Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

12th World AIDS Conference

Abstracts 42210-42214 815

460*/42210 Health care providers' awareness of the ACTG 076
findings and their adherence to government
guidelines to reduce perinatal transmission of HIV
Kaenan Hertz', D. Parham2, L. Soto-Torres2, S. Trent-Adams2. 1Macro
International, 3 Corporate SQ. NE, Suite 370, Atlanta, GA; 2HRSA, DHHS,
Bethesda, MD, USA
Background: Bureau of Primary Health Care funded programs provide care
for over 230,000 pregnant women, mostly through community health centers
(CHCs) in the US. Given CDC HIV seroprevalence estimates for pregnant women
(1.6/1000 pregnant women), BPHC funded programs are caring for an estimated
360 HIV infected pregnant women. The Bureau needed to know how well the
funded providers are (1) adhering to current protocols to reduce mother-child
transmission of HIV (ACTG 076 - administer a ZDV regimen to pregnant women
and their newborn infants), (2) adhering to counseling and testing guidelines (all
pregnant women should be offered HIV counseling and testing) as well as (3)
the providers' comfort level with treating HIV/AIDS patients. This information will
then allow the Bureau to develop targeted training programs to help educate the
providers and ensure that they provide the highest level of care to their patients.
Methods: 2000 health care workers (73% response rate) from 77 CHCs in
New Jersey, New York and Puerto Rico were surveyed by mail.
Results: (a) Substantial numbers of health care providers lack confidence in
the ACTG 076 research findings (16%).
(b) Only 53% of respondents routinely offer HIV screening to pregnant women
and 50% of respondents offer HIV screening to women of reproductive age.
(c) Almost one in five CHC health care providers are uncomfortable with treating
AIDS patients.
(d) Almost half of respondents felt that HIV infected individuals should receive
care only from specialists in HIV.
(e) Many health care providers refer all HIV infected patients for care (18%).
Conclusions: These providers work in federally funded public health clinics
in high HIV/AIDS incidence areas and yet, given the overwhelming medical evidence supporting the ACTG 076 findings and subsequent Public Health Service
guidelines to perinatal transmission of HIV and to offer routine HIV screening
to all pregnant women, it is surprising how many providers were unaware or
skeptical of the findings and recommendations. Additional education of health
care providers must take place to ensure that treatment protocols are followed.
42211 Effect of antiretroviral therapy on clinical outcomes and
cost in a university-based HIV/AIDS program: 1995-1997
Steven C. Johnson1, A. Hageman2, H. Wing2, M. Grodesky2, P. Romfh2,
W. Williams1. 1Univ. Colorado Health Science Center, Box B165 4200 East Ninth
Avenue, Denver, Colorado 80111; 2University Hospital, Denver, CO, USA
Background: The objective of this study was to assess the impact of highly effective antiretroviral therapy on clinical outcomes and cost over the 3-year period,
1995-1997.
Methods: Retrospective review of medical records and hospital information
systems. The University Hospital HIV/AIDS Program provides care to 550 persons with HIV infection (60% AIDS). From 1995-1997, we measured the rate of
hospitalization, the incidence of selected opportunistic infections (Pneumocystis
carinii Pneumonia (PCP), Disseminated Mycobacterium avium Complex Disease
(DMAC), Cytomegalovirus (CMV) Disease), mortality, and the cost of care for
program participants. We evaluated the relationship between improved clinical
outcomes and the use of antiretroviral therapy.
Results: Over the 3-year period, the use of highly effective antiretroviral therapy
increased from - 10% to -80% of program participants. The rate of hospitalization fell from 6.4 inpatient days per patient-year in 1995 to 1.1 inpatient days per
patient-year in 1997. Patients on antiretroviral therapy that included a protease
inhibitor had one third the rate of hospitalization of those who were not on this
therapy. The incidence of PCP fell from 13 cases per 100 patient-years in 1995
to 4.7 cases per 100 patient-years in 1997. Dramatic declines in DMAC and CMV
Disease were also noted. Mortality, expressed as a percentage of the entire clinic
population, fell from 15% in 1995 to 5% in 1997. Inpatient costs fell by $1.4 million
in 1996 compared to 1995 with a more modest decline in 1997.
Conclusions: The widespread use of highly effective antiretroviral therapy has
helped to produce a dramatic decline in HIV-related morbidity and mortality. In
addition, certain aspects of care are less costly.
42212 Adherence to opportunistic infections (Ols) prevention
guidelines in federally funded health care facilities in the
United States
Jonathan E. Kaplan', H. Amandus2, K. van Dyck2, J. Greaves2, B. Ellis2,
L. Soto-Torres3, D. Parham3. 1 Centers for Disease Control MS G-29, 1600
Clifton Rd, Atlanta, GA 30333; 2Battelle Centers for Public Health RES,
Arlington, VA,; 3Health Resources and Services Admin, Rockville, MD, USA

Objectives: To determine adherence by health care providers to guidelines for
prevention of Ols in HIV-infected adults in federally funded health care facilities
in the United States.
Design: Descriptive medical record review study.
Methods: The Ryan White Title III program funds medical care for 73,000
HIV-infected adults - approximately 1/5 of HIV-infected persons in care in the U.S
Records of HIV-infected adults ( 13 years) in 11 Ryan White facilities in Maryland,
New York, Georgia, and Illinois were reviewed by trained abstractors for infor
mation on 8 standard-of-care recommendations for care of HIV-infected adults
during Nov 1996-Aug 1997. Eligibility required a visit to the facility within 6 months
before date of abstraction and a lowest CD4+ lymphocyte count - 500 cells/p L.
Results: Reviews were completed for 148 subjects in Maryland and for 355,
370, and 538 subjects in New York, Georgia, and Illinois, respectively. Measurement of HIV plasma RNA and prescription of antiretroviral therapy was recorded
for 86% and 85% of patients, respectively. Prophylaxis against P carinii pneuminia (PCP) and M. avium complex (MAC) had been prescribed for 86% and 69%
of eligible patients; and tuberculin skin testing, (TST) pneumococcal vaccination
(PVAC), toxoplasma antibody testing, and Pap smear testing had been performed
for 80%, 70%, 85%, and 88%, respectively. Adherence to recommendations was
similar when analyzed by patient age and racial/ethnic group, gender, urban vs.
rural, and hospital vs. clinic setting. Among injection drug users (IDUs), prescription of MAC prophylaxis (63% vs. 70%), TST (71% vs. 82%), and PVAC (67%
vs. 71%) seemed less common than in other HIV risk groups, although only the
result for TST was statistially significant (p:.001).
Conclusion: These data indicate a high level of adherence by health care
providers to some, but not all, guidelines for preventing Ols in this sample of
federally funded facilities, suggesting that adherence to some guidelines (e.g.,
MAC prophylaxis, TST, and PVAC) in these facilities could be improved, especially
among IDUs.
42213 Quality of medical care for three common HIV-related
symptoms in a nationally representative sample of HIV+
persons in care in the US
Steven Asch1, B.J. Turner2, S.A. Bozzette3, J.A. McCutchan4, A.L. Gifford5,
M. Shapiro6, K. Kuromiya7. ' West Los Angeles VA, 11301 Wilshire Blvd
MC 111G Los Angeles CA 90073; 2 Thomas Jefferson University, Philadelphia,
PA; 3VA Medical Center, La Jolla, CA; 4USCD Treatment Center, San Diego, CA;
5UC San Diego, San Diego, CA; -6UCLA and Rand Corporation, Los Angeles,
CA; 7Critical Path AIDS Project, Philadelphia, PA, USA
Objective: We evaluated HIV quality of care using a patient-centered, symptombased framework.
Methods: Care was assessed for HIV+ patients who had any of 3 persistent,
bothersome symptoms (SX) in past 6 months: cough and/or shortness of breath
(C/SOB) -1 wk., diarrhea (DIAR) -1 wk., or weight loss (WL) >10%. Clinical
experts developed 14 quality of care indicators for these SX by defining appropriate history, physical, social service, diagnostic procedures, and therapies for
specific clinical scenarios. Study subjects were identified by a 3-stage probability
sampling design, in which site, providers in these sites and those providers'
patients were randomly selected. Patients were interviewed from 1/96-3/97 and
queried on demographics, socioeconomics, risk factors, recent CD4 count, and
aspects of SX in the past 6 months. Patients with bothersome, persistent SX
were asked about care for the most bothersome SX and one random SX. The
final sample of 2865 respondents is used with preliminary weights to adjust for
sampling, multiplicity, and nonresponse and linearization methods to correct for
weights and multistage sample design.
Results: Care for C/SOB was asked of 530 (18%), DIAR of 985 (34%), WL
of 543 (19%). Adherence to quality indicators ranged from 31% (endoscopy for
chronic unresponsive DIAR) to 100% (hospitalization or antibiotics for CD4.:200
and SOB with fever, chills, or hemoptosis). Adherence rates were. 80% for 6/14
indicators. Only 50% of patients had all appropriate quality of care indicators
met (C/SOB = 38%, DIAR = 59%, WL = 74%). Adherence was worst for invasive procedures (50%) and best for physical exam (97%). In a DIAR scenario
recommending endoscopy, only 6% of the uninsured had endocopy vs 84% of
patients with private health maintenance insurance. We found few demographic
or socioecomomic predictors (p -.05) of adherence.
Discussion: Quality of care appears to be commonly deficient for three common symptoms in HIV+ patients in the US. Quality adherence rates are poorest
for invasive, often expensive procedures and may be related to lack of insurance coverage. Futher characterization of factors preventing quality of care is
warranted.
42214 1 Satisfaction with medical care is associated with race,
HIV symptoms and recovery from substance abuse
among HIV-infected women
Rani Eversley1, D. Israelski2, S. Smith3, P. Kunwar4. 1 Dept of Social and
Behavioral Sciences, Box 0612 UCSF, University of California, San Francisco
San Francisco, CA; 2 Standford University Medical Center Stanford, CA; 3AIDS
Community Research Consortium Redwood City, CA; 4 UCSF San Francisco,
CA, USA
Objectives: To develop and test a measure to assess the unique issues of satisfaction with medical care among HIV-infected women. To examine the relationship
between demographic and psycho-social factors and satisfaction with care.
Methods: We developed Perceptions of Care" (POC), a twelve-item measure
to assess satisfaction with care among women with HIV. We surveyed a sample

of 41 women attending a county HIV clinic with the POC to examine the factor
structure of the measure and to determine the relationship between demographics, psychosocial factors, HIV symptoms and satisfaction with care. Data were
examined using principal components analysis with orthogonal rotation, ANOVA
and regression.
Results: The mean age was 39.6 years. 68% of these women were AfricanAmerican, 27% were Caucasian, 6% were of other ethnic backgrounds. The