Edward L. Machtinger

Psychological Trauma and PTSD in HIV-Positive Women: A Meta-Analysis

Women bear an increasing burden of the HIV epidemic and face high rates of morbidity and mortality. Trauma has been increasingly associated with the high prevalence and poor outcomes of HIV in this population. This meta-analysis estimates rates of psychological trauma and posttraumatic stress disorder (PTSD) in HIV-positive women from the United States. We reviewed 9,552 articles, of which 29 met our inclusion criteria, resulting in a sample of 5,930 individuals. The findings demonstrate highly disproportionate rates of trauma exposure and recent PTSD in HIV-positive women compared to the general population of women. For example, the estimated rate of recent PTSD among HIV-positive women is 30.0% (95% CI 18.8–42.7%), which is over five-times the rate of recent PTSD reported in a national sample of women. The estimated rate of intimate partner violence is 55.3% (95% CI 36.1–73.8%), which is more than twice the national rate. Studies of trauma-prevention and trauma-recovery interventions in this population are greatly needed.ResumenLas mujeres enfrentan un incremento en la epidemia de VIH y altos índices de morbilidad y mortalidad. El trauma psicológico ha sido cada vez más asociado con la alta prevalencia y los resultados pobres de VIH en esta población. El presente metaanálisis estima la tasa de trauma y Trastorno por Estrés Postraumático (TPEP) en mujeres estadounidenses. Fueron revisados 9,552 artículos de los cuales 29 cumplieron los criterios, resultando en una muestra total de 5,930 individuos. Los resultados demuestran una tasa desproporcionalmente alta de exposición a trauma y reciente TPEP en mujeres VIH positivas en comparación con la población general de mujeres estadounidenses. La tasa estimada de reciente TPEP entre mujeres VIH positivas es 30.0% (95% IC 18.8–42.7%), lo cual es cinco veces la tasa de reciente TPEP reportada en una muestra nacional de mujeres. La tasa estimada de violencia del compañero íntimo (VCI) es 55.3% (95% IC 36.1–73.8%), lo cual es más del doble de la tasa nacional. Estudios de prevención de trauma e intervenciones de recuperación de trauma en esta población son enormemente necesitados.

Health literacy and anticoagulation-related outcomes among patients taking warfarin.

BACKGROUND: Little is known about whether health literacy affects anticoagulation-related outcomes.OBJECTIVE: To assess how health literacy is associated with warfarin knowledge, adherence, and warfarin control (measured by the international normalized ratio [INR]).DESIGN: Survey.PARTICIPANTS: Patients taking warfarin through an anticoagulation clinic.MEASUREMENTS: Health literacy was measured using the short-form Test of Functional Health Literacy in Adults (s-TOFHLA), dichotomized as “limited” (score 0 to 22) and “adequate” (score 23 to 36). We asked patients to answer questions relating to their warfarin therapy and used multivariable logistic regression to assess whether health literacy was associated with incorrect answers. We also assessed whether health literacy was associated with nonadherence to warfarin as well as time in therapeutic INR range.RESULTS: Bilingual research assistants administered the survey and s-TOFHLA to 179 anticoagulated English- or Spanish-speaking patients. Limited health literacy was associated with incorrect answers to questions on warfarin’s mechanism (adjusted odds ratio [OR] 4.8 [1.3 to 17.6]), side-effects (OR6.4 [2.3 to 18.0]), medication interactions (OR 2.5 [1.1 to 5.5]), and frequency of monitoring (OR 2.7 [1.1 to 6.7]), after adjusting for age, sex, race/ethnicity, education, cognitive impairment, and years on warfarin. However, limited health literacy was not significantly associated with missing warfarin doses in 3 months (OR 0.9 [0.4 to 2.0]) nor with the proportion of person-time in therapeutic INR range (OR 1.0 [0.7 to 1.4]).CONCLUSIONS: Limited health literacy is associated with deficits in warfarin-related knowledge but not with self-reported adherence to warfarin or INR control. Efforts should concentrate on investigating alternative means of educating patients on the management and potential risks of anticoagulation.

From Treatment to Healing: The Promise of Trauma-Informed Primary Care

Author(s): Machtinger, Edward L; Cuca, Yvette P; Khanna, Naina; Rose, Carol Dawson; Kimberg, Leigh S

Language, literacy, and characterization of stroke among patients taking warfarin for stroke prevention: Implications for health communication

OBJECTIVE Warfarin is a medication commonly prescribed to prevent strokes associated with certain medical conditions such as atrial fibrillation; however, little is known about how people taking warfarin perceive the goal of therapy and how they describe strokes. We assessed the stroke-related health literacy of anticoagulated patients to inform ways in which to improve health communication among people taking warfarin. METHODS We conducted a mixed-methods study of an ethnically and linguistically diverse sample of people taking warfarin to prevent stroke (N=183) and measured literacy using the short-form Test of Functional Health Literacy in Adults. We asked participants to (1) describe their indication for warfarin, and (2) describe a stroke. Transcribed answers were coded as concordant or discordant with established indications for warfarin and definitions of stroke. RESULTS Forty-three percent of participants provided a discordant response when describing their indication for warfarin. Only 9.3% reported that the purpose of taking warfarin was to prevent stroke. Not speaking English [OR=2.4 (1.1-5.6)] and less than a college education [OR=3.3 (1.4-7.3)] were independently associated with discordant answers about warfarin. Nearly 40% of subjects had inaccurate perceptions of stroke, and only one-third of subjects described a symptom or sign of stroke. Among English and Spanish-speaking participants, inadequate literacy was strongly associated with discordant responses about stroke [OR=5.8 (2.1-15.6)]. CONCLUSION Among high-risk people taking warfarin to prevent stroke, significant gaps in stroke-related health literacy exist. These gaps likely represent mismatches in the ways clinicians teach and patients learn. PRACTICE IMPLICATIONS Since stroke risk awareness and early recognition of the signs and symptoms of stroke are critical aspects of stroke prevention and treatment, clinicians should more strongly link warfarin therapy to stroke prevention and ensure that patients know the presenting symptoms and signs of stroke. Public health communication strategies regarding stroke prevention need to target individuals with limited literacy and limited English proficiency.

An expressive therapy group disclosure intervention for women living with HIV improves social support, self-efficacy, and the safety and quality of relationships: a qualitative analysis.

&NA; Women living with HIV (WLHIV) face high rates of morbidity and mortality. HIV disclosure interventions have been identified as a promising but under‐evaluated approach for WLHIV to improve their health and well‐being. The Medea Project is an expressive therapy group intervention that was first developed to help incarcerated women develop the confidence and skills to tell their stories publicly in theatrical performances. The intervention was subsequently adapted as a community‐based disclosure intervention for WLHIV. Our study describes an analysis of the impact of the Medea Project on the lives of the WLHIV who participated. All participating WLHIV publicly disclosed their HIV status during the performances. Five impact themes emerged from the data: sisterhood, catharsis, self‐acceptance, safer and healthier relationships, and gaining a voice. Our study identifies a voluntary, effective, and broadly beneficial disclosure intervention for women living with HIV.

Atraumatic Splenic Rupture: An Unusual Manifestation of Acute HIV Infection

A 27-year-old white male, who had sex with other men, presented to the emergency department with 3 days of left shoulder and abdominal pain. He reported no history of trauma to the abdomen. On abdominal imaging, he was found to have hemoperitoneum from a ruptured spleen; he underwent splenectomy. Causes of atraumatic splenic rupture can be divided into six main categories: infectious, neoplastic, inflammatory, congenital or structural, iatrogenic, and idiopathic. Work-up of the atraumatic splenic rupture revealed that his HIV antibody was newly positive. He had a documented negative HIV antibody 3 weeks prior to the current admission. CD4 cell count, obtained after splenectomy, was 904 cells per microliter and the HIV-1 plasma RNA level was 4657 copies per milliliter. Spleen pathology demonstrated an enlarged spleen with increase in the number of small to intermediate size lymphoid cells in the red pulp, and reactive follicular lymphoid hyperplasia, with numerous secondary lymphoid follicles and reactive germinal centers in the white pulp. T-cell receptor (TCR) gene rearrangement studies demonstrated a positive TCR beta gene rearrangement, without a TCR gamma gene rearrangement, consistent with a clonal CD8(+) T-cell population. The case gives rare insight into what happens in the spleen during acute HIV infection and encourages HIV testing in those presenting with atraumatic splenic rupture. Counseling patients with acute HIV to avoid potential trauma should also be considered.

Seeking Safety Group Therapy for Co-Occurring Substance Use Disorder and PTSD among Transgender Women Living with HIV: A Pilot Study.

ABSTRACT Transgender women living with HIV experience high rates of substance use, violence, and post-traumatic stress disorder (PTSD). Seeking Safety is a manualized, present-focused, cognitive-behavioral therapy program designed to address co-occurring substance use and PTSD. Seeking Safety has evidence of efficacy in a variety of populations but had not been evaluated specifically with people living with HIV or transgender women. We pilot-tested a 12-session Seeking Safety program with a group of transgender women living with HIV who reported substance use and a history of violence. Seven transgender women living with HIV were recruited from two HIV primary care clinics in San Francisco and completed pre- and post-intervention assessments. Participants attended an average of 8 of the 12 sessions. Mean scores for all three outcome measures improved: PTSD symptom scores declined 17.5%, alcoholism screening scores declined 23.9%, and drug abuse screening scores declined 68.8%, on average. Despite the small sample, this pilot study showed Seeking Safety to be a promising intervention among transgender women living with HIV. The findings are encouraging and justify larger studies of Seeking Safety among transgender women and other people living with HIV who experience high rates of substance use and PTSD.

Gender differences in causes of death among persons with HIV/AIDS in San Francisco, California, 1996–2013

The objective was to examine gender differences in causes of death using the San Francisco HIV/AIDS and death registries. Data from San Francisco residents diagnosed with HIV/AIDS who died from 1996 to 2013 were analyzed. Age, race/ethnicity, year, and gender-adjusted standardized mortality ratios and Poisson 95% confidence intervals were calculated for underlying causes of death. Among the 6268 deaths, deaths attributed to drug use, mental disorders due to substance use, cerebrovascular disease, chronic obstructive pulmonary disease, renal disease, and septicemia were more likely among women than among men. Compared to the California population, women had elevated standardized mortality ratios for drug overdose (25.37), mental disorders due to substance abuse (27.21), cerebrovascular disease (2.83), chronic obstructive pulmonary disease (7.37), heart disease (2.37), and liver disease (5.54), and these were higher than the standardized mortality ratios for the men in our study. Men, but not women, had elevated standardized mortality ratios for suicide (2.70), undetermined intent (3.88), renal disease (2.29), and non-AIDS cancer (1.68) compared to population rates. Continued efforts to reduce HIV-related illnesses and an increased emphasis on diagnosing and treating preventable causes of death, including substance use, heart disease, and mental health disorders, are needed as part of comprehensive HIV care.