Diagnosis and Management of HIV-Associated Pulmonary Diseases in a Ryan White-Funded Primary Care Setting.
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ABSTRACT:
SUBMITTER: Harrington KRV
PROVIDER: S-EPMC8418444 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Outpatient human immunodeficiency virus (HIV) health care facilities receive funding from the Ryan White HIV/AIDS Program (RWHAP) to provide medical care and essential support services that help patients remain in care and adhere to treatment. Increased access to Medicaid and private insurance for HIV-infected persons may provide coverage for medical care but not all needed support services and may not supplant the need for RWHAP funding.To examine differences between RWHAP-funded and non-RWHAP-funded facilities and in patient outcomes between the 2 systems.The study was conducted from June 1, 2009, to May 31, 2012, using data from the 2009 and 2011 cycles of the Medical Monitoring Project, a national probability sample of 8038 HIV-infected adults receiving medical care at 989 outpatient health care facilities providing HIV medical care.Data were used to compare patient characteristics, service needs, and access to services at RWHAP-funded vs non-RWHAP-funded facilities. Differences in prescribed antiretroviral treatment and viral suppression were assessed. Data analysis was performed between February 2012 and June 2015.Overall, 34.4% of facilities received RWHAP funding and 72.8% of patients received care at RWHAP-funded facilities. With results reported as percentage (95% CI), patients attending RWHAP-funded facilities were more likely to be aged 18 to 29 years (8.5% [7.4%-9.5%] vs 5.0% [3.9%-6.2%]), female (29.2% [27.2%-31.2%] vs 20.1% [17.0%-23.1%]), black (47.5% [41.5%-53.5%] vs 25.8% [20.6%-31.0%]) or Hispanic (22.5% [16.4%-28.6%] vs 12.9% [10.6%-15.2%]), have less than a high school education (26.1% [24.0%-28.3%] vs 10.9% [8.7%-13.1%]), income at or below the poverty level (53.6% [50.3%-56.9%] vs 23.9% [19.7%-28.0%]), and lack health care coverage (25.0% [21.9%-28.1%] vs 6.1% [4.1%-8.0%]). The RWHAP-funded facilities were more likely to provide case management (76.1% [69.9%-82.2%] vs 15.4% [10.4%-20.4%]) as well as mental health (64.0% [57.0%-71.0%] vs 18.0% [14.0%-21.9%]), substance abuse (33.6% [27.0%-40.2%] vs 12.0% [8.0%-16.0%]), and other support services; patients attending RWHAP-funded facilities were more likely to receive these services. After adjusting for patient characteristics, the percentage prescribed ART antiretroviral therapy, reported as adjusted prevalence ratio (95% CI), was similar between RWHAP-funded and non-RWHAP-funded facilities (1.01 [0.99-1.03]), but among poor patients, those attending RWHAP-funded facilities were more likely to be virally suppressed (1.09 [1.02-1.16]).A total of 72.8% of HIV-positive patients received care at RWHAP-funded facilities. Many had multiple social determinants of poor health and used services at RWHAP-funded facilities associated with improved outcomes. Without facilities supported by the RWHAP, these patients may have had reduced access to services elsewhere. Poor patients were more likely to achieve viral suppression if they received care at a RWHAP-funded facility.
| S-EPMC4934897 | biostudies-literature
Project description:The Ryan White HIV/AIDS Program (RWHAP) provides persons infected with human immunodeficiency virus (HIV) with services not covered by other healthcare payer types. Limited data exist to inform policy decisions about the most appropriate role for RWHAP under the Patient Protection and Affordable Care Act (ACA).We assessed associations between RWHAP assistance and antiretroviral therapy (ART) prescription and viral suppression. We used data from the Medical Monitoring Project, a surveillance system assessing characteristics of HIV-infected adults receiving medical care in the United States. Interview and medical record data were collected in 2009-2013 from 18 095 patients.Nearly 41% of patients had RWHAP assistance; 15% relied solely on RWHAP assistance for HIV care. Overall, 91% were prescribed ART, and 75% were virally suppressed. Uninsured patients receiving RWHAP assistance were significantly more likely to be prescribed ART (52% vs 94%; P < .01) and virally suppressed (39% vs 77%; P < .01) than uninsured patients without RWHAP assistance. Patients with private insurance and Medicaid were 6% and 7% less likely, respectively, to be prescribed ART than those with RWHAP only (P < .01). Those with private insurance and Medicaid were 5% and 12% less likely, respectively, to be virally suppressed (P ? .02) than those with RWHAP only. Patients whose private or Medicaid coverage was supplemented by RWHAP were more likely to be prescribed ART and virally suppressed than those without RWHAP supplementation (P ? .01).Uninsured and underinsured HIV-infected persons receiving RWHAP assistance were more likely to be prescribed ART and virally suppressed than those with other types of healthcare coverage.
| S-EPMC5087096 | biostudies-literature
Project description:BACKGROUND:The Ryan White HIV/AIDS Care Act (now the Treatment Modernization Act; Ryan White Program, or RWP) is a source of federal public funding for HIV care in the United States. The Health Services and Resources Administration requires that facilities or providers who receive RWP funds ensure that HIV health services are accessible and delivered according to established HIV-related treatment guidelines. We used data from population-based samples of persons in care for HIV infection in three states to compare the quality of HIV care in facilities supported by the RWP, with facilities not supported by the RWP. METHODOLOGY/PRINCIPAL FINDINGS:Within each area (King County in Washington State; southern Louisiana; and Michigan), a probability sample of patients receiving care for HIV infection in 1998 was drawn. Based on medical records abstraction, information was collected on prescription of antiretroviral therapy according to treatment recommendations, prescription of prophylactic therapy, and provision of recommended vaccinations and screening tests. We calculated population-level estimates of the extent to which HIV care was provided according to then-current treatment guidelines in RWP-supported and non-RWP-supported facilities. For all treatment outcomes analyzed, the compliance with care guidelines was at least as good for patients who received care at RWP-supported (vs non-RWP supported) facilities. For some outcomes in some states, delivery of recommended care was significantly more common for patients receiving care in RWP-supported facilities: for example, in Louisiana, patients receiving care in RWP-supported facilities were more likely to receive indicated prophylaxis for Pneumocystis jirovecii pneumonia and Mycobacterium avium complex, and in all three states, women receiving care in RWP-supported facilities were more likely to have received an annual Pap smear. CONCLUSIONS/SIGNIFICANCE:The quality of HIV care provided in 1998 to patients in RWP-supported facilities was of equivalent or better quality than in non-RWP supported facilities; however, there were significant opportunities for improvement in all facility types. Data from population-based clinical outcomes surveillance data can be used as part of a broader strategy to evaluate the quality of publicly-supported HIV care.
| S-EPMC2535568 | biostudies-literature
Project description:Background: Immunodeficiencies (ID), in particular primary immunodeficiencies (PID), are often associated with haematological manifestations, such as peripheral cytopenias or lymphoproliferative syndromes. Early diagnosis and management have significant prognostic implications. Secondary immunodeficiencies (SID) may also be induced by oncohaematological diseases and their treatments. Haematologists and oncologists must therefore be aware of the association between blood disorders and cancer and ID, and be prepared to offer their patients appropriate treatment without delay. Our aim was to define the warning signs of primary and secondary IDs in paediatric and adult patients with oncohaematological manifestations. Methods: A multidisciplinary group of six experts (2 haematologists, 2 immunologists, and 2 paediatricians specializing in ID) conducted a literature review and prepared a document based on agreements reached an in-person meeting. An external group of 44 IDs specialists from all over Spain assessed the document and were consulted regarding their level of agreement. Results: This document identifies the haematological and extra-haematological diseases that should prompt a suspicion of PIDs in adults and children, in both primary care and haematology and oncology departments. Cytopenia and certain lymphoproliferative disorders are key diagnostic pointers. The diagnosis must be based on a detailed clinical history, physical exploration, complete blood count and standard laboratory tests. The immunological and haematological tests included in the diagnostic process will depend on the care level. Patients who are candidates for immunoglobulin replacement therapy must be carefully selected, and treatment should be offered as soon as possible to avoid the development of complications. Finally, this document recommends procedures for monitoring these patients. Conclusions: This document combines scientific evidence with the opinion of a broad panel of experts, and emphasizes the importance of an early diagnosis and treatment to avoid complications. The resulting document is a useful tool for primary care physicians and specialists who see both adult and paediatric patients with oncohaematological diseases.
| S-EPMC6448689 | biostudies-other
Project description:BackgroundLong-acting injectable (LAI) antiretroviral therapy (ART) has the potential to improve medication adherence, reduce human immunodeficiency virus (HIV) stigma, and promote equity in care outcomes among people with HIV (PWH). We describe our early experience implementing LAI-cabotegravir/rilpivirine (CAB/RPV) for maintenance HIV-1 treatment.MethodsWe launched a pilot LAI-ART program at a large Ryan White-funded clinic in the Southeast, which accept provider-initiated referrals from April 14, 2021 to December 1, 2021. Our interdisciplinary program team (Clinician-Pharmacy-Nursing) verified clinical eligibility and pursued medication access for eligible patients. We describe (1) demographic and clinical variables of PWH referred and enrolled and (2) early outcomes among those accessing LAI-CAB/RPV.ResultsAmong 58 referrals, characteristics were median age 39 (Q1-Q3, 30.25-50) years, 74% male, and 81% Black, and payor source distribution was 26% Private, 21% Medicare, 19% Medicaid, and 34% AIDS Drugs Assistance Program. Forty-five patients (78%) met clinical eligibility for LAI-CAB/RPV; ineligibility concerns included evidence of confirmed or possible RPV resistance (n = 8), HIV nonsuppression (n = 3), possible RPV hypersensitivity (n = 1), and pregnancy (n = 1). Among 45 eligible PWH, 39 (87%) enrolled and 15 (38%) initiated LAI-CAB/RPV after a median of 47 (Q1-Q3, 31-95) days since enrollment.ConclusionsImplementing LAI-ART at a Southern US Ryan White-funded clinic has been challenged by the following: substantial human resource capital to attain drug, administer injections, and support enrolled patients; delayed therapy initiation due to insurance denials; patient ineligibility primarily due to possible RPV resistance; and inability to provide drug regardless of payor source. These barriers may perpetuate disparities in ART access and outcomes among PWH and should be urgently addressed so that LAI-ART can be offered equitably.
| S-EPMC9487705 | biostudies-literature
Project description:While substantial research examines the dynamics prompting policy adoption, few studies have assessed whether enacted policies are modified to meet distributional equity concerns. Past research suggests that important forces limit such adaptation, termed here "policy inertia." We examine whether block grant allocations to states from the Ryan White HIV/AIDS Program have evolved in response to major technological and political changes. We assess the impact of initial allocations on later funding patterns, compared to five counterfactual distributional equity standards. Initial allocations strongly predict future allocations; in comparison, the standards are weak predictors, suggesting the importance of policy inertia. Our methodology of employing multiple measures of equity as a counterfactual to policy inertia can be used to evaluate the adaptability of federalist programs in other domains.
| S-EPMC3026439 | biostudies-literature
Project description:BackgroundAge-related chronic conditions are becoming more concerning for people with human immunodeficiency virus (PWH). We aimed to identify characteristics associated with multimorbidity and evaluate for association between multimorbidity and human immunodeficiency virus (HIV) outcomes.MethodsCohorts included PWH aged 45-89 with ≥1 medical visit at one Ryan White HIV/AIDS Program (RWHAP) Southeastern HIV clinic in 2006 (Cohort 1) or 2016 (Cohort 2). Multimorbidity was defined as ≥2 chronic diseases. We used multivariable logistic regression to assess for associations between characteristics and multimorbidity and between multimorbidity and HIV outcomes.ResultsMultimorbidity increased from Cohort 1 (n = 149) to Cohort 2 (n = 323) (18.8% vs 29.7%, P < .001). Private insurance was associated with less multimorbidity than Medicare (Cohort 1: adjusted odds ratio [aOR] = 0.15, 95% confidence interval [CI] = 0.02-0.63; Cohort 2: aOR = 0.53, 95% CI = 0.27-1.00). In Cohort 2, multimorbidity was associated with female gender (aOR, 2.57; 95% CI, 1.22-5.58). In Cohort 1, black participants were less likely to be engaged in care compared with non-black participants (aOR, 0.72; 95% CI, 0.61-0.87). In Cohort 2, participants with rural residences were more likely to be engaged in care compared with those with urban residences (aOR, 1.23; 95% CI, 1.10-1.38). Multimorbidity was not associated with differences in HIV outcomes.ConclusionsAlthough PWH have access to RWHAP HIV care, PWH with private insurance had lower rates of multimorbidity, which may reflect better access to preventative non-HIV care. In 2016, multimorbidity was higher for women. The RWHAP and RWHAP Part D could invest in addressing these disparities related to insurance and gender.
| S-EPMC7814386 | biostudies-literature
Project description:BackgroundThe Health Resources and Services Administration's (HRSA), HIV/AIDS Bureau (HAB) is responsible for leading the nation's efforts to provide health care, medications, and support services to low-income people living with HIV through the Ryan White HIV/AIDS Program (RWHAP). The RWHAP funds and coordinates with cities, states, and local community-based organizations to deliver efficient and effective HIV care, treatment, and support services for over half a million vulnerable people living with HIV (PLWH) and their families in the United States. The annual RWHAP Services Report (RSR) is an important source of information for monitoring RWHAP's progress towards National HIV/AIDS Strategy goals. Since 2010, HRSA HAB has used the annual client-level RSR data to monitor program-related outcomes, conduct program evaluations, understand service provision, and conduct extensive analysis on disparities in viral suppression and retention in HIV care. HRSA HAB receives annual RSR submissions from RWHAP recipients and sub-recipients. However, the de-identified nature of the data limits HRSA HAB's ability to expand beyond year-to-year analyses and conduct additional analyses to evaluate outcomes for clients who are seen in multiple years. The current paper describes the development and validation of a method to link RSR client-level records across multiple data years.Methods and findingsUsing seven RSR reporting years of data (2010 to 2016), we applied a Fellegi-Sunter (F-S) linkage model that used client demographic characteristics and their providers' geographic locations to calculate matching weights for each record pair based on estimated agreement and disagreement conditional probabilities across RSR years. To validate our methodology, we conducted an internal sample review and external validation to assess the level of accuracy of the linkage, and the extent to which the linked data set corresponds accurately to clinical records of individual clients. The linkage result yielded 70 to 80 percent year-to-year client carry-over rate over seven years of the RSR data; 96 percent linkage ratio from the internal sample review and 79.9 to 94.2 percent of provider network client carry- over rate per year from the external validation.ConclusionsThis methodology addresses a gap in data analysis capabilities by allowing HRSA HAB to link RWHAP clients across reporting years. Despite weak identifying information and lack of continuity of service reporting, the longitudinal linkage improves HRSA HAB's ability to evaluate the patterns of viral suppression and monitor service utilization over time for individuals who receive services in multiple years. These analyses will support future analytic activities in understanding the impact and outcomes of the RWHAP, and will assist HRSA HAB in monitoring progress toward meeting National HIV/AIDS Strategy goals. For those looking for ways to assess health services data, the F-S unsupervised method combining weak identifying attributes and geographic proximity offers practical solutions to the problem of linking de-identified information about individuals across multiple years and improving longitudinal research.
| S-EPMC7442495 | biostudies-literature
Project description:BackgroundPrevalence of anal cancer is increasing among people with HIV (PWH). Screening for anal cancer involves evaluating cytology and biopsy with high-resolution anoscopy (HRA) if indicated. In this study, we sought to identify the prevalence of abnormal anal cytology and biopsy-proven high-grade dysplasia, defined as anal intraepithelial neoplasia 2 and 3 (AIN2+).MethodsDemographic and clinical data were collected from participants age ≥30 years with ≥1 anal Pap smear performed during the study period (12/18/2017-05/29/2021). A subgroup analysis was performed on those with ≥1 HRA. Logistic regression estimated adjusted odds ratios (aORs) for variables of interest such as age, race, gender, presence of HPV strains, and sexual practices.ResultsOf 317 participants, 48% (n = 152) had abnormal cytology (93% low-grade squamous intraepithelial lesion [SIL] or atypical cells of undetermined significance [ASCUS] and 7% high-grade SIL). Most with abnormal cytology proceeded to HRA (n = 136/152). Of those with HRA, 62% (n = 84/136) had AIN2+. History of anoreceptive intercourse (aOR 4.62; 95% CI 1.08-23.09; P = .047), HPV 16 (aOR 4.13; 95% CI 1.63-11.30; P = .004), and "other" high-risk HPV strains (aOR 5.66; 95% CI 2.31-14.78; P < .001) were significantly associated with AIN2+.ConclusionsNearly half of those screened had abnormal cytology, highlighting the high prevalence of anal dysplasia in PWH. Though only 7% had high-grade SIL on cytology, 62% of those biopsied had AIN2+, suggesting that cytology underestimates the severity of dysplasia on biopsy. HPV 16 and "other" high-risk strains were associated with AIN2 + and could be considered for risk-stratifying patients in the screening algorithm.
| S-EPMC9709627 | biostudies-literature
Project description:BackgroundPrior research has found evidence of gender disparities in U.S. HIV healthcare access and outcomes. In order to assess potential disparities in our client population, we compared demographics, service needs, service utilization, and HIV care continuum outcomes between transgender women, cisgender women, and cisgender men receiving New York City (NYC) Ryan White Part A (RWPA) services.MethodsThe analysis included HIV-positive clients with an intake assessment between January 2016 and December 2017 in an NYC RWPA services program. We examined four service need areas: food and nutrition, harm reduction, mental health, and housing. Among clients with the documented need, we ascertained whether they received RWPA services targeting that need. To compare HIV outcomes between groups, we applied five metrics: engagement in care, consistent engagement in care, antiretroviral therapy (ART) use, point-in-time viral suppression, and durable viral suppression.ResultsAll four service needs were more prevalent among transgender women (N = 455) than among cisgender clients. Except in the area of food and nutrition services, timely (12-month) receipt of RWPA services to meet a specific assessed need was not significantly more or less common in any one of the three client groups examined. Compared to cisgender women and cisgender men, a lower proportion of transgender women were durably virally suppressed (39% versus 52% or 50%, respectively, p-value < 0.001).ConclusionsCompared with cisgender women and cisgender men, transgender women more often presented with basic (food/housing) and behavioral-health service needs. In all three groups (with no consistent between-group differences), assessed needs were not typically met with the directly corresponding RWPA service category. Targeting those needs with RWPA outreach and services may support the National HIV/AIDS Strategy 2020 goal of reducing health disparities, and specifically the objective of increasing (to ≥90%) the percentage of transgender women in HIV medical care who are virally suppressed.
| S-EPMC8248705 | biostudies-literature