TAG: "AIDS/HIV"

South African ‘Mentor Mothers’ help improve perinatal health outcomes


Community-based interventions lead to better health outcomes in both mothers and children.

The Mentor Mother program trains women to provide health information and conduct home visits to pregnant women and to help the mothers raise healthier children.

The incidence of HIV infection in South Africa tops that of any nation in the world, with some 6 million of the country’s nearly 50 million residents infected. Sadly, young women — and particularly young pregnant women — suffer some of the highest rates of HIV infection. More than one-fourth of pregnant South African women are infected with the virus; in some communities, the infection rates are even higher.

But a new study conducted by UCLA’s Mary Jane Rotheram-Borus, the director of the UCLA Global Center for Children and Families at the Semel Institute for Neuroscience and Human Behavior, and her colleagues from Stellenbosch University in South Africa found that community-based interventions could improve the health of children in those contexts. A paper about the randomized controlled trial appears in the current edition of the journal PLoS One.

The study found that regular home visits of pregnant mothers, and later of those mothers and their infants, by specially trained lay community mothers from the “Mentor Mothers” program led to significantly better health outcomes 18 months later in both the mothers and their children.

The Mentor Mother home visiting program, developed by South Africa’s Philani Maternal, Child Health and Nutrition Project, has been in existence for the past 15 years. Mentor mothers are trained to provide health information and health intervention (such as a home visit), support mothers to improve healthy births, and to help mothers develop coping mechanisms that enable them to raise healthier children. The program currently operates at eight clinic sites in Cape Town and out of Zithulele Hospital, located in a deeply rural part of the country’s Eastern Cape region.

Among other outcomes, the study found that Mentor Mother home visits led to a 50 percent improvement by mothers in completing tasks designed to prevent mother-to-child transmission of the HIV virus, compared to mothers in the control group of the study who did not receive home visits, just clinic-based pre- and postnatal care. The virus-transmission prevention tasks included pregnant mothers knowing their own HIV status and asking their sexual partners to be tested; mothers taking anti-retroviral drugs for the six weeks prior to childbirth and during labor; babies receiving anti-retroviral drugs for at least six weeks, until they can be tested for the virus; and mothers using one feeding method (breastfeeding or formula) for the first 6 months of their infants’ life, and, when possible, exclusively breastfeeding.

In addition, the study found that mothers who received regular home visits breastfed longer and, among HIV-infected mothers, were more likely to breastfeed exclusively for six months.

“There also tended to be fewer low birth weight babies, a condition which results in life-long problems,” said Rotheram-Borus, the Bat-Yaacov Professor of Child Psychiatry and Biobehavioral Sciences and the director of the Center for HIV Identification Prevention and Treatment Services at UCLA.

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UCSF-based team awarded $8M agreement with CDC


Team includes investigators from UC Berkeley, UC Davis, UC San Diego.

A UC San Francisco-based team has been awarded a multimillion-dollar, five-year cooperative agreement with the U.S. Centers for Disease Control and Prevention (CDC) to conduct economic modeling of disease prevention in five areas: HIV, hepatitis, STI (sexually transmitted infections), TB (tuberculosis) and school health. The team, led by James G. Kahn, M.D., M.P.H., and Paul Volberding, M.D., both faculty in Global Health Sciences, is a multi-institution consortium, with 39 investigators across UCSF; Stanford University; UC Berkeley, UC Davis, UC San Diego; the San Francisco Department of Public Health, Health Strategies International, and PATH. It will be based at the UCSF Philip R. Lee Institute for Health Policy Studies.

The consortium was awarded $1.6 million for the first year and $8 million over the full project period. Called CAPE (Consortium for the Assessment of Prevention Economics), it will conduct economic analyses including costing, cost-effectiveness analysis, cost-benefit analysis, resource allocation, and return on investment.

“We are looking at five different health areas, using a range of economic methods – this breadth is very unusual for an economics project,” said Kahn. “We are also excited about collaborating with colleagues in the Bay Area and throughout California.”

The project advances the UCSF Global Health Sciences vision for research that crosses and links disease areas, and that integrates economics with basic and applied science. While CAPE’s geographic focus is the United States, modeling methods and tools can be adapted to global settings, using local data on population and disease characteristics.

CAPE is the largest award arising from the UCSF Global Health Economic Consortium, established in 2013.

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Antiretroviral therapy benefits HIV-infected stimulant users


Many stimulant users take therapy at levels sufficient to avoid negative clinical outcomes.

Adam Carrico, UC San Francisco

New clinical research from UC San Francisco shows that 341 HIV-infected men who reported using stimulants such as methamphetamine or cocaine derived life-saving benefits from being on antiretroviral therapy that were comparable to those of HIV-infected men who do not use stimulants.

That said, those who reported using stimulants at more than half of at least two study visits did have modestly increased chances of progressing to AIDS or dying after starting antiretroviral therapy compared to non-users. The data was collected between 1996 and 2012.

“Patients with HIV who use stimulants and other substances often experience difficulties with accessing antiretroviral therapy, partially due to the concerns of health care providers that they will not be able take their medications as directed. Findings from this study demonstrate that many stimulant users take their antiretroviral therapy at levels sufficient to avoid negative clinical outcomes. When we look at overall mortality, antiretroviral therapy leads to similar clinical benefits for both stimulant users and non-users, notwithstanding stimulant use,” said the study’s primary investigator, Adam W. Carrico, Ph.D., UCSF assistant professor of nursing.

The research is available starting in October online ahead of print in the Journal of Acquired Immune Deficiency Syndromes.  The study included 1,313 HIV-infected men who have sex with men within the Multicenter AIDS Cohort Study, an ongoing nationwide prospective study of HIV infection among men who have sex with men in the U.S.

“If we are to achieve the goals of the President’s National HIV/AIDS Strategy and UNAIDS to end the HIV/AIDS epidemic, we will need to treat HIV-positive active substance users for their HIV while encouraging them to stop or reduce their substance use.  Programs integrating substance abuse services with HIV clinical care may both improve health outcomes for patients and reduce new infections,” said Carrico.

The UCSF Division of HIV/AIDS at San Francisco General Hospital has created an integrated care delivery system that could serve as a model for other clinics, added Carrico. The HIV primary care clinic utilizes a patient-centered team care approach that includes substance abuse services for stimulant and opioid users, along with mental health services, all located onsite. STOP, the “stimulant treatment outpatient program,” within the clinic provides outpatient substance abuse and mental health treatment integrated with patients’ primary medical care.

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How the body initially responds to HIV infection


Inflammatory response breaks down intestinal lining; help may come from friendly bacteria.

Researchers at UC Davis have made some surprising discoveries about the body’s initial responses to HIV infection. Studying simian immunodeficiency virus (SIV), the team found that specialized cells in the intestine called Paneth cells are early responders to viral invasion and are the source of gut inflammation by producing a cytokine called interleukin-1 beta (IL-1β).

Though aimed at the presence of virus, IL-1β causes breakdown of the gut epithelium that provides a barrier to protect the body against pathogens. Importantly, this occurs prior to the widespread viral infection and immune cell killing. But in an interesting twist, a beneficial bacterium, Lactobacillus plantarum, helps mitigate the virus-induced inflammatory response and protects gut epithelial barrier. The study was published in the journal PLoS Pathogens.

One of the biggest obstacles to complete viral eradication and immune recovery is the stable HIV reservoir in the gut.  There is very little information about the early viral invasion and the establishment of the gut reservoir.

“We want to understand what enables the virus to invade the gut, cause inflammation and kill the immune cells,” said Satya Dandekar, lead author of the study and chair of the Department of Medical Microbiology and Immunology at UC Davis.

“Our study has identified Paneth cells as initial virus sensors in the gut that may induce early gut inflammation, cause tissue damage and help spread the viral infection. Our findings provide potential targets and new biomarkers for intervening or blocking early spread of viral infection,” she said.

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Nanoparticles show promise for cancer treatment, possible HIV cure


UCLA-led team engineers vault nanoparticles to create novel drug delivery system.

A multidisciplinary team of scientists from UCLA and Stanford University has used a naturally occurring nanoparticle called a vault to create a novel drug delivery system that could lead to advances in the treatment of cancer and HIV.

The research team was led by Dr. Leonard Rome, associate director of UCLA’s California NanoSystems Institute, and Dr. Jerome Zack, co-director of the UCLA AIDS Institute, both of whom are also members of UCLA’s Jonsson Comprehensive Cancer Center. Co-first authors on the study were Daniel Buehler, a UCLA postdoctoral researcher and Matthew Marsden, adjunct assistant professor in the department of medicine and a member of the AIDS Institute.

Their findings could lead to cancer treatments that are more effective with smaller doses and to therapies that could potentially eradicate the HIV virus.

The paper is the cover story of the Aug. 26 print edition of the journal ACSNano, and it was recently published online.

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Providing a medical home for HIV patients


UC San Diego transforms HIV care as part of DSRIP pay-for-performance initiative.

UC San Diego Dr. Amy Sitapati (left) directs the Owen Clinic, which has become a model medical home for HIV patients.

By Rebecca Vesely, Special to UC Newsroom

Though incurable, HIV today is a manageable, chronic condition. With advances in drug therapy, those infected with HIV in North America can expect to live into their early 70s — almost as long as the general population.

However, HIV is a chronic illness that typically requires a complex treatment regimen and has the added layer of social stigma.

At UC San Diego Health System, providers have implemented a novel multidisciplinary approach to HIV care management that is improving outcomes for patients. This approach could be a model for chronic care management in other populations.

UC San Diego’s HIV care delivery transformation began under the California HIV/AIDS Research Program and was implemented as a special Delivery System Reform Incentive Program (DSRIP). DSRIP is a novel, pay-for-performance initiative in which California’s 21 designated public hospitals receive Medicaid dollars in exchange for meeting pre-set milestones.

California’s public hospitals had the option of participating in a fifth DSRIP category focused on HIV care. UC San Diego is one of the state’s 10 public hospitals working in this category.

UC San Diego, through DSRIP Category 5, was able to overhaul its outpatient care delivery for HIV/AIDS patients into a medical home model.

‘Truly transformative’

“This is what the ‘triple aim’ is all about,” said Dr. Angela Scioscia, chief medical officer at UC San Diego Health System. “This project has been truly transformative. We took a clinic that had lost its way in terms of structure and turned it into a model for care delivery.”

Also known as the Owen Clinic, the UC San Diego HIV/AIDS outpatient center is located on the third floor of a medical office building across the street from UC San Diego Medical Center at Hillcrest. The clinic treats about 3,500 patients annually. Last year, 500 new patients joined, with the demand for services growing by approximately 40 percent in the past five years, said Dr. Amy Sitapati, Owen Clinic director.

About 70 percent of patients served at the clinic are in Medi-Cal managed care plans. DSRIP support enabled the clinic to hire more staff, with a total of 60 personnel, both full- and part-time.

Team-based approach

The clinic uses a team-based approach, with four teams, each led by a primary care physician. Two of the teams have Spanish-language fluency.

Each morning, the teams meet in “huddles” and review the patient panel for that day. A computer printout shows patient names, ages and reasons for the visit, status on preventative screenings and viral loads. The printouts also show each patient’s Veterans Aging Cohort Study (VACS) score, an evidence-based score that assesses HIV patient risk of mortality. The Owen Clinic may be the only outpatient clinic in the country using patient VACS scores in daily huddles.

Knowing a patient’s risk of mortality helps to frame the office visit because providers understand before the patient walks through the door his or her need for additional support services, Sitapati said. A patient with a high VACS score might need more time in the clinic to meet with a staff pharmacist or psychiatrist or social worker, for instance.

Comprehensive, coordinated services are available to all patients. Because of the complexity of many of these patients’ treatment regimens (patients take on average seven medications each day), the staff aims to make each visit as productive as possible. For instance, staff pharmacists on site work together with physicians to educate patients about their prescriptions, help them find affordable options, get adequate reimbursement from payers and avoid adverse reactions to drugs.

Eight to 10 drugs are commonly used in HIV treatment, meaning there are between 30 and 50 total drug combinations. Finding the right balance for patients can be a challenge, especially with myriad side effects, co-payments and insurance pre-authorization requirements to fill a prescription.

“There are a lot of barriers to patients taking the right medications,” Sitapati said.

Incorporating health information technology

Access to health information technology resources has been crucial to the clinic’s transformation. UC San Diego assigned a four-person team of health IT specialists — including a physician informaticist, a data analyst, a programmer analyst and a Master of Public Health team member — to work on the clinic’s patient-centered medical home innovation projects. Having a clinical informatics team that understands the patient population, is invested in the clinic’s success and is aligned with the project’s vision and goals has been absolutely critical, Sitapati said.

Ongoing communication with patients is an important component to care. Patients at the clinic are avid adopters of MyUCSDChart, a Web portal that sends reminders for appointments and preventative screenings.

In 2013, there were an average of 1,003 MyUCSDChart patient encounters per month, up from 288 MyUCSDChart encounters in 2012. These patient portal interactions are on par with in-person and phone visits in 2013, which averaged 1,135 office visits and 1,455 average phone calls per month in 2013.

Perhaps one of the most valuable clinic informatics tools is SmartSet — an electronic medical record tool that allows clinicians to order lab tests in batches for patients who haven’t received recent laboratory screenings. The Centers for Disease Control and Prevention recommends annual screening for sexually transmitted diseases (STDs) in HIV-positive individuals. The SmartSet allows clinicians to quickly identify patients due for screenings and then order tests without manually ordering each lab for each patient, increasing clinic efficiencies and productivity.

Focusing on care transitions

The Owen Clinic focuses on care transitions for its patients. The clinic has a dedicated “nurse transition specialist” skilled in HIV/AIDS care to assist patients moving between inpatient care and the Owen Clinic. The nurse transition specialist program is part of another DSRIP project at UC San Diego.

These proactive, integrated approaches are garnering results. Viral load monitoring rose from a baseline of 63 percent in 2011 to 81.9 percent for the period of January through December 2013. Screening for both chlamydia and gonorrhea increased from 57.4 percent in 2011 to 84.2 percent for the period of January 2013 through December 2013. Wrap-around services for HIV care — including nutrition, substance abuse counseling, pharmacy, psychiatry and case management — increased 34 percent.

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Vulnerable population of women faces high rates of violence in San Francisco


Study focuses on unstably housed women who are HIV-infected or at risk to become infected.

Elise Riley, UC San Francisco

New research from UC San Francisco found that 60 percent of the city’s homeless and unstably housed women who are HIV-infected or at high risk to become infected have endured a recent experience of some form of violence.

“We looked at all types of violence — physical, sexual and emotional. We expected to find higher rates than those reported in the general population, but we were surprised at the amount of harm inflicted upon this incredibly vulnerable population of women and the multitude of perpetrators,” said study principal investigator, Elise D. Riley, Ph.D., associate professor of medicine at the UCSF HIV/AIDS Division at San Francisco General Hospital and Trauma Center.

The study appears today (July 17) online in “First Look” in the American Journal of Public Health.

The study found that, during the prior six months alone, just under two-thirds of the 291 participants experienced recent emotional violence, while just under one-third experienced physical violence and just under one-third experienced sexual violence.

“We were aware that domestic violence is a serious problem in this population; one that led to the recent death of a homeless woman in San Francisco. However, it’s even more extensive than that. Our finding that the women participating in our study are also victimized at similar rates, and sometimes even higher, by individuals throughout their neighborhood, unmasks an environment saturated with violence,” said Riley.

Contrary to prior studies of women from the general population, researchers found that social isolation decreased the odds of the women in the study experiencing violence. They go on to suggest that social isolation may be a means for some impoverished women to extricate themselves from dangerous environments in the absence of other options.

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Researchers predictively model likelihood of new HIV transmissions


UC San Diego study identifies persons at greater risk for transmitting the virus.

Researchers at the UC San Diego School of Medicine have mapped the transmission network of human immunodeficiency virus (HIV) in San Diego. The mapping of HIV infections, which used genetic sequencing, allowed researchers to predictively model the likelihood of new HIV transmissions and identify persons at greatest risk for transmitting the virus.

The findings are published online in today’s (June 5) issue of the journal PLOS ONE.

“The more we understand the structure and dynamics of an HIV transmission network, the better we can identify ‘hot spots’ of transmission,” said Susan Little, M.D., professor of medicine at the UC San Diego AntiViral Research Center and lead author of the study.

“Not everyone who is HIV-infected is equally likely to transmit the infection to others. There are clusters of more active disease transmission. We can use this information to target treatment interventions to those most likely to transmit the virus to others and markedly reduce the number of new infections.”

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Different approaches needed to control cardiovascular risks for those with HIV


Study authors recommend greater emphasis on cardiology in HIV treatment, research.

Heejung Bang, UC Davis

Even if treated, hypertension and high cholesterol are common for people with human immunodeficiency virus (HIV), according to a new study from researchers at Mount Sinai St. Luke’s and Mount Sinai Roosevelt hospitals in New York and UC Davis.

The finding — published online in the Journal of Acquired Immune Deficiency Syndromes — persuaded the study authors to recommend greater emphasis on cardiology in HIV treatment and research.

“It is clearly important to add cardiology specialists to the care teams for patients with HIV,” said Heejung Bang, professor of public health sciences at UC Davis and senior author of the study. “We also need more research focused on identifying treatments that work in controlling heart disease and stroke risks for this patient population.”

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UCLA receives $2M to provide dental care to patients with HIV/AIDS


Patients will receive diagnostic services and corrective care.

Accessing affordable medical and dental care is a major challenge for people living with HIV and AIDS, many of whom are disabled and can not afford dental exams and treatment. For this underserved, vulnerable population, maintaining oral health is important not only for functional and aesthetic reasons, but also as part of overall HIV disease management.

To address that need, the Los Angeles County Department of Public Health recently awarded the UCLA School of Dentistry a two-year grant of $2.36 million, which will enable UCLA to provide dental care for more than 1,000 people with HIV or AIDS each year.

The funding is being channeled through the federal government’s Ryan White HIV/AIDS Program, which works with cities, states and community-based organizations to provide HIV-related services to individuals who do not have sufficient health care coverage or financial resources. An estimated 50,550 people who have been diagnosed with HIV and AIDS are living in Los Angeles County — and, counting undiagnosed cases, experts believe the number might actually exceed 60,000.

“With this funding, we are going to be able to provide quality dental care and oral health specialty services to thousands of HIV and AIDS patients,” said Fariba Younai, a UCLA professor of clinical dentistry. “The patients who we will be treating are financially disadvantaged and have extremely limited access to care.”

Patients will receive diagnostic services such as exams and radiographs; preparatory work such as cleanings and removal of tooth decay; and corrective care including extractions, fillings, crowns and other prostheses, and periodontal surgery. In addition, care providers will emphasize prevention and early detection of oral diseases by teaching patients about the importance of proper oral care at home and periodic visits to the dental office for examinations.

“The dental needs of HIV-positive and AIDS patients can be extensive and complex,” said Dr. Paulo Camargo, the school’s associate dean of clinical dental sciences. “This contract allows the delivery of comprehensive dental treatment to a large patient population that would otherwise not have access to this type of care.”

The majority of the patients who will be treated will be referred by neighboring clinics that specialize in caring for people with HIV and AIDS. A patient care liaison will assist with communication between the referring clinics and the UCLA Dental Clinics to help position dental care as an integral component of the patients’ overall health.

“Thanks to this contract from the county of Los Angeles, we will be able to provide needed and valuable services and to work with other health care providers to improve quality of life for people with HIV/AIDS,” said Dr. No-Hee Park, the school’s dean. “This partnership helps us fulfill our mission of improving the oral and systemic health of people throughout our community.”

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New patient care model reduces readmission rates


Early results are promising.

Medical specialists within integrated care teams are helping to lower hospital re-admission rates for patients who are HIV positive. (Photo by Elena Zhukova)

>>Related: Pilot program reduces hospital readmissions for people with HIV and AIDS

By Kate Rix

A demonstration project aimed at improving patient care for people with HIV and AIDS has reduced the number of hospital readmissions at one Bay Area hospital by 44 percent.

The new approach — jointly funded by the California HIV/AIDS Research Program (CHRP) at the University of California, the Alameda County Health Care Services Agency, the Gordon and Betty Moore Foundation and Alameda Health System  — puts primary care physicians at the helm of an integrated care team that includes social workers, psychologists and medical specialists.

These collaborative teams form virtual “patient-centered medical homes” that work together to ensure that patients come to appointments, take their medications and get the care they need.

“The HIV epidemic has had a history of clients being advocates for their own care,” said John Mortimer, CHRP health policy and health services research program officer. “Our goal is to make medical care even more client-centered to help improve patient outcomes.”

Promising results

Early results are promising. Highland Hospital in Oakland looked at how many patients were readmitted to the hospital in 2010 before the demonstration project started and compared it to rehospitalizations during the pilot program.

As a result of patient-centered medical home care strategies, which included support for care transitions from hospital to outpatient care, the number of readmissions fell significantly. Of 89 patients admitted in 2010 for HIV-related treatment, 35 were readmitted within a month. From October 2012 to September 2013, 63 patients were admitted, and only 14 of them were readmitted within 30 days.

“This shows that our system is working,” says Dr. Kathleen Clanon, medical director of the Health Program of Alameda County. “The supports are successfully in place outside the hospital.”

In addition to Oakland’s Highland Hospital, four other community clinics are participating: the Tri-City Health Center in Fremont, Lifelong Medical Care in Berkeley, and La Clínica and Asian Health Services, both in Oakland.

“UC is happy to have supported this innovative and effective pilot research program,” said Dr. George Lemp, director of CHRP.

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Grad students to present research on STDs, parasites in Latin America


UCLA Blum Center conference to feature latest research on health, poverty in Latin America.

UCLA graduate student Claire Bristow conducted research at a Peruvian university.

In Peru, HIV and syphilis are more widespread among transgender women and men who have sex with men, and so ensuring that these groups get tested and treated is crucial.

A research project supported by UCLA’s Blum Center for Poverty and Health in Latin America is contributing to efforts in Peru to make this happen.

Claire Bristow, a UCLA Ph.D. student in public health who conducted research in Peru, and Rebecca Foelber, a master’s student in public health who worked in Brazil on another project, will present their research on behalf of the center at its Second Annual Spring Conference May 6-7 at UCLA’s De Neve Auditorium. Bristow and Foelber were selected for the Blum Center’s inaugural Summer Scholars Program.

Conference participants, who include UCLA students, faculty and staff as well as policy and health professionals from 10 Latin American countries, will discuss the latest research on health and poverty in Latin America. The conference will also highlight solutions and projects such as Bristow’s.

“The Summer Scholars Program was developed for students to examine how poverty, government practices and policies, and other factors impact poor health in Latin America,” said Dr. Michael Rodriguez, Blum Center director. “More importantly, the scholars’ research can lead to better health practices and solutions in a region that is so desperately in need of them.”

Bristow spent last summer in Lima, Peru, where she developed a study that asked people in these high-risk groups what type of HIV and syphilis testing they would prefer.

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