a framework with 1 or more laws that were inconsistent with 1 or more of the 3 provisions as inconsistent. Results Adult Consent for Testing According to the recommendations (1), a patient should be provided oral or written information about the test and the opportunity to ask questions and to decline testing, and with such notification, consent for HIV screening should be incorporated into the patients general informed consent for medical care. The statutory requirements for obtaining consent and the degree to which statutes were consistent with the consent provision of the recommendations varied considerably (Table 1) (1853). Table 1. State HIV Testing Laws Pertaining to Consent and Counseling in Health Care Settings Pre- and Posttest Counseling The recommendations state that personalized and interactive HIV risk reduction counseling should not be required for any patients at the time of testing; patients at high risk should instead be offered such counseling through referral. The recommendations do require the provision of pretest information, a step considered a key component of, or sometimes entirely constitutive of, pretest counseling by some state laws. The CDC defines pretest information as oral or written information that includes an explanation of HIV infection and the meanings of positive and negative test results. The recommendations state that negative test results may be conveyed without direct personal contact between patient and provider and that posttest counseling is not required. For positive results, the recommendations require communication of the result through personal contact along with efforts to ensure linkage to venues that provide HIV care and counseling. Table 1 presents the statutory requirements for counseling. Method of Offering Screening to Adults and Pregnant Women The CDC defines an opt-out screening process as informing a patient orally or in writing that HIV testing will be performed unless they decline. Opt-out screening is intended for all patients, including pregnant women during prenatal care and at labor and delivery, who do not have a documented negative test result. State consistency with these recommendations varied (Table 2) (5472). Table 2. State HIV Testing Laws Pertaining to Screening and Consent for Pregnant Women in Health Care Settings Overall Consistency of Each States Statutory Framework The Figure depicts the consistency of each states statutory framework. In the 16 states that were inconsistent, implementation of 1 or more of the 3 new provisions of the recommendations would not be possible without amendment of existing laws. Laws in the 20 states that were neutral neither promoted nor obstructed the 3 provisions. Among the 15 states that were consistent, 9 had laws that were in agreement with all 3 of the provisions and 6 had laws that were in agreement with 1 or 2 of the provisions and were neutral on the others. Figure. Consistency of state statutory frameworks with the Centers for Disease Control and Preventions revised recommendations for HIV testing in health care settings. As of 1 November 2008, 16 states have at least 1 law that is a barrier to implementation (inconsistent), 20 state statutory frameworks are silent on or do not conform to or contradict each of the provisions of the recommendations (neutral), and 15 states have laws that are consistent with 1 or more provisions of the recommendations and no law that is a barrier (consistent). In the 2 years since the release of the CDC recommendations, 9 states had passed laws that moved them from the inconsistent to consistent category and 2 others passed laws that moved them from neutral to consistent. No state passed new legislation to move in a less consistent direction. Discussion In the national discussion about how best to perform routine HIV screening in accordance with CDC recommendations, state law is often identified as a barrier to implementation. In this systematic review and analysis, we found that 34 states and Washington, DC, have statutory frameworks that are consistent with or neutral to the CDC recommendations. From a state statutory perspective, implementation of the recommendations is permissible in these states. Sixteen states have statutory frameworks that are inconsistent with the recommendati

Enhancing Dissemination, Implementation, and Improvement Science in CTSAs through Regional Partnerships

Challenges in healthcare policy and practice have stimulated interest in dissemination and implementation science. The Institute of Medicine Committee on the Clinical Translational Science Award (CTSA) program recommended expanding the CTSA programs investment and activity in this domain. Guidance is needed to facilitate successful growth of DII science infrastructure, activity and impacts.

Health Information Exchange—Obvious Choice or Pipe Dream?

Electronic health information exchange allows physicians and hospitals to access and share clinical data for individual patients with other health care personnel when and where these data are needed and across organizational and geographic boundaries. The timely exchange of electronic information, such as clinical summaries, laboratory results, radiology reports, and medication lists, may improve patient safety and outcomes, increase the efficiency of care, and prevent the unnecessary duplication of tests. The delivery and payment reform engendered in Medicare and Medicaid by the Affordable Care Act are incentives for the coordination of care across diverse locations, which also benefits from the efficient exchange of health information. In recent years, billions of dollars have been invested in developing technical standards for health information exchanges, providing incentives for their adoption, creating a national infrastructure for them, and supporting the organizations that operate them. Nonetheless, the meaningful and widespread exchange of health information is frequently viewed as a pipe dream. Despite the intuitive appeal of health information exchanges and the substantial investments already made in them, their future is at best unsure. It remains uncertain whether the theoretical benefits of health information exchanges can actually be achieved. The concerns about their viability include the business sustainability of organizations that operate exchanges, the lack of interoperability of electronic health record (EHR) systems, difficulties in physicians’ adoption of such systems, data security, and the perception among hospitals that their participation in an exchange may pose the risk of their losing their patient market share to competitors. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provided the financial incentives for the adoption of EHR systems that enable the exchange of electronic health information. Through the Medicare and Medicaid EHR Incentive Programs for the meaningful use of certified EHR technology, and a

Applying appropriate-use criteria to cardiac revascularisation in India

600 million investment in organizations that operate exchanges, HITECH provided incentives for the exchange of health information but did not specify how it should occur.1 Moreover, the initial criteria for meaningful use limited its focus to e-prescribing, electronic exchange of laboratory results, and electronic transmission of summary-of-care documents for at least 10% of transitions of patient care from one setting to another. The result has been a proliferation of exchange efforts that range from minimally meeting meaningful use requirements to broader and more ambitious exchanges of clinical information to achieve larger sets of objectives. National survey data from 2014 indicate that 76% of hospitals report exchanging health information with ambulatory care clinics and facilities and with other hospitals outside their own organizations, constituting an increase from 41% in 2008.2 About two-thirds of these hospitals reported exchanging laboratory results, clinical care summaries, and radiology reports with outside physicians and facilities.2 Although these self-reported hospital survey data are encouraging, a business rationale for a health information exchange requires a demonstration of its effects on clinical care as well as its improvement of patient outcomes and efficiencies of care. Two recent systemic reviews provide some clues, but mainly highlight the limitations of the literature with regard to these objectives.3,4 Most studies of the association of health information exchange initiatives with outcomes have found modest to moderate reductions in repeated diagnostic and imaging tests and associated costs. These findings were predominantly for emergency departments, but represented low-quality evidence because of study design and being based only on about 10 exchanges.3 Among 21 studies examining the use of health information exchanges by physicians and other care providers, use was very low, ranging from 2% to 10% of total patient encounters.3 Most studies of health information exchanges have been done when exchanges were still in their infancy and having limited numbers of local hospitals and clinics that shared key data, thereby diminishing the overall value of these exchanges to prospective physician users. Contextual and implementation factors related to the initiation and promotion of health information exchanges have not been fully accounted for.3 Clear understanding by hospital and medical group executives of the value-proposition for a health information exchange, its acceptance by physician staff leaders, and the training of physicians in how to incorporate it into their workflows affect the adoption and effectiveness of such exchanges. In addition, the literature has focused on firstgeneration technologies, such as direct messaging and query-based exchange, in which physicians must find and request information about a patient, usually from a web-based portal that is not a part of their EHRs system. The functionality of an advanced health information exchange permits active data integration and the incorporation of user-subscribed notifications. With active integration, a physician can easily pull data about a specific patient from an exchange database into an EHR system and readily access and view these data as part of the usual information workflow about the patient. With usersubscribed notifications, physicians can receive email alerts triggered in real time when their patients visit the emergency department or are admitted to the hospital. Such notifications facilitate and promote the use of VIEWPOINT

Developing Occupation-Based Preventive Programs for Late-Middle-Aged Latino Patients in Safety-Net Health Systems.

Objectives The high prevalence of coronary heart disease and dramatic growth of cardiac interventions in India motivate an evaluation of the appropriateness of coronary revascularisation procedures in India. Although, appropriate-use criteria (AUC) have been used to analyse the appropriateness of cardiovascular care in the USA, they are yet to be applied to care in India. In our study, we apply AUC to cardiac care in Karnataka, India, compare our results to international applications of AUC, and suggest ways to improve the appropriateness of care in India. Setting Data were collected from the Vajpayee Arogyashree Scheme, a government-sponsored health insurance scheme in Karnataka, India. These data were collected as part of the preauthorisation process for cardiac procedures. Participants The final data included a random sample of 600 patients from 28 hospitals in Karnataka, who obtained coronary artery bypass grafting or percutaneous coronary intervention between 1 October 2014 and 31 December 2014. Primary and secondary outcome measures We obtained our primary baseline results using a random imputation simulation to fill in missing data. Our secondary outcome measure was a best case–worst case scenario where missing data were filled to give the lowest or highest number of appropriate cases. Results Of the cases, 86.7% (CI 0.837% to 0.892%) were deemed appropriate, 3.65% (CI 0.023% to 0.055%) were inappropriate and 9.63% (CI 0.074% to 0.123%) were uncertain. Conclusions The vast majority of cardiac revascularisation procedures performed on beneficiaries of a government-sponsored insurance programme in India were found to be appropriate. These results meet or exceed levels of appropriate use of cardiac care in the USA.

Work hour restrictions and internal medicine residents’ health-related quality of life

Latino adults between ages 50 and 60 yr are at high risk for developing chronic conditions that can lead to early disability. We conducted a qualitative pilot study with 11 Latinos in this demographic group to develop a foundational schema for the design of health promotion programs that could be implemented by occupational therapy practitioners in primary care settings for this population. One-on-one interviews addressing routines and activities, health management, and health care utilization were conducted, audiotaped, and transcribed. Results of a content analysis of the qualitative data revealed the following six domains of most concern: Weight Management; Disease Management; Mental Health and Well-Being; Personal Finances; Family, Friends, and Community; and Stress Management. A typology of perceived health-actualizing strategies was derived for each domain. This schema can be used by occupational therapy practitioners to inform the development of health-promotion lifestyle interventions designed specifically for late-middle-aged Latinos.

Clinical Uncertainties, Health Service Challenges, and Ethical Complexities of HIV “Test-and-Treat”: A Systematic Review

Work hour restrictions in medical training emerged because of safety concerns, and also were expected to enhance residents’ health-related quality of life (HRQOL). Despite these expectations, there is little objective evidence. While there has been considerable evaluation of the effect of work hour restrictions, an evaluation of its impact on HRQOL among internal medicine residents has not been reported. Internal medicine residents at a single training site were surveyed using a preand postsurvey study design. Residents were asked about their training and HRQOL before and after the nationwide policy was implemented to reduce resident work hours to no more than 80 hours per week averaged over four weeks. We administered the SF-12 survey, a standardized survey measuring HRQOL with published nationally representative norms (1), one month before (June 2003) and one year after (June 2004) the institution of work hour restrictions. We also asked residents the number of hours that they slept and worked during each of the seven days prior to the administration of the survey. Demographic information such as gender and post-graduate education level were collected in the survey. IRB approval (#G03-05-077-01) was obtained and residents returned the survey on a voluntary basis. Forty-seven residents (64% response) completed the survey before and 70 residents (74% response) after implementation of work hour restrictions. Age (overall mean 28.7 years) and gender (57% male) were similar between samples, but prerestriction respondents were assigned fewer inpatient rotations and included fewer interns. Work and sleep hours did not change after the work hour rule. SF-12 Physical Component Summary (PCS) scores were identical before and after (mean1⁄4 58) restrictions, and higher than the average score for the 20–29 year old general U.S. population. SF-12 Mental Component Summary (MCS) scores before (mean1⁄4 50) and after (mean1⁄4 49) restrictions were similar to the U.S. population. Multivariate analysis controlling for type of rotation, gender, age, and post-graduate year of training did not show improvements in the SF-12 MCS or PCS after work hour restrictions. Although this evaluation is limited by small sample size and uneven pre and post samples, resident work hours did not decrease and HRQOL did not improve with work hour restrictions. HRQOL measurements are a useful way for monitoring resident function and well-being.