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Patient complexity Venn diagram. This Venn diagram demonstrates the complex interaction of psychiatric history, medical morbidity and unstable housing in 83 patients. Only 1.2% (n 01) did not have any of the complexity variables. *Note: Psychiatric diagnoses include substance misuse disorder and HIV-associated neurocognitive impairment.
Source publication
Abstract This retrospective chart review provides a profile of an emerging population of vulnerable HIV patients with complex comorbidities. Data were abstracted from all 87 patients admitted in 2008 to Casey House, a community-based hospital dedicated to supportive and palliative care for persons with HIV in Toronto, Canada. We describe patient ch...
Citations
... At the time of this study, in 2017, Casey Housel provided inpatient care (13-beds) through a multidisciplinary team, for people living with HIV/AIDS requiring sub-acute care for opportunistic infections, stabilization, respite, and palliative care. During this time the hospital annually saw approximately 100 patients (about 80 of whom were unique), and the average length of stay for all admissions was just over 40 days, with about one quarter of patients coming in for shorter respite stays of 2-weeks (Halman et al., 2012;unpublished data).The hospital was in the process of expanding its services to include a new outpatient day health program for people living with HIV/AIDS at risk for, or experiencing, deteriorating health not requiring 24-h care. Our exploratory study was designed to develop and implement an outcome evaluation system for the day health program, that included patient-identified metrics. ...
The current healthcare context prioritizes shorter hospital stays and fewer readmissions. However, these measures may not fully capture care experiences for people living with HIV, especially those experiencing medical, psychosocial, and economic complexity. As part of a larger study, we conducted seven focus groups with people living with HIV (n = 52), who were current/former patients at a Toronto-based specialty hospital, examining their desires/needs for hospital programs. Using a novel place attachment lens, we conducted a thematic analysis focusing on the emotional bond between person (patient) and place (hospital). Our findings show that participants wanted an ongoing connection to hospital to fulfill their need(s) for control, security, restoration and belonging. Indeed, continual attachment to hospital may be beneficial for patients with complex care needs. Our research has implications for care engagement and retention frameworks.
... Several records identified that the intersections of substance use, psychiatric disorders, and social inequities in health requires clinical programs to use a collaborative approach when providing palliative care to people with life-limiting illnesses, especially during communicable disease outbreaks. 48,52,54,57,65,68,69,75,76 Injecting drugs in unsafe environments place those injecting at risk of acquiring blood-borne viruses (e.g. HIV) 59 and people experiencing structural vulnerability may not be able to implement public health measures in response to communicable disease outbreaks (e.g. ...
... 22 We identified practical strategies that programs can use to help reduce health inequities including service coordination, facilitating transitions in care and developing reasonable, feasible care plans that meet patients where they are situated. 52,55,68 One document also suggested that emotional support and palliative care training should be provided for staff and organizations who provide care for people experiencing homelessness. 49 The literature suggests that community-based services, including hospices, can help loved ones remain together, avoid acute care hospitalization and, potentially, reduce healthcare costs. ...
... 79 Several records indicated that healthcare policies for people with life-limiting illnesses who use drugs should be flexible, trauma-informed and patient-centered, and ensure that patients have low barrier access to resources and comprehensive services where they can form trusting relationships with healthcare professionals. 48,49,68 The literature suggests that "culturally competent" systems of care be developed using strategies that minimize culture clashes between healthcare professionals and patients, such as expecting that there will be differences in beliefs about death and dying. 54 Efforts should also be made to include patients with multi-morbidity in research. ...
Background
People who use drugs with life-limiting illnesses experience substantial barriers to accessing palliative care. Demand for palliative care is expected to increase during communicable disease epidemics and pandemics. Understanding how epidemics and pandemics affect palliative care for people who use drugs is important from a service delivery perspective and for reducing population health inequities.
Aim
To explore what is known about communicable disease epidemics and pandemics, palliative care, and people who use drugs.
Design
Scoping review.
Data sources
We searched six bibliographic databases from inception to April 2021 as well as the grey literature. We included English and French records about palliative care access, programs, and policies and guidelines for people ⩾18 years old who use drugs during communicable disease epidemics and pandemics.
Results
Forty-four articles were included in our analysis. We identified limited knowledge about palliative care for people who use drugs during epidemics and pandemics other than HIV/AIDS. Through our thematic synthesis of the records, we generated the following themes: enablers and barriers to access, organizational barriers, structural inequity, access to opioids and other psychoactive substances, and stigma.
Conclusions
Our findings underscore the need for further research about how best to provide palliative care for people who use drugs during epidemics and pandemics. We suggest four ways that health systems can be better prepared to help alleviate the structural barriers that limit access as well as support the provision of high-quality palliative care during future epidemics and pandemics.
... Halman y cols. reportan resultados similares, el 74,7 % de casos bajo tratamiento con un 55 % de adherencia, mientras que en estudios españoles la cobertura por TARVAE es alrededor del 85 % con un índice de abandono del 69 % 11,12,15,18 . La optimización de la adherencia como vía para lograr, a partir de un control virológico, un impacto sobre la contención de la trasmisión de la enfermedad requiere más que consultas médicas convencionales y seguimiento de bioparámetros. ...
... In der Versorgungspraxis lassen sich zwei Versorgungsansätze entsprechend der Indi- (Halman et al., 2014) und Ihren Angehörigen (Giesbrecht et al., 2015). Darüber hinaus charakterisiert er auch die Komplexität der zu erbringenden Versorgung (Ohlen et al., 2017). ...
Um Patienten mit Palliativbedarf proaktiv zu identifizieren wurde am Universitätsklinikum Würzburg am 01.03.2019 ein Palliativscreening auf Basis der Pflegeanamnese etabliert. Dessen Prädiktivität auf das 6-Monats Überleben wurde in der vorliegenden Arbeit in einer uro-onkologischen Patientenkohorte untersucht. Für die Patientenkohorte wurden aus dem klinischen Informationssystem aufenthalts-, personen- und tumorspezifische Daten sowie das Palliativscreening aus der Pflegeanamnese ausgelesen. Ergänzend zur Auswertung des automatisiert generierten Palliativscreenings wurden die Einzelitems rechnerisch in einem berechneten Palliativscreening zusammengeführt um eine Zuverlässigkeitsprüfung des automatisiert generierten Palliativscreenings zu ermöglichen. In einer zweiten Auswertung wurde geprüft, ob der Patient im 6-Monats Nachbeobachtungszeitraum nach Aufnahme verstorben ist. Unsere Studie belegt die Prädiktivität des Palliativscreenings in einer uro-onkologischen Kohorte für das 6-Monats Überleben. Ein automatisiert generiertes Screening, ist in unserer Studie vergleichbar prädiktiv auf das 6-Monats Überleben als eine manuelle rechnerische Rekonstruktion. Bei Patienten mit Prostatakarzinom weist das Palliativscreening eine niedrigere Korrelation mit dem 6-Monats Überleben auf als bei Patienten mit anderen urologischen Entitäten.
... Comorbidities with HIV infection can be complicated by psychological factors, such as depression [22]. Previous literature reviews from Canada [17] and Australia [23] confirmed that mental illness remains one of the most common problems among PLWH. ...
Objectives
Prevention of comorbidity with HIV infection warrants more attention as people living with HIV (PLWH) tend to live longer in the era of effective antiretroviral therapy (ART). This study aimed to investigate the associations between various psychosocial variables and different comorbid conditions in South Carolina (SC), USA.
Methods
A cross‐sectional survey was conducted among PLWH from May to September 2018 in SC. Comorbid conditions were based on self‐report data and grouped into sexually transmitted infection (STI) comorbidities, noninfectious chronic comorbidities or any comorbidity. Multivariate logistic regression models were used to analyse the relevant associations.
Results
Among 402 participants, the prevalence of STI comorbidities, noninfectious chronic comorbidities, and any comorbidity was 61.7%, 21.9% and 69.4%, respectively. The multivariate analysis showed that higher depression scores were associated with an increased risk of any comorbidity, while higher anxiety scores were associated with an increased risk of STI comorbidities or any comorbidity. Higher resilience scores were associated with a decreased risk of noninfectious chronic comorbidities or any comorbidity.
Conclusions
The association between psychosocial factors and different types of comorbidity could inform holistic interventions, such as providing integrated mental health services (e.g. treating mental health problems or building resilience), to effectively cope with and manage the co‐existing medical conditions of PLWH.
... Provoking factors for common mental disorder in PLWHA are related to stress, low social support, number of negative life events, not disclosing HIV status and CD4 cell count of < 500 cells/mm 3 [10][11][12][13][14]. Despite the fact that developing countries carry more than 90% of the burden of HIV/AIDS, little information about the interaction between HIV/AIDS and mental health is available from low-and middle-income countries [4][5][6][7][8]. ...
Background:
Common mental disorder (CMD) is a group of disorders which include depression, anxiety and somatoform disorders with significant contributions to the burden of disease. It can lead to high social, economic and individual costs because it accounts for one-third of the days missed at work and a fifth of all primary health-care appointment. This study was aimed to assess the prevalence and factors associated with common mental disorders among HIV patients in Hawassa City, Ethiopia, 2018.
Methods:
The cross-sectional study was conducted at Hawassa University Comprehensive Specialized Hospital, Ethiopia, among 294 HIV patients who were recruited through systematic sampling techniques. Common mental disorder was assessed through face to face interviews by trained professional psychiatry nurses using a WHO-validated 20-item version of the Self-Reporting Questionnaire (SRQ-20). Other possible risk factors of CMD were assessed using a structured questionnaire, perceived HIV stigma scale and Oslo Item 3 Social Support Scale.
Results:
A total of 294 HIV patients participated in the study giving a response rate of 98.7%. The mean (± SD) age of the respondents was 35.86 years (± 9.23). Among the study participants, being female [AOR = 1.25, (95% CI 1.01, 2.43)], being widowed [AOR = 1.99, (95% CI 1.51, 5.28)], having poor social support [AOR = 2.44, (95% CI 1.33, 4.51)], having previous history of psychiatric illness [AOR = 3.83, (95% CI 1.89, 9.33)] and HIV-related perceived stigma [AOR = 1.97, (95% CI 1.63, 2.89)] were more likely to have common mental disorder when compared to their counterparts.
Conclusion:
The prevalence of common mental disorder was high. The Ministry of Health should develop a guideline which helps to screen and treat common mental disorders at ART clinics. Further interventional research on risk factors of common mental disorder should be conducted to strengthen and broaden the current findings.
... Delayed therapy is associated with worse immune reconstitution [6,7], higher frequency of opportunistic infections [8], increased morbidity [9], increased mortality [10], higher risk of cardiovascular and metabolic diseases [11], and higher risk and costs of noninfectious comorbidities [12]. From a societal perspective, late initiation of ART leads to more complex therapeutic regimens and increased costs [13,14]. Moreover, it contributes to HIV transmission since late initiators of ART have high circulating viral load for longer periods of time [15]. ...
Introduction
Highly active antiretroviral therapy has been available since 1996. Early initiation of antiretroviral therapy (ART) leads to improved therapeutic response and reduced HIV transmission. However, a significant number of people living with HIV (PLHIV) still start treatment late.
Objective
This study aimed to analyze characteristics and factors associated with late initiation of ART among HIV-infected treatment-naïve patients.
Methods
This cross-sectional study included PLHIV older than 17 years who initiated ART at two public health facilities from 2009 to 2012, in a city located in Midwestern Brazil. Pregnant women were excluded. Data were collected from medical records, antiviral dispensing forms, and the Logistics Control of Medications System (SICLOM) of the Brazilian Ministry of Health. Late initiation of ART was defined as CD4+ cell count < 200 cells/mm³ or presence of AIDS-defining illness. Uni- and multivariate analysis were performed to evaluate associated factors for late ARV using SPSS®, version 21. The significance level was set at p<0.05.
Results
1,141 individuals were included, with a median age of 41 years, and 69.1% were male. The prevalence of late initiation of ART was 55.8% (95%CI: 52.9-58.7). The more common opportunistic infections at ART initiation were pneumocystosis, cerebral toxoplasmosis, tuberculosis, and histoplasmosis. Overall, 38.8% of patients had HIV viral load equal to or greater than 100,000 copies/mL. Late onset of ART was associated with higher mortality. After logistic regression, factors shown to be associated with late initiation of ARV were low education level, sexual orientation, high baseline viral load, place of residence outside metropolitan area, and concomitant infection with hepatitis B virus.
Conclusion
These results revealed the need to increase early treatment of HIV infection, focusing especially on groups of people who are more socially vulnerable or have lower self-perceived risk.
... 6 7 Psychosocial factors may overlap with health challenges (eg, increased substance use, homelessness, unemployment, social isolation and food insecurity). [8][9][10] These complex difficulties can interrupt the cascade of care and increase the risk of mortality 1 ; in particular, substance use is a priority area of focus for care retention interventions. 11 The cascade of care (ie, HIV treatment cascade or the HIV care continuum) is a framework recommended by UNAIDS for member countries to measure their progress in ending the AIDS epidemic. ...
Objectives
To pilot a peer-based intervention for people living with HIV who used substances, had challenges with antiretroviral adherence and would be discharged from hospital to community.
Study design
A community-based, quasi-experimental pilot intervention study designed to assess feasibility, acceptability and connection to a community-based HIV organisation.
Setting
This study was conducted in Toronto, Canada, at Casey House (CH; hospital for people living with HIV) in collaboration with the AIDS Committee of Toronto (ACT; community-based HIV organisation).
Participants
People living with HIV who were CH inpatient between 1 April 2017 and 31 March 2018, struggled with antiretroviral adherence, actively used substances and would be discharged to community were eligible. Forty people met criteria, 19 were approached by an inpatient nurse and 17 consented. Average age was 48.8 years (SD=11.4), 58.8% were male and participants averaged 7.8 physical and mental health comorbidities (SD=3.1).
Intervention
Titled ’The ART of Conversation', the three-pronged personalised intervention was developed through input from CH clients and ACT volunteers, all living with HIV. Intervention components were (a) predischarge goal-setting (adherence, substance use and self-identified goal) with the study nurse; (b) predischarge meeting with an HIV+ peer volunteer (PV) and (c) nine postdischarge phone calls between PV and participant, once per day for 3 days, then once per week for 6 weeks.
Primary outcomes
Feasibility was measured through proportion of eligible participants recruited and PV availability. Acceptability was assessed through participant interviews at three times (preintervention, post-intervention and 6 weeks follow-up) and through PV call logs. Client records determined connection to ACT within the study timeframe.
Results
Twelve participants completed the intervention and nine connected with ACT. Predischarge goal-setting and PV meeting were both feasible and acceptable. Postdischarge phone calls were a challenge as half of completers missed at least one call.
Conclusions
Although predischarge goal-setting and PV meeting were feasible, methods to maintain connection following discharge require further investigation.
... First, the high prevalence of MHSUDs and their significant roles in ED visit outcomes in patients with HIV provide support for integrated care for these patients 30 to reduce their ED visits and costly hospital admissions and institutional care that follows. HIV patients' complex care needs are not likely to be met at EDs unless a holistic care approach that takes into account physical, mental, and social comorbidities (e.g., poverty, lack of consistent access to primary care, and socioeconomic deprivations such as unstable housing 31 ) is provided outside the ED. Community resources for psychiatric treatment especially for suicide risk prevention and substance use disorders and case management for unmet needs in other areas should be made available and easily accessible. ...
Introduction
A disproportionate number of individuals with human immunodeficiency virus (HIV) have mental health and substance-use disorders (MHSUDs), and MHSUDs are significantly associated with their emergency department (ED) visits. With an increasing share of older adults among HIV patients, this study investigated the associations of MHSUDs with ED outcomes of HIV patients in four age groups: 21–34, 35–49, 50–64, and 65+ years.
Methods
We used the 2012 Nationwide Emergency Department Sample (NEDS) dataset (unweighted n=23,244,819 ED events by patients aged 21+, including 115,656 visits by patients with HIV). Multinomial and binary logistic regression analyses, with “treat-and-release” as the base outcome, were used to examine associations between ED outcomes and MHSUDs among visits that included a HIV diagnosis in each age group.
Results
Mood and “other” mental disorders had small effects on ED-to-hospital admissions, as opposed to treat-and-release, in age groups younger than 65+ years, while suicide attempts had medium effects (RRR=3.56, CI [2.69–4.70]; RRR=4.44, CI [3.72–5.30]; and RRR=5.64, CI [4.38–7.26] in the 21–34, 35–49, and 50–64 age groups, respectively). Cognitive disorders had medium-to-large effects on hospital admissions in all age groups and large effects on death in the 35–49 (RRR=7.29, CI [3.90–13.62]) and 50–64 (RRR=5.38, CI [3.39–8.55]) age groups. Alcohol use disorders (AUDs) had small effects on hospital admission in all age groups (RRR=2.35, 95% CI [1.92–2.87]; RRR=2.15, 95% CI [1.95–2.37]; RRR=1.92, 95% CI [1.73–2.12]; and OR=1.93, 95% CI [1.20–3.10] in the 21–34, 35–49, 50–64, and 65+ age groups, respectively). Drug use disorders (DUDs) had small-to-medium effects on hospital admission (RRR=4.40, 95% CI [3.87–5.0]; RRR=4.07, 95% CI [3.77–4.40]; RRR=4.17, 95% CI [3.83–4.55]; and OR=2.53, 95% CI [2.70–3.78] in the 21–34, 35–49, 50–64, and 65+ age groups, respectively). AUDs and DUDs were also significantly related to the risk of death, and DUDs had a small effect on the risk of discharge against medical advice in the 35–49 and 50–64 age groups.
Conclusion
The high prevalence of MHSUDs and their significant roles in ED visit outcomes in patients with HIV provide support for integrated care for these patients outside the ED to reduce their ED visits and costly hospital admissions and institutional care that follows, especially for the increasing numbers of older adults with HIV.
... As the growing prevalence of multiple chronic health conditions threatens the quality of life for aging populations, the effective provision of palliative care is gaining visibility as a major public health issue (Riffin et al., 2015;Stjernsward, 2007). Especially at risk are people living with HIV (PLWH) who, having survived life-threatening HIV infection, are now developing multiple chronic conditions associated with aging, medication side effects, and the HIV disease process (Balderson et al., 2013;Chu & Selwyn, 2011;Halman, Carusone, Stranks, Schaefer-McDaniel, & Stewart, 2014;Simms, Higginson, & Harding, 2011). HIV has evolved into a medically controllable, chronic condition. ...
People living with HIV (PLWH) who survive to older adulthood risk developing multiple chronic medical conditions. Health policymakers recognize the role of early palliative care and advance care planning in improving health quality for at-risk populations, but misperceptions about palliative care, hospice, and advance care planning are common. Before testing a program of early palliative care for PLWH and other chronic conditions, we conducted focus groups to elicit perceptions of palliative care, hospice, and advance care planning in our target population. Overall, participants were unfamiliar with the term palliative care, confused concepts of palliative care and hospice, and/or associated hospice care with dying. Participants misunderstood advance care planning, but valued communication about health care preferences. Accepting palliative care was contingent on distinguishing it from hospice and historical memories of HIV and dying. Provision of high-quality, comprehensive care will require changing public perceptions and individuals’ views in this high-risk population.
