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New Initiatives and Updates from the United States-Mexico Border Binational Infectious Diseases Conference

USMBHCI was honored to represent the Texas/Oklahoma AIDS Education and Training Center (AETC) and the U.S.-Mexico Border AETC Steering Teem (UMBAST) this year at the United States – Mexico Border Binational Infectious Disease Conference in El Paso, Texas. This binational meeting is convened each year by the United States – Mexico Border Health Commission (BHC) in collaboration with other federal and state agencies. The Executive Director of the BHC, Jose Luis Velasco, was guest speaker at UMBAST’s recent annual meeting, and despite being relatively new in his position, is a champion of our work. I was never so happy to be bilingual as I was during the time at this conference, which was planned in such a way that every other session was in English or Spanish.  It was great to be able to understand all sessions without the need for an interpreter.

The Texas/Oklahoma AETC presented a poster on "Educating HIV/AIDS Providers along the U.S./Mexico Border." We looked at training provided along the U.S./Mexico border region since 2010 and found that 87% of participants reported that the information presented was applied in their practice/service, and 94% would recommend the training to their peers and other participants.  Based on the results of additional participant reports, we found there was an increase in participant knowledge upon completion of our trainings.

It was great to see representatives from federal, state and local levels from both sides of the border working together to address infectious diseases and minimize their effects along the border. A frequent theme was health inequalities along the border and the impact it has on each side of the border. For the context of this conference, health inequities referred to an individual without access to medical care, no or low education, someone without an employment source, no housing, basically anything that will place that individual living along the border at a health disadvantage.  What was impressive, however, was seeing the extent of collaboration to solve some of these issues. The people working daily on the border who study and address health concerns across two federal, ten state, and multiple local systems, deserve a lot of credit. 

The topics presented varied from federal to policy discussions, region-specific epidemiology updates including HIV/AIDS prevalence and incidence, HIV prevention, tuberculosis, and coccidioidomycosis. Breakout sessions were short, concise, and straight to the point, offering multiple tracks to fit the interest of participants.

A presentation that caught my interest was the panel discussion on communicable diseases in detention centers. Here, Commander Diana Elson from the U.S. Customs and Immigration Enforcement (U.S. ICE) provided a great explanation of the process an individual infected with a communicable disease, such as tuberculosis, goes through – from getting apprehended and testing positive, to treatment and being kept in isolation, if needed, at an ICE facility before finalizing the deportation process once there is a clean bill of health. UMBAST worked with Dr. Elson previously to create a fact sheet for providers of HIV patients who have been detained by U.S. ICE.

brochure coverAnother program that was mentioned throughout the conference is the Ventanilla de Salud (literally, “windows of health”) system, which is a program of the Mexican Department of Health and the Mexican Ministry of Foreign Affairs and implemented through 50+ Mexican consulates in the United States. The Ventanilla program provides health information, counseling, and referrals for Mexican nationals living in the United States. Their website offers information in English and Spanish – check to see if there is a Ventanilla program near you, and whether there are services available for your patients.

A big takeaway from this conference for me is that we have come a long way with collaboration; however, there is still room for growth between the United States and Mexico to minimize the impact of communicable diseases in this region. All of the presentations at this conference were excellent with great speakers and great sharing of ideas, but in the end one thing was clear: infectious diseases do not respect borders, sex, age, or social status. 

Texas-Oklahoma AETC’s collaborative border program includes a focus on online, on-demand training sessions, which are accessible to providers on either side of the border. We will continue to address topics that contribute to health disparities in this region, including substance abuse, TB, policy issues (Affordable Care Act, and continuity of care for deported patients) and patient- and community-focused concerns such as health literacy and cultural factors in the Latino community.

 
Source: 
Texas/Oklahoma AIDS Education and Training Center
Publish Date: 
Wednesday, July 16, 2014
Author(s): 
Author: 
Affiliation: 
Texas/Oklahoma AIDS Education and Training Center

Mortality Associated with Chronic Comorbidities among HIV-infected Persons in the United States

Combination antiretroviral therapy (cART) has substantially reduced HIV-related morbidity and mortality in the United States. HIV-infected persons today are living healthier and longer lives with expected lifespans near equal to those of uninfected person if the infection is effectively treated [1]. CDC estimates that by year 2020, over half of the HIV-infected persons in the United States will be aged 50 years or older [2]. With increased longevity, HIV-infected patients increasingly experience a variety of age-related chronic diseases [3] common in the general population, such as cardiovascular disease, liver disease, diabetes, and non-AIDS related cancers.

HIV-infected persons may experience similar or even higher rates of some of these comorbidities than HIV-uninfected persons. Reasons include the high prevalence of behavioral risk factors (e.g., tobacco use, alcohol use) and side effects of HIV-related treatments (e.g., kidney toxicity, unhealthy elevations in cholesterol). Emerging data suggest HIV itself may more directly increase risk for conditions such as atherosclerosis, low bone mineral density, and chronic obstructive pulmonary disease by stimulating a state of chronic inflammation that favors these outcomes. As a result, deaths among cART-treated persons in the United States are increasingly likely to result from non-AIDS-related causes [4,5].

Since 1993, The Centers for Disease Control and Prevention (CDC) have funded a multi-site study of HIV-infected patients cared for at HIV-specialty clinics: the HIV Outpatient Study (HOPS). In recent years, the HOPS investigators have shown that:

  • Most HOPS patients suffer from multiple chronic conditions in addition to HIV. In recent years, approximately two-thirds of HOPS patients had two or more chronic conditions in addition to HIV [3].
  • In 2004, among HOPS patients who died, 43% died solely from non-AIDS-related causes. In 1996, that percentage was 13% [4].
  • Despite persistent reductions in mortality among cART-treated HOPS patients (rates currently average at 1.6% percent per 100 persons per year, down from about 10% before 1996) disparities in mortality remain [6]. These sociodemographic disparities appear at least in part attributable to differences in the burden of chronic conditions not directly related to HIV infection. Among HOPS participants who died, comorbid conditions which may be prevented by lifestyle changes (e.g., tobacco smoking cessation, dietary changes) were often more prevalent among blacks/African Americans and Hispanics/Latinos than whites, and among publicly than privately insured participants [6].
figure 1
figure 2

As HIV-infected patients age and experience multiple comorbidities, the integration of HIV care and primary care is ever more important. HIV providers should be comfortable with standard chronic disease management and coordinate care with specialists as needed (e.g., cardiologists, nephrologists, hepatologists) while primary care providers will need to become more comfortable with the basic management of HIV infection. Because HIV-infected patients see their doctors for HIV care typically twice or more annually, HIV providers have repeated opportunities for brief messages related to chronic HIV disease prevention (e.g., including smoking cessation, exercise and weight loss) to reduce illness and death due to chronic conditions.

References:

1. Samji H, Cescon A, Hogg RS, et al for the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) of IeDEA. Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLoS One. 2013; 8(12):e81355.

2. Brooks JT, Buchacz K, Gebo KA, Mermin J. HIV infection and older Americans: the public health perspective. Am J Public Health. 2012;102(8):1516-26.

3. Buchacz K, Baker RK, Palella FJ Jr, et al for the HIV Outpatient Study Investigators. Disparities in prevalence of key chronic diseases by gender and race/ethnicity among antiretroviral-treated HIV-infected adults in the US. Antivir Ther. 2013;18(1):65-75.

4. Palella FJ Jr, Baker RK, Moorman AC, et al for the HIV Outpatient Study Investigators. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV outpatient study. J Acquir Immune Defic Syndr. 2006;43(1):27-34.

5. Adih WK, Selik RM, Hu X. Trends in Diseases Reported on US Death Certificates That Mentioned HIV Infection, 1996-2006. J Int Assoc Physicians AIDS Care. 2011;10(1):5-11.

6. Palella FJ Jr, Baker RK, Buchacz K, et al for the HOPS Investigators. Increased mortality among publicly insured participants in the HIV Outpatient Study despite HAART treatment. AIDS. 2011;25(15):1865-76.

Disclaimer: The findings and conclusions of this report are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Source: 
U.S. Centers for Disease Control and Prevention
Publish Date: 
Wednesday, June 18, 2014
Author(s): 
Author: 
Affiliation: 
U.S. Centers for Disease Control and Prevention

Mental Health Awareness: How Aware Are We?

May was Mental Health Awareness month.  How aware of mental health issues are we in our own lives as well as in those we treat every day?  As HIV care providers, how often do we hear “I am so down,”  “I haven’t had fun in so long,” or “I’m so stressed.”  Often in our patient’s lives everything becomes a problem, so do we truly recognize the stress they may be experiencing?  With clinic visits becoming shorter and patient volume growing larger, checking in on a person’s mood often falls by the wayside. 

Studies vary on the prevalence (0 – 80%) but most agree the incidence of depression in the HIV-infected population is similar to other chronic illnesses.  If this is correct, 25-30% of our patients meet the criteria for Major Depression.   Many more transiently feel “down” and could benefit from intervention of some sort, which may vary from some type of interpersonal therapy to psychopharmacologic intervention.  Screening tools become an important part of the patient visit to identify those who need further interventions.  Many tools are available and should be chosen based on ease of administration, and time for completion.  A short list includes Beck Depression Inventory -II (BDI-II), Brief Symptom Inventory (BSI), and the Patient Health Questionnaire (PHQ-9).  In states with Medicaid expansion and more aggressive Affordable Care Act rollout, the ability to intervene has increased.  For states without Medicaid expansion and fewer resources, mental health services remain status quo. Therefore, in states without Medicaid expansion, it behooves the Primary Care Provider (PCP) to learn about and use these resources.  Waiting for the initial psychiatric or therapy appointment to intervene is a waste of valuable therapeutic time.   Utilizing self-report screening tools allows providers to determine who needs further attention.  Referring case managers familiar with mental health issues then provides another level of support.  They can further assess the individual during the visit, and   make treatment recommendations for the provider to intervene. 

In these situations, it is important to for the PCP to understand how to use a few antidepressants/anti-anxiety medications.  There are many relatively safe medications that have few interactions with antiretrovirals. It is also important to know where the HIV-infected individual can be referred locally for therapy, as not all interventions need to be pharmacologic.  Starting medications may be sufficient without need for psychiatric referrals.  Following up with tools that assess progress on each visit or a phone call can help determine more intensive intervention (psychiatric referral).  For example, both the Beck Depression Inventory –II, and the Patient Health Questionnaire have been validated for interval use demonstrating progress of treatment. 

Treatment of mental health issues (specifically depression) is important for effective treatment of HIV.  With few treatment options, Primary Care Providers need to take more of a lead with treatment to assure positive patient outcomes. 

Source: 
Texas/Oklahoma AIDS Education and Training Center
Publish Date: 
Wednesday, June 4, 2014
Author(s): 
Affiliation: 
Texas/Oklahoma AIDS Education and Training Center

Health Care Reform and its Impact on People Living with HIV/AIDS - The Massachusetts Experience

In 2006, Massachusetts passed comprehensive health insurance reform in order to provide almost universal coverage for its residents. In doing so, the state introduced several health care reforms, which have become the foundation for the Affordable Care Act (ACA) and made MA the model for the Ryan White Program in a post-health care reform environment. Reforms included an individual mandate, Medicaid expansion, and increased access to subsidized private insurance and resulted in improved health outcomes and reduced health care costs for all residents. 

In 2001, Massachusetts became the first state in the nation to implement a federal waiver allowing Medicaid expansion to non-disabled people living with HIV (PLWH) with incomes up to 200% of the Federal Poverty Level (FPL). In 2006, Massachusetts became the first state to mandate that all residents carry health insurance coverage. These reforms allowed for subsidies for residents with incomes up to 300% of the FPL, and included the development of the first state health insurance exchange that certified plans with comprehensive benefits without preexisting condition exclusions. Additionally, the reforms preserved a comprehensive Medicaid benefits package for all residents, and the expansion of Medicaid to cover all uninsured residents with incomes up to 200% of the FPL. 

With local health care reform, Massachusetts has seen an impact on its Ryan White Program. Since 2006, funding to Massachusetts’s HIV Drug Assistance Program (HDAP) has been largely spent on health insurance plans and medication co-pays. The HDAP has maintained an unrestricted formulary and 500% FPL eligibility. The HDAP serves as a resource for ensuring Medicaid enrollment, as applicants must use the HDAP as the payer of last resort and show proof of having applied for Medicaid. In 2007, Massachusetts became the first state to receive a waiver to the 75/25 rule, which allows it to invest heavily in critical coverage completion services (such as medical case management and psychosocial support services) that are non-third-party reimbursable, but essential to ensure that PLWH are engaged, retained, and adherent to care. As a result of expanded insurance coverage, access to antiretroviral therapy, and a robust HIV provider network, including Ryan White-funded services, Massachusetts has seen a decline in new HIV diagnoses and has also achieved very high levels of viral suppression.

It is important to note that while the ACA will result in expanded access to health care for PLWH, as we have seen in Massachusetts, it will not address all needs PLWH face. Therefore, the Ryan White Program will continue to play a critical role in serving the needs of PLWH. Particularly, going forward with the ACA, the Ryan White Program will need to provide coverage completion services and continue to provide a full range of critical services for those who have no other source of coverage, including undocumented PLWH and legal residents living with HIV who are not yet eligible for public coverage. 

Source: 
New England AETC
Publish Date: 
Wednesday, May 21, 2014
Author(s): 
Affiliation: 
New England AETC

Sexual Transmission of Hepatitis C in HIV-Infected MSM: Raising Awareness through Screening

May is National Viral Hepatitis Awareness Month. We are at an exciting time in HCV awareness, screening and treatment. A recently updated Viral Hepatitis Action Plan, new United States Preventative Services Task Force (USPSTF) HCV screening guidelines for both the birth-cohort (the “baby boomer” guidelines of providing a one-time test for anyone born between 1945 and 1965) and risk-based populations, and advances in HCV treatments have brought a renewed focus to this historically “silent epidemic."  With at least 2.7 million people chronically infected, HCV is the most common blood-borne infection in the United States.

It is also the deadliest: HCV accounts for at least 15,000 deaths per year, and is the leading indicator for liver transplants in the U.S. It is estimated that at least 300,000 or 25% of people living with HIV are also infected with HCV. HCV-related liver disease is the leading non-AIDS cause of death in HIV-infected patients, and HCV disease progression is more rapid in this group, making detection of both acute and chronic HCV extremely important in clinical practice.

Injection drug use remains the most common risk factor for HCV, but in HIV-infected persons — particularly in MSM populations — sexual transmission is a significant risk factor. Sexual transmission of HCV among HIV-infected MSM has been consistently reported in medical literature since the early 2000s, but screening recommendations for the sexual transmission of HCV are not included in the CDC risk-based or birth cohort guidelines, nor are they in the USPSTF guidelines.

However, the CDC’s 2010 Sexually Transmitted Diseases Treatment Guidelines provide excellent guidance for HCV screening in HIV-infected patients. In addition to recommending HCV screening upon initial evaluation, these recommendations also call for routine monitoring of liver function tests to identify acute HCV infection. Finally, to account for the risk of possible sexual exposure in HIV-infected MSM, they suggest HCV testing at either routine intervals or when a patient presents with an ulcerative STD.

Guidelines for frequency of HCV screening have not been established, but the following list of risk exposures for HCV suggest a need for frequent screening (every 3-6 months, but at least annually):

  • Patients who report sharing injection drug using equipment (syringes, cookers, cotton, water, etc.);
  • Patients who report sharing non-injectable drugs (crack/crystal meth pipes, snorting straws), especially when used in conjunction with sex;
  • Patients who report sexual activity likely to cause trauma or bleeding from breaks in rectal tissues (such as fisting, multiple sex partners, use of sex toys);
  • Patients who report bleeding during anal sex;
  • Patients who report not using, or not consistently using barriers during anal sex (condoms, gloves for fisting);
  • Patients who practice serosorting;
  • Patients with a history of genital ulcerative diseases (HCV, LGV, primary syphilis).

HCV screening toolkitProject Inform can help your patients who are living with HIV/HCV co-infection, or are at risk of HCV infection. We have developed a three-booklet Health and Wellness series for patients living with HIV and HCV.

Additionally, you can direct your patients to a national hepatitis C helpline, Help-4-Hep at 1-877-Help-4-Hep (877-435-7443). Trained counselors and health educators are available to talk with your patients Monday-Friday, 9am to 7pm EST. You can also order Help-4-Hep posters, brochures and tear pads online.

This month, Project Inform also plans to launch “A Toolkit for Screening, Counseling and Patient Education: Hepatitis C Infection and People Living with HIV," which includes materials for medical providers and other health care staff as well as patient fact sheets. For more information on this toolkit or to request a free copy, visit the Project Inform website, or email Andrew Reynolds, Hepatitis C Education Manager, at areynolds@projectinform.org.

Source: 
Project Inform
Publish Date: 
Wednesday, May 7, 2014
Author(s): 
Affiliation: 
Project Inform

First-Line Therapy: Raltegravir, Darunavir, or Atazanavir?

ACTG 5257 is a randomized open-label comparison of 3 ARV regimens for initial therapy: atazanavir + ritonavir (ATV/r), darunavir + ritonavir (DRV/r), or raltegravir (RAL), each in combination with fixed-dose tenofovir/emtricitabine.

The 3 treatment groups (roughly 600 subjects each) were well matched for baseline characteristics and were more a diverse population than most: 24% were women, 42% were non-Hispanic black, and 22% were Hispanic. Median baseline HIV RNA was 4.6 log10 copies/mL and in 30% was >100,000 copies/mL; median baseline CD4 count was 308 cells/µL; and, per study protocol, there were no primary NRTI or PI resistance mutations. Study subjects were permitted to change treatment groups for toxicity reasons and remain in the trial.

Results at 96 weeks included the following:

  • Virologic failure (VF): rates of VF were not significantly different in the 3 treatment groups (10% in RAL, 15% in DRV/r, and 13% in ATV/r)
  • Tolerability failure (TF): rates of TF in the RAL and DRV/r groups were significantly lower than in the ATV/r group (1%, 5%, and 15%, respectively)
  • Cumulative incidence of either VF or TF: RAL was superior to both PIs, and DRV/r was superior to ATV/r (cumulative failure rates of 1%, 5%, and 16%, respectively)
    • This difference was attributable largely to tolerability issues in the ATV/r group (most common were jaundice, hyperbilirubinemia, or gastrointestinal symptoms)
  • Resistance:
    • The incidence of resistance in subjects with treatment failure was substantially higher in the RAL group (28% of those with VF and resistance test information) than in the PI groups (4% of the DRV/r group and 12% of the ATV/r group).
    • Additionally, the RAL group had more 2-class resistance than the PI groups (11/18 in the RAL group had both integrase and RT mutations, whereas the PI groups had RT mutations, plus 1 integrase mutation in each group and no protease mutations)
  • CD4 increases: >250 cells/µL in all groups
  • Metabolic effects:
    • Lipids: greater increases in LDL and TG were seen in the DRV/r and ATV/r groups than in the RAL group; there were no significant differences between the two PI groups.
    • Bone density: bone mineral density loss at the lumbar spine and total hip was less in the RAL group than in either PI group, and were not different in DRV/r versus ATV/r group.

Clinical Bottom Line

This study provides a welcome comparison of 3 standard regimens for initial HIV therapy (each is recommended by current DHHS and IAS-USA guidelines). As expected, each performed well in terms of virologic efficacy; that is, each ART regimen worked well for those able to take and tolerate it. However, the 3 regimens were differentiated by tolerability and resistance issues. ATV/r caused treatment-limiting adverse effects significantly much more frequently than did either RAL or DRV/r, and both PIs caused more lipid and bone mineral density perturbations than did RAL. Virologic failure was uncommon in each treatment group but in raltegravir recipients the consequences of VF were greater than in recipients of either PI--a greater proportion of the RAL VF group developed resistance mutations, and most had mutations to 2 ARV classes. Subjects in the DRV/r and ATV/r groups who experienced VF had NRTI mutations but no PI resistance mutations (each group also had 1 subject with an integrase mutation; this was not explained but perhaps reflects a change of treatment group during the study). Further analyses of the data should be forthcoming and may help to identify groups (eg, based on HIV RNA strata) who are more likely to succeed (or fail) with any of these regimens. For the time being, I am left with the question of whether ATV, compared to other agents, has any significant advantages for initial therapy.

References

  • Landovitz RL, Ribaudo HJ, Ofotokun I, et al. Efficacy and tolerability of atazanavir, raltegravir, or darunavir with FTC/tenofovir: ACTG 5257. In: Program and abstracts of the 2014 Conference on Retroviruses and Opportunistic Infections; March 3-6, 2014; Boston. Abstract 85.
  • Ofotokun I, Ribaudo H, Na L, et al. Darunavir or atazanavir vs raltegravir lipid changes are unlinked to ritonavir exposure: ACTG 5257. In: Program and abstracts of the 2014 Conference on Retroviruses and Opportunistic Infections; March 3-6, 2014; Boston. Abstract 746.
  • Brown T, Moser C, Currier J, et al. Bone density changes after antiretroviral initiation with protease inhibitors or raltegravir. In: Program and abstracts of the 2014 Conference on Retroviruses and Opportunistic Infections; March 3-6, 2014; Boston. Abstract 779LB.
Source: 
AETC National Resource Center
Publish Date: 
Monday, April 28, 2014
Author(s): 
Author: 
Affiliation: 
AETC National Resource Center
UCSF Center for HIV Information

Darunavir + Raltegravir without NRTIs: NEAT Study Results

Over the past few years, numerous studies have examined the use of NRTI-sparing regimens in initial therapy. These regimens generally have not been as effective as standard regimens, for reasons that are not entirely clear, or have had higher rates of toxicity. Two small studies previously examined the combination DRV/r + RAL, and showed very different efficacy results (see Dolutegravir + Raltegravir without NRTIs, Revisited). At CROI last month, researchers presented 96-week results of NEAT-001, a much larger randomized open-label comparison of RAL (BID) + DRV/r (QD) with TDF/FTC + DRV/r (all QD) in treatment-naive patients.

The two treatment groups (approximately 400 patients each) were generally well matched, with the median HIV RNA approximately 4.76 log10 and median CD4 count 333 cells/µL; by protocol, patients had no major resistance mutations at baseline.

Results at 96 weeks included the following:

  • Treatment failure:
    • Failure (which was defined by either virologic or clinical criteria) was seen in 17.4% of the RAL + DRV/r group and 13.7% of the TDF/FTC + DRV/r group at 96 weeks, a difference that was not statistically significant.
    • HIV RNA was <50 copies/mL in 89% of the RAL + DRV/r group and 93% of the standard therapy group at 96 weeks (89% and 91%, respectively, at 48 weeks).
    • In those with baseline HIV RNA levels of >100,000 copies/mL, failure was seen in 36% of the RAL + DRV/r recipients and 27% of TDF/FTC + DRV/r recipients (this result barely missed statistical significance); in those with baseline CD4 <200 copies/µL, failure rates were 39% and 21%, respectively (statistically significant).
  • Resistance
    • Resistance developed in patients with virologic failure in the RAL + DRV/r treatment group but not in the comparator group:
      • 5 of 28 evaluable genotypes in RAL + DRV/r patients showed emergent integrase mutations (1 also had a reverse transcriptase mutation).
      • No emergent resistance mutations were found in the 13 TDF/FTC + DRV/r patients with evaluable genotypes after virologic failure.
  • CD4 increases:
    • Mean CD4 increases were essentially the same in the two groups, 267 and 266 cells/µL.
  • Adverse effects:
    • There were no significant differences between treatment groups in serious adverse effects.
    • Lipids: There were greater increases in total cholesterol, LDL, and HDL in the RAL + DRV/r group; these were statistically significant but perhaps not clinically significant.
    • Renal: Creatinine clearance decreased in the TDF/FTC + DRV/r group (-3.8) and was little changed in the NRTI-sparing group (+0.9 mL/min); p = .02.

Clinical Bottom Line

Study researchers concluded that, for first-line therapy, the NRTI-sparing combination of RAL + DRV/r was noninferior to the standard regimen of TDF/FTC + DRV/r at 96 weeks. It is important to remember, however, that patients with high pretreatment HIV RNA or low CD4 counts on the NRTI-sparing regimen had higher rates of treatment failure. Additionally, patients with virologic failure on RAL + DRV/r paid a higher cost for that failure in terms of resistance mutations. For now, RAL + DRV/r may be a viable option for certain patients (eg, those with significant contraindications to NRTIs), but for most, the standard regimens remain appropriate.

For patients who "need" NRTI-sparing regimens, future studies examining the combination of dolutegravir + DRV/r (for an entirely once-daily regimen) may be useful, as would the inclusion of 3TC, a largely "benign" NRTI, to possibly increase regimen potency without adding significant toxicity.

References

  • Raffi F, Babiker AG, Richert L, et al. First-line RAL + DRV/r is non-inferior to TDF/FTC + DRV/r: The NEAT001/ANRS143 randomised trial. In: Program and abstracts of the 2014 Conference on Retroviruses and Opportunistic Infections; March 3-6, 2014; Boston. Abstract 84LB.
Source: 
AETC National Resource Center
Publish Date: 
Monday, April 28, 2014
Author(s): 
Author: 
Affiliation: 
AETC National Resource Center
UCSF Center for HIV Information

Highlights of the Quality Management Program at the François-Xavier Bagnoud Center

The Quality Management Program at the François-Xavier Bagnoud (FXB) Center, School of Nursing, Rutgers, The State University of New Jersey (NJ), plays a unique role in assuring quality care for patients with HIV. We work in collaboration with agencies throughout NJ at both the local and state levels.  Quality Management (QM) chart reviews and technical assistance are provided to the Newark Eligible Metropolitan Areas (EMA) Ryan White (RW) Part A grantees and NJ Department of Health, RW Part B agencies providing Primary Medical Care, Case Management and Dental care. Our staff includes a medical social worker, nurses, and a program development specialist.  The audit criteria parameters are defined by the HRSA HIV/AIDS Bureau performance measures guidelines, local (Newark) EMA indicators and indicators based upon the state’s needs, which can be found here.

The goal of our program is to bring together RW care providers to evaluate documented quality indicators and assist them in improving their performance quality when needed.  Medical Case Management (MCM) QM has expanded throughout NJ. The guidelines for MCM performance measures can be found here.  Examples of performance measures include specific laboratory tests, cervical Pap screenings, and oral health assessments.

Our work includes:

  • Comprehensive MCM Training is offered to all of the Medical Case Managers in the Newark EMA. Every year the training is tailored to lessons learned from the aggregate data gained from the chart review.
  • Quarterly Steering Committee Meetings for the RW Part B Network, which provide continuous feedback of audit findings and reports.  This leads to the discussion of barriers to achieving better quality indicator outcomes among the providers. They are able to collaborate, discuss best practices and share ideas for overcoming these challenges and barriers.  

Work Outcomes:

  • To improve patient access to dental care and increase oral health assessment performance measures, we implemented Dental QM for all Part B sites. Oral health needs to be an integral part of primary health care of all our patients with HIV. We have noted that Sites where patients have easier access to dental providers appear to have better outcomes for oral health assessments. We have been working closely with Rutgers School of Dental Medicine to educate ourselves on the dentist’s role in the care of the HIV-infected patient.  We have established a QM Dental Data Collection Tool to use at our site audits to ensure that the patients are receiving the best oral health care. The guidelines for Oral Health performance measures can be found here.  It is our hope that with an increased knowledge of Dental QM, a model of care can be established for increasing patients’ oral health care.
  • We are piloting a new clinical quality measure data collection tool that includes preconception care for women. We’re hoping this additional tool will help RW providers to increase their comfort level with starting the conversation about reproductive options and family planning care with HIV-infected women.

PRECONCEPTION CARE (Female Patients Only)

25. Is the patient newly enrolled in care during last six months of the year? Yes       No

26. Was the patient pregnant during the past 12 months?  Yes       No

27. Was her pregnancy intention documented? Yes       No

28. Does she desire pregnancy?  Yes     No     Not documented

28 a. If yes, was she referred for a reproductive health evaluation?   Yes       No

28 b. If no, does she have a documented method of contraception?  Yes       No

28 c. Is her method of contraception exclusively condoms?  Yes     No     Not documented

 

Since working with the Part B agencies, we have noted improvement in the following areas:

  • Hepatitis C screening improved from 83% to 97%.
  • Hepatitis B Screening improved from 82% to 95%.
  • Oral health assessments by a dentist improved from 32% to 47%.
  • Substance abuse screening and mental health screening are both now in the 90th percentile.

QM is constantly changing, and through technical assistance and enabling practitioners to use RW Networks as a platform for discussions, we try to stay up-to-date with all of the best practices and ways to overcome any barriers to care. We have found through our data collection and conversations with providers that multidisciplinary healthcare allows for the best overall health for our NJ patients.

Source: 
François-Xavier Bagnoud Center
Publish Date: 
Thursday, April 24, 2014
Author(s): 
Affiliation: 
François-Xavier Bagnoud Center
Author: 
Affiliation: 
François-Xavier Bagnoud Center
Author: 
Affiliation: 
François-Xavier Bagnoud Center
Author: 
Affiliation: 
François-Xavier Bagnoud Center

Tips for Preparing Online Education

How many times have you dozed off during a conference or webinar? It is easy to lose focus with educational formats that require little or no interaction. When we want to learn something fun and new, what methods do we choose? I bet a lot of us go to YouTube to watch short videos, go to Pinterest for ideas, or we turn to blog sites and other online communities for answers and instructions to tackle tasks. Why should continuing education for healthcare providers be any different? Healthcare providers and adult learners today are requesting that continuing education be convenient, short, interactive, and timely. Their time is valuable and they want to make the most of every moment.

HIV heart logoThe South Central Telehealth Resource Center, which is funded by HRSA’s Office of Rural Health Policy and Office for the Advancement of Telehealth, partnered with the Delta Region AETC to become Health, Education, Assessment, and Research in Telehealth, or HIV HEART.  In this partnership, telemedicine experts and HIV care experts work together to provide clinical care and HIV education to healthcare providers using interactive video and on-line education platforms, and offer consults for rural providers. Rural providers are appreciative of the consultation and support and have the option of participating in the telehealth visits, or receiving a consult report after the visit. To maximize time we try to make trainings as engaging and responsive as possible. At HIV HEART we have found that online and interactive presentations increase participation by allowing providers to access the education at their convenience - not just during the live presentation. Our online portal launched in December 2013, and over 1,000 healthcare providers in and around Arkansas have signed up for online training since then.

Here’s what we have found to be helpful when preparing online education programs:

  1. Shorter is better –Instead of an hour long webinar, change it up a bit and see how 30 minutes goes. Divide a traditional one-hour presentation into two half-hour presentations. The shortened length really helps to bring in the busy healthcare providers we aim to reach.
  2. Make it interactive – whether you poll the audience online during the webinar, or use a free poll service using mobile phones, this helps to bring the audience in. With increased interaction, the presenter may need to allow for more time for the content presentation. For example, this fits well with 20 minutes of content and 10 minutes for interaction throughout. The interactions allow the presenter to see what the baseline knowledge is of the audience and tailor the discussion to fit their needs.
  3. Make it case based – if at all possible, frame the educational event around a case. It will challenge the audience to ask/answer questions related to the appropriate care for the patient’s needs, and educators can then instruct on how to deliver the appropriate evidence-based care.
Learn On Demand logo

Shake up your next continuing education presentation! Make it interactive-add a little pizazz. It will eliminate the nods due to dozing and increase the nods related to positive discussion! For examples of interactive on-line modules, visit The University of Arkansas for Medical Sciences Learn on Demand web-page. Give the HIV HEART modules a try and let us know what you think.

learn telehealth logo

 
 
Source: 
Health, Education, Assessment, and Research in Telehealth
Publish Date: 
Wednesday, April 9, 2014
Author(s): 
Affiliation: 
Health, Education, Assessment, and Research in Telehealth

in+care Campaign: Keeping Patients in Care and in Good Health

The in+care Campaign is a multi-year effort managed by the National Quality Center and sponsored by the Health Resources Services Administration HIV/AIDS Bureau. It is designed to bring together local, regional and national organizations that are focused on improving patient retention in HIV care. in+care kicked off in October 2011 and has enrolled more than 700 individual HIV providers representing more than 500 provider organizations, including Ryan White grantees and subgrantees of all Parts funding. Based on the patients served by these HIV providers, the in+care Campaign has the power to reach more than 375,000 people living with HIV (best effort at de-duplication), which is more than 35% of the US HIV epidemic.

Wondering how you can take action based on the National HIV/AIDS Strategy? The in+care Campaign is a great place to start! It contains several activities to engage stakeholders from various backgrounds related to HIV care. Webinars, newsletters and website resources serve as a means of connecting these stakeholder groups and sharing information and strategies across the vast area of our country. Retention and viral suppression performance measures are submitted by participants every other month and are used to show the steady improvement in patient retention and viral suppression over time. Each Campaign participant is assigned a quality coach to help design, implement, and evaluate improvement strategies targeting opportunities to help achieve greater patient retention and viral suppression. Who doesn’t like free help? Visit www.incarecampaign.org for more information! Also, see the TARGET Center for a collection of 21 in+care webcasts held over the past several years. 

Since 2011, in+care staff has compiled a group of special reports based on submissions made to the in+care Campaign. Some of these reports compare performance between different types of providers in different settings and others catalogue the types of retention and viral suppression quality improvement strategies being implemented across the US in conjunction with the in+care Campaign. While the Campaign was not designed to identify which retention or viral suppression quality improvement strategies are most promising, it is a wonderful vehicle for sharing successes and disseminating evidence-based interventions throughout the national Ryan White provider community.

If you have any questions about this initiative or want to know how you can get involved, contact Michael Hager anytime! Add in+care Campaign services to your retention in care toolbox, and continue to refer to the AETC Engagement in Care Toolkit for additional resources.

Source: 
National Quality Improvement /Management Technical Assistance Center
Publish Date: 
Wednesday, March 26, 2014
Author(s): 
Author: 
Affiliation: 
National Quality Improvement /Management Technical Assistance Center

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