Hsiao Ying Liu

Effect of antiretroviral therapy on the incidence of cervical neoplasia among HIV-infected women: a population-based cohort study in Taiwan

Objective:Cervical cancer has been recognized as one of the AIDS-defining cancers since 1993. Receipt of HAART has been shown to reduce the risk of opportunistic infection and AIDS-defining malignancies. However, findings concerning the effect of HAART on cervical neoplasia have been inconsistent. Design:A population-based cohort design was used, in which 1360 HIV-infected women were compared to the general population (HIV-negative women). The comparison population included 358 141 HIV-negative women randomly selected from among all insured persons in Taiwan in 2000. Data from HIV-infected and uninfected women were analyzed through 2008. Methods:The age and calendar year-standardized incidence ratio was calculated to estimate the relative risk of cervical neoplasia, and Cox proportional hazards models were used to assess the effect of HAART on the incidence of cervical neoplasia. Results:The incidence of cervical neoplasia was four times higher in the HIV-infected women than in the general population [standardized incidence ratio 4.0, 95% confidence interval (CI) 2.16–6.95]. The most increased risk was noted in HIV-infected women aged 40–59 years. Receipt of HAART was associated with a significantly reduced risk of cervical neoplasia (0.20, 0.05–0.77). The most evident protective effect was noted in adherent to HAART at least 85%, and those treated with HAART for more than 3 years (0.01, 0.00–0.47). Conclusions:HIV-infected women have a substantially increased risk of cervical neoplasia. Adherent to HAART and prolonged HAART for more than 3 years may contribute to a reduction risk of cervical neoplasia.

Case Management Interventions for HIV-Infected Individuals

Engagement of HIV-positive persons into care and achieving optimal antiretroviral treatment outcomes is a fundamental HIV prevention strategy. Case management model was recommended as a beneficial model of care for patients with a new HIV diagnosis, focusing on individuals with unmet needs, and linking them with the coordinated health and social services to achieve desired outcomes. HIV case management is population-driven and programs are designed to respond to the unique needs of the client population they serve, such as substance users, homeless, youth, and prison inmates. This view found 28 studies addressing effectiveness and impacts of case management intervention for people living with or at risk of HIV/AIDS. Effectiveness of case management intervention was categorized as follows: decreased mortality and improve health outcomes, linkage to and retention in care, decreased unmet needs, and reducing risky behaviors.

Impact of the nurse-led case management program with retention in care on mortality among people with HIV-1 infection: A prospective cohort study

BACKGROUND Long-term retention of patients in care is emerging as an important factor for the mortality among persons with human immunodeficiency virus (HIV) infection. OBJECTIVES The study was to determine the impact of the case management with retention in care on mortality among HIV infected patients. DESIGN AND SETTINGS A longitudinal prospective cohort study was conducted at a tertiary referral HIV-designated hospital in Taiwan. PARTICIPANTS Charts from 1040 patients who had made at least one visit for HIV care at the HIV Clinic in the study hospital in 2009 were abstracted. METHODS A computerized data collection form was used to retrospectively retrieve the electronic demographic and clinical data generated during each clinic visit. Follow-up ended at death or at the last clinic visit as of December 31, 2009. RESULTS Less than half (44.2%) of 961 HIV-infected patients were retained for follow-up from 2005 to 2009. Patients who received case management were 4.78 times more likely to remain consistently in care than those who did not receive case management, after controlling for other confounding variables. In the Cox proportional hazard analysis, higher hazards of death were independently associated with older age (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 1.026-1.055), entering care before 2005 (HR: 1.73; 95% CI: 1.035-2.885), low baseline CD4 cell count (HR: 0.997; 95% CI: 0.995-0.998), without antiretroviral therapy (HR: 0.55; 95% CI: 0.334-0.909), irregular attendance of HIV care or loss to follow-up (HR: 0.058; 95% CI: 0.023-0.148), acquisition of HIV infection through sexual contact (HR: 2.95; 95% CI: 1.517-5.746), and irregular attendance or lost to follow-up and did not enrolled in the case management program (HR: 3.76; 95% CI: 1.015-14.777). CONCLUSION Retention in care is independently predictive of survival, and case management is a mediator affecting retention on survival. Case managers need to identify high risk patients for irregular attendance and to retain them in HIV care in order to maximize their health outcomes.

Low Papanicolaou smear screening rate of women with HIV infection: a nationwide population-based study in Taiwan, 2000-2010.

BACKGROUND Women infected by human immunodeficiency virus (HIV) have a higher risk of contracting cervical cancer. Recent guidelines recommend that all HIV-positive women should receive two Pap smears in the first year after their HIV diagnosis. METHODS This was a population-based cohort study, and the National Health Insurance Research Database (NHIRD) in Taiwan was used to estimate the Pap smear screening rate for 1449 HIV-infected women aged 18 years and over from 2000 to 2010. A multiple logistic regression analysis was used to identify factors associated with HIV-infected women who had received Pap smears. RESULTS Of 1449 women, 618 (43%) women received at least one Pap smear. Only 14.7% of the HIV-infected women received Pap smears within one year after being diagnosed with HIV. A logistic regression analysis showed that the factors associated with receiving at least one Pap smear after HIV diagnosis were increasing age (AOR 1.04, 95% CI 1.03-1.05), high monthly income (AOR 1.83, 95% CI 1.51-2.23), any history of antiretroviral therapy (AOR 1.78, 95% CI 1.38-2.29), retention in HIV care (AOR 1.36, 95% CI 1.04-1.77), a history of sexually transmitted diseases (AOR 1.96, 95% CI 1.50-2.56), and any history of treatment for opportunistic infections (AOR 2.46, 95% CI 1.91-3.16). CONCLUSIONS A great need exists to develop strategies for promoting receipt of Pap smear screening services that specifically target severely disadvantaged women with HIV, particularly younger, lower income women and those in an asymptomatic phase.

The rising trend of sexually transmitted infections among HIV-infected persons: A population-based cohort study in taiwan, 2000 through 2010

Objective:Positive prevention interventions for patients living with the HIV include the early detection and treatment of sexually transmitted infections (STIs). This study aimed to determine the incidence of selected STIs, including syphilis, genital warts, gonorrhea, chlamydial infection, and trichomoniasis, in a population-based cohort of individuals living with HIV. Methods:Clinical data from 2000 to 2010 were obtained from the Taiwan National Health Insurance Research Database identified 15,123 patients with HIV infection. The incidence rates were standardized by age and sex using the direct method that was based on the 2000 World Health Organization world standard population. Results:The overall rate ratio of STI episodes significantly increased [rate ratio: 34.0, 95% confidence interval (CI): 24.3 to 47.6, P < 0.01]. After an HIV diagnosis, 15.9% of patients with HIV had at least 1 of these 5 STIs. An incidence rate of 503.0 STI episodes/10,000 person-years (PYs) (95% CI: 487.1 to 519.5) was detected during the 11-year follow-up period. The most common STIs after an HIV diagnosis were syphilis (381.9 episodes/10,000 PYs; 95% CI: 368.0 to 396.3), followed by genital warts (138.9 episodes/10,000 PYs; 95% CI: 130.6 to 147.6). The incidence of STIs varied significantly according to gender. In women, the annual incidence of STIs remained stable. However, the annual incidence of syphilis, genital warts, and chlamydial infection increased in young men. Conclusions:An increase in STIs among HIV-positive persons highlights the need to identify the causal factors of these co-infections. Routine STI screenings and early preventive interventions against STIs in HIV-infected persons are crucial.

The impact of nurse-led case management on the quality of HIV care

BACKGROUND Monitoring the quality of human immunodeficiency virus (HIV) care and evaluating the effectiveness of HIV case management programs (CMPs) as approaches to raising the rate of HIV care retention and to improving the efficacy of viral suppression after the initiation of highly active antiretroviral therapy (HAART) are important focuses of research worldwide. PURPOSE This study describes the trends and evaluates the influence of CMPs on retention in care and viral suppression among patients in Taiwan diagnosed with HIV from 2008 to 2010. METHODS This retrospective study enrolled 1,302 HIV-positive individuals who had visited at least one outpatient clinic between 2008 and 2012. Of these patients, 715 (54.9%) were enrolled in an HIV CMP. Trend analysis and logistic regression were applied to investigate longitudinal trends and the impact of CMPs on the quality of HIV care. RESULTS Retention in care improved substantially from 44.5% in 2008 to 57.3% in 2012. The percentage of viral suppression within 12 months of the initiation of HAART increased from 88.4% in 2008 to 93.5% in 2012. Of the patients who were in HIV CMPs, 73.6% were retained in care, which was significantly higher than the 31.7% among those who were not enrolled in CMPs (p<.001). Among the patients who received HAART for more than 180 days, those who achieved viral suppression within 12 months were significantly more likely to be retained in care (adjusted odds ratio=5.36, 95% CI=2.6-10.9, p<.001). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Nurse-led case management programs play a role in improving HIV-related health outcomes. HIV CMPs are beneficial to HIV-infected patients by improving retention in care and are indirectly associated with successful viral suppression.

A Prospective Study of Interactions Between a Case Management Program and Retention in Care on HIV Suppression in Taiwan, 2008–2012

Dear Editor Achieving optimal antiretroviral treatment outcomes is a fundamental treatment as prevention (TasP) strategy. A successful program for HIV treatment includes making the diagnosis of HIV infection, linking infected individuals to outpatient care, and retaining patients in care. Case management (CM) has been shown to facilitate entry and engagement in care among persons living with HIV. In the United States, HIV CM is a federally legislated program funded by the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 (now the Ryan White Treatment Modernization Act). Japan, Brazil, and Rwanda have also initiated a integrated case management program by the government. HIV-infected patients in Taiwan have been provided with free antiretroviral therapy and medical care at AIDS-designated hospitals since the early 1990s. An estimated 70% of individuals living with HIV infection in Taiwan have sought HIV care, and 40% of individuals who have sought HIV care received HAART after the diagnosis of HIV infection with CD4 cell counts < 350 cells/mm. In 2005, the Taiwan Center for Disease Control (Taiwan CDC) initiated an HIV case management (CM) program in AIDS-designated hospitals to provide integrative services and risk reduction counseling for HIV-infected individuals. The current study provides a unique opportunity to observe the impact of HIV case management on achieving the optimal therapeutic effect of HAART among HIV-infected persons. A longitudinal prospective cohort study was conducted at an AIDS-designated hospital, National Cheng Kung University Hospital (NCKUH), with over 15 years of experience caring for HIV-infected patients in southern Taiwan. A total of 549 patients who were newly diagnosed during 2008–2012 provided data for analysis. Of the 549 patients, 427 (77.8%) ever enrolled in the hospital-based HIV case management program. Retention in care was defined as having two or more HIV clinical visits separated by ‡ 90 days during a calendar year over the 5-year observation period. Achievement of viral suppression was defined as the first HIV RNA level of < 400 copies per milliliter, and time to viral suppression was defined as the number of days between the initial diagnosis of HIV and the first viral load (VL) of < 400 copies per milliliter. Patients who never had a VL > 1000 copies per milliliter after viral suppression (VL < 400 copies per milliliter) by the time of death or at the end of the analysis period were considered to have maintained suppression. Of the 549 patients, the mean age was 31.6 years (SD 9.7, range: 16–77 years), 95.3% were male, and 69.2% reported men having sex with men (MSM) as a primary risk factor for HIV transmission. Median initial CD4 count during the year rose from 55.2 to 185.9 cells/mm. Applying the pre-2013 HAART initiation threshold of CD4 < 350 cells per cubic millimeter, 52–60% would have been eligible to begin HAART based on the first CD4 after the initial diagnosis. Almost two-thirds (n = 335, 72.2%) of the patients were retained in care until the end of the 5-year study period. The adjusted multivariate logistic regression indicated that persons retained in HIV care were significantly more likely to be female [adjusted odds ratio (aOR) 0.25, 95% confidence interval (CI): 0.75–0.84], to have initiated HAART (aOR 4.91, 95% CI: 2.81–8.60), and to be enrolled in the case management program (aOR 2.15, 95% CI: 1.11–4.16) than persons not retained in care during years 2008–2012. Overall, 257 (61.8%) of the patients newly diagnosed with HIV during 2008–2012 ever achieved viral suppression by the end of 2012; 26.6% achieved suppression within 6 months of diagnosis, and 39.8% within 12 months. Overall, 57.6% of the 257 persons who ever achieved viral suppression maintained their suppression for 12 months. Cox proportional hazards models showed significant interaction effects between retention in care and enrollment in CMP on viral suppression (Table 1). The patients were divided into three groups: retained in care plus case management (n = 294, 53.6%), either retained in care or enrolled in case management only (n = 174, 31.4%), and irregular/lost to follow-up and also without case management (n = 81, 14.8%). The Kaplan-Meier survival analysis showed that patients who were retained in care and also enrolled in CMP had the best outcomes of achieving viral

Gender differences in HIV manifestations at presentation to care and continuity of care among HIV-infected persons in Taiwan

Abstract The study aimed to compare the gender difference in clinical manifestations at time of HIV diagnosis and after one year of antiretroviral therapy, and to determine the influence of gender on HIV care continuity. A retrospective study was conducted using chart review of adults diagnosed with HIV infection from 1993–2008 at a university-affiliated AIDS-designated hospital in Taiwan. Men who acknowledged having sex with men were excluded in order to compare the gender differences among patients with similar routes of HIV transmission and social context. Of the 682 patients with HIV, 86.6% were men. There were no significant gender differences in clinical, immunological or virological parameters at baseline. After one year of antiretroviral therapy, the curves of changes in CD4 cell counts in men and women were parallel over time. Continuity of care, referring to at least one appointment in each six-month window during 2005–2008, was significantly associated with age >50 years (OR = 2.54, 95% CI: 1.04–6.16), being enrolled in the case management programme (OR = 4.93, 95% CI: 2.53–9.62), acquisition of HIV via heterosexual contact (OR = 3.63, 95% CI: 1.38–9.55), CD4 lymphocyte count <200 counts/mm3 at baseline (OR = 3.09, 95% CI: 1.38–6.96), being on highly active antiretroviral therapy (OR = 4.77, 95% CI: 2.37–9.59), and with sero-discordant partners (OR = 2.51, 95% CI: 1.07–5.87). The findings indicate that gender does not appear to be associated with HIV disease manifestations and continuity of care. Further research to develop optimal methods to retain patients in HIV care is needed.

Applying the Modified Delphi Technique to Develop the Role of HIV Case Managers and Essential Nursing Competencies in HIV Care

BACKGROUND Since 2005, the Taiwan Centers for Disease Control (Taiwan CDC) initiated an HIV case management program in AIDS-designated hospitals to provide integrative services and risk-reduction counseling for HIV-infected individuals. In light of the increasingly complex and highly specialized nature of clinical care, expanding and improving competency-based professional education is important to enhance the quality of HIV/AIDS care. PURPOSE The aim of this study was to develop the essential competency framework for HIV care for HIV case managers in Taiwan. METHODS We reviewed essential competencies of HIV care from Canada, the United Kingdom, and several African countries and devised descriptions of the roles of case managers and of the associated core competencies for HIV care in Taiwan. The modified Delphi technique was used to evaluate the draft framework of these roles and core competencies. A total of 15 HIV care experts were invited to join the expert panel to review and rank the draft framework. RESULTS The final framework consisted of 7 roles and 27 competencies for HIV case managers. In Round 1, only 3 items did not receive consensus approval from the experts. After modification based on opinions of the experts, 7 roles and 27 competencies received 97.06% consensus approval in Round 2 and were organized into the final framework for HIV case managers. These roles and associated core competencies were: HIV Care Expert (9 competencies), Communicator (1 competency), Collaborator (4 competencies), Navigator (2 competencies), Manager (4 competencies), Advocate (2 competencies), and Professional (5 competencies). CONCLUSIONS/IMPLICATIONS FOR PRACTICE The authors developed an essential competency framework for HIV care using the consensus of a multidisciplinary expert panel. Curriculum developers and advanced nurses and practitioners may use this framework to support developments and to ensure a high quality of HIV care.