Report on Provider-Client Interaction From 68 Methadone Maintenance Clinics in China.

Provider-client interaction is an integral of clinical practice and central to the delivery of high-quality medical care. This article examines factors related to the provider-client interaction in the context of methadone maintenance treatment (MMT). Data were collected from 68 MMT clinics in China. In total, 418 service providers participated in the survey. Linear mixed effects regression models were performed to identify factors associated with provider-client interaction. It was observed that negative attitude toward drug users was associated with lower level of provider-client interaction and less time spent with each client. Other factors associated with lower level of interaction included being female, being younger, being a nurse, and fewer years in medical field. Higher provider-client interaction was associated with provider reported job satisfaction. The findings of this study call for a need to address provider negative attitudes that can impact provider-client interaction and the effectiveness of MMT. Future intervention efforts targeting MMT providers should be tailored by gender, provider type, and medical experiences

Progress and Challenges of Implementing Decentralized HIV Testing For Prevention of Mother-to-Child Transmission of HIV - Myanmar.

BackgroundMyanmar has adopted point-of-care (POC) HIV testing for its prevention of mother-to-child transmission of HIV program, and was initiated in 84 townships in 2013. This study assessed the progress of HIV testing uptake from 2012, one year prior to POC testing, to 2015, and the challenges faced by service providers during the rapid rollout of this testing strategy.MethodsThis serial cross-sectional study included 23 townships randomly selected from the 84 townships. An open-question survey was used to collect information on the challenges faced by service providers. A random effects logistic model was used for assessing the progress of HIV testing uptake among urban and rural health center groups.ResultsHIV testing uptake for antenatal care (ANC) attendees increased from 60% to 90% for rural and from 70% to 90% for urban attendees. The proportion of ANC attendees who were tested at their first visit increased from 70% to 80% for rural and from 70% to 90% for urban attendees. In addition, the proportion receiving same-day test results increased from less than 10% to 90% for both groups. Major challenges faced during the initial rollout included low health awareness among pregnant women, fear of stigma and discrimination, long travel times and costs, and increased workloads of providers in rural settings.Conclusions and global health implicationsThe program should consider recruiting local volunteers to help reduce the workloads of service providers. Professional education based on need and continued mentoring and quality control schemes for HIV testing need to be in place. This decentralized strategy would be applicable to other resource-limited countries

Risky Sex and HIV Acquisition Among HIV Serodiscordant Couples in Zambia, 2002-2012: What Does Alcohol Have To Do With It?

In this paper we evaluate the effects of heavy alcohol consumption on sexual behavior, HIV acquisition, and antiretroviral treatment (ART) initiation in a longitudinal open cohort of 1929 serodiscordant couples in Lusaka, Zambia from 2002 to 2012. We evaluated factors associated with baseline heavy alcohol consumption and its association with condomless sex with the study partner, sex outside of the partnership, and ART initiation using multivariable logistic regression. We estimated the effect of alcohol consumption on HIV acquisition using multivariable Cox models. Baseline factors significantly associated with women's heavy drinking (drunk weekly or more in 12-months before enrollment) included woman's older age (adjusted prevalence odds ratio [aPOR] = 1.04), partner heavy drinking (aPOR = 3.93), and being HIV-infected (aPOR = 2.03). Heavy drinking among men was associated with less age disparity with partner (aPOR per year disparity = 0.97) and partner heavy drinking (aPOR = 1.63). Men's being drunk daily (aOR = 1.18), women's being drunk less than monthly (aOR = 1.39) vs. never drunk and being in a male HIV-negative and female HIV-positive union (aOR = 1.45) were associated with condomless sex. Heavy alcohol use was associated with having 1 or more outside sex partners among men (aOR drunk daily = 1.91, drunk weekly = 1.32, drunk monthly = 2.03 vs. never), and women (aOR drunk monthly = 2.75 vs. never). Being drunk weekly or more increased men's risk of HIV acquisition (adjusted hazard ratio [aHR] = 1.72). Men and women being drunk weekly or more was associated (p < 0.1) with women's seroconversion (aHR = 1.42 and aHR = 3.71 respectively). HIV-positive women who were drunk monthly or more had lower odds of initiating ART (aOR = 0.83; 95% CI = 0.70-0.99) adjusting for age, months since baseline and previous pregnancies. Individuals in HIV-serodiscordant couples who reported heavy drinking had more outside sex partnerships and condomless sex with their study partner and were more likely to acquire HIV. HIV-positive women had lower odds of initiating ART if they were heavy drinkers

Breast cancer detection using automated whole breast ultrasound and mammography in radiographically dense breasts

PurposeMammography, the standard method of breast cancer screening, misses many cancers, especially in dense-breasted women. We compared the performance and diagnostic yield of mammography alone versus an automated whole breast ultrasound (AWBU) plus mammography in women with dense breasts and/or at elevated risk of breast cancer.MethodsAWBU screening was tested in 4,419 women having routine mammography (Trial registrationClinicalTrials.gov Identifier: NCT00649337). Cancers occurring during the study and subsequent 1-year follow-up were evaluated. Sensitivity, specificity and positive predictive value (PPV) of biopsy recommendation for mammography alone, AWBU and mammography with AWBU were calculated.ResultsBreast cancer detection doubled from 23 to 46 in 6,425 studies using AWBU with mammography, resulting in an increase in diagnostic yield from 3.6 per 1,000 with mammography alone to 7.2 per 1,000 by adding AWBU. PPV for biopsy based on mammography findings was 39.0% and for AWBU 38.4%. The number of detected invasive cancers 10 mm or less in size tripled from 7 to 21 when AWBU findings were added to mammography.ConclusionAWBU resulted in significant cancer detection improvement compared with mammography alone. Additional detection and the smaller size of invasive cancers may justify this technology's expense for women with dense breasts and/or at high risk for breast cancer

Development of a GPT-4–Powered Virtual Simulated Patient and Communication Training Platform for Medical Students to Practice Discussing Abnormal Mammogram Results With Patients: Multiphase Study

BackgroundStandardized patients (SPs) prepare medical students for difficult conversations with patients. Despite their value, SP-based simulation training is constrained by available resources and competing clinical demands. Researchers are turning to artificial intelligence and large language models, such as generative pretrained transformers, to create communication training that incorporates virtual simulated patients (VSPs). GPT-4 is a large language model advance allowing developers to design virtual simulation scenarios using text-based prompts instead of relying on branching path simulations with prescripted dialogue. These nascent developmental practices have not taken root in the literature to guide other researchers in developing their own simulations.ObjectiveThis study aims to describe our developmental process and lessons learned for creating a GPT-4-driven VSP. We designed the VSP to help medical student learners rehearse discussing abnormal mammography results with a patient as a primary care physician (PCP). We aimed to assess GPT-4's ability to generate appropriate VSP responses to learners during spoken conversations and provide appropriate feedback on learner performance.MethodsA research team comprised of physicians, a medical student, an educator, an SP program director, a learning experience designer, and a health care researcher conducted the study. A formative phase with in-depth knowledge user interviews informed development, followed by a development phase to create the virtual training module. The team conducted interviews with 5 medical students, 5 PCPs, and 5 breast cancer survivors. They then developed a VSP using simulation authoring software and provided the GPT-4-enabled VSP with an initial prompt consisting of a scenario description, emotional state, and expectations for learner dialogue. It was iteratively refined through an agile design process involving repeated cycles of testing, documenting issues, and revising the prompt. As an exploratory feature, the simulation used GPT-4 to provide written feedback to learners about their performance communicating with the VSP and their adherence to guidelines for difficult conversations.ResultsIn-depth interviews helped establish the appropriate timing, mode of communication, and protocol for conversations between PCPs and patients during the breast cancer screening process. The scenario simulated a telephone call between a physician and patient to discuss the abnormal results of a diagnostic mammogram that that indicated a need for a biopsy. Preliminary testing was promising. The VSP asked sensible questions about their mammography results and responded to learner inquiries using a voice replete with appropriate emotional inflections. GPT-4 generated performance feedback that successfully identified strengths and areas for improvement using relevant quotes from the learner-VSP conversation, but it occasionally misidentified learner adherence to communication protocols.ConclusionsGPT-4 streamlined development and facilitated more dynamic, humanlike interactions between learners and the VSP compared to branching path simulations. For the next steps, we will pilot-test the VSP with medical students to evaluate its feasibility and acceptability

Comparing Factors Associated with Increased Stimulant Use in Relation to HIV Status Using a Machine Learning and Prediction Modeling Approach

Stimulant use is an important driver of HIV/STI transmission among men who have sex with men (MSM). Evaluating factors associated with increased stimulant use is critical to inform HIV prevention programming efforts. This study seeks to use machine learning variable selection techniques to determine characteristics associated with increased stimulant use and whether these factors differ by HIV status. Data from a longitudinal cohort of predominantly Black/Latinx MSM in Los Angeles, CA was used. Every 6 months from 8/2014-12/2020, participants underwent STI testing and completed surveys evaluating the following: demographics, substance use, sexual risk behaviors, and last partnership characteristics. Least absolute shrinkage and selection operator (lasso) was used to select variables and create predictive models for an interval increase in self-reported stimulant use across study visits. Mixed-effects logistic regression was then used to describe associations between selected variables and the same outcome. Models were also stratified based on HIV status to evaluate differences in predictors associated with increased stimulant use. Among 2095 study visits from 467 MSM, increased stimulant use was reported at 20.9% (n = 438) visits. Increased stimulant use was positively associated with unstable housing (adjusted [a]OR 1.81; 95% CI 1.27-2.57), STI diagnosis (1.59; 1.14-2.21), transactional sex (2.30; 1.60-3.30), and last partner stimulant use (2.21; 1.62-3.00). Among MSM living with HIV, increased stimulant use was associated with binge drinking, vaping/cigarette use (aOR 1.99; 95% CI 1.36-2.92), and regular use of poppers (2.28; 1.38-3.76). Among HIV-negative MSM, increased stimulant use was associated with participating in group sex while intoxicated (aOR 1.81; 95% CI 1.04-3.18), transactional sex (2.53; 1.40-2.55), and last partner injection drug use (1.96; 1.02-3.74). Our findings demonstrate that lasso can be a useful tool for variable selection and creation of predictive models. These results indicate that risk behaviors associated with increased stimulant use may differ based on HIV status and suggest that co-substance use and partnership contexts should be considered in the development of HIV prevention/treatment interventions

Failure to recognize Low non-treponemal titer syphilis infections in pregnancy May lead to widespread under-treatment

Objectives: Rates of maternal syphilis have increased five-fold in Brazil in the past decade. While penicillin remains the only appropriate treatment for maternal syphilis, we hypothesized that low non-treponemal titers (<1:16) may lead to reduced penicillin treatment in Brazil. Methods: Using Brazilian Ministry of Health data on women diagnosed with maternal syphilis between January 1, 2010, and December 31, 2018, we conducted a random-effects logistic regression model with a cluster correction at the state level to evaluate predictive factors of penicillin treatment. Results: We observed yearly increases in cases of pregnant women with syphilis from 2010 to 2018. There was significant variation by state: 52,451 cases were reported in São Paulo, followed by 26,838 in Rio de Janeiro. Among 215,937 cases of maternal syphilis, 91·3% received penicillin. In the random-effects model, a non-treponemal titer ≥1:16 was associated with 1·44 higher odds of receiving penicillin (95% confidence interval [CI]: 1·391·48), and prenatal care was associated with a 2·12 increased odds of receiving penicillin (95% CI: 2·022·21). Although there is an association between the absence of prenatal care and inadequate treatment for syphilis, 83·2% of women in this cohort who did not receive penicillin were engaged in prenatal care. Conclusions: Providers may inappropriately exclude low non-treponemal titers and thereby fail to use penicillin treatment in maternal syphilis. While the cause of the maternal syphilis epidemic in Brazil is multifactorial, we believe our findings can be used to develop targeted interventions throughout Brazil as well as shape public health initiatives globally.National Institute of Mental HealthRevisión por pare

PrEP Use and HIV Incidence Among Youth At-Risk for HIV Infection in Los Angeles and New Orleans: Findings From ATN 149

IntroductionExpanding HIV pre-exposure prophylaxis (PrEP) use is key to goals for lowering new HIV infections in the U.S. by 90% between 2022 and 2030. Unfortunately, youth aged 16-24 have the lowest PrEP use of any age group and the highest HIV incidence rates.MethodsTo examine the relationship between HIV seroconversion and PrEP uptake, adherence, and continuity, we used survival analysis and multivariable logistic regression on data of 895 youth at-risk for HIV infection enrolled in Adolescent Trials Network for HIV Medicine protocol 149 in Los Angeles and New Orleans, assessed at 4-month intervals over 24 months.ResultsThe sample was diverse in race/ethnicity (40% Black, 28% Latine, 20% White). Most participants (79%) were cis-gender gay/bisexual male but also included 7% transgender female and 14% trans masculine and nonbinary youth. Self-reported weekly PrEP adherence was high (98%). Twenty-seven participants acquired HIV during the study. HIV incidence among PrEP users (3.12 per 100 person year [PY]) was higher than those who never used PrEP (2.53/100 PY). The seroconversion incidence was highest among PrEP users with discontinuous use (3.36/100 PY). If oral PrEP users were adherent using 2-monthly long-acting injectables, our estimate suggests 2.06 infections per 100 PY could be averted.ConclusionsDiscontinuous use of PrEP may increase risk of HIV acquisition among youth at higher risk for HIV infection and indications for PrEP. Thus, to realize the promise of PrEP in reducing new HIV infections, reducing clinical burdens for PrEP continuation are warranted

A necessary conversation to develop chatbots for HIV studies: qualitative findings from research staff, community advisory board members, and study participants

Chatbots increase business productivity by handling customer conversations instead of human agents. Similar rationale applies to use chatbots in the healthcare sector, especially for health coaches who converse with clients. Chatbots are nascent in healthcare. Study findings have been mixed in terms of engagement and their impact on outcomes. Questions remain as to chatbot acceptability with coaches and other providers; studies have focused on clients.To clarify perceived benefits of chatbots in HIV interventions we conducted virtual focus groups with 13 research staff, eight community advisory board members, and seven young adults who were HIV intervention trial participants (clients). Our HIV healthcare context is important. Clients represent a promising age demographic for chatbot uptake. They are a marginalized population warranting consideration to avoid technology that limits healthcare access.Focus group participants expressed the value of chatbots for HIV research staff and clients. Staff discussed how chatbot functions, such as automated appointment scheduling and service referrals, could reduce workloads while clients discussed the after-hours convenience of these functions. Participants also emphasized that chatbots should provide relatable conversation, reliable functionality, and would not be appropriate for all clients. Our findings underscore the need to further examine appropriate chatbot functionality in HIV interventions