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Feasibility of a Computer-Based Intervention Addressing Barriers to HIV Testing Among Young Patients Who Decline Tests at Triage

Aronson, Ian David; Cleland, Charles M; Perlman, David C; Rajan, Sonali; Sun, Wendy; Bania, Theodore C
Young people face greatly increased human immunodeficiency virus (HIV) risk and high rates of undiagnosed HIV, yet are unlikely to test. Many also have limited or inconsistent access to health care, including HIV testing and prevention education, and prior research has documented that youth lack knowledge necessary to understand the HIV test process and to interpret test results. Computer-based interventions have been used to increase HIV test rates and knowledge among emergency department (ED) patients, including those who decline tests offered at triage. However, patients aged 18-24 years have been less likely to test, even after completing an intervention, compared to older patients in the same ED setting. The current pilot study sought to examine the feasibility and acceptability of a new tablet-based video intervention designed to address established barriers to testing among ED patients aged 18-24 years. In particular, we examined whether young ED patients would: agree to receive the intervention; complete it quickly enough to avoid disrupting clinical workflows; accept HIV tests offered by the intervention; demonstrate increased postintervention knowledge; and report they found the intervention acceptable. Over 4 weeks, we recruited 100 patients aged 18-24 in a high-volume urban ED; all of them declined HIV tests offered at triage. Almost all (98%) completed the intervention (mean time <9 mins), 30% accepted HIV tests offered by the tablets. Knowledge was significantly higher after than before the intervention (t = -6.67, p < .001) and patients reported generally high acceptability. Additional research appears warranted to increase postintervention HIV testing.
PMCID:5030062
PMID: 27565191
ISSN: 1087-0415
CID: 2232222

Accuracy of body weight perception and obesity among Chinese Americans

Liu, Shan; Fu, Mei R; Hu, Sophia H; Wang, Vincent Y; Crupi, Robert; Qiu, Jeanna M; Cleland, Chuck; D'Eramo Melkus, Gail
BACKGROUND: Accuracy of body weight perception is an individual's perception of their body weight in comparison with actual body weight and is associated with weight-related behaviors. Chinese Americans have increased risk for obesity but no studies have examined accuracy of body weight perception. METHODS: This study was a descriptive and cross-sectional study, which was conducted in a community health center in New York. Study subjects were all Chinese-American adults. Demographic information, accuracy of perception of body weight, anthropometric measures (weight, height, body mass index [BMI], waist circumference [WC], hip circumference [HC], weight to height ratio, weight to hip ratio), fasting plasma glucose (FPG), glycosylated hemoglobin (HbA1C) and obesity-related diseases (hypertension, diabetes, heart disease, and stroke) were assessed. RESULTS: A total of 162 Chinese Americans were recruited. 52 subjects (32%) did not perceive body weight correctly: 32 subjects had underestimation and 20 subjects had overestimation of body weight. Significant differences were found among subjects in the three groups of different accuracy of body weight perception in terms of gender (p=0.003), age (p=0.003), education years (p=0.047), WC (p<0.001), HC (p
PMCID:4627852
PMID: 25937164
ISSN: 1871-403x
CID: 2273392

Underreporting of ecstasy use among high school seniors in the US

Palamar, Joseph J; Keyes, Katherine; Cleland, Charles M
BACKGROUND: National surveys suggest ecstasy (3,4-methylenedioxymethamphetamine [MDMA]) use has decreased substantially among adolescents in the US since 2001; however, the recent phenomenon of "Molly" (ecstasy marketed as "pure MDMA") may be leading to underreporting of use as not all users are aware that "Molly" is a form of ecstasy. METHODS: We examined 2014 data from Monitoring the Future, a nationally representative survey of high school seniors in the US (N=6250, modal age: 18). Three randomly distributed survey forms asked about ecstasy use, and one included "Molly" in the definition. Self-reported lifetime, 12-month, and 30-day ecstasy use were compared to determine whether including "Molly" in the definition was associated with higher prevalence or frequency of use. RESULTS: The form including "Molly" in the definition had significantly higher prevalence than the two (combined) forms that did not. Lifetime use (8.0% vs. 5.5%) and 12-month use (5.1% vs. 3.6%) were significantly higher with "Molly" in the definition. Lifetime prevalence remained higher with "Molly" in the definition when controlling for correlates of ecstasy use; however, 12-month use did not. Differences in prevalence were associated with lifetime occasions of use, with lower concordance between forms at lower levels of lifetime occasions (e.g., 1-2 times). Survey form was not related to number of times used among more frequent users. CONCLUSIONS: Prevalence of ecstasy use appears to be underestimated when "Molly" is not included in the definition of ecstasy/MDMA. Surveys should include "Molly" in the definition of ecstasy to more adequately assess prevalence of use.
PMCID:4939104
PMID: 27296977
ISSN: 1879-0046
CID: 2142822

Accuracy of the Audio Computer Assisted Self Interview version of the Alcohol, Smoking and Substance Involvement Screening Test (ACASI ASSIST) for identifying unhealthy substance use and substance use disorders in primary care patients

Kumar, Pritika C; Cleland, Charles M; Gourevitch, Marc N; Rotrosen, John; Strauss, Shiela; Russell, Linnea; McNeely, Jennifer
BACKGROUND: An Audio Computer-assisted Self Interview (ACASI) version of the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) could reduce barriers to substance use screening and assessment in primary care settings. This study evaluated the diagnostic accuracy of an ACASI ASSIST for identification of unhealthy substance use and substance use disorders (SUD). METHODS: 399 adult patients were consecutively recruited from an urban safety-net primary care clinic. ACASI ASSIST scores for tobacco, alcohol, marijuana, and cocaine were compared against reference standard measures to assess the instrument's diagnostic accuracy for identifying unhealthy use and SUD, first using empirically-derived optimal cutoffs, and second using the currently recommended ASSIST cutoffs. RESULTS: For identifying any unhealthy use, at the empirically-derived cutoffs the ACASI ASSIST had 93.6% sensitivity and 85.8% specificity (AUC=0.90) for tobacco, 85.9% sensitivity and 60.3% specificity (AUC=0.73), for alcohol in men, 100% sensitivity and 62.4% specificity (AUC=0.81) for alcohol in women, 94.6% sensitivity and 81.6% specificity (AUC=0.88) for marijuana, and 86.1% sensitivity, 84.0% specificity (AUC=0.85) for cocaine. For SUD, sensitivity ranged from 79% (for alcohol in males), to 100% (for tobacco), and specificity was 83% or higher (AUCs ranged 0.83-0.91). For substances other than tobacco, empirically-derived cutoff scores were lower than the standard cutoffs, and resulted in higher sensitivity and lower specificity for identifying unhealthy substance use. CONCLUSIONS: The ACASI ASSIST is a valid measure of unhealthy use and SUD for substances that are commonly used by primary care patients, and could facilitate effective and efficient screening for substance use in medical settings.
PMCID:4962996
PMID: 27344194
ISSN: 1879-0046
CID: 2167262

An Example of Exposure Heterogeneity When Pooling Epidemiologic Studies for Meta-Analysis of Antiretroviral Medication Adherence [Meeting Abstract]

Mackesy-Amiti, Mary-Ellen; Strand, Lauren; Nance, Robin; Chandler, Redonna; Cunningham, William; Riley, Elise; Mehta, Shruti; Altice, Frederick; Wechsberg, Wendee; Cunningham, Chinazo; Cleland, Charles; Metsch, Lisa; Feaster, Daniel; del Rio, Carlos; Beckwith, Curt; Kurth, Ann; Kuo, Irene; Kruszka, Bridget; Springer, Sandra
ISI:000385483501087
ISSN: 1099-1557
CID: 2385732

Challenges in Recruiting People Who Use Drugs for HIV-Related Biomedical Research: Perspectives from the Field

Batista, Pedro; Deren, Sherry; Banfield, Angela; Silva, Evelyn; Cruz, Mario; Garnes, Preston; Cleland, Charles M; Mehandru, Saurabh; LaMar, Melissa; Markowitz, Martin
Recruitment of people who use drugs (PWUD) for HIV-related research has been undertaken since early in the epidemic. In early studies, recruitment was often performed by outreach workers with familiarity with the target population, who distributed risk reduction materials, and administered the surveys being conducted on drug use and risk behaviors. The evolution of effective treatments for HIV has provided opportunities for PWUD to participate in biobehavioral studies testing the efficacy of medical treatment advances and exploring the underlying biomedical basis for prevention and treatment efforts. Recruitment for these studies has led to new challenges for outreach workers and institutions conducting this research. PWUD, particularly those from race/ethnic minority populations, have had lower rates of engagement in HIV care and have been underrepresented in HIV/AIDS medical studies. To address these health disparities, enhanced efforts are needed to increase their participation in biomedical studies. This article examines the challenges identified by experienced outreach workers in recruiting PWUD for HIV-related biomedical studies, including individual (participant)-, institutional-, and recruiter-level challenges, and provides recommendations for addressing them.
PMCID:4991596
PMID: 27509238
ISSN: 1557-7449
CID: 2211942

Linguistic and Cultural Adaptation of a Computer-Based Counseling Program (CARE+ Spanish) to Support HIV Treatment Adherence and Risk Reduction for People Living With HIV/AIDS: A Randomized Controlled Trial

Kurth, Ann E; Chhun, Nok; Cleland, Charles M; Crespo-Fierro, Michele; Pares-Avila, Jose A; Lizcano, John A; Norman, Robert G; Shedlin, Michele G; Johnston, Barbara E; Sharp, Victoria L
BACKGROUND: Human immunodeficiency virus (HIV) disease in the United States disproportionately affects minorities, including Latinos. Barriers including language are associated with lower antiretroviral therapy (ART) adherence seen among Latinos, yet ART and interventions for clinic visit adherence are rarely developed or delivered in Spanish. OBJECTIVE: The aim was to adapt a computer-based counseling tool, demonstrated to reduce HIV-1 viral load and sexual risk transmission in a population of English-speaking adults, for use during routine clinical visits for an HIV-positive Spanish-speaking population (CARE+ Spanish); the Technology Acceptance Model (TAM) was the theoretical framework guiding program development. METHODS: A longitudinal randomized controlled trial was conducted from June 4, 2010 to March 29, 2012. Participants were recruited from a comprehensive HIV treatment center comprising three clinics in New York City. Eligibility criteria were (1) adults (age >/=18 years), (2) Latino birth or ancestry, (3) speaks Spanish (mono- or multilingual), and (4) on antiretrovirals. Linear and generalized mixed linear effects models were used to analyze primary outcomes, which included ART adherence, sexual transmission risk behaviors, and HIV-1 viral loads. Exit interviews were offered to purposively selected intervention participants to explore cultural acceptability of the tool among participants, and focus groups explored the acceptability and system efficiency issues among clinic providers, using the TAM framework. RESULTS: A total of 494 Spanish-speaking HIV clinic attendees were enrolled and randomly assigned to the intervention (arm A: n=253) or risk assessment-only control (arm B, n=241) group and followed up at 3-month intervals for one year. Gender distribution was 296 (68.4%) male, 110 (25.4%) female, and 10 (2.3%) transgender. By study end, 433 of 494 (87.7%) participants were retained. Although intervention participants had reduced viral loads, increased ART adherence and decreased sexual transmission risk behaviors over time, these findings were not statistically significant. We also conducted 61 qualitative exit interviews with participants and two focus groups with a total of 16 providers. CONCLUSIONS: A computer-based counseling tool grounded in the TAM theoretical model and delivered in Spanish was acceptable and feasible to implement in a high-volume HIV clinic setting. It was able to provide evidence-based, linguistically appropriate ART adherence support without requiring additional staff time, bilingual status, or translation services. We found that language preferences and cultural acceptability of a computer-based counseling tool exist on a continuum in our urban Spanish-speaking population. Theoretical frameworks of technology's usefulness for behavioral modification need further exploration in other languages and cultures. TRIAL REGISTRATION: ClinicalTrials.gov NCT01013935; https://clinicaltrials.gov/ct2/show/NCT01013935 (Archived by WebCite at http://www.webcitation.org/6ikaD3MT7).
PMCID:4963608
PMID: 27417531
ISSN: 1438-8871
CID: 2179802

Response to the calculation of population attributable fractions of risk factors for hepatitis C transmission: authors' reply

Hagan, Holly; Jordan, Ashly E; Cleland, Charles M
PMID: 27243778
ISSN: 1473-5571
CID: 2124932

Understanding the relative contributions of idu and HCV on systemic immune activation [Meeting Abstract]

Markowitz, M; Deren, S; Cleland, C; LaMar, M; Silva, E; Batista, P; St , Bernard L; Gettie, N; Lee, H; Mehandru, S
Background: Persistent immune activation is associated with a variety of adverse clinical outcomes. People who inject drugs (PWID) have high levels of immune activation in blood and mucosal tissues; however, the relative contributions of chronic HCV infection, highly prevalent among PWIDs, and the non-sterile injection of illicit drugs have remained obscure. Methods: We recruited (N=48 for each group): 1) active injectors of heroin 2) individuals who ceased injecting heroin for 1-2 months 3) individuals who ceased injecting heroin for 3-4 months 4) healthy non-injecting volunteers. Soluble (including sCD14, hs-CRP, TNF-a, IFN-g, IL-10, MIP-1a) and cell associated (CD38+HLA-DR+ CD4 and CD8+ T cells) markers of immune activation were quantified. Mixed-effects regression models with random intercepts to account for participation in more than one group were used to compare groups on markers of immune activation. Results: Participant characteristics are shown in Table 1 below. Levels of IL-12p70, IL-15, IL-1b, IL-2, IL-4, and IL-6 determined by multiplex ELISA were at or below the level of detection in 50% or more of the active injectors and were not analyzed. Mean levels of selected markers of systemic and cellular immune activation are shown in Table 2 below. Participants in Groups 2 and 3 had statistically significantly lower levels of TNF-a and % CD4+ and CD8+ CD38+/HLA-DR+ T cells compared to actively injecting Group 1 subjects only if HCV infection was spontaneously controlled or if subjects were HCV uninfected (HCV-aviremic). sCD14 levels in HCV-aviremic Group 3 subjects were significantly lower than in aviremic Group 1 subjects and comparable to Group 4. Additionally, hs-CRP levels were significantly lower in Group 2 but not in Group 3 compared to Group 1 subjects. In contrast, in HCV-viremic subjects, the above parameters were not significantly different between the groups and were significantly higher than in the healthy non-injecting volunteers. Levels of IFN-g, IL-10, and MIP-1a were comparable across Groups 1, 2, and 3 independent of the presence/absence of viremia. Conclusions: Active IDU and HCV viremia are associated with persistent immune activation. Select markers of immune activation are significantly lower among the HCV-aviremic who cease injecting but not in those who are HCV viremic. These findings may have public health consequences. Aggressive treatment of HCV infection as well as enhanced harm reduction efforts should converge to optimize long-term outcomes. (Table Presented)
EMBASE:613269131
ISSN: 2161-5853
CID: 2359912

Glycemic Status and Infection Risk in Nondiabetic Autologous Hematopoietic Cell Transplantation Recipients

Hammer, Marilyn J; Melkus, Gail D'Eramo; Knobf, M Tish; Casper, Corey; Fletcher, Jason; Cleland, Charles M
BACKGROUND: Patients undergoing hematopoietic cell transplantation (HCT) for hematological malignancies experience a number of challenges during treatment. There is growing evidence that malglycemia (hyperglycemia, hypoglycemia, and/or increased glycemic variability) contributes to HCT-related complications, even in patients without preexisting diabetes. The purpose of this pilot study was to investigate factors influencing glycemic status and associated infection occurrences in nondiabetic autologous HCT recipients. METHODS: Oncology patients without preexisting diabetes treated with autologous HCT at a National Cancer Institute-designated cancer center were followed from admission through discharge or 28 days post-HCT. Patients had morning fasting laboratory tests. Descriptive statistics and Cox proportional hazards models were used to examine associations between BG levels and risk for infection while adjusting for baseline covariates including age, body mass index (BMI), cumulative glucocorticoid dose, and diagnosis. RESULTS: The sample included 28 female and 25 male predominately non-Hispanic White patients (mean age 55.7 years, SD = 11.32). Blood glucose (BG) range was 35-325 mg/dl. Twenty-three patients incurred at least one infection. BMI >/= 25 kg/m2 was associated with high BG and infections. In the multivariate Cox model, an increase of 1 interquartile range in BG 2 days before infection was associated with a moderately increased risk of infection (hazard ratio = 1.44, p = .008). CONCLUSIONS: Understanding the contributors to and consequences of malglycemic events can lead to better protocols for identifying patients at greater risk for infection. Further investigation is warranted for interventions to mitigate BG events for improved outcomes.
PMCID:5942491
PMID: 26792914
ISSN: 1552-4175
CID: 1933332