Jessica S. Merlin

Pain, mood, and substance abuse in HIV: implications for clinic visit utilization, antiretroviral therapy adherence, and virologic failure.

Background:Cooccurring pain, mood disorders, and substance abuse are common in HIV-infected patients. Our objective was to investigate the relationship between pain, alone and in the context of mood disorders and substance abuse, on clinic utilization, antiretroviral therapy adherence, and virologic suppression. Methods:Pain, mood disorders, and substance abuse were assessed at the first visit. No-show and urgent visits were measured over a 1-year period. Models were adjusted for age, race, sex, insurance status, CD4+ T-lymphocyte count, and HIV risk factor. Results:Among 1521 participants, 509 (34%) reported pain, 239 (16%) had pain alone, 189 (13%) had pain and a mood disorder, and 30 (2%) had pain and substance abuse. In univariate models, participants with pain, mood disorders, and substance abuse had higher odds of a no-show visit than those without these conditions [odds ratio (OR), 1.4; 95% confidence interval (CI), 1.1–1.8; OR, 1.5; 95% CI, 1.2–1.9; OR, 2.0; 95% CI, 1.4–2.8, respectively]. In the multivariable model, pain increased the odds of a no-show visit only in participants without substance abuse (OR, 1.5; 95% CI, 1.1–1.9) and pain reduced the odds of a no-show visit in participants with substance abuse (OR, 0.5; 95% CI, 0.2–0.9; P for interaction = 0.0022). Conclusions:In this study, pain increased the odds of no-show visits but only for participants without substance abuse. Because pain, mood disorders, and substance abuse are highly prevalent in HIV-infected patients, our findings have implications for HIV treatment success. Interventions that incorporate pain management may be important for improving health outcomes in patients living with HIV infection.

Gain-of-function signal transducer and activator of transcription 1 (STAT1) mutation-related primary immunodeficiency is associated with disseminated mucormycosis.

We identified a novel gain of function mutation in STAT1 in a patient with disseminated Apophysomyces trapeziformis infection who had never had mucocutaneous candidiasis or autoimmunity. To our knowledge this is the first report of a genetic predisposition associated with mucormycosis.

Characteristics of an Ambulatory Palliative Care Clinic for HIV-Infected Patients

BACKGROUND Many HIV-infected patients in the current treatment era have substantial symptom burden, but few HIV palliative care clinics have been described. Our objective was to describe the University of Alabama at Birmingham (UAB) HIV palliative care clinic (HPCC) and compare it to the overall HIV clinic. METHODS We conducted a chart review of patients referred to the HPCC between April 2008 and June 2011. We evaluated the reason for referral and other issues addressed during palliative care visits. Patient Reported Outcome (PRO) data was used to assess depression (PHQ-9), anxiety (PHQ-A), and substance abuse (ASSIST). RESULTS Among 124 patients, mean age was 44 (range 27-64), and median CD4 count was 352 cells/mm(3) (IQR 209-639). Depression (43, 35%), anxiety (40, 32%), and current 8 (7%) or prior 68 (56%) substance abuse occurred at higher rates than in the overall HIV clinic (p<0.05). Pain was the most common reason for referral (118, 95%); most was chronic (113, 90%) and included back pain (26, 21%) and neuropathic pain (15, 12%). Other problems commonly addressed by the palliative team included nonpain symptoms such as depression (39, 48%) and anxiety (17, 21%), insomnia (25, 30%), and constipation (26, 32%). CONCLUSIONS This is the first description of a palliative care clinic embedded within an HIV primary care clinic in a developed country that sees patients at all stages of illness. Chronic pain and nonpain symptom management in patients with psychiatric and substance abuse comorbidities are important components of ambulatory palliative care for HIV-infected patients.

Pain is independently associated with impaired physical function in HIV-infected patients.

INTRODUCTION Human immunodeficiency virus (HIV)-infected patients in the current treatment era can achieve normal life expectancies but experience a high degree of medical and psychiatric comorbidity. Impaired physical function and pain, often in the context of mood disorders and substance abuse, are common in HIV-infected patients. The objective of this study was to investigate the relationship of pain, a modifiable condition, to functional impairment in HIV-infected patients, independent of mood disorders and substance abuse. METHODS Participants in a prospective cohort of HIV-infected patients at the University of Alabama at Birmingham were included. Patient-reported outcome measures were used to cross-sectionally assess pain and physical function (EuroQOL), mood disorders (PHQ), and substance abuse (ASSIST). Univariate and multivariable models were built with pain as the principal independent variable of interest and three domains of physical function (mobility, self-care, and usual activities) as outcomes. Covariates included mood, substance abuse, age, race, sex, insurance status, HIV transmission risk factor, and CD4+ T-cell count. RESULTS Among 1,903 participants, 693 (37%) reported pain; 509 (27%) had a mood disorder; and 157 (8.4%) reported current substance abuse. In multivariable models, pain was independently associated with increased odds of impairment in all three domains of physical function investigated-mobility (aOR 10.5, 95% CI 7.6-14.6), self-care (aOR 4.1, 95% CI 2.2-7.4), and usual activities (aOR 5.4, 95% CI 4.0-7.4). DISCUSSION Pain was associated with substantially increased odds of impairment in physical function. Pain should be an important consideration in HIV primary care. Interventions to address pain and impaired physical function should be investigated.

A Conceptual Framework for Understanding Chronic Pain in Patients with HIV

Chronic pain is common in persons with HIV and is often associated with psychiatric illness and substance abuse. Current literature links psychiatric illness and substance abuse with worse HIV outcomes; however, the relationship of chronic pain, alone and in the context of psychiatric illness and substance abuse, to outcomes in HIV has not been described. To develop this new area of inquiry, we propose an adapted biopsychosocial framework specifically for chronic pain in HIV. This framework will describe these relationships and serve as a conceptual framework for future investigations.

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.

Structural community factors and sub-optimal engagement in HIV care among low-income women in the Deep South of the USA

Abstract This study describes the ways in which poverty and other structural factors create a risk environment for sub-optimal engagement in HIV care among low-income women living with HIV in the Southern USA, contributing to existing health disparities. We conducted a qualitative study in 2012, involving in-depth interviews with 14 stakeholders (service providers and representatives of community-based organisations) and 7 focus-group discussions with 46 women living with HIV (89% African American). A thematic approach in the context of the social ecological model guided data analysis. Data were coded and analysed using NVivo qualitative software. The findings suggested that structural community factors, such as poverty, poor employment opportunities, limited access to healthcare resources, stigma, transportation challenges and access to illicit substances, may work independently and in synergy to impact women’s health seeking behaviour and decision-making, thereby influencing their ability to engage in HIV care. Interventions designed to improve engagement in HIV care should address structural factors to bolster low-income women’s ability to engage in care.

Aberrant drug-related behaviors: A qualitative analysis of medical record documentation in patients referred to an HIV/Chronic pain clinic

BACKGROUND Due to rising rates of opioid addiction and overdose among individuals on chronic opioid therapy, aberrant drug-related behaviors (ADRBs) are an important and challenging issue. Our objective was to qualitatively investigate the documentation of ADRBs in the medical record. METHODS Manually abstracted provider notes from an HIV primary care clinic were analyzed using content analysis methods. RESULTS Categories of ADRBs identified included patients requesting opioids, obtaining nonprescribed opioids, and becoming emotional about opioids. We also identified several types of provider language used when documenting ADRBs, including purely descriptive language and emotional language such as labeling, frustration, and concern, and responses such as setting conditions for opioid prescription and action-oriented language. CONCLUSIONS The impact of including emotional language in the medical record is unknown. Development of instruments that can be used to facilitate ADRB documentation, as well as evidence-based approaches to addressing ADRBs, is needed.

Qualitative Investigation of a Brief Chronic Pain Screening Tool in HIV-Infected Patients

UNLABELLED Chronic pain in HIV-infected patients is prevalent but understudied. A limitation of HIV/chronic pain research to date is the lack of a widely used chronic pain screening tool. A Brief Chronic Pain Screening tool (BCPS) has been described, but has not yet been tested in a clinical population. This study sought to evaluate how the BCPS is experienced by HIV-infected individuals, and adapt its questions if necessary. We conducted cognitive interviews using cognitive inquiry in participants from the UAB 1917 HIV Clinic Cohort. Data were analyzed using a process of inductive, iterative coding by three investigators. RESULTS Of 30 participants, most were male, African American, and less than 50 years old. Participants reported that the questions were understandable; however, feedback suggested concerns regarding lack of specificity in regard to the intensity and consistency of pain. An introductory statement aimed at improving clarity resulted in more divergent responses. This research team concluded that the version of the BCPS used in the first 30 interviews was optimum. Its inclusive language allows the respondent to decide what pain merits reporting. This study is the first investigation of the BCPS in a clinical population, and should lead to further quantitative validation studies of this tool.

Blood and Body Fluid Exposures Among US Medical Students in Botswana

IntroductionMedical students from resource-rich countries who rotate in resource-limited settings have little pre-departure experience performing procedures, and lack familiarity with local equipment. The risk of blood and body fluid exposures during such rotations is significant.Aim1) Determine whether a simulation-based intervention reduced exposures among US medical students on a rotation in Botswana; 2) determine whether exposures were underreported; 3) describe exposures and provision of human immunodeficiency virus (HIV) post-exposure prophylaxis (PEP).SettingUniversity of Pennsylvania medical students who traveled to Botswana for a clinical rotation from July 2007 to February 2010 were eligible to participate.Program DescriptionTwenty-two students participated in the simulation-based intervention.Program EvaluationTo evaluate the intervention, we used a pre/post quasi-experimental design and administered a retrospective survey. The response rate was 81.7% (67/82). Needlesticks were eliminated [8/48 (16.7%) to 0/19 (0.0%), p = 0.07]. Splashes were unchanged (6/48 [12.5%) to 3/19 (15.8%), p=>0.99]. Three students did not report their exposure. Fifteen exposures were reported to an attending, who counseled the student regarding HIV PEP. Three students did not take PEP because the exposure was low-risk.DiscussionOur intervention was associated with a decrease in needlestick exposures. Medical schools should consider training to reduce exposures abroad.