Leon Cosler

Relationship of Gender, Depression, and Health Care Delivery With Antiretroviral Adherence in HIV‐infected Drug Users

BACKGROUND: Antiretroviral adherence is worse in women than in men, and depression can influence medication adherence.OBJECTIVE: To evaluate the relationship of gender, depression, medical care, and mental health care to adherence in HIV-infected drug users.DESIGN: Retrospective cohort study.SETTING: New York State Medicaid program.PARTICIPANTS: One thousand eight hundred twenty-seven female and 3,246 male drug users on combination antiretroviral therapy for more than 2 months in 1997.MAIN MEASURES: A pharmacy-based measure of adherence was defined as ≥95% days covered by at least 2 prescribed antiretroviral drugs. Independent variables were: depression, regular drug treatment (≥6 months), regular medical care (2+ and >35% of visits), HIV-focused care (2+ visits), psychiatric care (2+ visits), and antidepressant therapy.RESULTS: Women were less adherent than men (18% vs 25%, respectively, P<.001) and more likely to be diagnosed with depression (34% vs 29%). In persons with depression, the adjusted odds ratio (AOR) for adherence was greater for those with psychiatric care alone (AOR 1.52; 95% confidence interval [95% CI], 1.03 to 2.26) or combined with antidepressants (AOR 1.49; 95% CI, 1.04 to 2.15). In separate models by gender in persons with depression, psychiatric care plus antidepressants had a slightly stronger association with adherence in women (AOR 1.92; 95% CI, 1.00 to 3.68) than men (AOR, 1.26; 95% CI, 0.81 to 1.98). In drug users without depression, antidepressants alone were associated with greater adherence (AOR, 1.23; 95% CI, 1.02 to 1.49) with no difference by gender. Regular drug treatment was positively associated with adherence only in men.CONCLUSIONS: In this drug-using cohort, women had worse pharmacy-measured antiretroviral adherence than men. Mental health care was significantly associated with adherence in women, while regular drug treatment was positively associated with adherence in men.

Adherence to antiretroviral therapy by pregnant women infected with human immunodeficiency virus: a pharmacy claims-based analysis.

Objective To assess adherence to antiretroviral therapy with the use of Medicaid pharmacy claims data for human immunodeficiency virus (HIV)-infected pregnant women and to identify associated maternal and health care factors. Methods We retrospectively studied a cohort of 2714 HIV-infected women in New York State who delivered live infants from 1993–96. Among 682 women prescribed antiretroviral therapy in the last two trimesters, we studied 549 who started therapy more than 2 months before delivery. Adherence was defined as adequate if the supplied drug covered at least 80% of the days from the first prescription in the last two trimesters until delivery. Multivariable analyses were used to examine associations between maternal and health care factors and adherence. Results Only 34.2% of 549 subjects had at least 80% adherence based on pharmacy data, a rate that remained stable over time. The adjusted odds ratios (ORs) of adherence for black (OR 0.47, 95% confidence interval [CI] 0.30, 0.75) and Hispanic (OR 0.49, 95% CI 0.29, 0.82) women were nearly 50% lower than for white women. The OR of adherence was 0.32 (95% CI 0.12, 0.90) for teenagers compared with women aged 25–29 years and 0.56 (95% CI 0.34, 0.92) for women in New York City versus those residing elsewhere. Women on antiretroviral therapy before pregnancy were more likely to adhere (OR 1.55, 95% CI 1.02, 2.35). Conclusion Teenagers, women of minority groups, and women living in New York City had greater risks of poor antiretroviral adherence, whereas women already prescribed antiretrovirals before pregnancy had better adherence. Our conservative pharmacy data–based measure showed that most HIV-infected women adhered poorly and adherence did not improve over the 4-year study.

Antiretroviral use and pharmacy-based measurement of adherence in postpartum HIV-infected women

Background.Antiretroviral treatment for HIV-infected women is standard during pregnancy to prevent vertical transmission, but data on postpartum therapy for the mother are lacking. Objective.The objective of this study was to examine the impact of provider and patient characteristics on receipt of antiretroviral therapy and pharmacy-based measurement of adherence by postpartum HIV-infected women. Research Design.This was a retrospective cohort study. Subjects.The study included 2,648 New York State Medicaid–enrolled HIV-infected women who delivered from January 1993 through October 1996 and were followed up through September 1997. Measures.From Medicaid claims in the first postpartum year, the study examined any prescribed antiretroviral therapy and, among women treated >2 months, adherence, defined as ≥80% days covered by prescribed therapy from first to last antiretroviral prescription. Results.Antiretroviral therapy was prescribed for 681 (26%) study women. Of 292 women treated >2 months, 28% were adherent on the basis of the pharmacy-based measure. The proportion of treated women was highest in 1996 (40%), and adherence was best in 1995 (44%) when most women took monotherapy. The adjusted odds ratios (AORs) of treatment were 1.67 (95% CI, 1.24 to 2.25) for women receiving HIV-focused services and 2.71 (95% CI, 1.99 to 3.69) for women with a provider in an HIV-related specialty. The AORs of adherence were greater for women with HIV-focused services (2.13; 95% CI, 1.05 to 4.30) and for former illicit drug users versus nonusers (2.40; 95% CI, 1.05 to 5.50). Conclusions.This population-based pharmacy analysis reveals improving antiretroviral use but continuing poor pharmacy-based adherence by postpartum HIV-infected women. Receipt of HIV-focused services appears to be particularly beneficial in increasing the likelihood of treatment and adherence.

A controlled study of the effects of state surveillance on indicators of problematic and non-problematic benzodiazepine use in a Medicaid population.

Objective: Benzodiazepines (BZs) are safe, effective drugs for treating anxiety, sleep, bipolar, and convulsive disorders, but concern is often expressed about their overuse and potential for abuse. We evaluated the effects of physician surveillance through a Triplicate Prescription Program (TPP) on problematic and non-problematic BZ use. Method: This study uses interrupted time series analyses of BZ use in the New York (intervention) and New Jersey (control) Medicaid programs for 12 months before and 24 months after the New York BZ TPP. The regulation required NY physicians to order BZs on triplicate prescription forms with one copy forwarded by pharmacies to a state surveillance unit. Study participants were community-dwelling persons over age 18 continuously enrolled between January 1988 and December 1990 in New York (n = 125,837) or New Jersey Medicaid (n = 139,405). Results: During the baseline year, 20.2% of New York and 19.3% of New Jersey cohort members received at least one BZ prescription. After the TPP, there was a sudden, sustained reduction in BZ use of 54.8% (95% CI = [51.4%, 58.3%]) in New York with no changes in New Jersey. Significantly greater reductions were experienced by young women, and persons living in zip codes that were urban, predominantly Black, or with a high density of poor households. Increases in potential substitute medications were modest. At baseline, nearly 60% of BZ recipients had no evidence of potentially problematic use. Despite a somewhat greater likelihood of discontinuation of BZ therapy among those with potentially problematic use, the largest impact of the TPP was a substantially greater relative reduction in access to BZs among non-problematic users. Conclusions: State-mandated physician surveillance dramatically reduces BZ use with limited substitution of alternative drugs, lowers rates of possible abuse, but may severely limit non-problematic BZ use.

Association of maternal HIV infection with low birth weight

We evaluated factors associated with low birth weight (LBW) in an HIV-infected cohort (n = 772) and a general sample (n = 2,377) of women delivering a live singleton in federal fiscal years 1989 and 1990 while enrolled in New York State Medicaid. The association of LBW and HIV infection was studied in logistic models, controlling for illicit drug use, demographic characteristics, adequacy of prenatal care, and medical risk factors. Overall, 29% of the HIV-infected women had a LBW infant compared to 9.3% of the general sample (p < 0.001). The adjusted odds of LBW for HIV-infected women were twofold higher than for uninfected women [odds ratio (OR) = 2.04 and 95% confidence interval (Cl) = 1.54, 2.69]. Odds of LBW were also increased for illicit drug users (OR = 2.16; 95% CI = 1.59, 2.94), cigarette smokers (OR = 1.81; 95% CI = 1.37, 2.39), and African-American versus non-Hispanic white women (OR = 1.89; 95% CI = 1.31, 2.72). Lower odds appeared for women with adequate prenatal care (OR = 0.54; 95% CI = 0.42, 0.68). Among only women with full-term deliveries, the association of HIV with LBW remained strong as we found nearly threefold greater odds of LBW for HIV-infected women. This study indicates that HIV-infected women have an increased risk of bearing a L.BW infant, even after adjusting for the effects of drug use, health care delivery, and other social and medical risk factors.

A retrospective data analysis of the impact of the New York triplicate prescription program on benzodiazepine use in medicaid patients with chronic psychiatric and neurologic disorders

BACKGROUND Benzodiazepines are treatment mainstays for several disorders, but there is often concern about dependency and addiction. In January 1989, New York implemented regulations requiring physicians to order benzodiazepines using state-monitored triplicate prescription forms. OBJECTIVE The purpose of this study was to assess the effects of the triplicate prescription program (TPP) on changes in use of benzodiazepines and other psychoactive drugs in clinically vulnerable Medicaid populations. METHODS Using an interrupted time series with comparison series design, psychoactive medication use was examined in the New York (intervention) and New Jersey (control) Medicaid programs before and after implementation of the New York benzodiazepine TPP among community-dwelling Medicaid beneficiaries aged >/=19 years continuously enrolled from January 1988 through December 1990 in New York or New Jersey with diagnoses of schizophrenia, schizophreniform disorder, schizoaffective disorder, schizoid personality disorder, or schizotypal personality disorder; bipolar disorder; epilepsy; and/or panic disorder, agoraphobia without history of panic disorder, social phobia, or specific phobia. RESULTS A total of 125,837 New York and 139,405 New Jersey Medicaid beneficiaries were continuously enrolled and met the study inclusion criteria. Of these, there were 6054 Medicaid enrollees in New York and 6875 enrollees in New Jersey who were clinically vulnerable patients with >/=1 of the specified diagnoses. New York Medicaid patients with any of these diagnoses experienced a -48.1% relative change (95% CI, -50.0% to -46.2%) in benzodiazepine use at 6 months after TPP implementation, with no decline in use in New Jersey patients. The largest reduction in benzodiazepine use was seen among patients with seizure disorder (-59.9% at 6 months; 95% CI, -63.9% to -55.9%). Although use of substitute drugs increased slightly in New York after the TPP, it did not offset reductions in benzodiazepine use. The effects of TPP were sustained for 7 years of follow-up and had the greatest impact on nonproblematic benzodiazepine use. CONCLUSIONS During the time period studied in this analysis, the New York TPP reduced benzodiazepine use among chronically ill patients for whom these agents represent effective treatment. Our findings suggest that many patients previously receiving benzodiazepines did not receive any pharmacologic intervention.

A population-based comparison of the clinical course of children and adults with AIDS

ObjectiveTo examine the association of clinical complications and age at diagnosis with survival for a cohort of children and adults with AIDS. DesignA population-based analysis of 734 children and 5584 adults diagnosed with AIDS from 1985 to 1990 in New York State. ResultsThe initial AIDS-defining diagnoses for 68% of children were lymphoid interstitial pneumonitis or infections specified in the Centers for Disease Control and Preventions (CDC) pediatric AIDS case definition but not the CDCs 1987 adult AIDS case definition. Of opportunistic infections in both case definitions, Pneumocystis carinii pneumonia (PCP) was the most common initial AIDS diagnosis, occurring in 53% of adults, 47% of children aged < 6 months at diagnosis (n = 122) and 14% aged ≥6 months at diagnosis (n = 612). Median survival after AIDS diagnosis was 62 months for all children compared with 11 months for adults. For children initially diagnosed with conditions only in the pediatric case definition, median survival ranged from 27 to 62 months compared with less than 12 months for children and adults with PCP. Compared with children aged 6–54 months, the estimated hazards of death for younger and older children were 2.06 [95% confidence interval (Cl), 1.48–2.86] and 1.54 (95% Cl, 1.10–2.16), respectively. ConclusionChildren survived significantly longer than adults after AIDS diagnosis, but their survival varied by age at diagnosis. Differences in the types of common initial AIDS-defining diagnoses appear to contribute to the observed differences in survival.

Association of provider and patient characteristics with HIV-infected women's antiretroviral therapy regimen.

Objective: We explored the effect of patient and provider factors on the type of antiretroviral regimen among women receiving therapy. Patients: Five hundred ninety‐five New York State nonpregnant HIV+ women with full Medicaid eligibility and at least 1 month of a prescribed antiretroviral regimen in federal fiscal years (FFY) 1997‐1998 and intervals in FFY 1997‐1998, who had delivered a liveborn baby within 5 years. Measurements: From pharmacy claims in 4 6‐month intervals in FFY 1997‐1998, data were extracted on (1) an acceptable ≥2 antiretroviral combination regimen per expert guidelines; and (2) a highly active regimen, including a protease inhibitor or nonnucleoside analog (highly active antiretroviral therapy [HAART]). Results: Of 1514 woman‐6‐month intervals with filled antiretroviral prescriptions, 82% had an acceptable regimen, and of 1246 woman‐6‐month intervals on acceptable antiretroviral therapy, half demonstrated the use of HAART. Adjusted odds ratios (AORs) of acceptable antiretroviral therapy were higher (p < .05) for HIV specialty care (AOR = 1.71 for one or two visits; AOR = 2.10 for 3+ visits) or HIV clinical trials site care (AOR = 1.43; 95% confidence interval [CI]: 1.01, 2.04). Among women on acceptable antiretroviral regimens, those aged older than 25 years (AOR = 1.69; CI: 1.13, 2.53) or who were high school graduates (AOR = 1.50; CI: 1.09, 2.06) had higher odds of HAART. Mcthadone‐treated women had twofold and nearly threefold higher AORs of acceptable antiretroviral regimens and HAART, respectively, than current drug users. Conclusion: Provider HIV expertise is associated with receipt of an acceptable antiretroviral regimen in women, although receipt of HAART is affected more by age, education, and current drug abuse. Methadone treatment seems to improve access to acceptable antiretroviral regimens as well as to HAART.

Clinic HIV‐Focused Features and Prevention of Pneumocystis Carinii Pneumonia

OBJECTIVE: To examine the association of clinic HIV-focused features and advanced HIV care experience with Pneumocystis carinii pneumonia (PCP) prophylaxis and development of PCP as the initial AIDS diagnosis.DESIGN: Nonconcurrent prospective study.SETTING: New York State Medicaid Program.PARTICIPANTS: Medicaid enrollees diagnosed with AIDS in 1990–1992.MEASUREMENTS AND MAIN RESULTS: We collected patient clinical and health care data from Medicaid files, conducted telephone interviews of directors of 125 clinics serving as the usual source of care for study patients, and measured AIDS experience as the cumulative number of AIDS patients treated by the study clinics since 1986. Pneumocystis carinii pneumonia prophylaxis in the 6 months before AIDS diagnosis and PCP at AIDS diagnosis were the main outcome measures. Bivariate and multivariate analyses adjusted for clustering of patients within clinics. Of 1,876 HIV-infected persons, 44% had PCP prophylaxis and 38% had primary PCP. Persons on prophylaxis had 20% lower adjusted odds of developing PCP (95% confidence interval [CI] 0.64, 0.99). The adjusted odds of receiving prophylaxis rose monotonically with the number of HIV-focused features offered by the clinic, with threefold higher odds (95% CI 1.6, 5.7) for six versus two or fewer such features. Patients in clinics with three HIV-focused features had 36% lower adjusted odds of PCP than those in clinics with one or none. Neither clinic experience nor specialty had a significant association with prophylaxis or PCP.CONCLUSIONS: PCP prevention in our study cohort appears to be more successful in clinics offering an array of HIV-focused features.

The effect of ethnicity and maternal birthplace on small-for-gestational-age deliveries to HIV-infected women.

ObjectiveTo examine the relative role of ethnicity and maternal birthplace on small-for-gestational-age (SGA) deliveries of a cohort of mothers in New York who were infected with human immunodeficiency virus.MethodsMedicaid claims and linked vital statistics records were examined for 2,525 singleton deliveries to HIV-infected women from 1993 through 1996. We estimated adjusted odds ratios (AORs) and 95% confidence intervals (CIs) of SGA delivery associated with ethnicity (i.e., white, white-Latina, black, and black-Latina) and maternal birthplace (i.e., native US/Puerto Rican vs. foreign born) in a series of multivariate regression models to which we sequentially added demographic, health services, and lifestyle factors (i.e., alcohol, tobacco, and illicit drug use).ResultsOf the deliveries, 10% were SGA. The odds of SGA infants for black and white women did not differ by maternal birthplace. Foreign-born white-Latinas and black-Latinas had lower unadjusted odds of a SGA delivery than their US-born counterparts (OR 0.29, CI 0.14, 0.61 and OR 0.22, CI 0.07, 0.71, respectively). After adjustment for maternal lifestyle characteristics, the odds of SGA delivery were 0.50 (CI 0.23, 1.09) for white-Latina mothers and 0.60 (CI 0.17, 2.08) for black-Latina mothers.ConclusionsSGA outcomes did not differ by maternal birthplace for black and white women. Differences in lifestyle factors appear to contribute to lower odds of SGA delivery for foreign-born versus US-born white- and black-Latina HIV-infected women.