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

854 Abstracts 42401-42404

12th World AIDS Conference

aims to utilize and incorporate the affected community into the direction and
management of the research ensuring that research benefits the community.
Steering and advisory committees were composed of a diverse range of PWAs,
community members, and care providers. Five community researchers were
trained to perform standardized physical and self-assessment measures. Data
was also collected through standardized telephone and structured interviews, and
focus groups. The range of rehabilitation services focused on fitness, nutrition,
and support interventions. Rehabilitation professionals assisted PWA community
researchers in acquiring those skills and knowledge integral to the research
project.
Results: More than 100 PWAs participated in the Pozfit program. 5 PWA community researchers collected the majority of the data. 46 participants completed
comprehensive physical, health self-assessment, and descriptive measurements
at the onset and completion of the research project. Quantitative data collected
demonstrated that community-based rehabilitation interventions such as Pozfit
significantly improved the cardiovascularcardiovspacity and endurance of PWAs. Qualitative data using the HOPES (HIV-Overview of Problems-Evaluation System)
inventory demonstrated that individuals involved in the Pozfit program had improved quality of life measures. Descriptive data collected demonstrates that the
Pozfit program resulted in increased self-esteem, self-efficacy, social integration,
hope, and community empowerment.
Lessons Learned: PWAs can undertake community-based, research when
supported by professionals, academics, and project managers. The participatory
action research model can be used to focus community-based resources and
promote community development. Community-based rehabilitation services can
provide physical and quality of life benefits to PWAs.
42401 Development of a community-based, capitated managed
care program for HIV/AIDS patients
Judith Steinberg1, C. Tobias2, L. Maisels2, C. Imbriano', M.S. Medeiros',
0. Penal, J.O. Taylor'. 'East Boston Neighborhood Health Center, 10 Gove
Street, East Boston, MA 02128; 2Medicaid Working Group, Boston, MA, USA
Issue: The increasing penetration of capitated, managed care in the health care
market has the potential to adversely affect specialized populations, such as
HIV/AIDS patients. Community-based programs, which meet the special needs
of HIVAIDS patients, and risk adjusted capitated rates are necessary to ensure
quality care.
Project: This inner city, full service, community health center has developed a
model of care for HIV/AIDS patients under capitated managed care. Supported
by a HRSA SPNS grant, we are evaluating this model of care using clinical
outcomes, quality of life, patient satisfaction and quality of care indicators. We are
also determining the service utilization and costs of care for HIV infected patients
at all stages of disease to determine reasonable risk adjusted capitation rates.
Results: Project SHINE serves 95 patients, with the following demographics:
43% female, 51% white, 28% Latino, and transmission categories: 41% injection
drug users, 30% heterosexual 20% gay/bisexual. Our model of care has evolved
from a categorical program to one that is integrated within our Adult Medicine
Department yet retains infectious disease specialty care, due to changes in the
health care environment and lessons learned from process reviews. The core
of our model is a multidisciplinary team and clinical case management that is
led by the Primary Care Provider. Patients may be enrolled in a managed care
organization that receives a risk adjusted capitation from Medicaid. A subcapitation arrangement is under consideration. Network development, health center
wide changes in clinical practice in response to managed care, and systems to
measure outcomes, quality of care and costs have been instituted. Initial data
and lessons learned will be presented.
Lessons Learned: An integrated model, that preserves HIV specialty care, is
an efficient and practical approach to capitated care in a full service, community-based setting and can be applied to the e areof patients with other chronic
disabilities. Risk adjusted capitation rates, which accurately reflect the intensity of services required, are key to the success and quality of capitated care
programs.
|r42402 i Retention in primary health care of clients diagnosed
with HIV by Ryan White CARE Act health care providers
over a 30-month period
Katherine Marconi'2, Richard C. Durbin2, Steve J. Niemcryk2, Robert L. Baitty3.
15600 Fishers Lane 7A-07, Department Health Human Services; 2Health
Resources Services Admin. (HRSA); 3RWCA Data Demonstrat. Workgroup,
Rockville MD, USA
Recent significant advances have been made in the treatment of HIV; however,
the treatments are only effective as long as the person remains in care. Factors associated with the retention in primary health care of HIV-infected clients
by approximately 200 health care providers located in three states and four
metropolitan areas of the United States are examined for the 30-month period
between January 1995 through June 1997. It is hypothesized that both provider

characteristics (e.g. the provider size, as measured by the number of clients in a
reporting period, urban/rural location, region of the country) and client characteristics (e.g. gender, race/ethnicity and disease stage) influence retention in care.
Bivariate and multivariate analyses are conducted. Additionally, some stratified
analyses are planned; for example, the retention of minority clients are examined
with respect to whether they are seen by a self-identified minority provider or a
non-minority provider. Data for this study were provided by seven Ryan White

CARE Act funded grantees. The Ryan White CARE Act (RWCA) is administered
by the US Health Resources and Services Administration and provided $1.150
billion in 1997 for HIV services. Approximately 15,000 RWCA clients are included
in this study.
Retention in primary care is a continuing challenge, especially for medically
underserved populations. Health practitioners and planners need to build incentives that promote medical adherence for individuals with HIV into their health
care systems.
42403 Viral detectability and CD4 levels in patients receiving
protease inhibitors in clinical practice: Results from the
CHORUS observational database
Joseph W. Bigley', Stephen Raffanti2, S. Becker3, D. Dieterich4, A. Scarsella5,
R. Moore6, E. Igboko1, N. Hansen7, G. Sawyerr', W. Mangialardi', J. Bigley'.
The Chorus Program Team; GlaxoWellcome Inc, 5 Moore Drive, Research
Triangle Park, NC 27709;:2Comprehensive Care Center, Nashville, TN; 3Pacific
Horizon Medical Group, San Francisco, CA; 4Liberty Medical LLP New York, NY;
5Pacific Oaks Medical Group, Beverly Hills, CA; 6John Hopkins University
Baltimore, MD; 7Research Triangle Institute, Res Tri Park, ND, USA
Background: CHORUS is a community-based observational database research
program following longitudinal outcomes in HIV/AIDS pts. at 4 US clinical practice sites. Treatment and healthcare questions are analyzed under the auspices
of an independent advisory board. The addition of protease inhibitors (PI) are
associated with improved suppression of HIV and decreased viral resistance.
Objective: This study assesses patient's baseline PI use with HIV RNA loads
and CD4 levels in 4 community-based sites participating in CHORUS.
Design: CHORUS includes 12 months of retrospective data collection, assessments at baseline, and 3 years of longitudinal follow-up. Up to 6000 patients are
expected to be enrolled in the study.
Methods: All patients provide informed written consent and the study is IRB
approved. Data collection began on 29Aug97 and patient enrollment is continuing.
Patients were evaluated for antiretroviral medication use at baseline. Those receiving treatment were stratified by the presence or absence of PI in the regimen.
Patients with a CD4 count and/or a HIV RNA level within 3 months of entry were
included. Chi square tests were used to perform statistical analyses.
Results: As of 15Jan98, 3148 patients had consented to participate. Data
were available from 1225 patients for viral load and 1226 patients for CD4 counts.
Patients receiving Pi's were more likely to have undetectable viral RNA at study
entry (54%) than patients not using Pi's (37%; p < 0.001). Conversely, patients
using Pi's were more likely to have lower CD4 counts (26%, 0-199 cells; 21%,
500+ cells) than those not receiving such treatments (14%, 0-199 cells; 40%,
500+ cells; p < 0.001). Levels of viral load and CD4 cells for all stratified patients
will be presented.
Conclusions: Patients receiving Pi's in their antiretroviral treatment regimens
were more likely to have undetectable HIV RNA levels but lower CD4 cell counts
than those not receiving such drugs in routine HIV clinical practice at the four
participating sites.
S42404 Primary CNS lymphoma and HAART
Brian Boyle, S. Merrick, J. Jacobs. New York Hospital-Cornell Med. Center, 525
E 68th St F24 New York NY 10021, USA
Background: There are numerous reports of the favorable effect of Highly Active
Antiretroviral Therapy (HAART) on the course of HIV-related opportunistic infections (Ols), but few reports of the effect of HAART on HIV-related malignancies.
Primary Central Nervous System (CNS) lymphoma occurs in HIV-infected patients
who are severely immunocompromised and is associated with the Ebstein-Barr
Virus. Systemic and neurologic complications of CNS lymphoma are profound and
the prognosis is almost uniformly poor, with life expectancy generally measured
in months. Death is usually due to an 0I.
Method: Case report of AIDS patient with initial CD4 count of 6 and biopsyproven Primary CNS Lymphoma treated with whole-brain radiotherapy, systemic
steroids and HAART.
Results: On the patient's initial presention, he was obtunded and had a rightsided hemiplegia. A brain MRI revealed a large mass in the left temporal lobe with
surrounding edema. Toxoplasmosis titers were negtive and a brain SPECT Thallium was positive. A tentative diagnosis of Primary CNS Lymphoma was made
and subsequently confirmed by biopsy. The patient was given brain radiotherapy
and systemic steroids initially and after his condition improved somewhat he was
started on HAART, including indinavir, zidovudine and lamivudine. In the one and
one-half years since this treatment, he has regained almost complete neurologic
function, his CD4 count has risen to 266, he has not had any Ols, and repeat
brain MRIs do not reveal any evidence of a recurrence of the lymphoma.
Conclusion: As it does with opportunistic infections, HAART may alter the
course of HIV-related malignancies. Accordingly, clinicians' past experiences with
these conditions may no longer be entirely valid. Patients with HIV-related tumors,
including Primary CNS Lymphoma, may benefit from treatment with regimens that

include HAART