Biomedical subjects

M Chesney

Publications and source records attributed to M Chesney.

At least 19 recordsLinked to original sources

PubMed2005

Quality of life in HIV-infected individuals receiving antiretroviral therapy is related to adherence.

This study assesses changes in quality of life (QoL) over time among HIV-infected individuals receiving antiretroviral therapy (ART) and evaluates how this relates to ARTadherence. Prospective, longitudinal data were examined from 1050 participants in two large, randomized, multi-centre antiretroviral clinical trials. QoL was assessed by the SF-12; adherence by the Terry Beirn Community Programs for Clinical Research on AIDS Antiretroviral Medication Self-report. Participants included 20% women, 53% African Americans, 16% Latinos; mean age was 39 years; mean baseline CD4+ cell count 230 cells/mm3; 89% were ART-naïve at entry. Baseline physical and mental health summary QoL scores were 45.4 and 42.9, comparable to scores reported in other advanced HIV populations. Significant improvements in mean QoL scores were seen for the group as a whole after 1 to 4 months on new ART regimens, and persisted for 12 months. Participants reporting 100% ART adherence achieved significantly higher QoL scores at 12 months compared to those with poorer adherence, particularly if 100% adherence was consistent (p < 0.001). Those with at least 80% ART adherence had smaller gains in QoL at 12 months when compared to baseline, while those with < 80% adherence had worsening of QoL. In this analysis, ART adherence was associated with improved QoL, particularly if adherence was sustained.

Adult↗

PubMed2002

What happened to home HIV test collection kits? Intent to use kits, actual use, and barriers to use among persons at risk for HIV infection.

Through sequential cross-sectional surveys, we examined intent to use home HIV test collection kits, actual use and barriers to use among persons at high risk for HIV infection. Interest in kits was assessed in the 1995-96 HIV Testing Survey (HITS, n=1683). Kit use, knowledge of kits and barriers to use were assessed in the 1998-99 HITS (n=1788), after kits had become widely available. When asked to choose among future testing options, 19% of 1995-96 participants intended to use kits. Untested participants were more likely than previously tested HIV-negative participants to choose kits for their next HIV test (p < 0.001). Among 1998-99 participants, only 24 (1%) had used kits; 46% had never heard of kits. Predictors of not knowing about kits included never having been HIV tested and black or Latino race. Common reasons for not using kits among participants aware of home test kits were concerns about accuracy, lack of in-person counselling and cost. Despite high rates of anticipated use, kits have had minimal impact on the testing behaviour of persons at high risk for HIV infection. Increasing awareness of kits, reducing price and addressing concerns about kit testing procedures may increase kit use, leading to more HIV testing by at-risk individuals.

Cross-Sectional Studies↗

PubMed2001

Postexposure prophylaxis for human immunodeficiency virus infection after sexual or injection drug use exposure: identification and characterization of the source of exposure.

In a nonrandomized study of nonoccupational postexposure prophylaxis (PEP), a cross-sectional evaluation of subjects who were the source of human immunodeficiency (HIV) exposure was performed to characterize partners of index subjects seeking nonoccupational PEP against HIV. Among 401 index subjects, 64 (16%) recruited a source subject. Those in a steady relationship and those who knew that the source subject was HIV antibody positive were more likely to recruit their source subject. Source subjects reported high rates of past (78%) and current (69%) antiretroviral use; 46% of those using antiretroviral drugs had detectable plasma HIV-1 RNA levels. Antiretroviral resistance was detected in many source subjects who reported any use of antiretrovirals and was rare among source subjects who reported no history of antiretroviral use. Clinicians often make treatment decisions on the basis of incomplete knowledge of the source subject's HIV status or antiretroviral treatment history. The treatment history, particularly nonuse of a class of antiretroviral drugs, can be used to predict drug resistance.

Adult↗

PubMed2001

Provider assessment of adherence to HIV antiretroviral therapy.

BACKGROUND: Adherence assessment is an essential component of monitoring HIV antiretroviral therapy. Prior studies suggest that medical providers frequently estimate individual patient adherence inaccurately. OBJECTIVE: We compared provider estimates of nonadherence to antiretroviral therapy with unannounced pill counts and structured patient interviews to determine the accuracy of adherence information obtained by providers and patients. DESIGN, SETTING, AND PARTICIPANTS: Comparison of three adherence measures in homeless or marginally housed persons receiving HIV antiretroviral therapy (n = 45) and their providers (n = 35). MEASUREMENTS: Provider estimate of percentage of pills taken; three successive patient structured reports of number of doses missed in the last 3 days; and three successive unannounced pill counts. RESULTS: 13% (95% confidence interval [CI], 4%-22%) of patients were not following their regimen as directed. Provider-adherence estimate explained only 26% (95% CI, 6%-47%) of the variation in pill count adherence, whereas patient report explained 72% (95% CI, 52%-96%). The sensitivity and specificity of provider estimates of nonadherence, defined as <80% of pills taken by pill count, were 40% and 85%, respectively. The sensitivity and specificity of patient interview were 72% and 95%, respectively. CONCLUSIONS: Provider estimate of adherence was inaccurate whereas structured patient report was more closely related to pill count. Structured assessment over several short intervals may improve accuracy of adherence assessment in clinical practice.

Antiretroviral Therapy, Highly Active↗

PubMed2001

Feasibility of postexposure prophylaxis (PEP) against human immunodeficiency virus infection after sexual or injection drug use exposure: the San Francisco PEP Study.

The feasibility of providing postexposure prophylaxis (PEP) after sexual or injection drug use exposures to human immunodeficiency virus (HIV) was evaluated. PEP was provided within 72 h to individuals with exposures from partners known to have or to be at risk for HIV infection. PEP consisted of 4 weeks of antiretroviral medications and individually tailored risk-reduction and medication-adherence counseling. Among 401 participants seeking PEP, sexual exposures were most common (94%; n=375). Among sexual exposures, receptive (40%) and insertive (27%) anal intercourse were the most common sexual acts. The median time from exposure to treatment was 33 h. Ninety-seven percent of participants were treated exclusively with dual reverse-transcriptase inhibitors, and 78% completed the 4-week treatment. Six months after the exposure, no participant developed HIV antibodies, although a second PEP course for a subsequent exposure was provided to 12%. PEP, after nonoccupational HIV exposure, is feasible for persons at risk for HIV infection.

Adolescent↗

PubMed2001

Safety and tolerability of BufferGel, a novel vaginal microbicide, in women in the United States.

BufferGel (ReProtect, LLC) is a vaginal gel with an acidic buffering action that was designed to prevent vaginal neutralization by semen. The purpose of this study was to evaluate the safety and tolerability of BufferGel (ReProtect, Limited Liability Company) applied vaginally either once or twice daily by 27 women who were at low risk for acquisition of human immunodeficiency virus (HIV). Participants initially used the product once daily for 14 days and then twice daily for 14 days; they underwent colposcopy before and after product exposure. BufferGel was well tolerated, although two-thirds of the participants reported at least 1 mild or moderate adverse experience. The most common adverse events were irritative genitourinary symptoms. Product use was discontinued after 3 adverse events. BufferGel was well tolerated in women at low risk for acquisition of HIV; toxicity was limited and occurred at frequencies similar to those in women who did not use any vaginal product and at levels lower than in women who used detergent-based microbicides.

Acrylic Resins↗

PubMed2001

Development and validation of a self-completed HIV symptom index.

Traditional, open-ended provider questions regarding patient symptoms are insensitive. Better methods are needed to measure symptoms for clinical management, patient-oriented research, and adverse drug-event reporting. Our objective was to develop and initially validate a brief, self-reported HIV symptom index tailored to patients exposed to multidrug antiretroviral therapies and protease inhibitors, and to compare the new index to existing symptom measures. The research design was a multistage design including quantitative review of existing literature, qualitative and quantitative analyses of pilot data, and quantitative analyses of a prospective sample. Statistical analyses include frequencies, chi-square tests for significance, linear and logistic regression. The subjects were from a multisite convenience sample (n = 73) within the AIDS Clinical Trials Group and a prospective sample from the Cleveland Veterans Affairs Medical Center (n = 115). Measures were patient-reported symptoms and health-related quality of life, physician-assessed disease severity, CD4 cell count, and HIV-1 RNA viral quantification. A 20-item, self-completed HIV symptom index was developed based upon prior reports of symptom frequency and bother and expert opinion. When compared with prior measures the index included more frequent and bothersome symptoms, yet was easier to use (self-report rather than provider interview). The index required less than 5 minutes to complete, achieved excellent completion rates, and was thought comprehensive and comprehensible in a convenience sample. It was further tested in a prospective sample of patients and demonstrated strong associations with physical and mental health summary scores and with disease severity. These associations were independent of CD4 cell count and HIV-1 RNA viral quantification. This 20-item HIV symptom index has demonstrated construct validity, and offers a simple and rational approach to measuring HIV symptoms for clinical management, patient-oriented research, and adverse drug reporting.

Antiretroviral Therapy, Highly Active↗

PubMed2001

Patient- and provider-reported adherence: toward a clinically useful approach to measuring antiretroviral adherence.

We seek to develop a clinically useful measure of antiretroviral medication adherence. Because there is no gold standard for adherence, we will assess the clinical validity of patient- and provider-reported adherence by the strength of their expected associations with current viral load, depressive symptoms, alcohol and illicit drug use, and homelessness. The Veterans Aging Cohort 3 Site Study (VACS 3) is a multisite study of 881 patients at Cleveland, Houston, and Manhattan Veterans Affairs health care systems. Data was collected on adherence using patient report and provider assessment; depressive symptoms using the Center for Epidemiological Studies Depression (CESD) and provider assessment; alcohol use using the Alcohol Use Disorders Identification Test (AUDIT) and provider assessment; and homelessness using patient report only. Viral load was collected from electronic laboratory data. Although agreement between providers and patients about the patient's adherence was not better than chance (61%; weighted kappa =.07), both patient and provider-reported adherence were related to viral load (P <.001), current alcohol use (P <.01), current drug use (P <.01), and depressive symptoms (P <.001). Patient-reported adherence was also associated with homelessness (P <.05). In multivariate regression models, provider assessment of adherence demonstrated independent associations with viral load (P <.001), current alcohol use (P <.001), current drug use (P <.001), and depressive symptoms (P <.001) after adjustment for the patient's report of adherence (also significantly associated). The consistent and largely independent association between patient and provider reported adherence and a range of variables previously shown to be associated with adherence suggests that patient- and provider-reported adherence independently measure actual adherence. Future work will explore how patient- and provider-reported adherence might best be combined, and whether the measure may be further enhanced with pharmacy refill data.

Antiretroviral Therapy, Highly Active↗

PubMed2001

Adverse impact of cigarette smoking on dimensions of health-related quality of life in persons with HIV infection.

Because effects of cigarette smoking on health-related quality of life (HRQL) have not been well described, we carried out a cross-sectional assessment of HRQL using the Medical Outcomes Survey Scale adapted for patients with human immunodeficiency virus (MOS-HIV questionnaire) in 585 HIV-infected homosexual/bisexual men, injection drug users, and female partners enrolled in a multicenter, prospective study of the pulmonary complications of HIV infection. Mean scores for the following dimensions of HRQL were calculated: general health perception, quality of life, physical functioning, bodily pain, social functioning, role functioning, energy, cognitive functioning, and depression. A multivariate model was used to determine the impact on HRQL of the following factors: smoking, CD4 loss, acquired immune deficiency syndrome (AIDS) diagnoses, number of symptoms, study site, education, injection drug use, gender, and age. Current smoking was independently associated with lower scores for general health perception, physical functioning, bodily pain, energy, role functioning, and cognitive functioning (all with p < 0.05). We conclude that patients with HIV infection who smoke have poorer HRQL than nonsmokers. These results support the use of smoking cessation strategies for HIV-infected persons who smoke cigarettes.

Adult↗

PubMed2001

Dilemmas of self in the method.

In this article, the author focuses on the researcher in research. Challenged by the theory and criticism of self-indulgence, the author has, as the researcher, come out through reflection and self-scrutiny to address some of the dilemmas the research process has held for her. Dilemmas concerning interviewing women from Pakistan using interpreters have been covered previously. The dilemmas discussed in this article concern the position of the researcher and honesty, the criticism of Western dominance, and how the research process has changed the author.

Developed Countries↗

PubMed2000

Home collection for frequent HIV testing: acceptability of oral fluids, dried blood spots and telephone results. HIV Early Detection Study Group.

OBJECTIVE: To assess the feasibility and acceptability of bimonthly home oral fluid (OF) and dried blood spot (DBS) collection for HIV testing among high-risk individuals. DESIGN: A total of 241 participants [including men who have sex with men (MSM), injecting drug users (IDU), and women at heterosexual risk] were recruited from a randomly selected subset of study participants enrolled at four sites in the HIV Network for Prevention Trials (HIVNET) cohort, and assigned at random to bimonthly home collection of OF or DBS specimens over a 6 month interval. Participants could select telephone calls or clinic visits to receive HIV test results. METHODS: Bimonthly specimens were tracked for adherence to the schedule, were evaluated for adequacy for testing, and tested using antibody assays and polymerase chain reaction (PCR) for DBS. The acceptability of bimonthly home OF and DBS collection and telephone counseling was assessed in an end-of-study questionnaire. RESULTS: The laboratory received 96 and 90% of expected OF and DBS specimens, respectively; 99% of each specimen type was adequate for testing. Almost all (95%) participants chose results disclosure by telephone. The majority of participants (85%) reported that bimonthly testing did not make them worry more about HIV, and almost all (98%) judged that with bimonthly testing their risk behavior remained the same (77%) or became less risky (21%). CONCLUSION: Bimonthly home specimen collection of both OF and DBS with telephone counseling is acceptable and feasible among study participants at high risk. These methods will be useful for the early detection of HIV infection and remote follow-up of research cohort participants in HIV vaccine and prevention trials.

AIDS Serodiagnosis↗

PubMed2000

Adherence to isoniazid prophylaxis in the homeless: a randomized controlled trial.

OBJECTIVES: To test 2 interventions to improve adherence to isoniazid preventive therapy for tuberculosis in homeless adults. We compared (1) biweekly directly observed preventive therapy using a $5 monetary incentive and (2) biweekly directly observed preventive therapy using a peer health adviser, with (3) usual care at the tuberculosis clinic. METHODS: Randomized controlled trial in tuberculosis-infected homeless adults. Outcomes were completion of 6 months of isoniazid treatment and number of months of isoniazid dispensed. RESULTS: A total of 118 subjects were randomized to the 3 arms of the study. Completion in the monetary incentive arm was significantly better than in the peer health adviser arm (P = .01) and the usual care arm (P = .04), by log-rank test. Overall, 19 subjects (44%) in the monetary incentive arm completed preventive therapy compared with 7 (19%) in the peer health adviser arm (P = .02) and 10 (26%) in the usual care arm (P = .11). The median number of months of isoniazid dispensed was 5 in the monetary incentive arm vs 2 months in the peer health adviser arm (P = .005) and 2 months in the usual care arm (P = .04). In multivariate analysis, independent predictors of completion were being in the monetary incentive arm (odds ratio, 2.57; 95% CI, 1.11-5.94) and residence in a hotel or other stable housing at entry into the study vs residence on the street or in a shelter at entry (odds ratio, 2.33; 95% CI, 1.00-5.47). CONCLUSIONS: A $5 biweekly cash incentive improved adherence to tuberculosis preventive therapy compared with a peer intervention or usual care. Living in a hotel or apartment at the start of treatment also predicted the completion of therapy.

Adult↗

PubMed2000

Spit (smokeless) tobacco use by high school baseball athletes in California.

OBJECTIVE: To describe the prevalence, patterns, and correlates of spit (smokeless) tobacco (ST) use in a sample of high school baseball athletes in California. DESIGN: This cross sectional study was a survey of 1226 baseball athletes attending 39 California high schools that were randomly selected from a list of all publicly supported high schools with baseball teams. At a baseball team meeting, athletes who agreed to participate and had parental consent completed the study questionnaire. To enhance the accuracy of self reported ST use status, a saliva sample was collected from each subject. The questionnaires and saliva samples were coded and salivary cotinine assay was performed on a random subsample of 5% of non-users who also were non-smokers. Biochemical assay indicated that 2% tested positive for cotinine inconsistent with self reported ST non-use. RESULTS: Overall, 46% had ever used ST and 15% were current users. Odds ratios and 95% confidence intervals (CI) suggested that, among high school baseball athletes, age, living in a rural area, being white, smoking cigarettes, drinking alcohol, not knowing about the adverse effects of ST, perceiving little personal risk associated with ST use, and believing that friends, role models, teammates, and same age baseball athletes in general used ST, increased the likelihood of being an ST user. CONCLUSION: The findings indicate that considerable experimentation with ST products occurs among high school baseball athletes in California, and many are current users. ST interventions targeting this population are needed to stop the transition from experimental ST use to tobacco dependence. Correlates of ST use for consideration in future intervention studies are identified.

Adolescent↗

PubMed2000

Helping the urban poor stay with antiretroviral HIV drug therapy.

Recent studies have documented dramatic decreases in opportunistic infections, hospitalizations, and mortality among HIV-infected persons, owing primarily to the advent of highly active antiretroviral medications. Unfortunately, not all segments of the population living with HIV benefit equally from treatment. In San Francisco, only about 30% of the HIV-infected urban poor take combination highly active antiretroviral medications, as compared with 88% of HIV-infected gay men. Practitioners who care for the urban poor are reluctant to prescribe these medications, fearing inadequate or inconsistent adherence to the complicated medical regimen. Persons typically must take 2 to 15 pills at a time, 2 to 3 times a day. Some of the medications require refrigeration, which may not be available to the homeless poor. Most homeless persons do not have food available to them on a consistent schedule. Therefore, they may have difficulty adhering to instructions to take medications only on an empty stomach or with food. Lack of a safe place to store medications may be an issue for some. In addition, many urban poor live with drug, alcohol, or mental health problems, which can interfere with taking medications as prescribed. Inconsistent adherence to medication regimens has serious consequences. Patients do not benefit fully from treatments, and they will become resistant to the medications in their regimen as well as to other medications in the same classes as those in their regimen. Development of resistance has implications for the broader public health, because inadvertent transmission of multidrug-resistant strains of HIV has been demonstrated. Concern that the urban poor will not adhere to highly active antiretroviral medication regimens has led to debate on the role of clinicians and public health officials in determining who can comply with these regimens. Rather than define the characteristics that would predict adherence to these regimens, the San Francisco Department of Public Health created a program to support adherence among those who may have the greatest difficulty complying with complicated highly active antiretroviral medication regimens. The program, dubbed the Action Point Adherence Project, was conceived through a community planning process in preparation for a city-wide summit on HIV/AIDS that took place in January 1998. Action Point is funded by the city and the county of San Francisco. Now in its 10th month, the program continues to show promising evidence of improving clients' biological and social indicators.

Adult↗

PubMed1999

Novel four-drug salvage treatment regimens after failure of a human immunodeficiency virus type 1 protease inhibitor-containing regimen: antiviral activity and correlation of baseline phenotypic drug susceptibility with virologic outcome.

Twenty human immunodeficiency virus-infected patients experiencing virologic failure of an indinavir- or ritonavir-containing treatment regimen were evaluated in a prospective, open-label study. Subjects received nelfinavir, saquinavir, abacavir, and either another nucleoside analog (n=10) or nevirapine (n=10). Patients treated with the nevirapine-containing regimen experienced significantly greater virologic suppression at week 24 than those not treated with nevirapine (P=.04). Baseline phenotypic drug susceptibility was strongly correlated with outcome in both treatment arms. Subjects with baseline virus phenotypically sensitive to 2 or 3 drugs in the salvage regimen experienced significantly greater virus load suppression than those with baseline virus sensitive to 0 or 1 drug (median week-24 change=-2.24 log and -0.35 log, respectively; P=.01). In conclusion, non-nucleoside reverse transcriptase inhibitors may represent a potent drug in salvage therapy regimens after failure of an indinavir or ritonavir regimen. Phenotypic resistance testing may provide a useful tool for selecting more effective salvage regimens.

Adult↗

PubMed1999

Access to antiretroviral treatment among French HIV infected injection drug users: the influence of continued drug use. MANIF 2000 Study Group.

STUDY OBJECTIVE: To determine the influence of continued drug use and its perception by prescribing physicians on access to antiretroviral treatment among French HIV infected injection drug users (IDUs). DESIGN: Cross sectional including enrollment data (October 1995-1996) of the cohort study MANIF 2000. Access to treatment is compared in three groups: former IDUs (n = 68) and active IDUs whether or not this behaviour remains undetected (n = 38) or detected (n = 17) by physicians. SETTING: Hospital departments for specialist AIDS care in south eastern France and inner suburbs of Paris. PATIENTS: All enrolled patients with CD4+ cell counts < 400 with detailed clinical history, access to treatment, risk behaviours, and past drug use as reported by both physicians and patients (n = 123). MAIN RESULTS: A minority (43.9%) already received an antiretroviral treatment. Active IDUs had worst socioeconomic and psychological conditions but only those detected by physicians were considered as poorly compliant. Logistic regression showed that, with respect to ex-IDUs and independently of clinical stage, active IDUs, whether or not they were perceived as such by physicians, were threefold more likely not to receive antiretroviral treatment. CONCLUSIONS: Even among French HIV infected IDUs who have regular access to AIDS specialised hospital care, continued drug use reduced the likelihood of being prescribed antiretroviral treatment. To reduce delays in access to new treatments, specific efforts must be devoted towards both AIDS specialists and IDU patients to overcome current stereotypes of non-compliance associated with continued injection.

Adolescent↗

PubMed1999

Tracking and follow-up of marginalized populations: a review.

Maintaining study cohorts is a key element of longitudinal research. Participant attrition introduces the possibility of bias and limits the generalizability of a study's findings, but with appropriate planning it is possible to sustain contact with even the most transient participants. This paper reviews the essential elements of tracking and follow-up of marginalized populations, which are (1) collection of contact information, (2) thorough organization of tracking efforts, (3) attention to staff training and support, (4) use of phone and mail follow-up, (5) use of incentives, (6) establishing rapport with participants, (7) assurance of confidentiality, (8) use of agency tracking, (9) use of field tracking, and (10) attention to safety concerns. Diligent application of these tracking strategies allows researchers to achieve follow-up rates of 75 percent to 97 percent with vulnerable populations such as homeless, mentally ill adults, injection drug users, and runaway youth.

Adolescent↗

PubMed1999

Effect of incentives on the use of indicated services in managed care.

In managed care, financial incentives and utilization review create conflicts of interest for physicians. We sought to determine whether these incentives would lead physicians to deny indicated services. We surveyed internists practicing in areas with at least 30% penetration of managed care. Our questionnaire included four scenarios in which a test or referral is indicated according to clearly established practice guidelines. We randomly assigned physicians to receive one of five versions of the questionnaire, which differed only in the type of reimbursement incentive and utilization review that applied to the scenarios. We received responses from 710 (70%) of 1,009 internists. Although physicians underutilized services regardless of incentives in all scenarios, physicians whose questionnaires depicted full capitation said that they would order fewer services than physicians whose questionnaires depicted fee-for-service. In the scenario in which an x-ray of the lumbosacral spine is indicated for a patient with low back pain, 86% of physicians randomized to the full capitation version said that they would order the test compared to 94% in the fee-for-service version. Similarly, physicians randomized to scenarios requiring utilization review said that they would order fewer services than those randomized to scenarios requiring completion of an insurance form. Scenarios depicting managed care incentives caused consistent, modest underutilization compared to fee-for-service scenarioes, although physicians underutilized services under all financial incentives and utilization review. In response, physicians must develop better methods for detecting underutilization and devise programs to increase the provision of indicated services.

Adult↗