Retained in HIV Care But Not on Antiretroviral Treatment: A Qualitative Patient-Provider Dyadic Study

Background

Patients retained in HIV care but not on antiretroviral therapy (ART) represent an important part of the HIV care cascade in the United States. Even in an era of more tolerable and efficacious ART, decision making in regards to ART offer and uptake remains complex and calls for exploration of both patient and provider perspectives. We sought to understand reasons for lack of ART usage in patients meeting the Health Resources Services Administration definition of retention as well as what motivated HIV primary care appointment attendance in the absence of ART.

Methods and Findings

We conducted a qualitative study consisting of 70 in-depth interviews with ART-naïve and ART-experienced patients off ART and their primary care providers in two urban safety-net HIV clinics in San Francisco and New York. Twenty patients and their providers were interviewed separately at baseline, and 15 dyads were interviewed again after at least 3 mo and another clinic visit in order to understand any ART use in the interim. We applied dyadic analysis to our data. Nearly all patients were willing to consider ART, and 40% of the sample went on ART, citing education on newer antiretroviral drugs, acceptance of HIV diagnosis, social support, and increased confidence in their ability to adhere as facilitators. However, the strength of the provider recommendation of ART played an important role. Many patients had internalized messages from providers that their health was too good to warrant ART. In addition, providers, while demonstrating patient-centered care through sensitivity to patients experiencing psychosocial instability, frequently muted the offer of ART, at times unintentionally. In the absence of ART, lab monitoring, provider relationships, access to social services, opiate pain medications, and acute symptoms motivated care. The main limitations of this study were that treatment as prevention was not explored in depth and that participants were recruited from academic HIV clinics in the US, making the findings most generalizable to this setting.

Conclusions

Provider communication with regard to ART is a key focus for further exploration and intervention in order to increase ART uptake for those retained in HIV care.     

Selenium and cellular immunity

Selenium deficiency can lead to impaired immune function and reduced T-cell counts, as well as various specific disorders. Significantly, in ARC and AIDS patients, a progressive decline in plasma Se, paralleling T-cell loss, has been widely documented. Since evidence now suggests that there is an extremely high turnover of CD4+ T-cells in AIDS patients, with billions of new cells lost and replaced daily, any exceptional requirement for Se in lymphocytes could contribute to this progressive Se depletion. Thus, it may be significant that, over-lapping the known genes in the +1 reading frame, the mRNAs of several T-cell associated genes (CD4, CD8, HLA-DR p33) have open reading frames (ORFs) with as many as 10 in-frame UGA codons (CD4, p33), a clustering that is highly improbable by chance alone, and reminiscent of selenoprotein P, the predominant plasma form of Se. The presence of these ORFs, along with potential stem-loop RNA structures displaying consensus selenocysteine insertion sequences, AUG(N)_mAAA(N)_nUGR, suggests that these mRNAs may encode selenoproteins, in addition to the known T-cell glycoproteins. If so, the roles of Se in the immune system may be more diverse than previously suspected.     

Using an in vitro cytotoxicity assay to aid in compound selection for in vivo safety studies

Recent publications have demonstrated that using calculated physiochemical properties can help in the design of compounds that have a decreased risk of significant findings in rodent toxicology studies. In this Letter, we extend this concept and incorporate results from a high throughput cytotoxicity assay to help the drug discovery community select compounds for progression into in vivo studies. The results are presented in an easily interpretable odds ratio so that teams can readily compare compounds and progress potential clinical candidates to the necessary rodent in vivo studies.     

Changes in forest understory associated with Juniperus encroachment in Oklahoma,USA

Question: Does understory vegetation cover and richness decline along a gradient of increasing Juniperus virginiana midstory canopy cover and is that decline best correlated with litter accumulation? Location: Cross Timbers Forest in Payne County, OK, USA. Methods: We measured vegetation in forest gaps as well as forest areas without J. virginiana, at the inner and outer edge of J. virginiana canopies and near J. virginiana trunks (200 plots) and compared vegetation differences among location to light, litter, soil and microclimate variables. Results: Species richness (11 spp m^?2 to 6 spp m^?2) and summer vegetation cover (53.3% to 12.7%) declined with proximity to trunks. Regression indicated that richness declines (R²=0.08) and cover (R²=0.18) were best correlated with J. virginiana litter accumulation. Partial canonical correspondence analysis (pCCA) revealed two strong canonical axes, one related to litter/light and another to cover of Quercus spp. versus J. virginiana. Tree seedlings and woody vines dominated near J. virginiana. Forbs, graminoids and Quercus spp. seedlings were more common in areas without J. virginiana. Conclusions: Increasing J. virginiana and consequent litter additions alter understory biomass and composition and, through inhibiting Quercus spp. recruitment, may lead to changes in overstory composition. Decreases in herbaceous litter, which historically contributed to fuel accumulation, may have positive feedback effects on midstory encroachment by reducing the potential for prescribed burning.     

Climate change, conservation and management: an assessment of the peer-reviewed scientific journal literature

Recent reviews of the conservation literature indicate that significant biases exist in the published literature regarding the regions, ecosystems and species that have been examined by researchers. Despite the global threat of climatic change, similar biases may be occurring within the sub-discipline of climate-change ecology. Here we hope to foster critical thought and discussion by considering the directions taken by conservation researchers when addressing climate change. To form a quantitative basis for our perspective, we assessed 248 papers from the climate change literature that considered the conservation management of biodiversity and ecosystems. We found that roughly half of the studies considered climate change in isolation from other threatening processes. We also found that the majority of surveyed scientific publications were conducted in the temperate forests of Europe and North America. Regions such as Latin America that are rich in biodiversity but may have low adaptive capacity to climate change were not well represented. We caution that such biases in research effort may be distracting our attention away from vulnerable regions, ecosystems and species. Specifically we suggest that the under-representation of research from regions low in adaptive capacity and rich in biodiversity requires international collaboration by those experienced in climate-change research, with researchers from less wealthy nations who are familiar with local issues, ecosystems and species. Furthermore, we caution that the propensity of ecologists to work in essentially unmodified ecosystems may fundamentally hamper our ability to make useful recommendations in a world that is experiencing significant global change.     

Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users

Background

North America''s first medically supervised safer injecting facility for illicit injection drug users was opened in Vancouver on Sept. 22, 2003. Although similar facilities exist in a number of European cities and in Sydney, Australia, no standardized evaluations of their impact have been presented in the scientific literature.

Methods

Using a standardized prospective data collection protocol, we measured injection-related public order problems during the 6 weeks before and the 12 weeks after the opening of the safer injecting facility in Vancouver. We measured changes in the number of drug users injecting in public, publicly discarded syringes and injection-related litter. We used Poisson log-linear regression models to evaluate changes in these public order indicators while considering potential confounding variables such as police presence and rainfall.

Results

In stratified linear regression models, the 12-week period after the facility''s opening was independently associated with reductions in the number of drug users injecting in public (p < 0.001), publicly discarded syringes (p < 0.001) and injection-related litter (p < 0.001). The predicted mean daily number of drug users injecting in public was 4.3 (95% confidence interval [CI] 3.5–5.4) during the period before the facility''s opening and 2.4 (95% CI 1.9–3.0) after the opening; the corresponding predicted mean daily numbers of publicly discarded syringes were 11.5 (95% CI 10.0–13.2) and 5.4 (95% CI 4.7–6.2). Externally compiled statistics from the city of Vancouver on the number of syringes discarded in outdoor safe disposal boxes were consistent with our findings.

Interpretation

The opening of the safer injecting facility was independently associated with improvements in several measures of public order, including reduced public injection drug use and public syringe disposal.Many cities are experiencing epidemics of bloodborne diseases as a result of illicit injection drug use,^1,2,3 and drug overdoses have become a leading cause of death in many urban areas.^4,5,6 Public drug use also plagues many inner city neighbourhoods, and the unsafe disposal of syringes in these settings is a major community concern.^{7,8,9,10,11,12,13}In over 2 dozen European cities and, more recently, in Sydney, Australia, medically supervised safer injecting facilities, where injection drug users (IDUs) can inject previously obtained illicit drugs under the supervision of medical staff, have been established in an effort to reduce the community and public health impacts of illicit drug use.¹⁴ Inside these facilities IDUs are typically provided with sterile injecting equipment, emergency care in the event of overdose, as well as primary care services and referral to addiction treatment.^13,15 Although anecdotal reports have suggested that such sites may improve public order,¹² reduce the number of deaths from overdose¹⁶ and improve access to care,¹⁷ no standardized evaluations of their impact are available in the scientific literature.¹⁸On Sept. 22, 2003, health officials in Vancouver opened a government-sanctioned safer injecting facility as pilot project. The facility, the first in North America, is centrally located in Vancouver''s Downtown Eastside, which is the most impoverished urban neighbourhood in Canada and home to well-documented overdose and HIV epidemics among the estimated 5000 IDUs who reside there.^19,20 Federal approval for the 3-year project was granted on the condition that the health and social impacts of the facility be rigorously evaluated. Although evaluation of the facility''s impact on certain outcomes (e.g., HIV incidence) is ongoing and will take several years, it is now possible to examine the impacts of the site on public order. Therefore, we conducted this study to test the hypothesis that changes in improperly discarded syringes and public drug use would be observed after the opening of the safer injecting facility.     

Low and annually variable migratory connectivity in a long‐distance migrant: Whinchats Saxicola rubetra may show a bet‐hedging strategy

The spatial scale of non‐breeding areas used by long‐distance migrant animals can vary from specific, relatively small non‐breeding areas for each independent breeding population (high connectivity) to a distribution over a large non‐breeding area with mixing of breeding populations (low connectivity). Measuring variation in the degree of connectivity and how it arises is crucial to predict how migratory animals can respond to global habitat and climate change because low connectivity is likely to be an adaptation to environmental uncertainty. Here, we assess whether use of non‐breeding areas in a long‐distance migrant may be stochastic by measuring the degree of connectivity, and whether it is annually variable. Twenty‐nine wintering Whinchats tagged with geolocators over 2 years within 40 km² in central Nigeria were found to be breeding over 2.55 million km² (26% of the land area of Europe), without an asymptote being approached in the relationship between area and sample size. Ranges differed in size between years by 1.51 million km² and only 15% of the total breeding range across both years overlapped (8% overlap between years when only first‐year birds were considered), well above the range size difference and below the proportion of overlap that would be predicted from two equivalent groups breeding at random locations within the observed range. Mean distance between breeding locations (i.e. migratory spread) differed significantly between years (604 ± 18 km in 2013 and 869 ± 33 km in 2014). The results showed very low and variable connectivity that was reasonably robust to the errors and assumptions inherent in the use of geolocators, but with the caveat of having only ranges of 2 years to compare, and the sensitivity of range to the breeding locations of a small number of individuals. However, if representative, the results suggest the scope for between‐year variation (cohort effects) to determine migrant distribution on a large scale. Furthermore, for species with similarly low connectivity, we would predict breeding population trends to reflect average conditions across large non‐breeding areas: thus, as large areas of Africa become subject to habitat loss, migrant populations throughout Europe will decline.     

Seasonal patterns in rainforest litterfall: Detecting endogenous and environmental influences from long‐term sampling

Tropical rainforests play an important role in the storage and cycling of global terrestrial carbon. In the carbon cycle, net primary productivity of forests is linked to soil respiration through the production and decomposition of forest litter. Climate seasonality appears to influence the production of litter although there is considerable variability within and across forests that makes accurate estimates challenging. We explored the effects of climate seasonality on litterfall dynamics in a lowland humid rainforest over a 7‐year period from 2007 to 2013, including an El Niño/La Niña cycle in 2010/2011. Litterfall was sampled fortnightly in 24 traps of 0.50 m diameter within a 1‐ha forest plot. Total mean litterfall was 10.48 ± 1.32 (±SD, dry weight) Mg ha^?1 year^?1 and seasonal in distribution. The different components of litterfall were divided into L_Leaf (63.5%), L_Wood (27.7%) and L_{FF[flowers & fruit]} (8.8%), which all demonstrated seasonal dynamics. Peak falls in L_Leaf and L_Wood were highly predictable, coinciding with maximum daily temperatures and 1 and 2 months prior to maximum monthly rainfall. The El Niño/La Niña cycle coincided with elevated local winter temperatures and peak falls of L_Leaf and L_Wood. Importantly, we establish how sampling length and generalized additive models eliminate the requirement for extensive within‐site sampling when the intention is to describe dynamics in litterfall patterns. Further, a greater understanding of seasonal cycles in litterfall allows us to distinguish between endogenous controls and environmental factors, such as El Niño events, which may have significant impacts on biochemical cycles.     

Genetic portrait of Lisboa immigrant population from Cabo Verde with mitochondrial DNA analysis

Journal of Genetics -