Anna E. Church

Patient and provider priorities for self-reported domains of HIV clinical care.

We sought to understand how HIV-infected patients, their providers, and HIV care researchers prioritize self-reported domains of clinical care. Participants rank-ordered two lists of domains. A modified Delphi process was used for providers and researchers. Approximately 25% of patients were interviewed to discuss rationale for rank order choices. List 1 included anger, anxiety, depression, fatigue, physical function, pain, and sleep disturbance. List 2 included alcohol abuse, cognitive function, HIV stigma, HIV and treatment symptoms, medication adherence, positive affect, sexual risk behavior, sexual function, social roles, spirituality/meaning of life, and substance abuse. Seventy-four providers, 80 HIV care researchers, and 66 patients participated. Patients ranked context-based domains, such as HIV stigma, more highly than providers, while health behaviors, such as drug or alcohol use, ranked lower. Patients described a need to address wider-context challenges such as HIV stigma in order to positively impact health behaviors. Divergent patient and provider priorities highlight the importance of incorporating views from all stakeholders and suggests the need for a care approach that more effectively addresses contextual barriers to adverse health behaviors.

A Comparison of Adherence Timeframes Using Missed Dose Items and Their Associations with Viral Load in Routine Clinical Care: Is Longer Better?

Questions remain regarding optimal timeframes for asking about adherence in clinical care. We compared 4-, 7-, 14-, 30-, and 60-day timeframe missed dose items with viral load levels among 1099 patients on antiretroviral therapy in routine care. We conducted logistic and linear regression analyses examining associations between different timeframes and viral load using Bayesian model averaging (BMA). We conducted sensitivity analyses with subgroups at increased risk for suboptimal adherence (e.g. patients with depression, substance use). The 14-day timeframe had the largest mean difference in adherence levels among those with detectable and undetectable viral loads. BMA estimates suggested the 14-day timeframe was strongest overall and for most subgroups although findings differed somewhat for hazardous alcohol users and those with current depression. Adherence measured by all missed dose timeframes correlated with viral load. Adherence calculated from intermediate timeframes (e.g. 14-day) appeared best able to capture adherence behavior as measured by viral load.ResumenAún hay preguntas pendientes relacionadas con los períodos de tiempo óptimos para preguntar sobre el cumplimiento en la atención clínica. Comparamos períodos de tiempo de 4, 7, 14, 30 y 60 días de dosis omitidas de elementos con niveles de carga viral entre 1099 pacientes sometidos a terapia antirretroviral en la atención de rutina. Llevamos a cabo análisis de regresión logística y lineal para examinar relaciones entre distintos períodos de tiempo y cargas virales con el Promediado Bayesiano de Modelos (BMA, por sus siglas en inglés). Llevamos a cabo análisis de sensibilidad con subgrupos de riesgo incrementado de cumplimiento inferior al óptimo (por ejemplo, pacientes con depresión, consumo de drogas). El período de tiempo de 14 días mostró la diferencia media más importante en los niveles de cumplimiento entre los períodos de tiempo con cargas virales perceptibles e imperceptibles. Los cálculos del BMA sugieren que el período de tiempo de 14 días fue el más predominante entre todos y en la mayoría de los subgrupos, aunque los hallazgos difieren un tanto para los consumidores peligrosos de alcohol y las personas que actualmente presentan depresión. El cumplimiento medido para todos los períodos de tiempo de dosis omitidas se correlacionaron con la carga viral. El cumplimiento calculado de períodos de tiempo intermedios (por ejemplo, 14 días) pareció capturar de mejor forma la conducta de cumplimiento, de acuerdo con lo medido por carga viral.

Effects of testosterone replacement on cognition in men with low testosterone levels and mild cognitive impairment

Background: The ADAS-Cog is widely used in AD clinical trials and administered repeatedly during 18-month trials. The ADAS-Cog score decline s by an average of 4.3 to 9.1 points in mild to moderate AD clinical trials over 18-month trials (Schneider and Sano 2009). There has not been systematic investigation into the 11 items that comprise the total ADAS-Cog score and how performance on each item changes over this time period.Methods: Data from the 11-item ADAS-Cog from four ADCS-sponsored trials was examined at baseline, month 6, month 12 and month 18. The average score for each item at each visit was recorded, as well as the individual components that comprise each item. Results: Across the four trials, the ADASCog was administered at baseline (n 1⁄4 2007), month 6 (n 1⁄4 1777), month 12 (n1⁄4 1650), andmonth 18 (n1⁄4 1523). The score onmany individual tasks remained relatively consistent across 18 months for many items and worsened noticeably for others. Items with less than or equal to a 3% increase in the number of subjects unable to complete the task over 18 months include “Make a Fist,” drawing the circle, cube, and naming the middle finger, ring finger and tongs. Orientation test items showed the largest decline with at least 8%more patients making an error in performance on each of the following: month, date, year, day, season, and time of day compared to baseline. Conclusions: While the ADAS-Cog score reliably declined but to a variable extent over 18 months, decline on individual items varied widely, and the orientation items contributed most to the change. Identifying errors on specific items provides information on the pattern of and contributors to change on the ADAS-Cog. The orientation items contributed substantially more to the decline in ADAS-Cog total score. Further investigations will include whether decline in performance on individual items varies by MMSE strata and education.