Understanding patient acceptance and refusal of HIV testing in the emergency department

<p>ABSTRACT</p> <p>Background</p> <p>Despite high rates of patient satisfaction with emergency department (ED) HIV testing, acceptance varies widely. It is thought that patients who decline may be at higher risk for HIV infection, thus we sought to better understand patient acceptance and refusal of ED HIV testing.</p> <p>Methods</p> <p>In-depth interviews with fifty ED patients (28 accepters and 22 decliners of HIV testing) in three ED HIV testing programs that serve vulnerable urban populations in northern California.</p> <p>Results</p> <p>Many factors influenced the decision to accept ED HIV testing, including curiosity, reassurance of negative status, convenience, and opportunity. Similarly, a number of factors influenced the decision to decline HIV testing, including having been tested recently, the perception of being at low risk for HIV infection due to monogamy, abstinence or condom use, and wanting to focus on the medical reason for the ED visit. Both accepters and decliners viewed ED HIV testing favorably and nearly all participants felt comfortable with the testing experience, including the absence of counseling. While many participants who declined an ED HIV test had logical reasons, some participants also made clear that they would prefer not to know their HIV status rather than face psychosocial consequences such as loss of trust in a relationship or disclosure of status in hospital or public health records.</p> <p>Conclusions</p> <p>Testing for HIV in the ED as for any other health problem reduces barriers to testing for some but not all patients. Patients who decline ED HIV testing may have rational reasons, but there are some patients who avoid HIV testing because of psychosocial ramifications. While ED HIV testing is generally acceptable, more targeted approaches to testing are necessary for this subgroup.</p

Interventions Delivered in Clinical Settings are Effective in Reducing Risk of HIV Transmission Among People Living with HIV: Results from the Health Resources and Services Administration (HRSA)’s Special Projects of National Significance Initiative

To support expanded prevention services for people living with HIV, the US Health Resources and Services Administration (HRSA) sponsored a 5-year initiative to test whether interventions delivered in clinical settings were effective in reducing HIV transmission risk among HIV-infected patients. Across 13 demonstration sites, patients were randomized to one of four conditions. All interventions were associated with reduced unprotected vaginal and/or anal intercourse with persons of HIV-uninfected or unknown status among the 3,556 participating patients. Compared to the standard of care, patients assigned to receive interventions from medical care providers reported a significant decrease in risk after 12 months of participation. Patients receiving prevention services from health educators, social workers or paraprofessional HIV-infected peers reported significant reduction in risk at 6 months, but not at 12 months. While clinics have a choice of effective models for implementing prevention programs for their HIV-infected patients, medical provider-delivered methods are comparatively robust

Transiting Disintegrating Planetary Debris around WD 1145+017

More than a decade after astronomers realized that disrupted planetary material likely pollutes the surfaces of many white dwarf stars, the discovery of transiting debris orbiting the white dwarf WD 1145+017 has opened the door to new explorations of this process. We describe the observational evidence for transiting planetary material and the current theoretical understanding (and in some cases lack thereof) of the phenomenon.Comment: Invited review chapter. Accepted March 23, 2017 and published October 7, 2017 in the Handbook of Exoplanets. 15 pages, 10 figure

The Evolution of Compact Binary Star Systems

We review the formation and evolution of compact binary stars consisting of white dwarfs (WDs), neutron stars (NSs), and black holes (BHs). Binary NSs and BHs are thought to be the primary astrophysical sources of gravitational waves (GWs) within the frequency band of ground-based detectors, while compact binaries of WDs are important sources of GWs at lower frequencies to be covered by space interferometers (LISA). Major uncertainties in the current understanding of properties of NSs and BHs most relevant to the GW studies are discussed, including the treatment of the natal kicks which compact stellar remnants acquire during the core collapse of massive stars and the common envelope phase of binary evolution. We discuss the coalescence rates of binary NSs and BHs and prospects for their detections, the formation and evolution of binary WDs and their observational manifestations. Special attention is given to AM CVn-stars -- compact binaries in which the Roche lobe is filled by another WD or a low-mass partially degenerate helium-star, as these stars are thought to be the best LISA verification binary GW sources.Comment: 105 pages, 18 figure

A wager on the future: a practicable response to HIV pre-exposure prophylaxis (PrEP) and the stubborn fact of process

In this article we focus on public health’s wager on the social implications of a daily antiretroviral pill to prevent HIV, referred to as PrEP (pre-exposure prophylaxis). The wager is shown to rely on modes of inquiry overly tied to what is known of the present in order to predict the future. Although such inquiry is not unusual when social research is called upon to assist health policy, predictive methodologies are unable to appreciate the dynamic and thus indeterminate nature of process. We ask: what mode of inquiry might practicably appreciate that what happens in the present will have a bearing on the future, without foreclosing on unknown possibles? Drawing on speculative and pragmatic philosophy, we reflect on our own qualitative research on PrEP to suggest that conventional methodological approaches can contribute to the future without seeking to determine what it will become

Pulsating White Dwarf Stars and Precision Asteroseismology

Galactic history is written in the white dwarf stars. Their surface properties hint at interiors composed of matter under extreme conditions. In the forty years since their discovery, pulsating white dwarf stars have moved from side-show curiosities to center stage as important tools for unraveling the deep mysteries of the Universe. Innovative observational techniques and theoretical modeling tools have breathed life into precision asteroseismology. We are just learning to use this powerful tool, confronting theoretical models with observed frequencies and their time rate-of-change. With this tool, we calibrate white dwarf cosmochronology; we explore equations of state; we measure stellar masses, rotation rates, and nuclear reaction rates; we explore the physics of interior crystallization; we study the structure of the progenitors of Type Ia supernovae, and we test models of dark matter. The white dwarf pulsations are at once the heartbeat of galactic history and a window into unexplored and exotic physics.Comment: 70 pages, 11 figures, to be published in Annual Review of Astronomy and Astrophysics 200

Distinct roles of presynaptic dopamine receptors in the differential modulation of the intrinsic synapses of medium-spiny neurons in the nucleus accumbens

Background: In both schizophrenia and addiction, pathological changes in dopamine release appear to induce alterations in the circuitry of the nucleus accumbens that affect coordinated thought and motivation. Dopamine acts principally on medium-spiny GABA neurons, which comprise 95% of accumbens neurons and give rise to the majority of inhibitory synapses in the nucleus. To examine dopamine action at single medium-spiny neuron synapses, we imaged Ca2+ levels in their presynaptic varicosities in the acute brain slice using two-photon microscopy. Results: Presynaptic Ca2+ rises were differentially modulated by dopamine. The D1/D5 selective agonist SKF81297 was exclusively facilitatory. The D2/D3 selective agonist quinpirole was predominantly inhibitory, but in some instances it was facilitatory. Studies using D2 and D3 receptor knockout mice revealed that quinpirole inhibition was either D2 or D3 receptor-mediated, while facilitation was mainly D3 receptor-mediated. Subsets of varicosities responded to both D1 and D2 agonists, showing that there was significant co-expression of these receptor families in single medium-spiny neurons. Neighboring presynaptic varicosities showed strikingly heterogeneous responses to DA agonists, suggesting that DA receptors may be differentially trafficked to individual varicosities on the same medium-spiny neuron axon. Conclusion: Dopamine receptors are present on the presynaptic varicosities of medium-spiny neurons, where they potently control GABAergic synaptic transmission. While there is significant coexpression of D1 and D2 family dopamine receptors in individual neurons, at the subcellular level, these receptors appear to be heterogeneously distributed, potentially explaining the considerable controversy regarding dopamine action in the striatum, and in particular the degree of dopamine receptor segregation on these neurons. Assuming that post-receptor signaling is restricted to the microdomains of medium-spiny neuron varicosities, the heterogeneous distribution of dopamine receptors on individual varicosities is likely to encode patterns in striatal information processing

If someone cares about you, you are more apt to come around: improving HIV care engagement by strengthening the patient&ndash;provider relationship

Troy J Wood,1 Kimberly A Koester,2 Katerina A Christopoulos,3 John A Sauceda,1 Torsten B Neilands,1 Mallory O Johnson1 1Department of Medicine, University of California, San Francisco, CA, USA; 2AIDS Policy Research Center, Department of Medicine, University of California, San Francisco, CA, USA; 3Zuckerberg San Francisco General Hospital, Division of HIV, ID and Global Medicine, University of California, San Francisco, CA, USA Purpose: The patient&ndash;provider relationship is a central factor that can promote or hinder long-term engagement in care among people living with chronic illnesses. In this paper, we explore characteristics of the patient&ndash;provider relationship that facilitated or hindered engagement in care among patients receiving care at HIV specialty clinics.Patients and methods: We conducted 6 focus group discussions with a total of 43 well-retained and less well-retained HIV+ patients in San Francisco, Seattle, and Birmingham, to elicit a wide range of perspectives on engagement in HIV care. Borrowing from the field of psychotherapy, we examined patient&ndash;provider relationship characteristics through the lens of the therapeutic alliance, and with regard to their therapeutic efficacy and impact on patient engagement.Results: The majority of participants emphasized how a strong patient&ndash;provider relationship defined by trust, intimacy, and collaboration promoted engagement, while a weak patient&ndash;provider relationship impeded engagement.Conclusion: We discuss practical strategies and therapeutic techniques that may be helpful to providers in building strong patient&ndash;provider relationship and contend that a strong patient&ndash;provider relationship is crucial for patients to feel cared for during clinical encounters, which can promote long-term and sustained engagement in HIV care. Keywords: focus groups, engagement in care, therapeutic alliance, psychotherapy, HIV, HIV care&nbsp