Adapting HIV prevention evidence-based interventions in practice settings: an interview study

Background

A knowledge broker (KB) is a popular knowledge translation and exchange (KTE) strategy emerging in Canada to promote interaction between researchers and end users, as well as to develop capacity for evidence-informed decision making. A KB provides a link between research producers and end users by developing a mutual understanding of goals and cultures, collaborates with end users to identify issues and problems for which solutions are required, and facilitates the identification, access, assessment, interpretation, and translation of research evidence into local policy and practice. Knowledge-brokering can be carried out by individuals, groups and/or organizations, as well as entire countries. In each case, the KB is linked with a group of end users and focuses on promoting the integration of the best available evidence into policy and practice-related decisions.

Methods

A KB intervention comprised one of three KTE interventions evaluated in a randomized controlled trial.

Results

KB activities were classified into the following categories: initial and ongoing needs assessments; scanning the horizon; knowledge management; KTE; network development, maintenance, and facilitation; facilitation of individual capacity development in evidence informed decision making; and g) facilitation of and support for organizational change.

Conclusion

As the KB role developed during this study, central themes that emerged as particularly important included relationship development, ongoing support, customized approaches, and opportunities for individual and organizational capacity development. The novelty of the KB role in public health provides a unique opportunity to assess the need for and reaction to the role and its associated activities. Future research should include studies to evaluate the effectiveness of KBs in different settings and among different health care professionals, and to explore the optimal preparation and training of KBs, as well as the identification of the personality characteristics most closely associated with KB effectiveness. Studies should also seek to better understand which combination of KB activities are associated with optimal evidence-informed decision making outcomes, and whether the combination changes in different settings and among different health care decision makers.     

Innate immunity against HIV: a priority target for HIV prevention research

The xenotropic/polytropic subgroup of mouse leukemia viruses (MLVs) all rely on the XPR1 receptor for entry, but these viruses vary in tropism, distribution among wild and laboratory mice, pathogenicity, strategies used for transmission, and sensitivity to host restriction factors. Most, but not all, isolates have typical xenotropic or polytropic host range, and these two MLV tropism types have now been detected in humans as viral sequences or as infectious virus, termed XMRV, or xenotropic murine leukemia virus-related virus. The mouse xenotropic MLVs (X-MLVs) were originally defined by their inability to infect cells of their natural mouse hosts. It is now clear, however, that X-MLVs actually have the broadest host range of the MLVs. Nearly all nonrodent mammals are susceptible to X-MLVs, and all species of wild mice and several common strains of laboratory mice are X-MLV susceptible. The polytropic MLVs, named for their apparent broad host range, show a more limited host range than the X-MLVs in that they fail to infect cells of many mouse species as well as many nonrodent mammals. The co-evolution of these viruses with their receptor and other host factors that affect their replication has produced a heterogeneous group of viruses capable of inducing various diseases, as well as endogenized viral genomes, some of which have been domesticated by their hosts to serve in antiviral defense.     

Development and implementation of evidence-based guidelines for IV insulin: A statewide collaborative approach

Purpose: Recent studies have shown that the outcomes of hospitalized patients are greatly enhanced when steps are taken to improve control of their blood glucose levels. The Georgia Hospital Association Research and Education Foundation's Partnership for Health Accountability established a Diabetes Special Interest Group (D-SIG) in February 2003. Goals of the D-SIG were to enlighten health care professionals in Georgia hospitals about the benefits of controlling hyperglycemia in hospitalized patients and to develop processes to assist hospitals in the adoption of an IV insulin dosing algorithm, development of an IV insulin standing order set, and implementation of a hyperglycemia management plan.Methods: The D-SIG created an assessment tool titled “Key Elements of IV Insulin Guidelines” and evaluated numerous published IV insulin administration algorithms and protocols. After an extensive literature review, including international protocols and guidelines, user-friendly guidelines for subcutaneous and IV insulin were developed by a multidisciplinary work group, with members representing hospitals and other stakeholders from throughout the state. The group chose a well-researched method that was available in both computerized and hand-calculated formats and developed a Columnar Insulin Dosing Chart to assist with IV insulin infusions. This insulin-infusion table stems from mathematical formulas published by multiple investigators since the 1980s. The D-SIG guidelines and dosing chart were evaluated for ease of use, effectiveness, and safety in 3 settings: a small, rural critical-access hospital (CAH); an intensive care unit (ICU) in the trauma center of a large Georgia teaching hospital; and a surgical ICU in a midsize metropolitan hospital.Results: After implementation of the guidelines, the incidence of hypoglycemia (blood glucose level <60 mg/dL) was 0.9% in the trauma center ICU and 0.6% in the surgical ICU. All hypoglycemic patients in these 2 settings were asymptomatic, remained hypoglycemic only for a short time, and experienced no complications attributable to hypoglycemia. Using a moderate insulin sensitivity level for dosing initiations resulted in a time to target blood glucose level (80–110 mg/dL) of 6.4 hours, whereas using the most conservative approach required 12.8 hours to attain target range. At the CAH, time to reach the target blood glucose level (90–140 mg/dL) was 5.8 hours, and no episodes of hypoglycemia were reported. Although not part of the pilot initiative, the surgical ICU also reported a 5-fold reduction in surgical infection rates. The success of the dosing chart and standing order set paralleled that of the computerized formula when similar initiation doses were used.Conclusions: The Columnar Insulin Dosing Chart and sample clinical guidelines were piloted at 3 different settings and found to be safe and effective. Furthermore, by including the treatment for hypoglycemia in the guidelines, nurses in all patient care areas were able to manage blood glucose levels below the target range in a safe and timely manner. Use of the dosing chart and guidelines reduced blood glucose levels to the target range with no clinically significant hypoglycemia.     

Dynamics behind the scale up of evidence-based obesity prevention: protocol for a multi-site case study of an electronic implementation monitoring system in health promotion practice

Background

The effectiveness of many interventions to promote health and prevent disease has been well established. The imperative has therefore shifted from amassing evidence about efficacy to scale-up to maximise population-level health gains. Electronic implementation monitoring, or ‘e-monitoring’, systems have been designed to assist and track the delivery of preventive policies and programs. However, there is little evidence on whether e-monitoring systems improve the dissemination, adoption, and ongoing delivery of evidence-based preventive programs. Also, given considerable difficulties with e-monitoring systems in the clinical sector, scholars have called for a more sophisticated re-examination of e-monitoring’s role in enhancing implementation.

Methods

In the state of New South Wales (NSW), Australia, the Population Health Information Management System (PHIMS) was created to support the dissemination of obesity prevention programs to 6000 childcare centres and elementary schools across all 15 local health districts. We have established a three-way university-policymaker-practice research partnership to investigate the impact of PHIMS on practice, how PHIMS is used, and how achievement of key performance indicators of program adoption may be associated with local contextual factors. Our methods encompass ethnographic observation, key informant interviews and participatory workshops for data interpretation at a state and local level. We use an on-line social network analysis of the collaborative relationships across local health district health promotion teams to explore the relationship between PHIMS use and the organisational structure of practice.

Discussion

Insights will be sensitised by institutional theory, practice theory and complex adaptive system thinking, among other theories which make sense of socio-technical action. Our working hypothesis is that the science of getting evidence-based programs into practice rests on an in-depth understanding of the role they play in the on-going system of local relationships and multiple accountabilities. Data will be synthesised to produce a typology to characterise local context, PHIMS use and key performance indicator achievement (of program implementation) across the 15 local health districts. Results could be used to continuously align e-monitoring technologies within quality improvement processes to ensure that such technologies enhance practice and innovation. A partnership approach to knowledge production increases the likelihood that findings will be put into practice.

     

Implementing evidence-based interventions in health care: application of the replicating effective programs framework

Background

For people with dementia, patient-centred care should involve timely explanation of the diagnosis and its implications. However, this is not routine. Theoretical models of behaviour change offer a generalisable framework for understanding professional practice and identifying modifiable factors to target with an intervention. Theoretical models and empirical work indicate that behavioural intention represents a modifiable predictor of actual professional behaviour. We identified factors that predict the intentions of members of older people's mental health teams (MHTs) to perform key behaviours involved in the disclosure of dementia.

Design

Postal questionnaire survey.

Participants

Professionals from MHTs in the English National Health Service.

Methods

We selected three behaviours: Determining what patients already know or suspect about their diagnosis; using explicit terminology when talking to patients; and exploring what the diagnosis means to patients. The questionnaire was based upon the Theory of Planned Behaviour (TPB), Social Cognitive Theory (SCT), and exploratory team variables.

Main outcomes

Behavioural intentions.

Results

Out of 1,269 professionals working in 85 MHTs, 399 (31.4%) returned completed questionnaires. Overall, the TPB best explained behavioural intention. For determining what patients already know, the TPB variables of subjective norm, perceived behavioural control and attitude explained 29.4% of the variance in intention. For the use of explicit terminology, the same variables explained 53.7% of intention. For exploring what the diagnosis means to patients, subjective norm and perceived behavioural control explained 48.6% of intention.

Conclusion

These psychological models can explain up to half of the variation in intention to perform key disclosure behaviours. This provides an empirically-supported, theoretical basis for the design of interventions to improve disclosure practice by targeting relevant predictive factors.

Trial Registration

ISRCTN15871014.     

Accomplishments in HIV prevention science: implications for stemming the epidemic

The past two decades have witnessed substantial advances in the science of preventing HIV infection. Although important issues remain and there is a need for continuing research, arguably the biggest challenge in preventing HIV transmission is the full implementation of existing preventive interventions worldwide.     

Nanobead-based interventions for the treatment and prevention of tuberculosis

Tuberculosis (TB), caused by Mycobacterium tuberculosis, is one of the most devastating bacterial diseases to affect humans. M. tuberculosis is a robust pathogen that has evolved the capacity to survive and grow inside macrophage phagosomes. A cocktail of antibiotics has long been successfully used against M. tuberculosis but is becoming less effective owing to the emergence of multidrug resistance. The only available preventive vaccine, using Mycobacterium bovis bacille Calmette-Guérin, is considered to be ineffective against adult pulmonary TB, the most prevalent form of the disease. Here, we review the potential use of biodegradable nanoparticle-based anti-TB drug delivery systems that have been shown to be more effective against M. tuberculosis in animal models than conventional antibiotic treatment regimens. This technology also has substantial potential for vaccination and other therapeutic strategies against TB and other infectious diseases.     

Intermediate coronary artery stenosis: evidence-based decisions in interventions to avoid the oculostenotic reflex

The prevalence of intermediate coronary artery stenosis (defined as a diameter stenosis of 40% to 70%) is quite large in patients undergoing PTCA. The coronary angiogram is considered the 'gold standard' for the definition of coronary anatomy, in spite of various limitations associated with its use. In recent years, sensor tipped guidewire based methods of physiologic assessment of stenosis severity, like myocardial fractional flow reserve, and poststenotic coronary flow reserve had established their role in the decision making in catheterization laboratory. The decision making should combine morphologic and physiologic assessment as better evidence based approach in guiding therapy to avoid the 'oculostenotic reflex'.     

Drugs of abuse and HIV infection/replication: implications for mother-fetus transmission

Human immunodeficiency virus (HIV) infection and progression of acquired immunodeficiency syndrome (AIDS) can be modulated by a number of cofactors, including drugs of abuse. Opioids, cocaine, cannabinoids, methamphetamine (METH), alcohol, and other substances of abuse have been implicated as risk factors for HIV infection, as they all have the potential to compromise host immunity and facilitate viral replication. Although epidemiologic evidence regarding the impact of drugs of abuse on HIV disease progression is mixed, in vitro studies as well as studies using in vivo animal models have indicated that drugs of abuse have the ability to enhance HIV infection/replication. Drugs of abuse may also be a risk factor for perinatal transmission of HIV. Because high levels of viral load in maternal blood are associated with increased risk of HIV vertical transmission, it is likely that drugs of abuse play an important role in promoting mother-fetus transmission. Furthermore, because the neonatal immune system differs qualitatively from the adult system, it is possible that maternal exposure to drugs of abuse would exacerbate neonatal immunity defects, facilitating HIV infection of neonate immune cells and promoting HIV vertical transmission. The availability and use of antiretroviral therapy for women infected with HIV increase, there is an increasing interest in determining the impact of drug abuse on efficacy of AIDS Clinical Trials Group (ACTG)-standardized treatment regimens for woman infected with HIV in the context of HIV vertical transmission.     

Genome-scale RNAi screen for host factors required for HIV replication

Human immunodeficiency virus (HIV)-1 depends on the host cell machinery to support its replication. To discover cellular factors associated with HIV-1 replication, we conducted a genome-scale siRNA screen, revealing more than 311 host factors, including 267 that were not previously linked to HIV. Surprisingly, there was little overlap between these genes and the HIV dependency factors described recently. However, an analysis of the genes identified in both screens revealed overlaps in several of the associated pathways or protein complexes, including the SP1/mediator complex and the NF-kappaB signaling pathway. cDNAs for a subset of the identified genes were used to rescue HIV replication following knockdown of the cellular mRNA providing strong evidence that the following six genes are previously uncharacterized host factors for HIV: AKT1, PRKAA1, CD97, NEIL3, BMP2K, and SERPINB6. This study highlights both the power and shortcomings of large scale loss-of-function screens in discovering host-pathogen interactions.     

Substance use and HIV disease progression in the HAART era: implications for the primary prevention of HIV

Prior to the era of highly active anti-retroviral therapy (HAART), cohort studies provided equivocal evidence to support the hypothesis that substance use predicts more rapid HIV disease progression. The present review examined the effects of substance use on HIV disease progression in cohort studies with follow-up that continued into the HAART era. Of the 20 studies included in this review, 16 observed that substance use predicted at least one indicator of HIV disease progression. Ten of the 11 studies that followed participants exclusively in the HAART era observed an effect of substance use on HIV disease progression. Findings across studies indicate that stimulant use promotes more rapid HIV disease progression and the effects of substance use on HIV disease progression can persist after controlling for self-reported HAART non-adherence. Future investigations that examine the bio-behavioral pathways whereby substance use promotes HIV disease progression should include: measures of HIV genotypic and phenotypic resistance, multi-method assessment of adherence, and assessment of co-morbid infections that are more prevalent among substance users. Although further mechanistic research is needed, findings from existing cohort studies have clear clinical implications. Implementing screening, brief intervention and referral to substance abuse treatment in HIV medical care could optimize health outcomes and decrease HIV transmission rates by boosting the effectiveness of "Test and Treat" approaches to HIV prevention.     

A room for reflection: self-observation and transformation in participatory HIV prevention work

This article looks at HIV prevention projects in which established stigmatized and stigmatizing roles were actively reversed and manipulated in pursuit of HIV harm reduction. In two Norwegian projects, sex workers and drug users carried out harm-reduction activities with other drug users and sex workers. Although HIV-related harm reduction was the aim of the projects, termination or reduction of drug use or sex work was not. Such changes nevertheless occurred among the sex workers and drug users who took active part in the project. The article considers these changes in order to reflect on the meanings and roles of participation in HIV prevention work. In particular, the discussion theorizes on possible ways in which alteration of roles and subject positions may produce self-reflective effects with transformative potentials.     

Inhibition of HIV replication by amino-sugar derivatives

The plant alkaloids castanospermine, dihydroxymethyldihydroxypyrrolidine and deoxynojirimycin have recently been shown to have potential anti-HIV activity [(1987) Proc. Natl. Acad. Sci. USA 84, 8120-8124; (1987) Nature 330, 74-77; (1987) Lancet i, 1025-1026]. They are thought to act by inhibiting alpha-glucosidase I, an enzyme involved in the processing of N-linked oligosaccharides on glycoproteins. We report here the relative efficacy of a spectrum of amino-sugar derivatives as inhibition of HIV cytopathicity. Several alpha-glucosidase inhibitors and alpha-fucosidase inhibitors were found to be active at concentrations which were non-cytotoxic.