To examine temporal associations between obstetrics/gynecology (ob/gyn) care, substance abuse treatment (SAT), and antiretroviral therapy (ART) during and after pregnancy among HIV-infected women on Medicaid.We identified 345 women, representing 378 deliveries, from merged New Jersey AIDS/HIV surveillance data and paid Medicaid claims data between 1992 and 1998. T-tests were used to analyze person-level differences in service use before and after delivery. Data were converted to person-months to predict SAT and receipt of ART in multivariate regressions that corrected for correlations among repeated observations.Compared to antepartum months there were significant reductions in ART and ob/gyn care in postpartum months and a significant increase in substance abuse. Multivariate analyses showed that compared to other months, women were more likely to obtain SAT during the postpartum period (odds ratio [OR] 1.51, 95% confidence interval [CI], 1.31-1.74); conversely, women were more likely to receive ART in the antepartum period (OR 1.77, 95% CI, 1.43-2.17). Ob/gyn care predicted ART and SAT, regardless of the timing of care relative to delivery. African American women were least likely to receive SAT and ART.Our findings underscore that ob/gyn providers have a central position in pathways to care for a vulnerable population of women with multiple health care needs and that patterns of ART use and SAT shift markedly during the months before and after delivery. However, receipt of ob/gyn care during these months is not associated with the changes, suggesting that ob/gyn providers may have untapped opportunities during the ante- and postpartum months to educate women with HIV/AIDS about the importance of consistent use of ART and to provide SAT referrals as needed. These results may have implications for policy makers interested in promoting adherence to ART and decreasing substance abuse among women with HIV/AIDS.
Airway clearance therapies (ACTs) are recommended as an integral part of the management of non-cystic fibrosis bronchiectasis (BE) to prevent inflammation, mucus accumulation, and infection that occur because of ineffective secretion clearance. Adherence to ACTs is low, in part because of perceived burden and a lack of standardization of education and training programs for patients. Poor adherence is associated with more frequent exacerbations, worse health outcomes, and worse quality of life. Structured educational programs increase adherence to ACT among people with cystic fibrosis and may show similar results for people with BE.
This study estimates the rate of zidovudine (ZDV) use during pregnancy among HIV-infected women receiving Medicaid. The rates of ZDV use during pregnancy are compared before (preperiod) and after (postperiod) the 1994 publication of US Public Service Task Force guidelines, recommending use of ZDV during pregnancy. The authors also compare and contrast the correlates of ZDV use during pregnancy in each of the preguideline and postguideline periods.New Jersey AIDS/HIV surveillance data and paid Medicaid claims data between 1992 and 1996 were merged to examine ZDV use during pregnancy. Among ZDV users, the authors also examined persistence of ZDV use during the 3 months preceding delivery. In these analyses, the authors examined care received during pregnancy and differentiated routine medical care from pregnancy-specific care. Correlates of intrapregnancy ZDV use were examined using chi2 analysis and robust regression techniques that correct for correlation among repeated observations.Use of ZDV during pregnancy steadily increased from 13% in 1992 to 70% in 1996, with the upward trend beginning before the release of the guidelines. Averaged over the full preperiod (1992-1994), the rate was 29%, increasing to 57% during the full postperiod (1995-1996). Women with no health care during pregnancy did not receive any ZDV prophylaxis. Women who had some health care contacts, but did not receive pregnancy-specific care, had low rates of ZDV use that did not increase after the promulgation of the guidelines (21% in preperiod and 27% in postperiod). Women who received pregnancy-specific care, whether from obstetrician-gynecologists (OB-GYNs) or other providers, substantially increased their use of ZDV in the postguideline period (from 37% to 63% for those who saw OB-GYNS, and from 20% to 59% for those who received pregnancy-specific care from other providers). However, among users of ZDV, only a minority (24%) used ZDV persistently during the 3 months preceding delivery. African American women were less likely to be persistent ZDV users, even after controlling for other factors.The study highlights the underutilization of ZDV by women who did not receive pregnancy-related care, even after the publication of guidelines. Lack of pregnancy-specific medical care during pregnancy is an important barrier to ZDV prophylaxis. This study confirms that the receipt of prenatal care during pregnancy is a key intervening variable in the real world application of the PHS guidelines and underscores the importance of proactive efforts to provide prenatal care to pregnant women with HIV.
Objectives. This study compared the use of new antiretroviral treatments across sociodemographic subgroups during the 3 years after the introduction of these treatments and examined diffusion of the therapies over time. Methods. Merged surveillance and claims data were used to examine use of protease inhibitors and non-nucleoside reverse transcriptase inhibitors (PI/NNRTIs) among New Jersey Medicaid beneficiaries with AIDS. Results. In 1996, there were sharp disparities in use of PI/NNRTI therapy among racial minorities and injection drug users, even after control for other patient characteristics. These gaps had decreased by 1998. Higher PI/NNRTI treatment rates were also observed among beneficiaries enrolled in a statewide HIV/AIDS-specific home- and community-based Medicaid waiver program. Conclusions. Even within a population of individuals similar in regard to health coverage, there were substantial sociodemographic differences in use of PI/NNRTIs during the early years after their introduction. These differences narrowed as new treatments became standard. Participation in a case-managed Medicaid waiver program seems to be associated with a more appropriate pattern of use. These results suggest a need to address nonfinancial barriers to care.
This study examines the place of death for persons with AIDS, and the adequacy of the pain treatment that they received in their final months of life. Variations in the use of pain treatment during three months before death and place of death by patient's characteristics such as gender, race/ethnicity, mode of transmission, and geographical location are examined. We used merged AIDS surveillance data and paid Medicaid claims data for the period between 1991 and 1998 to examine the outcomes. Multivariate analysis was done using logistic regressions. Overall, approximately half of the sample received an outpatient prescription for analgesics during the last three months of life. A majority of the decedents (62 percent) died in a hospital. Significant differences in pain treatment and place of death existed between members of racial minority groups and Whites. Higher rates of pain treatment and lower likelihood of dying in a hospital were noted among beneficiaries enrolled in a statewide HIV/AIDS-specific home- and community-based Medicaid-waiver program. Despite financial eligibility, racial minorities, especially African-Americans, were disadvantaged in their access to healthcare services during their last months of life; some of these racial differences appear to be mediated by the use of the waiver program. There was some evidence that access to home care services and case-management mechanisms such as those built into the waiver program were an effective means of facilitating palliative care by increasing the use of pain medication and reducing the likelihood of dying in a hospital.
Summary: This study provides population-based estimates of the incidence of constituent symptoms associated with HIV-related lipodystrophy syndrome. Possible predictors of symptomatology based on analysis of accrued cases are provided after adjustment for a broad range of personal, clinical, and treatment characteristics. Patients enrolled in a province-wide HIV/AIDS treatment program reported annually on the occurrence of lipoatrophy, lipohypertrophy, and elevated triglyceride and cholesterol levels. Of 1261 individuals who provided baseline data, 745 were available at follow-up, among whom incidence was 27% for lipoatrophy, 21% for lipohypertrophy, and 10% and 16% for increased triglyceride and cholesterol levels, respectively. In logistic multivariate modeling, incident lipoatrophy was associated with duration of stavudine (per quarter) (adjusted odds ratio [AOR] 1.18; 95% confidence interval [CI] 1.09-1.27) and having been diagnosed with AIDS (AOR 2.07; 95% CI 1.20-3.56). Lipohypertrophy risk increased with use of protease inhibitor (AOR 3.53; 95% CI 1.81-6.86) and stavudine (AOR 3.67; 95% CI 1.61-8.38). Incident cholesterol or triglyceride abnormalities were associated with protease inhibitor use (AOR 7.17; 95% CI 2.46-20.96) and duration of ritonavir (per quarter) (AOR 1.12; 95% CI 1.04-1.21). Our findings suggest high annual rates of incidence and a role of first line antiretroviral therapies in symptom development. These outcomes, in conjunction with the findings of others have important implications for evolving treatment patterns.
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