Rose S. Bono

Clinical outcomes of HIV care delivery models in the US: a systematic review

ABSTRACT With over 1 million people living with HIV, the US faces national challenges in HIV care delivery due to an inadequate HIV specialist workforce and the increasing role of non-communicable chronic diseases in driving morbidity and mortality in HIV-infected patients. Alternative HIV care delivery models, which include substantial roles for advanced practitioners and/or coordination between specialty and primary care settings in managing HIV-infected patients, may address these needs. We aimed to systematically review the evidence on patient-level HIV-specific and primary care health outcomes for HIV-infected adults receiving outpatient care across HIV care delivery models. We identified randomized trials and observational studies from bibliographic and other databases through March 2016. Eligible studies met pre-specified eligibility criteria including on care delivery models and patient-level health outcomes. We considered all available evidence, including non-experimental studies, and evaluated studies for risk of bias. We identified 3605 studies, of which 13 met eligibility criteria. Of the 13 eligible studies, the majority evaluated specialty-based care (9 studies). Across all studies and care delivery models, eligible studies primarily reported mortality and antiretroviral use, with specialty-based care associated with mortality reductions at the clinician and practice levels and with increased antiretroviral initiation or use at the clinician level but not the practice level. Limited and heterogeneous outcomes were reported for other patient-level HIV-specific outcomes (e.g., viral suppression) as well as for primary care health outcomes across all care delivery models. No studies addressed chronic care outcomes related to aging. Limited evidence was available across geographic settings and key populations. As re-design of care delivery in the US continues to evolve, better understanding of patient-level HIV-related and primary care health outcomes, especially across different staffing models and among different patient populations and geographic locations, is urgently needed to improve HIV disease management.

The Case for Considering Education and Health

Awareness of the impact of education on health remains relatively low among the public, professionals, and policy makers. Virginia Commonwealth University’s Center on Society and Health sought to raise awareness among key decision makers about the impact of education on health outcomes through its Education and Health Initiative (EHI). EHI utilized four key strategies to raise awareness: user-oriented research, strategic communication, local and national stakeholder engagement, and policy outreach to decision makers. We review the research highlighted in four stages of EHI product releases, as well as the development, process, products, and key outcomes associated with this initiative.

Comprehensive Ryan White Assistance and Human Immunodeficiency Virus Clinical Outcomes: Retention in Care and Viral Suppression in a Medicaid Nonexpansion State

Background Knowledge gaps remain about how the Ryan White human immunodeficiency virus (HIV)/AIDS Program (RW) contributes to health outcomes. We examined the association between different RW service classes and retention in care (RiC) or viral suppression (VS). Methods We identified Virginians engaged in any HIV care between 1 January and 31 December 2014. RW beneficiaries were classified by receipt of ≥1 service from 3 classes: Core medical, Support, and insurance and/or direct medication assistance through the AIDS Drug Assistance Program (ADAP). Receipt of all RW classes was defined as comprehensive assistance. We used multivariable logistic regression to compare the odds of RiC and of VS by comprehensive assistance and by RW classes alone and in combination. Results Among 13104 individuals, 58% received any RW service and 17% comprehensive assistance. Comprehensive assistance is significantly associated with RiC (adjusted odds ratio [aOR], 8.8 [95% confidence interval {CI}, 7.2-10.8]) and viral suppression (aOR, 3.3 [95% CI, 2.9-3.8]). Receiving any 2 RW classes or Core alone is significantly associated with RiC and VS, with the strength of association decreasing as the number of classes decreases. Recipients of Support alone are significantly less likely to have VS (aOR, 0.75 [95% CI, .59-.96]). For ADAP recipients also receiving Core and/or Support, insurance assistance is significantly associated with VS compared to receiving direct medication only (aOR, 1.6 [95% CI, 1.3-1.9]); this relationship is not significant for those who receive ADAP alone. Conclusions Receiving more classes of RW-funded services is associated with improved HIV outcomes. For some populations with insurance, RW-funded services may still be required for optimal health outcomes.

Implementing parallel spreadsheet models for health policy decisions: The impact of unintentional errors on model projections

Background Spreadsheet software is increasingly used to implement systems science models informing health policy decisions, both in academia and in practice where technical capacity may be limited. However, spreadsheet models are prone to unintentional errors that may not always be identified using standard error-checking techniques. Our objective was to illustrate, through a methodologic case study analysis, the impact of unintentional errors on model projections by implementing parallel model versions. Methods We leveraged a real-world need to revise an existing spreadsheet model designed to inform HIV policy. We developed three parallel versions of a previously validated spreadsheet-based model; versions differed by the spreadsheet cell-referencing approach (named single cells; column/row references; named matrices). For each version, we implemented three model revisions (re-entry into care; guideline-concordant treatment initiation; immediate treatment initiation). After standard error-checking, we identified unintentional errors by comparing model output across the three versions. Concordant model output across all versions was considered error-free. We calculated the impact of unintentional errors as the percentage difference in model projections between model versions with and without unintentional errors, using +/-5% difference to define a material error. Results We identified 58 original and 4,331 propagated unintentional errors across all model versions and revisions. Over 40% (24/58) of original unintentional errors occurred in the column/row reference model version; most (23/24) were due to incorrect cell references. Overall, >20% of model spreadsheet cells had material unintentional errors. When examining error impact along the HIV care continuum, the percentage difference between versions with and without unintentional errors ranged from +3% to +16% (named single cells), +26% to +76% (column/row reference), and 0% (named matrices). Conclusions Standard error-checking techniques may not identify all errors in spreadsheet-based models. Comparing parallel model versions can aid in identifying unintentional errors and promoting reliable model projections, particularly when resources are limited.

Effects of Electronic Cigarette Liquid Flavors and Modified Risk Messages on Perceptions and Subjective Effects of E-Cigarettes

Understanding how two characteristics—flavors and modified risk messages—affect perceptions and subjective effects of electronic cigarettes (e-cigarettes) can inform tobacco control efforts. In two within-subjects studies (N = 17 and N = 19), the effects of e-cigarette flavors (tobacco vs. menthol and unflavored vs. cherry) and hypothetical modified risk messages (“reduced harm relative to cigarettes” vs. no message and “reduced carcinogen exposure relative to cigarettes” vs. no message) on cigarette smokers’ perceptions of e-cigarettes were measured after participants self-administered condition-specific products (own-brand cigarettes; e-cigarettes). Perceptions/subjective effects were tested using linear mixed-effects regressions. Cigarettes were perceived as most harmful but rated more positively than e-cigarettes (ps < .05). Cherry and menthol e-cigarettes increased perceived pleasantness, taste, and physical sensations compared with unflavored and tobacco-flavored e-cigarettes, respectively (ps < .05). Modified risk messages were associated with reduced ratings of aversive effects (ps < .05) but not harm perceptions. Overall, few perceptions/subjective effects differed by e-cigarette flavor or message. Flavors and messages may have some influence on how smokers experience e-cigarettes.

Triangulating abuse liability assessment for flavoured cigar products using physiological, behavioural economic and subjective assessments: a within-subjects clinical laboratory protocol

Introduction In the USA, Food and Drug Administration regulations prohibit the sale of flavoured cigarettes, with menthol being the exception. However, the manufacture, advertisement and sale of flavoured cigar products are permitted. Such flavourings influence positive perceptions of tobacco products and are linked to increased use. Flavourings may mask the taste of tobacco and enhance smoke inhalation, influencing toxicant exposure and abuse liability among novice tobacco users. Using clinical laboratory methods, this study investigates how flavour availability affects measures of abuse liability in young adult cigarette smokers. The specific aims are to evaluate the effect of cigar flavours on nicotine exposure, and behavioural and subjective measures of abuse liability. Methods and analyses Participants (projected n=25) are healthy smokers of five or more cigarettes per day over the past 3 months, 18–25 years old, naive to cigar use (lifetime use of 50 or fewer cigar products and no more than 10 cigars smoked in the past 30 days) and without a desire to quit cigarette smoking in the next 30 days. Participants complete five laboratory sessions in a Latin square design with either their own brand cigarette or a session-specific Black & Mild cigar differing in flavour (apple, cream, original and wine). Participants are single-blinded to cigar flavours. Each session consists of two 10-puff smoking bouts (30 s interpuff interval) separated by 1 hour. Primary outcomes include saliva nicotine concentration, behavioural economic task performance and response to various questionnaire items assessing subjective effects predictive of abuse liability. Differences in outcomes across own brand cigarette and flavoured cigar conditions will be tested using linear mixed models. Ethics and dissemination The Virginia Commonwealth University Institutional Review Board approved the study (VCU IRB: HM20007848). Dissemination channels for study findings include scientific journals, scientific meetings, and policy briefs. Trial registration number NCT02937051.

Structural barriers to comprehensive, coordinated HIV care: geographic accessibility in the US South

ABSTRACT Structural barriers to HIV care are particularly challenging in the US South, which has higher HIV diagnosis rates, poverty, uninsurance, HIV stigma, and rurality, and fewer comprehensive public health programs versus other US regions. Focusing on one structural barrier, we examined geographic accessibility to comprehensive, coordinated HIV care (HIVCCC) in the US South. We integrated publicly available data to study travel time to HIVCCC in 16 Southern states and District of Columbia. We geocoded HIVCCC service locations and estimated drive time between the population-weighted county centroid and closest HIVCCC facility. We evaluated drive time in aggregate, and by county-level HIV prevalence quintile, urbanicity, and race/ethnicity. Optimal drive time was ≤30 min, a common primary care accessibility threshold. We identified 228 service locations providing HIVCCC across 1422 Southern counties, with median drive time to care of 70 min (IQR 64 min). For 368 counties in the top HIV prevalence quintile, median drive time is 50 min (IQR 61 min), exceeding 60 min in over one-third of these counties. Among counties in the top HIV prevalence quintile, drive time to care is six-folder higher for rural versus super-urban counties. Counties in the top HIV prevalence quintiles for non-Hispanic Blacks and for Hispanics have >50% longer drive time to care versus for non-Hispanic Whites. Including another potential care source—publicly-funded health centers serving low-income populations—could double the number of high-HIV burden counties with drive time ≤30 min, representing nearly 35,000 additional people living with HIV with accessible HIVCCC. Geographic accessibility to HIVCCC is inadequate in the US South, even in high HIV burden areas, and geographic and racial/ethnic disparities exist. Structural factors, such as geographic accessibility to care, may drive disparities in health outcomes. Further research on programmatic policies, and evidence-based alternative HIV care delivery models improving access to care, is critical.

Drinking, Cigarette Smoking, and Employment Among American College Freshmen at a Four-Year University

ABSTRACT Background: For American college students, alcohol and cigarette use are important health concerns, and employment concurrent with school attendance is on the rise. Given the lifelong importance of employment and substance use trajectories begun in college, parsing out the relationship between the two is meaningful. Objectives: This studys purpose is to determine whether employment during college is associated with substance use. Methods: Cross-sectional associations between employment (work hours, earnings) and substance use (drinking frequency, drinking quantity, smoking frequency) were estimated using partial proportional odds models in a sample of N = 1457 freshmen attending a large, public 4-year university in 2011, after accounting for demographics, personality, social environment, and parental influences. Results: Working 10 more hours and earning

Effect of Flavors and Modified Risk Messages on E-cigarette Abuse Liability

50 more per week as a freshman had modest positive associations with higher smoking frequency and with moderate drinking frequency and quantity prior to adjustment. After adjustment, work hours remained modestly associated with moderate drinking frequency and quantity. No adjusted associations were found among employment measures and smoking or between weekly earnings and drinking frequency. Different relationships emerged for moderate versus heavy alcohol use frequency and quantity. Conclusions: Both employment and substance use are commonplace among college freshmen. After extensive controls for potential confounders, the relationship between the two appears modest. Employment may yet play a role in college student substance use, but work hours and earnings are likely only small parts of a larger web of influences on drinking and smoking.