Publications

BACKGROUND

The high burden of undiagnosed HIV in sub-Saharan Africa limits treatment and prevention efforts. Community-based HIV testing campaigns can address this challenge and provide an untapped opportunity to identify non-communicable diseases (NCDs). We tested the feasibility and diagnostic yield of integrating NCD and communicable diseases into a rapid HIV testing and referral campaign for all residents of a rural Ugandan parish.

METHODS

A five-day, multi-disease campaign, offering diagnostic, preventive, treatment and referral services, was performed in May 2011. Services included point-of-care screening for HIV, malaria, TB, hypertension and diabetes. Finger-prick diagnostics eliminated the need for phlebotomy. HIV-infected adults met clinic staff and peer counselors on-site; those with CD4 ≤ 100/µL underwent intensive counseling and rapid referral for antiretroviral therapy (ART). Community participation, case-finding yield, and linkage to care three months post-campaign were analyzed.

RESULTS

Of 6,300 residents, 2,323/3,150 (74%) adults and 2,020/3,150 (69%) children participated. An estimated 95% and 52% of adult female and male residents participated respectively. Adult HIV prevalence was 7.8%, with 46% of HIV-infected adults newly diagnosed. Thirty-nine percent of new HIV diagnoses linked to care. In a pilot subgroup with CD4 ≤ 100, 83% linked and started ART within 10 days. Malaria was identified in 10% of children, and hypertension and diabetes in 28% and 3.5% of adults screened, respectively. Sixty-five percent of hypertensives and 23% of diabetics were new diagnoses, of which 43% and 61% linked to care, respectively. Screening identified suspected TB in 87% of HIV-infected and 19% of HIV-uninfected adults; 52% percent of HIV-uninfected TB suspects linked to care.

CONCLUSIONS

In an integrated campaign engaging 74% of adult residents, we identified a high burden of undiagnosed HIV, hypertension and diabetes. Improving male attendance and optimizing linkage to care require new approaches. The campaign demonstrates the feasibility of integrating hypertension, diabetes and communicable diseases into HIV initiatives.

BACKGROUND

Depression has been associated with elevated white blood cell (WBC) count - indicative of systemic inflammation - in cross-sectional studies, but no longitudinal study has evaluated whether depressive symptoms predict subsequent WBC count or vice versa. We sought to evaluate the bidirectional association between depressive symptoms and WBC count in patients with coronary heart disease (CHD).

METHODS

Depressive symptoms were assessed at baseline and annually during 5 consecutive years of follow-up in 667 outpatients with stable CHD from the Heart and Soul Study. The presence of significant depressive symptoms was defined as a score of ≥10 on the Patient Health Questionnaire (PHQ-9) at one or more assessments. WBC count was measured in blood samples collected at baseline and after 5 years of follow-up.

RESULTS

Of the 667 participants, 443 (66%) had no depressive symptoms (PHQ-9<10), 86 (13%) had depressive symptoms (PHQ-9≥10) at 1 assessment, and 138 (21%) had depressive symptoms at 2 or more annual assessments. Across the three groups, participants with recurrent depressive symptoms had higher WBC levels after 5 years of follow-up (p<.001). This relationship was essentially unchanged after adjustment for demographics, traditional cardiovascular risk factors, cardiac disease severity, inflammatory cytokine levels, and health behaviors (p=.009). Baseline WBC count was not associated with subsequent depressive symptoms (p=.18).

CONCLUSIONS

Depressive symptoms independently predicted higher subsequent WBC count in patients with stable CHD, but baseline WBC count did not predict subsequent depressive symptoms. These findings support a unidirectional relationship in which depression is a risk-factor for inflammation.

BACKGROUND

Patients requiring complex care are at high risk during the transition from one setting of care to another. Effective interventions to support care transitions have been designed but are very resource intensive. Telemonitoring has been considered as an approach to enhance care transition support, but many telemonitoring systems require special equipment or web-based interfaces to interact with patients and caregivers.

METHODS/DESIGN

In this paper we report our protocol for developing and testing E-Coach, an interactive voice response (IVR)-enhanced care transition intervention that monitors patients at home using their personal phone. The elements described include 1) development of an IVR monitoring system that will be based on Coleman's four pillars of care transition support; 2) development of a web-based "dashboard" of IVR responses that alert care transition nurses (CTN) of patient/caregiver concerns after discharge and allow documentation by the CTN when patients/caregivers are called; 3) pilot testing of the IVR system by patients and providers with refinement of the system based on patient/provider input; and 4) a pragmatic protocol for formal testing through a randomized controlled trial (RCT) of the E-Coach intervention in congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) patients admitted to a large tertiary hospital.

TRIAL REGISTRATION

CT.gov#: NCT01135381.

BACKGROUND

Food insecurity, or the uncertain availability of nutritionally adequate, safe foods, has been associated with poor HIV outcomes. There are few data on the extent to which food insecurity impacts patterns of health-care utilization among HIV-infected individuals.

OBJECTIVE

We examined whether food insecurity was associated with hospitalizations, Emergency Department (ED) visits, and non-ED outpatient visits.

METHODS

HIV-infected, homeless and marginally housed individuals participating in the San Francisco Research on Access to Care in the Homeless (REACH) cohort underwent quarterly structured interviews and blood draws. We measured food insecurity with the validated Household Food Insecurity Access Scale, and categorized participants as food secure, mild/moderately food insecure, and severely food insecure. Primary outcomes were: (1) any hospitalizations, (2) any ED visits, and (3) any non-ED outpatient visits. Generalized estimating equations were used to estimate model parameters, adjusting for socio-demographic (age, sex, ethnicity, education, income, housing status, health insurance) and clinical variables (CD4 nadir, time on antiretroviral therapy, depression, and illicit drug use).

RESULTS

Beginning in November 2007, 347 persons were followed for a median of 2 years. Fifty-six percent of participants were food insecure at enrollment. Compared with food-secure persons, those with severe food insecurity had increased odds of hospitalizations [adjusted odds ratio (AOR) = 2.16, 95 % confidence interval (CI) = 1.50-3.09] and ED visits (AOR = 1.71, 95 % CI = 1.06-2.30). While the odds of an outpatient visit were 41 % higher for severely food insecure individuals, the effect was not statistically significant (AOR = 1.41, 95 % CI = 0.99-2.01). Mild/moderate food insecurity was also associated with increased hospitalizations (AOR = 1.56, 95 % CI = 1.06-2.30), ED visits (AOR = 1.57, 95 % CI = 1.22-2.03), and outpatient visits (AOR = 1.68, 95 % CI = 1.20-2.17).

CONCLUSIONS

Food insecurity is associated with increased health services utilization among homeless and marginally housed HIV-infected individuals in San Francisco. Increased ED visits and hospitalizations are not related to fewer ambulatory care visits among food-insecure individuals. Addressing food insecurity should be a critical component of HIV treatment programs and may reduce reliance on acute care utilization.

Due to genome instability, most cancers exhibit loss of regions containing tumor suppressor genes and collateral loss of other genes. To identify cancer-specific vulnerabilities that are the result of copy number losses, we performed integrated analyses of genome-wide copy number and RNAi profiles and identified 56 genes for which gene suppression specifically inhibited the proliferation of cells harboring partial copy number loss of that gene. These CYCLOPS (copy number alterations yielding cancer liabilities owing to partial loss) genes are enriched for spliceosome, proteasome, and ribosome components. One CYCLOPS gene, PSMC2, encodes an essential member of the 19S proteasome. Normal cells express excess PSMC2, which resides in a complex with PSMC1, PSMD2, and PSMD5 and acts as a reservoir protecting cells from PSMC2 suppression. Cells harboring partial PSMC2 copy number loss lack this complex and die after PSMC2 suppression. These observations define a distinct class of cancer-specific liabilities resulting from genome instability.