Wynne E. Norton

Early Retention in HIV Care and Viral Load Suppression: Implications for a Test and Treat Approach to HIV Prevention

BackgroundAfter HIV diagnosis and linkage to care, achieving and sustaining viral load (VL) suppression has implications for patient outcomes and secondary HIV prevention. We evaluated factors associated with expeditious VL suppression and cumulative VL burden among patients establishing outpatient HIV care. MethodsPatients initiating HIV medical care from January 2007 to October 2010 at the University of Alabama at Birmingham and University of Washington were included. Multivariable Cox proportional hazards and linear regression models were used to evaluate factors associated with time to VL suppression (<50 copies/mL) and cumulative VL burden, respectively. Viremia copy-years, a novel area under the longitudinal VL curve measure, was used to estimate 2-year cumulative VL burden from clinic enrollment. ResultsAmong 676 patients, 63% achieved VL <50 copies per milliliter in a median 308 days. In multivariable analysis, patients with more time-updated “no show” visits experienced delayed VL suppression (hazard ratio = 0.84 per “no show” visit, 95% confidence interval = 0.76 to 0.92). In multivariable linear regression, visit nonadherence was independently associated with greater cumulative VL burden (log10 viremia copy-years) during the first 2 years in care (Beta coefficient = 0.11 per 10% visit nonadherence, 95% confidence interval = 0.04 to 0.17). Across increasing visit adherence categories, lower cumulative VL burden was observed (mean ± standard deviation log10 copy × years/mL); 0%–79% adherence: 4.6 ± 0.8; 80%–99% adherence: 4.3 ± 0.7; and 100% adherence: 4.1 ± 0.7 log10 copy × years/mL, respectively (P < 0.01). ConclusionsHigher rates of early retention in HIV care are associated with achieving VL suppression and lower cumulative VL burden. These findings are germane for a test and treat approach to HIV prevention.

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.

Perceived Barriers to HIV Care Among HIV-Infected Women in the Deep South

Despite the wide availability of effective treatments for HIV disease, many HIV-infected individuals are not in care, and HIV-infected women, particularly those residing in resource-poor areas, may have greater difficulty accessing HIV care than men. The purpose of this research was to explore perceived barriers to care experienced by HIV-infected women living in the Deep South region of the United States. Qualitative research methods were used to generate in-depth descriptions of womens experiences in accessing HIV care. Participants (N = 40) were recruited from 4 community-based HIV service organizations to participate in focus groups. Sessions lasted approximately 2 hours and were audio recorded. Verbatim transcripts, demographic data, and observational notes were subjected to content analysis strategies that coded the data into categories. Five categories of barriers to HIV care were identified as follows: personal, social, financial, geographic/transportation, and health system barriers. Implications of the findings for future research and practice are discussed in this study.

Coping with HIV Stigma: Do Proactive Coping and Spiritual Peace Buffer the Effect of Stigma on Depression?

Although HIV stigma is a significant predictor of depression, little is known about which factors might most effectively buffer, or attenuate, this effect. We examined whether two coping-related factors—proactive coping and spiritual peace—modified the effect of HIV stigma on likelihood of depression among a sample of 465 people living with HIV/AIDS (PLWHA). In a cross-sectional analysis, we conducted hierarchical logistic regressions to examine the effect of HIV stigma, proactive coping, spiritual peace, and their interactions on likelihood of significant depressive symptoms. Spiritual peace moderated the effect of HIV stigma on depression at high—but not low—levels of HIV stigma. No such effect was observed for proactive coping. Findings suggest that spiritual peace may help counteract the negative effect of HIV stigma on depression. Intervention components that enhance spiritual peace, therefore, may potentially be effective strategies for helping PLWHA cope with HIV stigma.ResumenAunque el estigma del VIH es un predictor significativo de la depresión, se sabe poco sobre los factores que podría resultar más eficaz de atenuar este efecto. Se examinó si los dos factores relacionados con la frente—afrontamiento proactivo y espiritual de la paz—modificó el efecto del estigma del VIH en la probabilidad de depresión en una muestra de 465 personas que viven con el VIH/SIDA (PVVS). En un análisis de corte transversal, se realizó regresión logística jerárquica para examinar el efecto del estigma del VIH, afrontamiento proactivo, la paz espiritual, y sus interacciones sobre la probabilidad de síntomas depresivos significativos. La paz espiritual moderó el efecto del estigma del VIH sobre la depresión en niveles altos de estigma del VIH, pero este efecto no ocurrió en los niveles bajos de estigma del VIH. Sin embargo, este efecto no se observó con el afrontamiento proactivo. Los resultados sugieren que la paz espiritual puede ayudar a contrarrestar el efecto negativo del estigma del VIH en la depresión. Componentes de intervención que mejoren la paz espiritual, por lo tanto, potencialmente pueden ser estrategias eficaces para ayudar a las PVVS hacer frente al estigma del VIH.

Patient- and delivery-level factors related to acceptance of HIV counseling and testing services among tuberculosis patients in South Africa: a qualitative study with community health workers and program managers

BackgroundSouth Africa has a high tuberculosis (TB)-human immunodeficiency virus (HIV) coinfection rate of 73%, yet only 46% of TB patients are tested for HIV. To date, relatively little work has focused on understanding why TB patients may not accept effective services or participate in programs that are readily available in healthcare delivery systems. The objective of the study was to explore barriers to and facilitators of participation in HIV counseling and testing (HCT) among TB patients in the Free State Province, from the perspective of community health workers and program managers who offer services to patients on a daily basis. These two provider groups are positioned to alter the delivery of HCT services in order to improve patient participation and, ultimately, health outcomes.MethodsGroup discussions and semistructured interviews were conducted with 40 lay counselors, 57 directly observed therapy (DOT) supporters, and 13 TB and HIV/acquired immune deficiency syndrome (AIDS) program managers in the Free State Province between September 2007 and March 2008. Sessions were audio-recorded, transcribed, and thematically analyzed.ResultsThe themes emerging from the focus group discussions and interviews included four main suggested barrier factors: (1) fears of HIV/AIDS, TB-HIV coinfection, death, and stigma; (2) perceived lack of confidentiality of HIV test results; (3) staff shortages and high workload; and (4) poor infrastructure to encourage, monitor, and deliver HCT. The four main facilitating factors emerging from the group and individual interviews were (1) encouragement and motivation by health workers, (2) alleviation of health worker shortages, (3) improved HCT training of professional and lay health workers, and (4) community outreach activities.ConclusionsOur findings provide insight into the relatively low acceptance rate of HCT services among TB patients from the perspective of two healthcare workforce groups that play an integral role in the delivery of effective health services and programs. Community health workers and program managers emphasized several patient- and delivery-level factors influencing acceptance of HCT services.

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.

Developing the next generation of dissemination and implementation researchers: insights from initial trainees

BackgroundDissemination and implementation (D&I) research is a relatively young discipline, underscoring the importance of training and career development in building and sustaining the field. As such, D&I research faces several challenges in designing formal training programs and guidance for career development. A cohort of early-stage investigators (ESI) recently involved in an implementation research training program provided a resource for formative data in identifying needs and solutions around career development.ResultsResponses outlined fellows’ perspectives on the perceived usefulness and importance of, as well as barriers to, developing practice linkages, acquiring additional methods training, academic advancement, and identifying institutional supports. Mentorship was a cross-cutting issue and was further discussed in terms of ways it could foster career advancement in the context of D&I research.ConclusionsAdvancing an emerging field while simultaneously developing an academic career offers a unique challenge to ESIs in D&I research. This article summarizes findings from the formative data that outlines some directions for ESIs and provides linkages to the literature and other resources on key points.

Primary care and public health partnerships for implementing pre-exposure prophylaxis.

published by admin on Fri, 03/14/2014 9:08am Title Primary care and public health partnerships for implementing pre-exposure prophylaxis. Publication Type Journal Article Year of Publication 2013 Authors Norton, WE, R Larson, S, Dearing, JW Journal Am J Prev Med Volume 44 Issue 1 Suppl 2 Pagination S77-9 Date Published 2013 Jan ISSN 1873-2607

A stakeholder-driven agenda for advancing the science and practice of scale-up and spread in health

BackgroundAlthough significant advances have been made in implementation science, comparatively less attention has been paid to broader scale-up and spread of effective health programs at the regional, national, or international level. To address this gap in research, practice and policy attention, representatives from key stakeholder groups launched an initiative to identify gaps and stimulate additional interest and activity in scale-up and spread of effective health programs. We describe the background and motivation for this initiative and the content, process, and outcomes of two main phases comprising the core of the initiative: a state-of-the-art conference to develop recommendations for advancing scale-up and spread and a follow-up activity to operationalize and prioritize the recommendations. The conference was held in Washington, D.C. during July 2010 and attended by 100 representatives from research, practice, policy, public health, healthcare, and international health communities; the follow-up activity was conducted remotely the following year.DiscussionConference attendees identified and prioritized five recommendations (and corresponding sub-recommendations) for advancing scale-up and spread in health: increase awareness, facilitate information exchange, develop new methods, apply new approaches for evaluation, and expand capacity. In the follow-up activity, ‘develop new methods’ was rated as most important recommendation; expanding capacity was rated as least important, although differences were relatively minor.SummaryBased on the results of these efforts, we discuss priority activities that are needed to advance research, practice and policy to accelerate the scale-up and spread of effective health programs.

Measurement resources for dissemination and implementation research in health.

BackgroundA 2-day consensus working meeting, hosted by the United States National Institutes of Health and the Veterans Administration, focused on issues related to dissemination and implementation (D&I) research in measurement and reporting. Meeting participants included 23 researchers, practitioners, and decision makers from the USA and Canada who concluded that the field would greatly benefit from measurement resources to enhance the ease, harmonization, and rigor of D&I evaluation efforts. This paper describes the findings from an environmental scan and literature review of resources for D&I measures.FindingsWe identified a total of 17 resources, including four web-based repositories and 12 static reviews or tools that attempted to synthesize and evaluate existing measures for D&I research. Thirteen resources came from the health discipline, and 11 were populated from database reviews. Ten focused on quantitative measures, and all were generated as a resource for researchers. Fourteen were organized according to an established D&I theory or framework, with the number of constructs and measures ranging from 1 to more than 450. Measure metadata was quite variable with only six providing information on the psychometric properties of measures.ConclusionsAdditional guidance on the development and use of measures are needed. A number of approaches, resources, and critical areas for future work are discussed. Researchers and stakeholders are encouraged to take advantage of a number of funding mechanisms supporting this type of work.