Publications

Abstract

Substance misusers are at risk for contracting HIV/AIDS, and substance user treatment programs (SUTPs)1 are uniquely situated to address their HIV-related needs. In New York State, some SUTPs have implemented a centralized model of substance user treatment and HIV care. We synthesize past literature and use data from semistructured interviews with SUTP staff, analyzed with qualitative software, to describe implementation barriers. These interviews were conducted in 2003-2004 at three SUTPs in Texas and New York as part of a study funded by the National Institutes of Health. With study limitations noted, main implications include a need for a combined medical-addiction treatment philosophy to facilitate multidisciplinary care.

Abstract

Our knowledge of pharmacogenetic variability in diverse populations is scarce, especially in sub-Saharan Africa. To bridge this gap in knowledge, we characterised population frequencies of clinically relevant pharmacogenetic traits in two distinct South African population groups. We genotyped 211 tagging single nucleotide polymorphisms (tagSNPs) in 12 genes that influence antiretroviral drug disposition, in 176 South African individuals belonging to two distinct population groups residing in the Western Cape: the Xhosa (n = 109) and Cape Mixed Ancestry (CMA) (n = 67) groups. The minor allele frequencies (MAFs) of eight tagSNPs in six genes (those encoding the ATP binding cassette sub-family B, member 1 [ABCB1], four members of the cytochrome P450 family [CYP2A7P1, CYP2C18, CYP3A4, CYP3A5] and UDP-glucuronosyltransferase 1 [UGT1A1]) were significantly different between the Xhosa and CMA populations (Bonferroni p < 0.05). Twentyseven haplotypes were inferred in four genes (CYP2C18, CYP3A4, the gene encoding solute carrier family 22 member 6 [SLC22A6] and UGT1A1) between the two South African populations. Characterising the Xhosa and CMA population frequencies of variant alleles important for drug transport and metabolism can help to establish the clinical relevance of pharmacogenetic testing in these populations.

Abstract

OBJECTIVES: To estimate risk factors for premature neonates not receiving antenatal steroids in a population-based cohort and to determine whether the gains of a quality-improvement collaborative project on antenatal steroid administration were sustained long-term. METHODS: Clinical data for premature neonates born in 2005-2007 were obtained from the California Perinatal Quality Care Collaborative, which collects data on more than 90% of neonatal admissions in California. Eligible neonates had a birth weight of less than 1,500 g or gestational age less than 34 weeks and were born at a Collaborative hospital. These data were linked to administrative data from California Vital Statistics. Sociodemographic and medical risk factors for not receiving antenatal steroids were determined. We also examined the effect of birth hospital participation in a previous quality-improvement collaborative project. A random effects logistic regression model was used to determine independent risk factors. RESULTS: Of 15,343 eligible neonates, 23.1% did not receive antenatal steroids in 2005-2007. Hispanic mothers (25.6%), mothers younger than age 20 (27.6%), and those without prenatal care (52.2%) were less likely to receive antenatal steroids. Mothers giving birth vaginally (26.8%) and mothers with a diagnosis of fetal distress (26.5%) were also less likely to receive antenatal steroids. Rupture of membranes before delivery and multiple gestations were associated with higher likelihood of antenatal steroid administration. Hospitals that participated in a quality-improvement collaborative in 1999-2000 had higher rates of antenatal steroid administration (85% compared with 69%, P<.001). CONCLUSION: A number of eligible mothers do not receive antenatal steroids. Quality-improvement initiatives to improve antenatal steroid administration could target specific high-risk groups.

Abstract

Background: Few studies have examined the association between self-reported sexual risk behaviors and biologic outcomes in human immunodeficiency virus (HIV)-1-seropositive African adults. Methods: We conducted a prospective cohort study in 898 HIV-1-seropositive women who reported engaging in transactional sex in Mombasa, Kenya. Primary outcome measures included detection of sperm in genital secretions, pregnancy, and sexually transmitted infections. Because 3 outcomes were evaluated, data are presented with odds ratios [OR] and 96.7% confidence intervals [CI] to reflect that we would reject a null hypothesis if a P-value was ≤0.033 (Simes' methodology). Results: During 2404 person-years of follow-up, self-reported unprotected intercourse was associated with significantly higher likelihood of detecting sperm in genital secretions (OR: 2.32, 96.7% CI: 1.93, 2.81), and pregnancy (OR: 2.78, 96.7% CI: 1.57, 4.92), but not with detection of sexually transmitted infections (OR: 1.20, 96.7% CI: 0.98, 1.48). At visits where women reported being sexually active, having >1 sex partner in the past week was associated with lower likelihood of detecting sperm in genital secretions (OR: 0.74, 96.7% CI: 0.56, 0.98). This association became nonsignificant after adjustment for reported condom use (adjusted OR: 0.81, 96.7% CI: 0.60, 1.08). Conclusions: Combining behavioral and biologic outcomes, which provide complementary information, is advantageous for understanding sexual risk behavior in populations at risk for transmitting HIV-1. The paradoxical relationship between higher numbers of sex partners and less frequent identification of sperm in genital secretions highlights the potential importance of context-specific behavior, such as condom use dependent on partner type, when evaluating sexual risk behavior.

Abstract

Aim: Endothelial lipase (EL) is a key enzyme in lipid metabolism, and a polymorphism in the EL gene may be a candidate for modulating lipid parameters in type 2 diabetic (T2D) patients. Methods: In 396 T2D patients (age: 59.5±10.7 years; BMI: 28.9±5.3kg/m2; HbA1c: 8.2±1.9%), the c.584C>T polymorphism (rs2000813, p.Thr111Ile) was studied in 225 men (frequency of c.584T: 0.351) and 171 women (frequency of c.584T: 0.304). Patients' metabolic parameters, and macrovascular and microvascular complications, were assessed at baseline and at follow-up (mean: 4.2 years). Results: Patients who were homozygous for the minor allele displayed modestly decreased low-density lipoprotein (LDL) cholesterol and raised apolipoprotein B at baseline, and raised systolic blood pressure and high-density lipoprotein (HDL) cholesterol on follow-up. Homozygosity for the minor allele was significantly associated with frequency of retinopathy (P=0.025), with TT homozygous patients more likely to have diabetic retinopathy (OR: 3.505; 95% CI: 1.491-8.239) both initially and at follow-up. Conclusion: The c.584C > T EL polymorphism is associated with a higher risk of diabetic retinopathy that could be linked to modifications in HDL-cholesterol metabolism and blood pressure levels.

Abstract

Although death rates from cardiovascular disease (CVD) have declined in recent years, it continues to be the leading cause of death for women in the United States. The risk factors for CVD are well established and include physical inactivity. According to the Centers for Disease Control, in 2008, 38% of women reported no physical activity. For many women who experience a cardiac event, their first opportunity to become physically active is through a formal cardiac rehabilitation (CR) program. Unfortunately, women often underutilize CR programs. The purpose of this integrative review was to examine the barriers to participation in a CR program among women with CVD.

Abstract

The aim of the present study was to examine the impact of the New Cooperative Medical Scheme (NCMS) on rural elders' access to health-care services. Articles were identified from PubMed, Elsevier, Wiley, EBSCO, EMBASE, SCI Expanded, ProQuest, Google, and CNKI which is the most informative database in Chinese, with the search terms "rural", "China", "old", "older", or "elder", "elderly", or "aged", "aging", "medical insurance", or "community-based medical insurance", or "cooperative medical scheme". Related websites and yearbooks were searched as well. The NCMS has improved the health-care utilization of rural elders, and they have the highest satisfaction with it among all age groups. However, affordability difficulty remained the common barrier for the rural elderly to access quality health care, in spite of the special considerations given to the rural elderly, such as premium remission and free check-ups. Faced with ever-growing health challenges, some impoverished rural elders with poor physical health and functional limitations may lack sufficient access to basic health-care services. Followed by the provider payment reform initiated by the NCMS, a stricter regulation for doctors' prescriptions, clinical practice and disease management is needed to promote rural elders' access to health-care services. Health management for rural elders can be expected for the NCMS to promote rural elders' health-care access once a better coordination between the NCMS and health-care system can be achieved.

Abstract

We assessed sexual behaviors before and 12-months after ART initiation among 277 Mozambicans attending an HIV clinic. Measured behaviors included the number of sexual partners, condom use, concurrent relationships, disclosure of HIV status, alcohol use, and partners' serostatus. Compared to before ART initiation, increases were seen 12 months after ART in the proportion of participants who were sexually active (48% vs. 64% respondents, P <0.001) and the proportion of participants with HIV-negative or unknown serostatus partners (45% vs. 80%, P < 0.001). Almost all (96%) concurrent partnerships reported at 12 months formed after ART initiation. Although reported correct and consist condom use increased, the number of unprotected sexual relationships remained the same (n = 45). Non-disclosure of HIV-serostatus to sexual partners was the only significant predictor of practicing unprotected sex with partners of HIV-negative or unknown serostatus. Sexual activity among HIV-positive persons on ART increased 12 months after ART initiation. Ongoing secondary transmission prevention programs addressing sexual activity with multiple partners, disclosure to partners and consistent condom use with serodisconcordant partners must be incorporated throughout HIV care programs.

Abstract

No single HIV prevention strategy will be sufficient to control the HIV pandemic. However, a growing number of interventions have shown promise in partially protecting against HIV transmission and acquisition, including knowledge of HIV serostatus, behavioral risk reduction, condoms, male circumcision, needle exchange, treatment of curable sexually transmitted infections, and use of systemic and topical antiretroviral medications by both HIV-infected and uninfected persons. Designing the optimal package of interventions that matches the epidemiologic profile of a target population, delivering that package at the population level, and evaluating safety, acceptability, coverage, and effectiveness, all involve methodological challenges. Nonetheless, there is an unprecedented opportunity to develop "prevention packages" that combine various arrays of evidence-based strategies, tailored to the needs of diverse subgroups and targeted to achieve high coverage for a measurable reduction in population-level HIV transmission. HIV prevention strategies that combine partially effective interventions should be scaled up and evaluated.

Abstract

Combining extant datasets with differing outcome measures, an economical method to generate evidence guiding older adults' cancer care, may introduce heterogeneity leading to invalid study results. We recently conducted a study combining extant datasets from five oncology nurse-directed clinical trials (parent studies) using norm-based scoring to standardize the differing outcome measures. The purpose of this article is to describe and analyze our methods in the recently completed study. Despite addressing and controlling for heterogeneity, our analysis found statistically significant heterogeneity (p < 0.0001) in temporal trends among the five parent studies. We concluded that assessing heterogeneity in combined extant datasets with differing outcome measures is important to ensure similar magnitude and direction of findings across parent studies. Future research should include investigating reasons for heterogeneity to generate hypotheses about subgroup differences or differing measurement domains that may have an impact on outcomes.

Abstract

Purpose: To investigate the variation in average daily travel time to work among registered nurses (RNs) living in urban, suburban, and rural areas. We examine how travel time varies across RN characteristics, job setting, and availability of local employment opportunities. Method: Descriptive statistics and linear regression using a 5% sample from the 2000 Census and a longitudinal survey of newly licensed RNs (NLRN). Travel time for NLRN respondents was estimated using geographic information systems (GIS) software. Findings: In the NLRN, rural nurses and those living in small towns had significantly longer average commute times. Young married RNs and RNs with children also tended to have longer commute times, as did RNs employed by hospitals. Conclusions: The findings indicate that travel time to work varies significantly across locale types. Further research is needed to understand whether and to what extent lengthy commute times impact RN workforce needs in rural and urban areas.

Abstract

Providers in emergency care settings (ECSs) often face barriers to expanded HIV testing. We undertook formative research to understand the potential utility of a computer tool, CARE, to facilitate rapid HIV testing in ECSs. Computer tool usability and acceptability were assessed among 35 adult patients, and provider focus groups were held, in two ECSs in Washington State and Maryland. The computer tool was usable by patients of varying computer literacy. Patients appreciated the tool's privacy and lack of judgment and their ability to reflect on HIV risks and create risk reduction plans. Staff voiced concerns regarding ECS-based HIV testing generally, including resources for follow-up of newly diagnosed people. Computer-delivered HIV testing support was acceptable and usable among low-literacy populations in two ECSs. Such tools may help circumvent some practical barriers associated with routine HIV testing in busy settings though linkages to care will still be needed.

Abstract

OBJECTIVE: To estimate differences in continuation of oral contraceptive pills (OCPs) between U.S. resident women obtaining pills in U.S. family planning clinics compared with over-the-counter in Mexican pharmacies. METHODS: In El Paso, Texas, we recruited 514 OCP users who obtained pills over the counter from a Mexican pharmacy and 532 who obtained OCPs by prescription from a family planning clinic in El Paso. A baseline interview was followed by three consecutive surveys over 9 months. We asked about date of last supply, number of pill packs obtained, how long they planned to continue use, and experience of side effects. Retention was 90%, with only 105 women lost to follow-up. RESULTS: In a multivariable Cox proportional hazards model, discontinuation was higher for women who obtained pills in El Paso clinics compared with those who obtained their pills without a prescription in Mexico (hazard ratio 1.6, 95% confidence interval [CI] 1.1-2.3). Considering the number of pill packs dispensed to clinic users, discontinuation rates were higher (hazard ratio 1.8, 95% CI 1.2-2.7) for clinic users who received one to five pill packs. However, there was no difference in discontinuation between clinic users receiving six or more pill packs and users obtaining pills without a prescription. CONCLUSION: Results suggest providing OCP users with more pill packs and removing the prescription requirement would lead to increased continuation.

Abstract

OBJECTIVE: To compare the estimated proportion of contraindications to combined oral contraceptives between women who obtained combined oral contraceptives in U.S. public clinics compared with women who obtained combined oral contraceptives over the counter (OTC) in Mexican pharmacies. METHODS: We recruited a cohort of 501 women who were residents of El Paso, Texas, who obtained OTC combined oral contraceptives in Mexico and 514 women who obtained combined oral contraceptives from family planning clinics in El Paso. Based on self-report of World Health Organization category 3 and 4 contraindications and interviewer-measured blood pressure, we estimated the proportion of contraindications and, using multivariable-adjusted logistic regression, identified possible predictors of contraindications. RESULTS: The estimated proportion of any category 3 or 4 contraindication was 18%. Relative contraindications (category 3) were more common among OTC users (13% compared with 9% among clinic users, P=.006). Absolute contraindications (category 4) were not different between the groups (5% for clinic users compared with 7% for OTC users, P=.162). Hypertension was the most prevalent contraindication (5.6% of clinic users and 9.8% of OTC users). After multivariable adjustment, OTC users had higher odds of having contraindications compared with clinic users (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.11-2.29). Women aged 35 years or older (OR 5.30, 95% CI 3.59-7.81) and those with body mass index 30.0 or more (OR 2.24, 95% CI 1.40-3.56) also had higher odds of having contraindications. CONCLUSION: Relative combined oral contraceptive contraindications are more common among OTC users in this setting. Progestin-only pills might be a better candidate for the first OTC product given their fewer contraindications.