Anthony K. Wutoh

Assessment and predictors of antiretroviral adherence in older HIV-infected patients.

Summary: Advances in the diagnosis and treatment of HIV disease have resulted in increased survival for HIV‐infected patients. Strict adherence to antiretroviral therapy is required to obtain these benefits, however. This holds true for older patients who often are diagnosed later in their disease course and who have shorter survival periods than younger patients. Although there have been few studies of antiretroviral adherence in older HIV patients, this article reviews the literature regarding antiretroviral adherence in younger HIV‐infected adults as well as studies of medication adherence in older patients with other disease states. It then discusses the application of adherence interventions in these other populations to older HIV‐infected adults. Several methods have been used in measuring antiretroviral adherence, including electronic monitoring, self‐report, pill counts, viral load, therapeutic drug monitoring, and several other techniques. The advantages and disadvantages of these methods also are presented as well as recommendations for future adherence research in older HIV‐infected adults. Finally, this article details areas of unmet research need concerning HIV medication adherence in older adults.

Off-label prescribing patterns of antidepressants in children and adolescents.

To understand the extent of off‐label prescribing among pediatrics, the study assesses the prescribing patterns of antidepressants in ambulatory settings.

HIV Knowledge and Sexual Risk Behaviors of Street Children in Takoradi, Ghana

A pilot survey was conducted among 100 street children aged 11–19 years and data collected regarding HIV knowledge, risk behaviors, home and sexual experiences, and factors that contributed to their relocation to the street environment. Data indicated that 80% of the street children had at least minimal knowledge of HIV and 54% perceived themselves to be at risk for contracting HIV. More than three-fourths of the females, and over half of the boys reported ever having sex. There were significant differences between males and females for sexual activity, physical and sexual abuse, and prostitution, as girls were more likely to be sexually active, physically abused, and involved in prostitution.

Malignancies in HIV: Pre- and Post-Highly Active Antiretroviral Therapy

OBJECTIVES A study was conducted at a large metropolitan tertiary-care teaching hospital to investigate the incidence of cancers among HIV-infected patients over a 13-year period. DESIGN Retrospective cohort study. METHODS A retrospective cohort study was conducted among HIV-infected patients diagnosed with cancer between January 1990 and December 2003 at a large metropolitan teaching hospital. Any HIV-infected patient who also had a confirmed diagnosis of Kaposis sarcoma, primary central nervous system lymphoma, invasive cervical cancer or non-Hodgkins lymphoma was categorized as having AIDS-defining cancer (ADC) according to the CDCs initial case definition for AIDS, while patients with other malignancies were classified as having non-ADCs. A clinical database was created consisting of HIV patients diagnosed with cancer at this teaching hospital, and data were abstracted for the current project. RESULTS A total of 203 HIV-infected patients diagnosed with cancer were identified during the study period. Ninety-three cases occurred before 1995 and 110 after 1996. The median age of patients (at cancer diagnosis) in the era before highly active antiretroviral therapy (HAART) was 37 years and in the post-HAART era was 43 years (p<0.05). Mean CD4 count at cancer diagnosis in the pre-HAART era was 101 cells/mm3, and 183 cells/mm3 in the post-HAART period (p<0.05). Six patients had diagnoses of both ADC and NADC during the study period. Of the 197 remaining cases, 129 (65.4%) were ADCs and 68 (34.6%) were NADCs (p<0.05). The incidence of Kaposis sarcoma decreased significantly, while the incidence of lung cancer increased significantly. CONCLUSIONS Of 197 patients with a single diagnosis of either ADC or NADC, there was statistically a larger proportion of NADC cases diagnosed in the post-HAART period compared to the pre-HAART period. The number of ADC diagnoses decreased between the pre- and post-HAART period.

Association between Lifestyle Factors and Metabolic Syndrome among African Americans in the United States

Background. Although there is a reported association between lifestyle factors and metabolic syndrome, very few studies have used national level data restricted to the African Americans (AAs) in the United States (US). Methods. A cross-sectional evaluation was conducted using the National Health and Nutrition Examination Survey from 1999 to 2006 including men and nonpregnant women of 20 years or older. Multiple logistic regression models were constructed to evaluate the association between lifestyle factors and metabolic syndrome. Results. AA women had a higher prevalence of metabolic syndrome (39.43%) than AA men (26.77%). After adjusting for sociodemographic factors, no significant association was found between metabolic syndrome and lifestyle factors including alcohol drinking, cigarette smoking, and physical activity. Age and marital status were significant predictors for metabolic syndrome. With increase in age, both AA men and AA women were more likely to have metabolic syndrome (AA men: ORadj = 1.05, 95% CI 1.04–1.06, AA women: ORadj = 1.06, 95% CI 1.04–1.07). Single AA women were less likely to have metabolic syndrome than married women (ORadj = 0.66, 95% CI 0.43–0.99). Conclusion. Lifestyle factors had no significant association with metabolic syndrome but age and marital status were strong predictors for metabolic syndrome in AAs in the US.

Long-Term Effect of the Women's Health Initiative Study on Antiosteoporosis Medication Prescribing

AIM To describe long-term prescribing patterns of osteoporosis therapy before and after the Womens Health Initiative (WHI) publication. METHODS We conducted a time-series analysis from 1997 to 2005 using nationally representative data based on office-based physician and hospital ambulatory clinic visits. Bivariate and multivariable analyses were conducted using chi-square tests and logistic regression, respectively, and trends in the prevalence of osteoporosis therapies were evaluated per 6-month (semiannual) intervals. Linear regression and graphic techniques were used to determine statistical differences in the prevalence trends between the two periods. RESULTS Overall prevalence of therapeutic or preventive osteoporosis therapy was similar between the WHI periods. However, a significant decrease in estrogen therapy and increases in bisphosphonates, calcium/vitamin D were observed in the period after the WHI publication (p < 0.05). Multiple logistic regression analysis showed older age and white race were associated with a higher likelihood of antiosteoporosis medication (AOM) prescription, and Medicaid insurance type was associated with a lower likelihood of an AOM prescription. Excluding calcium/vitamin D, nonestrogen therapy was more likely to be prescribed in the after-WHI period (office-based physician clinic: [adjusted OR, aOR] 2.49 [2.04-4.04]; hospital-based clinic: aOR 2.42 [1.67-7.50]) Nonestrogen therapy was more prevalent in visits made by older women, women of white race, women with contraindicated conditions for estrogen therapy, and women from the Northeast region. CONCLUSIONS After the WHI publication, the overall prevalence of osteoporosis therapy did not change; however, a shift from estrogen to nonestrogen therapy was observed after the WHI publication. Black women were less likely to receive nonestrogen antiosteoporosis therapy in hospital-based clinics.

The Incidence and Types of Medication Errors in Patients Receiving Antiretroviral Therapy in Resource-Constrained Settings

Purpose This study assessed the incidence and types of medication errors, interventions and outcomes in patients on antiretroviral therapy (ART) in selected HIV treatment centres in Nigeria. Methods Of 69 health facilities that had program for active screening of medication errors, 14 were randomly selected for prospective cohort assessment. All patients who filled/refilled their antiretroviral medications between February 2009 and March 2011 were screened for medication errors using study-specific pharmaceutical care daily worksheet (PCDW). All potential or actual medication errors identified, interventions provided and the outcomes were documented in the PCDW. Interventions included pharmaceutical care in HIV training for pharmacists amongst others. Chi-square was used for inferential statistics and P<0.05 indicated statistical significance. Results Of 6,882 participants, 67.0% were female and 93.5% were aged ≥15years old. The participants had 110,070 medications filling/refilling visits, average (±SD) of 16.0 (±0.3) visits per patient over the observation period. Patients were followed up for 9172.5 person-years. The number of drug items dispensed to participants was 305,584, average of 2.8 (±0.1) drug items per patient. The incidence rate of medication errors was 40.5 per 100 person-years. The occurrence of medication errors was not associated with participants’ sex and age (P>0.05). The major medications errors identified were 26.4% incorrect ART regimens prescribed; 19.8% potential drug-drug interaction or contraindication present; and 16.6% duration and/or frequency of medication inappropriate. Interventions provided included 67.1% cases of prescriber contacted to clarify/resolve errors and 14.7% cases of patient counselling and education; 97.4% of potential/actual medication error(s) were resolved. Conclusion The incidence rate of medication errors was somewhat high; and majority of identified errors were related to prescription of incorrect ART regimens and potential drug-drug interactions; the prescriber was contacted and the errors were resolved in majority of cases. Active screening for medication errors is feasible in resource-limited settings following a capacity building intervention.

Pilot Study to Assess HIV Knowledge, Spirituality, and Risk Behaviors Among Older African Americans

A pilot study was conducted in anticipation of implementation of a larger project to assess human immunodeficiency virus (HIV) risk behaviors among older African Americans. A cross-sectional methodology was employed, including 33 African Americans aged more than 50 years in the metropolitan Washington, DC, area. The average age of the participants was 66 years old, with an age range from 51 to 86 years. Data were collected utilizing previously validated instruments that were administered using an audio computer-assisted survey instrument. There was relatively high knowledge regarding HIV, with female participants scoring significantly higher compared to male participants (p=.003). Another specific finding of the preliminary study was the association between higher levels of spirituality and lower levels of HIV sexual risk behaviors (Spearmans correlation=-0.369, p=.035). Results of this pilot study suggest that older African American females may be more knowledgeable regarding HIV than older African American males. This may suggest that educational and behavioral interventions developedfor this group may need to be structured based upon the targeted gender of the audience. The association between increased spirituality and decreased risk behaviors may suggest that spiritually-based interventions may provide some benefit regarding reduction of HIV risk behaviors in this population. However, the small sample size in this study warrants caution in the conclusions and highlights the need for further research in this population.

Osteoporosis pharmacotherapy and counseling services in US ambulatory care clinics: Opportunities for multidisciplinary interventions

OBJECTIVE This study was conducted to assess rates and predictors of osteoporosis management with medication or nonmedication therapy, and to compare rates of medication and nonmedication therapy in office-based and hospital-based ambulatory care settings in the United States. METHODS This cross-sectional study included data on all ambulatory office visits made by patients aged >or=60 years in 2000-2005 in 2 national survey databases representing US ambulatory clinics. Visits with and without a record of anti-osteoporosis medication were identified, and bivariate and multivariate analyses were performed to determine predictive factors for receipt of medication or nonmedication therapy for the prevention and treatment of osteoporosis. RESULTS During 2000-2005, visits by patients with a diagnosis of osteoporosis or fragility fracture represented <2% of all visits in office- and hospital-based ambulatory care settings. Medication therapy for osteoporosis was documented in 53.2% of these visits, and nonmedication therapy was documented in 31.5%. The most frequently prescribed drug class was bisphosphonates (36.0%), followed by calcium and vitamin D supplementation (23.9%). The most commonly used nonmedication therapies were exercise (16.7%) and diet/nutrition counseling (19.4%). Rates of medication therapy did not differ significantly by ambulatory care setting. However, visits to hospital-based clinics were significantly less likely than visits to office-based clinics to involve nonmedication therapy (adjusted odds ratio [OR] = 0.6; 95% CI, 0.5-0.9; P = 0.004). Compared with visits by women, visits by men were significantly less likely to involve medication therapy (adjusted OR = 0.6; 95% CI, 0.4-0.9; P = 0.013), nonmedication therapy (adjusted OR = 0.3; 95% CI, 0.2-0.6; P < 0.001), or any therapy (adjusted OR = 0.4; 95% CI, 0.3-0.6; P<0.001). Patients aged >or=80 years were significantly less likely to receive nonmedication therapy than were those aged 60 to 69 years (adjusted OR = 0.6; 95% CI, 0.4-0.9; P = 0.023). Visits by patients with public insurance were significantly less likely to involve medication therapy than visits by patients with other sources of payment (adjusted OR = 0.7; 95% CI, 0.5-1.0; P = 0.040). No difference in the prevalence of any type of therapy was observed in relation to race. CONCLUSIONS Based on the prevalence of medication and nonmedication therapies, levels of osteoporosis care did not differ by ambulatory care setting. However, patterns of care varied by certain visit characteristics, including insurance type, age, and sex.

Improving pharmacy practice through public health programs: experience from Global HIV/AIDS initiative Nigeria project.

BackgroundThe use of medicines is an essential component of many public health programs (PHPs). Medicines are important not only for their capacity to treat and prevent diseases. The public confidence in healthcare system is inevitably linked to their confidence in the availability of safe and effective medicines and the measures for ensuring their rational use. However, pharmacy services component receives little or no attention in most public health programs in developing countries. This article describes the strategies, lessons learnt, and some accomplishments of Howard University Pharmacists and Continuing Education (HU-PACE) Centre towards improving hospital pharmacy practice through PHP in Nigeria.MethodIn a cross-sectional survey, 60 hospital pharmacies were randomly selected from 184 GHAIN-supported health facilities. The assessment was conducted at baseline and repeated after at least 12 months post-intervention using a study-specific instrument. Interventions included engagement of stakeholders; provision of standards for infrastructural upgrade; development of curricula and modules for training of pharmacy personnel; provision of job aids and tools amongst others. A follow-up hands-on skill enhancement based on identified gaps was conducted. Chi-square was used for inferential statistics. All reported p-values were 2-tailed at 95% confidence interval.ResultsThe mean duration of service provision at post-intervention assessment was 24.39 (95% CI, 21.70–27.08) months. About 16.7% of pharmacies reported been trained in HIV care at pre-intervention compared to 83.3% at post-intervention. The proportion of pharmacies with audio-visual privacy for patient counseling increased significantly from 30.9% at pre-intervention to 81.4% at post-intervention. Filled prescriptions were cross-checked by pharmacist (61.9%) and pharmacy technician (23.8%) before dispensing at pre-intervention compared to pharmacist (93.1%) and pharmacy technician (6.9%) at post intervention. 40.0% of pharmacies reported tracking consumption of drugs at pre-intervention compared to 98.3% at post-intervention; while 81.7% of pharmacies reported performing periodic stock reconciliation at pre-intervention compared to 100.0% at post-intervention. 36.5% of pharmacies were observed providing individual counseling on medication use to patients at pre-intervention compared to 73.2% at post-intervention; and 11.7% of pharmacies had evidence of monitoring and reporting of suspected adverse drug reaction at pre-intervention compared to 73.3% at post-intervention. The institution of access to patients’ clinical information by pharmacists in all pharmacies at post-intervention was a paradigm shift.ConclusionThrough public health program, HU-PACE created an enabling environment and improved capacity of pharmacy personnel for quality HIV/AIDS and TB services. This has contributed in diverse ways to better monitoring of patients on pharmacotherapy by pharmacists through access of pharmacists to patients’ clinical information.