Beverly S. Musick

Longitudinal Study of Depression and Health Services Use Among Elderly Primary Care Patients

OBJECTIVE: To describe the prevalence and 9‐month incidence of depressive symptoms among a cohort of elderly primary care patients and to determine whether different patterns of depression are associated with different patterns of health services use.

Prevalence of cognitive impairment Data from the Indianapolis Study of Health and Aging

Background: The epidemiology and natural history of cognitive impairment that is not dementia is important to the understanding of normal aging and dementia. Objective: To determine the prevalence and outcome of cognitive impairment that is not dementia in an elderly African American population. Method: A two-phase, longitudinal study of aging and dementia. A total of 2212 community-dwelling African American residents of Indianapolis, IN, aged 65 and older were screened, and a subset (n = 351) received full clinical assessment and diagnosis. Subsets of the clinically assessed were seen again for clinical assessment and rediagnosis at 18 and 48 months. Weighted logistic regression was used to generate age-specific prevalence estimates. Results: The overall rate of cognitive impairment among community-dwelling elderly was 23.4%. Age-specific rates indicate increasing prevalence with increasing age: 19.2% for ages 65 to 74 years, 27.6% for ages 75 to 84 years, and 38.0% for ages 85+ years. The most frequent cause of cognitive impairment was medically unexplained memory loss with a community prevalence of 12.5%, followed by medical illness–associated cognitive impairment (4.0% prevalence), stroke (3.6% prevalence), and alcohol abuse (1.5% prevalence). At 18-month follow-up, 26% (17/66) of the subjects had become demented. Conclusions: Cognitive impairment short of dementia affects nearly one in four community-dwelling elders and is a major risk factor for later development of dementia.

Knowledge and beliefs about cancer in a socioeconomically disadvantaged population

Americans living in poverty experience a higher incidence of and greater mortality from cancer than the nonpoor. At least 50% of the difference in mortality is believed to be due to delay in diagnosis, although risk‐promoting lifestyles and behaviors also contribute to decreased survival. A potential exacerbating factor among the poor is inadequate information and knowledge about cancer and its treatment. Interviews were conducted with 128 cancer patients from a socioeconomically disadvantaged population to assess knowledge of cancer and its treatment and to evaluate care‐seeking behaviors. Results indicated that although patients relied primarily on their physicians for information about their disease and treatment, a number of misconceptions regarding cancer existed in this population. Notably, nearly 50% of the patients surveyed either denied or did not know that smoking was related to the development of cancer. Additionally, patients frequently reported inappropriate care‐seeking behaviors when asked to respond to a series of common disease‐related signs or symptoms. These findings suggest that misinformation and misconceptions regarding cancer and its treatment among patients in this sample may contribute to inappropriate care‐seeking behaviors.

Outcomes of HIV-infected orphaned and non-orphaned children on antiretroviral therapy in western Kenya

Objectives:Determine outcome differences between orphaned and non-orphaned children receiving antiretroviral therapy (ART). Design:Retrospective review of prospectively recorded electronic data. Setting:Nine HIV clinics in western Kenya. Population:279 children on ART enrolled between August 2002 and February 2005. Main Measures:Orphan status, CD4%, sex- and age-adjusted height (HAZ) and weight (WAZ) z scores, ART adherence, mortality. Results:Median follow-up was 34 months. Cohort included 51% males and 54% orphans. At ART initiation (baseline), 71% of children had CDC clinical stage B or C disease. Median CD4% was 9% and increased dramatically the first 30 weeks of therapy, then leveled off. Parents and guardians reported perfect adherence at every visit for 75% of children. Adherence and orphan status were not significantly associated with CD4% response. Adjusted for baseline age, follow-up was significantly shorter among orphaned children (median 33 vs. 41 weeks, P = 0.096). One-year mortality was 7.1% for orphaned and 6.6% for non-orphaned children (P = 0.836). HAZ and WAZ were significantly below norm in both groups. With ART, HAZ remained stable, while WAZ tended to increase toward the norm, especially among non-orphans. Orphans showed identical weight gains as non-orphans the first 70 weeks after start of ART but experienced reductions afterwards. Conclusions:Good ART adherence is possible in western rural Kenya. ART for HIV-infected children produced substantial and sustainable CD4% improvement. Orphan status was not associated with worse short-term outcomes but may be a factor for long-term therapy response. ART alone may not be sufficient to reverse significant developmental lags in the HIV-positive pediatric population.

Sampling-based approaches to improve estimation of mortality among patient dropouts: Experience from a large PEPFAR-funded program in Western Kenya

Background Monitoring and evaluation (M&E) of HIV care and treatment programs is impacted by losses to follow-up (LTFU) in the patient population. The severity of this effect is undeniable but its extent unknown. Tracing all lost patients addresses this but census methods are not feasible in programs involving rapid scale-up of HIV treatment in the developing world. Sampling-based approaches and statistical adjustment are the only scaleable methods permitting accurate estimation of M&E indices. Methodology/Principal Findings In a large antiretroviral therapy (ART) program in western Kenya, we assessed the impact of LTFU on estimating patient mortality among 8,977 adult clients of whom, 3,624 were LTFU. Overall, dropouts were more likely male (36.8% versus 33.7%; p = 0.003), and younger than non-dropouts (35.3 versus 35.7 years old; p = 0.020), with lower median CD4 count at enrollment (160 versus 189 cells/ml; p<0.001) and WHO stage 3–4 disease (47.5% versus 41.1%; p<0.001). Urban clinic clients were 75.0% of non-dropouts but 70.3% of dropouts (p<0.001). Of the 3,624 dropouts, 1,143 were sought and 621 had their vital status ascertained. Statistical techniques were used to adjust mortality estimates based on information obtained from located LTFU patients. Observed mortality estimates one year after enrollment were 1.7% (95% CI 1.3%–2.0%), revised to 2.8% (2.3%–3.1%) when deaths discovered through outreach were added and adjusted to 9.2% (7.8%–10.6%) and 9.9% (8.4%–11.5%) through statistical modeling depending on the method used. The estimates 12 months after ART initiation were 1.7% (1.3%–2.2%), 3.4% (2.9%–4.0%), 10.5% (8.7%–12.3%) and 10.7% (8.9%–12.6%) respectively. Conclusions/Significance Abstract Assessment of the impact of LTFU is critical in program M&E as estimated mortality based on passive monitoring may underestimate true mortality by up to 80%. This bias can be ameliorated by tracing a sample of dropouts and statistically adjust the mortality estimates to properly evaluate and guide large HIV care and treatment programs.

Outcomes of HIV-exposed children in western Kenya: efficacy of prevention of mother to child transmission in a resource-constrained setting.

Objectives:To compare rates of mother to child transmission of HIV and infant survival in women-infant dyads receiving different interventions in a prevention of Mother to Child Transmission (pMTCT) program in western Kenya. Design:Retrospective cohort study using prospectively collected data stored in an electronic medical record system. Setting:Eighteen HIV clinics in western Kenya. Population:HIV-exposed infants enrolled between February 2002 and July 2007, at any of the United States Agency for International Development-Academic Model Providing Access To Healthcare partnership clinics. Main outcome measures:Combined endpoint (CE) of infant HIV status and mortality at 3 and 18 months. Analysis:Descriptive statistics, χ2 Fisher exact test, and multivariable modeling. Results:Between February 2002 and July 2007, 2477 HIV-exposed children were registered for care by the United States Agency for International Development-Academic Model Providing Access To Healthcare partnership pMTCT program before 3 months of age. Median age at enrollment was 6.1 weeks; 50.4% infants were male. By 3 months, 31 of 2477 infants (1.3%) were dead and 183 (7.4%) were lost to follow-up. One thousand (40%) underwent HIV DNA Polymerase Chain Reaction virologic test at a median age of 8.3 weeks: 5% were HIV infected, 89% uninfected, and 6% were indeterminate. Of the 968 infants with specific test results or mortality data at 3 months, the CE of HIV infection or death was reached in 84 of 968 (8.7%) infants. The 3-month CE was significantly impacted (A) by maternal prophylaxis [51 of 752 (6.8%) combination antiretroviral therapy (cART); 8 of 69 (11.6%) single-dose nevirapine (sdNVP); and 25 of 147 (17%) no prophylaxis (P < 0.001)] and (B) by feeding method for the 889 of 968 (91.8%) mother-infant pairs for which feeding choice was documented [5 of 29 (17.2%) exclusive breastfeeding; 13 of 110 (11.8%) mixed feeding; and 54 of 750 (7.2%) formula feeding (P = 0.041)]. Of the 1201 infants ≥18 months of age: 41 (3.4%) were deceased and 329 (27.4%) were lost to follow-up. Of 621 of 831 (74.7%) infants tested, 65 (10.5%) were infected resulting in a CE of 103 of 659 (15.6%). CE differed significantly by maternal prophylaxis [52 of 441 (11.8%) for cART; 13 of 96 (13.5%) for sdNVP; and 38 of 122 (31.2%) no therapy group (P < 0.001)] but not by feeding method for the 638 of 659 (96.8%) children with documented feeding choice [7 of 35 (20%) exclusive breastfeeding, 14 of 63 (22.2%) mixed, and 74 of 540 (13.7%) formula (P = 0.131)]. On multivariate analysis, sdNVP (odds ratio: 0.4; 95% confidence interval: 0.2 to 0.8) and cART (odds ratio: 0.3; 95% confidence interval: 0.2 to 0.6) were associated with fewer CE. At 18 months, feeding method was not significantly associated with the CE. Conclusions:Though ascertainment bias is likely, results strongly suggest a benefit of antiretroviral prophylaxis in reducing infant death and HIV infection, but do not show a benefit at 18-months from the use of formula. There was a high rate of loss to follow up, and adherence to the HIV infant testing protocol was less than 50% indicating the need to address barriers related to infant HIV testing, and to improve outreach and follow-up services.

A feasibility study of a family seizure management program: 'Be Seizure Smart'

&NA; A feasibility study of a psychoeducational family intervention, “Be Seizure Smart,” aimed at improving attitudes and increasing family functioning was conducted. The intervention was individually tailored for each family member by (a) providing information about epilepsy, treatment, and seizure management according to the individuals knowledge base, (b) addressing unique concerns and fears, and (c) providing emotional support. Participants were 10 families of children with epilepsy ages 7 to 13 years. Data were collected about 2 weeks before and after the intervention, which was delivered over 3 to 4 months, by using structured interviews. One‐tailed paired t tests were used to determine changes from pretest to posttest. Participants also were asked to evaluate the intervention and make suggestions about how the intervention could better meet their needs. Results generally indicated that the intervention had the anticipated effects. Knowledge scores increased for both parents and children. Children had fewer concerns and were more satisfied with family relationships. Information and support needs decreased for both children and their parents. Information need reductions were statistically significant for both parents and children; support need reductions were significantly reduced only for parents. Although child and parent attitudes were more positive after the intervention, this finding was not statistically significant. Moreover, parents indicated overall satisfaction with the program and appreciated the convenience of in‐home telephone interactions with the nurse and receiving information specific to their needs in the mail. It was concluded that the “Be Seizure Smart” intervention had strong potential to help children with epilepsy and their families and that the intervention should be developed further and piloted on a larger sample.

Association of antiretroviral and clinic adherence with orphan status among HIV-infected children in Western Kenya.

Background:Pediatric adherence to antiretroviral therapy (ART) is not well studied in resource-limited settings. Reported ART adherence may be influenced by contextual factors, such as orphan status. Objectives:The objectives of this study were to describe self- and proxy-reported pediatric ART adherence in a resource-limited population and to investigate associated contextual factors. Patients and Methods:This was a retrospective study involving pediatric, HIV-infected patients in Western Kenya. We included patients aged 0-14 years, who were on ART and had at least 1 adherence measurement (N = 1516). We performed logistic regression to assess the association between orphan status and odds of imperfect adherence, adjusting for sex, age, clinic site, number of adherence measures, and ART duration, stratified by age and ART duration. Results:Of the 1516 children, only 33% had both parents living when they started ART. Twenty-one percent had only father dead, 28% had only mother dead, and 18% had both parents dead. Twenty-nine percent reported imperfect ART adherence. The odds of ART nonadherence increase for children with both parents dead. Fifty-seven percent of children had imperfect clinic adherence. There was no significant association between orphan status and imperfect clinic adherence. Conclusions:The majority of pediatric patients in this resource-limited setting maintained perfect ART adherence, though only half kept all scheduled clinic appointments. Understanding contextual factors, such as orphan status, will strengthen adherence interventions.

Trends in the clinical characteristics of HIV-infected patients initiating antiretroviral therapy in Kenya, Uganda and Tanzania between 2002 and 2009

BackgroundEast Africa has experienced a rapid expansion in access to antiretroviral therapy (ART) for HIV-infected patients. Regionally representative socio-demographic, laboratory and clinical characteristics of patients accessing ART over time and across sites have not been well described.MethodsWe conducted a cross-sectional analysis of characteristics of HIV-infected adults initiating ART between 2002 and 2009 in Kenya, Uganda and Tanzania and in the International Epidemiologic Databases to Evaluate AIDS Consortium. Characteristics associated with advanced disease (defined as either a CD4 cell count level of less than 50 cells/mm3 or a WHO Stage 4 condition) at the time of ART initiation and use of stavudine (D4T) or nevirapine (NVP) were identified using a log-link Poisson model with robust standard errors.ResultsAmong 48, 658 patients (69% from Kenya, 22% from Uganda and 9% from Tanzania) accessing ART at 30 clinic sites, the median age at the time of ART initiation was 37 years (IQR: 31-43) and 65% were women. Pre-therapy CD4 counts rose from 87 cells/mm3 (IQR: 26-161) in 2002-03 to 154 cells/mm3 (IQR: 71-233) in 2008-09 (p < 0.001). Accessing ART at advanced disease peaked at 35% in 2005-06 and fell to 27% in 2008-09. D4T use in the initial regimen fell from a peak of 88% in 2004-05 to 59% in 2008-09, and a greater extent of decline was observed in Uganda than in Kenya and Tanzania. Self-pay for ART peaked at 18% in 2003, but fell to less than 1% by 2005. In multivariable analyses, accessing ART at advanced immunosuppression was associated with male sex, women without a history of treatment for prevention of mother to child transmission (both as compared with women with such a history) and younger age after adjusting for year of ART initiation and country of residence. Receipt of D4T in the initial regimen was associated with female sex, earlier year of ART initiation, higher WHO stage, and lower CD4 levels at ART initiation and the absence of co-prevalent tuberculosis.ConclusionsPublic health ART services in east Africa have improved over time, but the fraction of patients accessing ART with advanced immunosuppression is still high, men consistently access ART with more advanced disease, and D4T continues to be common in most settings. Strategies to facilitate access to ART, overcome barriers among men and reduce D4T use are needed.

Impact of integrated family planning and HIV care services on contraceptive use and pregnancy outcomes: a retrospective cohort study.

ObjectiveTo determine the impact of routine care (RC) and integrated family planning (IFP) and HIV care service on family planning (FP) uptake and pregnancy outcomes. DesignRetrospective cohort study conducted between October 10, 2005, and February 28, 2009. SettingUnited States Agency for International Development—Academic Model Providing Access To Healthcare (USAID-AMPATH) in western Kenya. SubjectsRecords of adult HIV-infected women. InterventionIntegration of FP into one of the care teams. Primary Outcomes MeasuresIncidence of FP methods and pregnancy. ResultsFour thousand thirty-one women (1453 IFP; 2578 RC) were eligible. Among the IFP group, there was a 16.7% increase (P < 0.001) [95% confidence interval (CI): 13.2% to 20.2%] in incidence of condom use, 12.9% increase (P < 0.001) (95% CI: 9.4% to 16.4%) in incidence of FP use including condoms, 3.8% reduction (P < 0.001) (95% CI: 1.9% to 5.6%) in incidence of FP use excluding condoms, and 0.1% increase (P = 0.9) (95% CI: −1.9% to 2.1%) in incidence of pregnancies. The attributable risk of the incidence rate per 100 person-years of IFP and RC for new condom use was 16.4 (95% CI: 11.9 to 21.0), new FP use including condoms was 13.5 (95% CI: 8.7 to 18.3), new FP use excluding condoms was −3.0 (95% CI: −4.6 to −1.4) and new cases of pregnancies was 1.2 (95% CI: −0.6 to 3.0). ConclusionsIntegrating FP services into HIV care significantly increased the use of modern FP methods but no impact on pregnancy incidence. HIV programs need to consider integrating FP into their program structure.