Biomedical subjects
Harry Hollander
Publications and source records attributed to Harry Hollander.
Effect of a brief antiretroviral adherence intervention delivered by HIV care providers.
Antiretroviral therapy (ART) is effective in controlling viral load in many people infected with HIV, but high levels of adherence to ART are needed for prolonged viral suppression. This study evaluated a brief adherence intervention delivered to HIV-positive patients by primary care providers during routine medical examinations. Six clinics were randomly allocated to deliver an intervention focusing on ART adherence (2 clinics) or safer sex (4 clinics). Interventions included written information (posters, brochures, and flyers) and brief counseling from providers and were evaluated with cohorts of randomly selected patients (n = 437) measured before and after a 10-month intervention. Among those 95% or greater adherent at baseline, 91% of patients who received the adherence intervention remained 95% or greater adherent at follow-up compared with 75% of the patients who received the safer sex intervention (chi = 12.59, P < 0.01). This difference was significant in a logistic regression analysis (odds ratio = 2.26; 95% confidence interval = 1.27-4.04), adjusting for baseline adherence, demographics, and HIV medical status. The adherence intervention did not significantly increase the prevalence of 95% or greater adherence among patients less than 95% adherent at baseline. Similar but nonsignificant results were observed for viral load. A brief intervention delivered to HIV patients by their primary providers helped to maintain adequate adherence to ART regimens. More intensive intervention is needed to improve adherence among patients who are initially less than 95% adherent.
Case records of the Massachusetts General Hospital. Case 22-2005. An 81-year-old man with cough, fever, and altered mental status.
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Use of and adherence to antiretroviral therapy is associated with decreased sexual risk behavior in HIV clinic patients.
Previous research suggested that the availability of highly active antiretroviral therapy (ART) was associated with increased risky sexual behavior. This study examined the relationship between unprotected anal or vaginal sex (UAV) and ART use and adherence in a cross-sectional survey conducted in 874 randomly selected, sexually active patients at 6 public HIV clinics in California. Patients completed a standardized interview in 1998-1999 regarding HIV history, sexual behavior, illicit drug use, and ART use and adherence. Thirty-four percent reported UAV, defined as anal or vaginal sex without a condom within the past 3 months. Of 79% on ART, 26% reported <95% adherence. Decreased odds for UAV were found for both ART use, odds ratio (OR) 0.5 (95% CI 0.4-0.7, P < 0.001) and adherence to ART of > or = 95%, OR 0.6 (95% CI 0.4-0.8, P < 0.001). These relationships persisted in most stratified analysis for both ART use and adherence but in multivariate analysis only for ART use. An undetectable HIV RNA was associated with decreased odds of UAV, OR 0.6 (95% CI 0.5-0.8, P < 0.001). Contrary to expectations, use of and adherence to ART and their consequent suppression of HIV were associated with a decreased prevalence of self-reported risky sexual behavior.
Using patient risk indicators to plan prevention strategies in the clinical care setting.
OBJECTIVE: Successful behavioral interventions to promote safe sex must be tailored to the sexual behaviors and relationships of individual patients. The aim of this study is to examine the distribution of unprotected anal and vaginal sex (UAV) and nondisclosure (ND) among categories of HIV-positive men and women based on relationship factors. These factors can be easily assessed and used as a basis for tailoring safer sex counseling in the clinic setting. METHODS: Eight hundred forty HIV-positive persons who were sexually active and attending 1 of 6 clinics in California were surveyed. Participants were categorized on the basis of numbers of partners, sexual orientation, type of relationship, and partner serostatus. Self-reported UAV, ND, and duration of the relationship were reported for each category and were examined. RESULTS: UAV was lower for those with 1 partner (26%) as compared with those with 2 or more partners (50%). ND was also lower for those with 1 partner (20%) as compared with those with 2 or more partners (60%). For those with 1 main partner, we found no significant differences in UAV by sexual orientation. UAV with seronegative main partners ranged from 16% to 20%, whereas UAV with seropositive partners ranged from 37% to 46%. Among men who have sex with men with 2 or more partners, relationships were more likely to be casual, of short duration, and to have higher levels of UAV and ND. CONCLUSION: The number of sex partners, type of relationship, and perceived HIV serostatus of a partner influence sexual behaviors and may be an efficient and effective basis for tailoring prevention messages.
Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: a multi-clinic assessment.
OBJECTIVE: To test the efficacy of brief, safer-sex counseling by medical providers of HIV-positive patients during medical visits. SETTING: Six HIV clinics in California. DESIGN: Clinics were randomized to intervention arms evaluated with cohorts of randomly selected patients measured before and after the intervention. PARTICIPANTS: Five-hundred and eighty-five HIV-positive persons, sexually active prior to enrollment. INTERVENTIONS: Prevention counseling from medical providers supplemented with written information. Two clinics used a gain-framed approach (positive consequences of safer-sex), two used a loss-frame approach (negative consequences of unsafe sex), and two were attention-control clinics (medication adherence). Interventions were given to all patients who attended the clinics. OUTCOME MEASURE: Self-reported unprotected anal or vaginal intercourse (UAV). RESULTS: Among participants who had two or more sex partners at baseline, UAV was reduced 38% (P < 0.001) among those who received the loss-frame intervention. UAV at follow-up was significantly lower in the loss-frame arm [odds ratio (OR), 0.42; 95% confidence interval (CI), 0.19-0.91; P = 0.03] compared with the control arm. Using generalized estimating equations (GEE) to adjust for clustering did not change the conclusions (OR, 0.34; 95% CI, 0.24-0.49; P = 0.0001). Similar results were obtained in participants with casual partners at baseline. No effects were seen in participants with only one partner or only a main partner at baseline. No significant changes were seen in the gain-frame arm. CONCLUSIONS: Brief provider counseling emphasizing the negative consequences of unsafe sex can reduce HIV transmission behaviors in HIV-positive patients presenting with risky behavioral profiles.
Clinical problem-solving. Index of suspicion.
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Comprehensive ambulatory medicine training for categorical internal medicine residents.
It is challenging to create an educational and satisfying experience in the outpatient setting. We developed a 3-year ambulatory curriculum that addresses the special needs of our categorical medicine residents with distinct learning objectives for each year of training and clinical experiences and didactic sessions to meet these goals. All PGY1 residents spend 1 month on a general medicine ambulatory care rotation. PGY2 residents spend 3 months on an ambulatory block focusing on 8 core medicine subspecialties. Third-year residents spend 2 months on an advanced ambulatory rotation. The curriculum was started in July 2000 and has been highly regarded by the house staff, with statistically significant improvements in the PGY2 and PGY3 evaluation scores. By enhancing outpatient clinical teaching and didactics with an emphasis on the specific needs of our residents, we have been able to reframe the thinking and attitudes of a group of inpatient-oriented residents.
Are HIV care providers talking with patients about safer sex and disclosure?: A multi-clinic assessment.
OBJECTIVES: To examine HIV-positive patients' reports of whether HIV care providers ever talked with them about practicing safer sex and disclosing seropositive status to sex partners. DESIGN: Cross-sectional survey (1998-1999) of HIV-positive men and women sampled randomly at six public HIV clinics in California. METHODS: Participants were interviewed and asked whether applicable clinic providers (physician, physician assistant, nurse practitioner, nurse, social worker, health educator, psychologist, psychiatrist) ever talked with them about safer sex or disclosure. Responses were analyzed by clinic site, HIV medical status (viral load), demographic, and behavioral variables (unprotected intercourse, non-disclosure). RESULTS: The sample (n = 839) included heterosexual men (n = 127), men who have sex with men (MSM; n = 607), and women (n = 105). Thirty-nine percent were white, 36% Hispanic, 17% black, and 8% other/mixed ethnicity. Overall, 71% reported that an applicable provider had talked with them at least once about safer sex (range across clinics, 52-94%); 50% reported discussion of disclosure (range across clinics, 31-78%). Discussion of safer sex was more prevalent with physicians than with other clinic staff. In multivariate analyses, in addition to significant clinic differences, MSM (versus heterosexual men) and whites (versus blacks or Hispanics) were less likely to receive prevention messages on these topics. Patients' behaviors (unsafe sex, non-disclosure) and HIV medical status were not independently associated with provider communication. CONCLUSIONS: HIV clinics differed substantially in the percentage of patients who reported that they received prevention messages from clinic staff. Care providers should assess and overcome barriers to providing prevention messages to patients.
An anticipatory quality improvement process for curricular reform.
OBJECTIVE: Over half of American medical schools are currently engaged in significant curricular reform. Traditionally, evaluation of the efficacy of educational changes has occurred well after the implementation of curricular reform, resulting in significant time elapsed before modification of goals and content can be accomplished. We were interested in establishing a process by which a new curriculum could be reviewed and refined before its actual introduction. DESCRIPTION: The University of California, San Francisco (UCSF) School of Medicine embarked upon a new curriculum for the class entering in September 2001. Two separate committees coordinated plans for curricular change. The Essential Core Steering Committee was responsible for the first two years of training, and the Integrated Clinical Steering Committee guided the development of the third-and fourth-year curriculum. Both groups operated under guidelines of curricular reform, established by the School's Committee on Curriculum and Educational Policy, that emphasized integration of basic, clinical, and social sciences; longitudinal inclusion of themes such as behavior, culture, and ethics; use of clinical cases in teaching; and inclusion of small-group and problem-based learning. In early 2001, the deans of education and curricular affairs appointed an ad hoc committee to examine the status of the first-year curriculum, which had been entirely reformulated into a series of new multidisciplinary block courses. This ad hoc committee was composed of students and clinical faculty members who had not been substantially involved in the detailed planning of the blocks. The charge to the committee was to critique the progress of individual courses, and the first year as a whole, in meeting the goals outlined above, and to make recommendations for improving the preparation of students for the clinical years. To accomplish these goals, the committee reviewed background planning documents; interviewed each course director using a standardized set of questions; and examined course schedules, cases, and detailed learning objectives for particular sessions. In July 2001, the committee reported back to the deans with specific recommendations for coordinating the block courses, and about the success in creating integration and the overall balance of topics students would learn. Specific recommendations included increasing the use of pediatric and geriatric cases across courses, creating a case database, developing explicit plans to relocate uncovered material in the four-year curriculum, and bolstering participation of clinical faculty during the first-year blocks. These recommendations were then presented to and endorsed by the Essential Core Steering Committee, which implemented an action plan prior to the September 2001 start date. DISCUSSION: This proactive approach to quality improvement added an evaluation point before the new curriculum was actually unveiled. The anticipatory planning process substantially aided the interdisciplinary developmental process, increased input into the first-year curriculum by clerkship directors, and identified problems that would have otherwise become apparent after implementation. We believe this model adds value to the curriculum planning process.