Maggie Chartier

Psychiatric correlates of HAART utilization and viral load among HIV-Positive Impoverished Persons

Objective: Research on the role psychiatric factors in HIV disease management has yielded discrepant findings, possibly because prior studies did not include comprehensive psychiatric screeners. This study administered a validated screener to examine psychiatric correlates of highly active antiretroviral therapy (HAART) utilization and viral load. Design: Community-recruited, HIV-positive impoverished persons provided sociodemographic information, completed a Diagnostic Interview Schedule that screened for psychiatric disorders, and provided a blood sample to measure HIV disease markers. Methods: In this cross-sectional investigation with 227 participants, a multiple logistic regression model examined correlates of HAART utilization compared to a reference group that was eligible for (i.e. CD4+ cell count <350 cells/μl) but not taking HAART. A multiple linear regression model examined correlates of HIV viral load among 147 participants on HAART. Results: Sleeping on the street [adjusted OR (AOR) = 0.06; 95% confidence interval (CI) = 0.01–0.26] and screening positive for a stimulant use disorder (AOR = 0.29; 95% CI = 0.13–0.65) were independently associated with lower odds of HAART utilization. Conversely, enrollment in the AIDS Drug Assistance Program (AOR = 3.94; 95% CI = 1.45–10.73) and receipt of mental health treatment (AOR = 4.78; 95% CI = 1.77–12.87) were independently associated with increased odds of HAART utilization. Among those on HAART, screening positive for a severe mental illness was independently associated with a six-fold higher viral load. Conclusion: Providing psychiatric treatment could optimize health outcomes among HIV-positive impoverished persons and boost the effectiveness of ‘test and treat’ approaches to HIV prevention.

Spiritual striving, acceptance coping, and depressive symptoms among adults living with HIV/AIDS.

We prospectively examined the effects of spiritual striving, social support, and acceptance coping on changes in depressive symptoms among adults living with HIV/AIDS. Participants were 180 culturally diverse adults with HIV/AIDS. Participants completed measures of spiritual striving, social support, coping styles, and depressive symptoms at baseline, three-month follow-up, and six-month follow-up. A path model showed that spiritual striving had direct and indirect inverse effects on changes in depressive symptoms. The relationship between spiritual striving and depressive symptoms was partially mediated by acceptance coping, but not by social support. Results suggest that people living with HIV/AIDS who strive for spiritual growth in the context of their illness experience less negative affect.

Passive Versus Active Parental Permission: Implications for the Ability of School‐Based Depression Screening to Reach Youth at Risk*

BACKGROUND Depression is prevalent among children and adolescents and often goes untreated with adverse effects on academic success and healthy development. Depression screening can facilitate early identification and timely referral to prevention and treatment programs. Conducting school-based emotional health screening, however, raises the controversial issue of how to obtain informed parental permission. METHODS During implementation of a depression screening program in an urban school district in the Pacific Northwest, the districts parental permission protocol changed from passive (information provided to parents via a school mailer with parents having the option to actively decline their childs participation) to active (information provided to parents via a school mailer requiring the written permission of the parents for their childs participation). This change provided an opportunity to examine differences in participation under these 2 conditions. RESULTS A total of 1533 students were enrolled in this program across both years. Compared to conditions of passive permission, participation was dramatically reduced when children were required to have written parental permission, dropping from 85% to 66% of eligible children. Furthermore, under conditions of active parental permission, participation decreased differentially among student subgroups with increased risk for depression. CONCLUSIONS Successful implementation of school-based emotional health screening programs requires careful consideration of how to inform and obtain permission from parents.

The Montreal cognitive assessment to screen for cognitive impairment in HIV patients older than 60 years.

Abstract:Progress in HIV treatments has led to HIV-infected patients living into their 60s and older. Because HIV-associated neurocognitive disorder (HAND) in older age is associated with more executive dysfunction, cognitive screening instruments tapping this domain may be optimal. We examined the Montreal Cognitive Assessment to identify HAND in 67 HIV-infected patients older than 60 years, of which 40% were diagnosed with HAND. Receiver operating characteristic curve identified an optimal cutpoint of ⩽ 25 for HAND with a sensitivity of 72% and specificity of 67%. We conclude that the Montreal Cognitive Assessment has only moderate performance characteristics for cognitive screening of HIV-infected elders.

Cascade of Care for Hepatitis C Virus Infection Within the US Veterans Health Administration

OBJECTIVES We measured the quality of HCV care using a cascade of HCV care model. METHODS We estimated the number of patients diagnosed with chronic HCV, linked to HCV care, treated with HCV antivirals, and having achieved a sustained virologic response (SVR) in the electronic medical record data from the Veterans Health Administrations Corporate Data Warehouse and the HCV Clinical Case Registry in 2013. RESULTS Of the estimated 233,898 patients with chronic HCV, 77% (181,168) were diagnosed, 69% (160,794) were linked to HCV care, 17% (39,388) were treated with HCV antivirals, and 7% (15,983) had achieved SVR. CONCLUSIONS This Cascade of HCV Care provides a clinically relevant model to measure the quality of HCV care within a health care system and to compare HCV care across health systems.

Curing Hepatitis C Virus Infection: Best Practices From the U.S. Department of Veterans Affairs

Since the introduction of direct-acting antivirals (DAAs) for hepatitis C virus (HCV) infection, the U.S. Department of Veterans Affairs (VA) has made extensive progress in advancing HCV care and curing substantial numbers of infected veterans. As the nations largest provider of care to patients with HCV infection, the VA is uniquely suited to inform the recent National Strategy for the Elimination of Viral Hepatitis, produced by the National Academies of Sciences, Engineering, and Medicine (1). The national strategy emphasizes prevention, screening, and universal treatmentareas in which the VA has become a recognized leader (13). The strategy presents specific actions to reduce the burden of HCV infection, with 5 distinct areas outlined: information, interventions, service delivery, financing, and research (1, 2). The VAs best practices and successes, informed by extensive population health data analysis, national guidance, and policies, may inform other health care organizations and providers in reducing the national burden of HCV infection. The VAs commitment to prioritizing HCV care is reflected in dedicated funding for HCV treatment, unrestricted access to DAAs, detailed guidance on individualizing care, and the establishment of Veterans Integrated Service Network Hepatitis C Innovation Teams (HITs) (4). This work, in collaboration with other key VA offices, is supported by the VAs National Viral Hepatitis Program, which develops national guidance, policy, and patient and provider resources (5). The resources and efforts that the VA and its HCV providers have dedicated to prioritizing this disease at every level of the organization are being tangibly realized. Between January 2014 and June 2017, a total of 92000 HCV-infected veterans initiated DAA treatment, achieving cure rates exceeding 90% (6, 7) (U.S. Department of Veterans Affairs. Unpublished data). As of July 2017, a total of 51000 veterans remain potentially eligible for treatment, compared with more than 168000 three years ago (8) (U.S. Department of Veterans Affairs. Unpublished data). The Table shows the characteristics of the HCV-infected veteran population before all-oral DAA treatment became available (U.S. Department of Veterans Affairs. Unpublished data). Table. Demographic and Clinical Characteristics of the HCV-Infected Veteran Population Before All-Oral Direct-Acting Antiviral Treatment Became Available in 2014 Although elimination seems attainable, the VA recognizes the reality of the HCV epidemic and populationnamely, many of those in care who remain to be treated have complex substance use, mental health, and medical comorbidities, and many are challenged by homelessness, lack of transportation, and rurality, which have been considerable barriers to engagement in care and treatment. Epidemiologic control of HCV in the VA includes a long tail of persistence driven by system, patient, and care delivery determinants (Figure 1). Figure 1. Number of veterans with HCV infection in VA care requiring HCV antiviral treatment over time. On 1 October 2013, a total of 168708 veterans in VA care were identified as having chronic HCV infection requiring treatment; by 1 July 2017, the number had decreased to 50986. The trend line indicates the projected number of veterans requiring treatment through 30 September 2021. HCV= hepatitis C virus; VA= U.S. Department of Veterans Affairs. Information: Population Health Management Using national databases and analytics, the VA employs population health management strategies to measure, monitor, and identify trends in HCV care, gaining insight into patterns of access and tailoring care provision accordingly. Veterans in VA care who are diagnosed with HCV infection are followed in the VAs National Hepatitis C Clinical Case Registry, developed in part to ensure that veterans with chronic HCV infection are linked to care (9). This registry, which is used for both local and national population reporting, provides administrative data on the number of known HCV-infected patients together with clinical information, including patient and disease characteristics, care delivery site, treatment, and clinical outcomes. The VAs Corporate Data Warehouse, a repository of electronic medical record data, has spurred the creation of local and regional HCV dashboards, which provide access to patient-specific data reports for real-time intervention and tracking. These sources allow for comprehensive monitoring of incidence, prevalence, and disease course; national, regional, and individual-facility data are posted, enabling providers, teams, and leadership to assess progress and goals. This leveraging of health systems data transforms numbers into knowledge and guides providers and the VA toward more informed and effective delivery of care for each veteran. Essential Interventions Improved Case Identification A critical first step in improving HCV care is identifying infected persons. In 2012, the Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force each developed recommendations for testing persons born between 1945 and 1965, a cohort determined to have the highest prevalence of HCV infection (10, 11). Before 2014, VA guidance recommended risk-based testing and testing of Vietnam-era veterans, a group that largely overlaps with the 19451965 birth cohort (3). Using information systems to track screening, the VA has identified and targeted additional populations at risk for HCV infection, including African American males, in whom prevalence is more than double that in white males (17.7% vs. 8.3%); homeless persons, who have a prevalence more than triple that in nonhomeless persons (13.4% vs. 3.5%); and persons who inject drugs (12, 13). To date, the VA has screened 79.5% of the 2.7 million veterans in the 19451965 birth cohort and 89.6% of its homeless population (13). Using updated calculations of annual prevalence, the VA estimates that only about 15000 additional veterans in VA care would test positive for HCV if the entire population were screened. Testing Initiatives The most important initiatives the VA has undertaken to increase HCV testing include national electronic point-of-care clinical reminders for HCV risk assessment and testing, automated letters recommending HCV testing (which also serve as laboratory orders when presented to VA laboratories), and weekly primary care panel reviews identifying patients with upcoming appointments who require testing. To emphasize this as a priority, the VA added birth cohort testing as a national performance measure in 2015 and reports quarterly screening rates by facility and region. To ensure complete testing and an efficient patient-centered approach, the VA recommends automatic reflex confirmatory HCV RNA testing with the same laboratory sample for all patients with a positive antibody test result; greater than 97% adherence was achieved in 2015. These factors have resulted in a 3% to 4% annual increase in the proportion of veterans screened for HCV infection, substantially higher than in other large health care systems (14). Hepatitis C Innovative Team Collaborative Recognizing that care is not delivered the same way in all settings, regional HITs, comprising a multidisciplinary group of 15 to 30 health care providers, administrators, and information technology and system redesign specialists, have implemented Lean Process Improvement methods to maximize clinical expertise and redesign the process of HCV testing, treatment, and management to provide the most efficient and effective care possible for the populations they serve (15, 16). The HIT Collaborative has enabled a clinically focused foundation to share and implement best practices across and within teams, supported by local and regional administrators (17). The development of the HIT infrastructure, which has leveraged and supported the work of dedicated VA providers, has been a critical implementation arm that has allowed the VA to respond to challenges in funding variability and other access issues that have arisen since the introduction of DAAs. Service Delivery: Improving Linkage and Access Population health data, the HIT infrastructure, and legions of dedicated providers have been instrumental in enhancing the VAs outreach and engagement. Efforts have focused on raising provider and staff awareness about HCV testing and treatment availability, promoting direct outreach to at-risk veterans, utilizing mobile phone applications and secure messaging, and broadening veteran community outreach through national and local social media and advertising campaigns. Expanding Capacity Telemedicine and Electronic Technologies The VA has focused on increasing specialist capacity through telemedicine and real-time clinical video teleconferencing, whereby HCV clinicians provide care to patients and/or consultation to providers at other locations. Largely modeled on Project ECHO (Extension for Community Healthcare Outcomes) (18), the expanded HCV VA-ECHO model includes urban, rural, and homeless clinics and incorporates pharmacist-led provider programs and mental health and substance use programs to aid providers in treating HCV infection in patients with these comorbidities. The HCV VA-ECHO program was associated with a 20% higher HCV treatment initiation rate than sites without this program (19). By leveraging electronic databases, HCV teams can identify treatment candidates, notify primary care providers through the electronic medical record, and provide immediate HCV management recommendations. Similarly, primary care providers can efficiently consult HCV specialists on management and treatment via interprovider electronic consults, eliminating the need for specialty visits. Nonphysician Advanced Practice Providers The VA has emphasized the expansion of HCV care beyond specialty providers. A substantial portion of HCV treatment has shifted from liver and infectious disease specialty cli

Attachment style and coping in relation to posttraumatic stress disorder symptoms among adults living with HIV/AIDS

Research indicates that a significant proportion of people living with HIV/AIDS report symptoms of posttraumatic stress disorder (PTSD). Moreover, attachment style has been associated with psychological and behavioral outcomes among persons living with HIV/AIDS. Attachment style may influence the ability to cope with traumatic stress and affect PTSD symptoms. To examine the association between attachment style and coping with PTSD symptoms, we assessed 94 HIV-positive adults on self-report measures of posttraumatic stress, coping, and attachment style. In multiple regression analysis, avoidant attachment and emotion-focused coping were positively and significantly associated with greater PTSD symptomatology. Support was also found for the moderating effects of avoidant and insecure attachment styles on emotion-focused coping in relation to greater PTSD symptoms. Taken altogether, these results suggest that interventions that develop adaptive coping skills and focus on the underlying construct of attachment may be particularly effective in reducing trauma-related symptoms in adults living with HIV/AIDS.

Personal Values and Meaning in the Use of Methamphetamine Among HIV-Positive Men Who Have Sex With Men

Our aim with this qualitative study was to understand the role of personal values, meaning, and impact of drug use among HIV-positive men who have sex with men (MSM) who struggle with methamphetamine use. Participants were 22 MSM recruited from an ethnically diverse county in the San Francisco Bay area of California. Grounded theory was used to analyze the data collected in individual interviews. Emergent constructs of context, meaning, and perceived impact were identified and are described in a theoretical narrative format. The importance of broadening our understanding of HIV and methamphetamine addiction and their interaction is highlighted. This study contributes to the understanding of the complexity of methamphetamine use within the specific population of MSM living with HIV/ AIDS, and suggests possible directions for addressing important maintaining factors like adaptive use and enhancing factors that could contribute to an individuals ability to make better choices based on meaning and personal values.

Individual, peer, and family variables associated with risky sexual behavior among male and female incarcerated adolescents

Abstract This study examined individual, peer, and family variables associated with adolescent sexual risk behavior. Participants included 1008 adolescents (857 males and 151 females) incarcerated in Virginia juvenile correctional facilities. At the bivariate level, externalizing behaviors, social problems, perceived friend support, perceived family support, and family structure were significantly correlated (p < .10) with the lifetime number of sexual partners. After controlling age, multivariate analyses found that externalizing behaviors, social problems, perceptions of better family support, and family structure were significantly associated with the lifetime number of sexual partners for the full sample (p < .01) and males (p < .01). For females, externalizing behaviors and social problems were significantly associated with lifetime number of sexual partners (p < .01). These findings support the need to consider social influences on sexual risk-taking among adolescents. Intervention efforts aimed at reducing risk behavior among adolescents should be gender specific and focus on developing effective coping behaviors and bolstering social support, particularly within family systems.

Chlamydia Prevalence Among Adolescent Females and Males in Juvenile Detention Facilities in California

With the advent of urine–based chlamydia tests, screening can be conducted in juvenile detention facilities. To determine chlamydia infection rates among female and male juvenile detainees in seven detention facilities in California, urine–based chlamydia testing was conducted from September 2000 through July 2002. Participants provided data on demographics and use of health care services. Among the 1,284 females, chlamydia prevalence was 12.9%; among the 4,778 males, prevalence was 6.0%. Overall, 54.3% of females and 70.5% of males reported not having received primary care in the previous year. High chlamydia prevalence combined with poor access to primary care among adolescents in detention warrants screening for chlamydia in juvenile detention facilities.