Rebecca Dillingham - Academia.edu (original) (raw)

Papers by Rebecca Dillingham

JMIR mHealth and uHealth, 2021

Background Mobile health (mHealth) apps can provide support to people living with a chronic disea... more Background Mobile health (mHealth) apps can provide support to people living with a chronic disease by offering resources for communication, self-management, and social support. PositiveLinks (PL) is a clinic-deployed mHealth app designed to improve the health of people with HIV. In a pilot study, PL users experienced considerable improvements in care engagement and viral load suppression. To promote its expansion to other HIV clinics, we developed an implementation strategy consisting of training resources and on-demand program support. Objective The objective of our study was to conduct an interim analysis of the barriers and facilitators to PL implementation at early adopting sites to guide optimization of our implementation strategy. Methods Semistructured interviews with stakeholders at PL expansion sites were conducted. Analysis of interviews identified facilitators and barriers that were mapped to 22 constructs of the Consolidated Framework for Implementation Research (CFIR)....

Background Most people diagnosed with Hepatitis C virus (HCV) have not linked to care. The patien... more Background Most people diagnosed with Hepatitis C virus (HCV) have not linked to care. The patient perspective on decision-making regarding linkage to care (LTC) in the direct acting antivirals treatment era is limited. We assess perceptions that impacted the choice not to pursue care among non-urban patients in the South who failed to attend an HCV clinic appointment. Methods We conducted a demographic survey and semi-structured interview with participants referred to our HCV clinic between 2014 and 2018 who did not attend an appointment. Data collection and analyses were guided by the Health Belief Model. Results Twelve participants enrolled, including 7 men and 5 women. Barriers to care were common including being uninsured (33%), having unreliable transportation (42%), unstable housing (33%), and a history of substance use disorder requiring treatment (58%). Participants demonstrated good knowledge of HCV disease, complications, and treatment. Emerging themes regarding failure o...

Open Forum Infectious Diseases, 2020

Background The Affordable Care Act’s (ACA’s) major reforms started in 2014. In addition to assess... more Background The Affordable Care Act’s (ACA’s) major reforms started in 2014. In addition to assessing HIV clinicians’ ACA knowledge and attitudes, this study aims to evaluate HIV clinicians’ perspectives on whether the ACA has impacted the quality of HIV care and whether it addresses the main barriers to HIV care. Methods HIV clinicians were emailed a survey weblink in 2018. Descriptive statistics, Mann-Whitney U tests, and binary logistic regression were performed. Results Of the 211 survey participants, the majority (70%) answered all 4 knowledge questions correctly. About 80% knew correctly whether their state had expanded Medicaid. Participants from Medicaid expansion states were more likely to report an improved ability to provide high-quality care compared with participants from Medicaid nonexpansion states (50% vs 34%; P = .01). The average response to whether the ACA addresses the main barriers to HIV care was neutral and did not differ based on Medicaid status. The top 3 mai...

Open Forum Infectious Diseases, 2019

Background Direct-acting antivirals (DAAs) have simplified and expanded access to Hepatitis C vir... more Background Direct-acting antivirals (DAAs) have simplified and expanded access to Hepatitis C virus (HCV) treatment. Only 17% of the estimated 2.4 million Americans currently infected with HCV have linked to HCV specialty care. We evaluated linkage to care (LTC) in a non-urban hepatitis C referral clinic with a nurse navigator model of care and identified disparities in LTC during the DAA era. Methods A single-center retrospective cohort analysis was performed among all patients referred to an infectious diseases HCV clinic between 2014 and 2018. The primary outcome was LTC, defined as attendance at a clinic appointment. A multivariable Poisson regression model estimated associations of patient characteristics with LTC. Results Among 824 referred patients, 624 (76%) successfully linked to care and 369 (45%) achieved sustained virologic response. The mean age was 48.5 years (SD 13.5 years) and 46% (382 of 824) were uninsured. Common reasons for failure of LTC included no-shows (26.5%...

Open Forum Infectious Diseases, 2019

Background mHealth (mobile health) is a promising tool to deliver healthcare interventions to und... more Background mHealth (mobile health) is a promising tool to deliver healthcare interventions to underserved populations. Across low- and middle-income countries (LMIC), the prevalence of smartphones has risen to 42%. Effective mHealth deployment in LMIC requires an understanding of how LMIC populations use mobile technology. We characterized the use of mobile devices in rural KwaZulu-Natal, South Africa to tailor mHealth interventions for people living with HIV and at risk for acquiring HIV. Methods We surveyed participants in community settings and offered free HIV counseling and testing. Participants self-reported their gender, age, relationship status, living distance from preferred clinic, receipt of monthly grant, condomless sex frequency, and circumcision status (if male). Outcomes included cell phone and smartphone ownership, private data access, health information seeking, and willingness to receive healthcare messages. We performed multivariable logistic regression to assess ...

The American Journal of Tropical Medicine and Hygiene, 2019

In this study, we report on the prevalence of 19 virulence genes in enteroaggregative Escherichia... more In this study, we report on the prevalence of 19 virulence genes in enteroaggregative Escherichia coli (EAEC) isolates from northern South Africa. Stool samples obtained prospectively from 97 children from 1 to 12 months of age were analyzed, and EAEC isolates were confirmed based on the presence of aaiC or aatA genes. We investigated 177 enteroaggregative Escherichia coli isolates for the prevalence of virulence genes using multiplex polymerase chain reaction. The chromosomal gene aaiC was detected at higher frequency (48.0%) compared with aatA (26.0%). The gene encoding the open reading frame Orf61 was the most prevalent putative virulence trait detected among the isolates (150/ 177; 84.7%). None of the genes was statistically associated with diarrhea (P > 0.05). Detection rates were higher during 7-12 month of life with an association observed for the pic gene and the age group 7-12 months (P = 0.04). Winter was the season with the highest detection rates. Our data reveal a high prevalence of Orf61, Orf3, and astA in South African EAEC isolates. Specific genes may provide additional markers for the study of disease associations with age and season of sample collection.

AIDS Research and Human Retroviruses, 2019

Many AIDS drug assistance programs (ADAPs) purchased Affordable Care Act (ACA) qualified health p... more Many AIDS drug assistance programs (ADAPs) purchased Affordable Care Act (ACA) qualified health plans (QHPs) for low-income people living with HIV. To date, little has been written about this from the client perspective. The study's objective was to gain information about the experience of Virginia ADAP-funded QHP enrollment and the impact of this change. English-speaking clients who were eligible for ADAP-funded QHPs were recruited at three HIV clinics in Virginia. The goal was to enroll ‡5% of those who were eligible for ADAP-funded QHPs in two Virginia Department of Health planning districts. Participants were surveyed about demographic characteristics, and semi-structured interviews were performed. Descriptive analyses were performed for cohort characteristics. Using an open coding strategy, codebooks were generated for the interviews and themes were identified. The cohort (n = 53) met our recruitment goal. Two-thirds gained their ACA knowledge at HIV clinics from case managers and social workers. Many barriers to enrollment were identified, including internet access/literacy. Almost 9 out of 10 participants had concerns about privacy, which centered on QHP's mandated use of mail-order pharmacies. Except for medication concerns, most participants had positive perceptions of the impact of QHP enrollment on their health care. HIV clinic case managers and social workers are often the primary source of knowledge for patients about insurance options and their assistance is crucial for QHP enrollment. Our findings indicate that reducing identified barriers and addressing privacy concerns by allowing people to opt out of mail order pharmacies may encourage QHP enrollment.

Telemedicine and e-Health, 2019

Purpose: Secure messaging between patients and their health care team can facilitate chronic care... more Purpose: Secure messaging between patients and their health care team can facilitate chronic care management. Positive-Links Ò (PL) is a clinic-affiliated smartphone application designed for patients living with HIV that includes a secure messaging feature for patients, PL staff, and clinic providers to communicate. Our aim was to examine the content and function of messaging within PL. Methodology: We examined messages exchanged through PL from November 2017 through January 2018. Qualitative analysis included categorization of topics as: related to the app, medical care, or social needs. Messaging functions were categorized as information exchange or rapport building. Results: Of the 1,474 PL messages analyzed, 44% were sent by PL staff, 38% by patients, and 18% by providers, whereas 61% were received by patients, 22% by providers, and 17% by PL staff. Message topics included app-related (57.6%), medical care (34.3%), and social concerns (12.4%). Apprelated messages addressed technical difficulties, software updates, or coordinating phone payments. Medical messages included medical information, medications, appointments, outreach, and care coordination for physical and mental health. Social messages related to insurance, transportation, housing, food, utilities, disability, finances, and work absences. Message function coding showed that 87.3% of messages contained information exchange and 33.8% contained rapport building. Messages sent by providers were most likely to contain rapport building at 54.8%. Conclusion: PL messaging was used to handle medical and social needs with potential impact on patients' health and offers an opportunity to strengthen patient-provider relationships through responsiveness and rapport building. Secure messaging through a clinic-affiliated smartphone app could enhance patient-centered care between clinical visits.

The Journal of Nutrition, 2019

Background Child cognitive development is influenced by early-life insults and protective factors... more Background Child cognitive development is influenced by early-life insults and protective factors. To what extent these factors have a long-term legacy on child development and hence fulfillment of cognitive potential is unknown. Objective The aim of this study was to examine the relation between early-life factors (birth to 2 y) and cognitive development at 5 y. Methods Observational follow-up visits were made of children at 5 y, previously enrolled in the community-based MAL-ED longitudinal cohort. The burden of enteropathogens, prevalence of illness, complementary diet intake, micronutrient status, and household and maternal factors from birth to 2 y were extensively measured and their relation with the Wechsler Preschool Primary Scales of Intelligence at 5 y was examined through use of linear regression. Results Cognitive T-scores from 813 of 1198 (68%) children were examined and 5 variables had significant associations in multivariable models: mean child plasma transferrin rece...

BMC Infectious Diseases, 2018

Background: Injection drug use (IDU) is a growing public health threat in Virginia, though there ... more Background: Injection drug use (IDU) is a growing public health threat in Virginia, though there is limited knowledge of related morbidity. The purpose of this study was to describe the temporal, geographic and clinical trends and characteristics of infective endocarditis associated with IDU (IDU-IE) and to identify opportunities for better-quality care of people who inject drugs (PWID). Methods: We reviewed charts for all admissions coded for both IE and drug use disorders at the University of Virginia Medical Center (UVA) from January 2000 to July 2016. A random sample of 30 admissions coded for IE per year were reviewed to evaluate temporal trends in the proportion of IDU associated IE cases. Results: There were a total of 76 patients with IDU-IE during the study period, 7.54-fold increase (prevalence ratio: 8.54, 95% CI 3.70-19.72) from 2000 to 2016. The proportion of IE that was IDU-associated increased by nearly 10% each year (prevalence ratio of IDU per year: 1.09, 95% CI: 1.05-1.14). Patients with IDU-IE had longer hospital stays [median days (interquartile range); IDU-IE, 17 (10-29

Water, 2018

Consumption of microbial-contaminated water can result in diarrheal illnesses and enteropathy wit... more Consumption of microbial-contaminated water can result in diarrheal illnesses and enteropathy with the heaviest impact upon children below the age of five. We aimed to provide a comprehensive analysis of water quality in a low-resource setting in Limpopo province, South Africa. Surveys were conducted in 405 households in rural communities of Limpopo province to determine their water-use practices, perceptions of water quality, and household water-treatment methods. Drinking water samples were tested from households for microbiological contamination. Water from potential natural sources were tested for physicochemical and microbiological quality in the dry and wet seasons. Most households had their primary water source piped into their yard or used an intermittent public tap. Approximately one third of caregivers perceived that they could get sick from drinking water. All natural water sources tested positive for fecal contamination at some point during each season. The treated municipal supply never tested positive for fecal contamination; however, the treated system does not reach all residents in the valley; furthermore, frequent shutdowns of the treatment systems and intermittent distribution make the treated water unreliable. The increased water quantity in the wet season correlates with increased treated water from municipal taps and a decrease in the average contaminant levels in household water. This research suggests that wet season increases in water quantity result in more treated water in the region and that is reflected in residents' water-use practices.

Open Forum Infectious Diseases, 2018

Background Injection drug use disorder (IDD) is a growing public health threat in Virginia, altho... more Background Injection drug use disorder (IDD) is a growing public health threat in Virginia, although there is limited knowledge of related morbidity. The purpose of this study was to describe the temporal, geographic, and clinical trends and characteristics of infective endocarditis associated with IDD (IDD-IE) and to identify opportunities for better-quality care of people with IDD. Methods We reviewed charts for all admissions coded for both IE and drug use disorders at the University of Virginia Medical Center (UVA) from January 2000 to July 2016. A random sample of 30 admissions coded for IE per year were reviewed to evaluate temporal trends in the proportion of IDD associated IE cases. Results There were a total of 76 patients with IDD-IE during the study period, with a 7-fold increase in cases of IDD-IE from the early 2000s to 2016. The proportion of IE that was IDD-associated increased by nearly 10% each year (prevalence ratio of IDD per year: 1.09, 95% CI: 1.05–1.14). Patien...

AIDS and behavior, Jan 7, 2018

Stigma has negative consequences for quality of life and HIV care outcomes. PositiveLinks is a mo... more Stigma has negative consequences for quality of life and HIV care outcomes. PositiveLinks is a mobile health intervention that includes a secure anonymous community message board (CMB). We investigated discussion of stigma and changes in stigma scores. Of 77 participants in our pilot, 63% were male, 49% Black, and 72% had incomes below the federal poverty level. Twenty-one percent of CMB posts (394/1834) contained stigma-related content including negative (experiencing stigma) and positive (overcoming stigma) posts addressing intrapersonal and interpersonal stigma. Higher baseline stigma was positively correlated with stress and negatively correlated with HIV care self-efficacy. 12-month data showed a trend toward more improved stigma scores for posters on the CMB versus non-posters (- 4.5 vs - 0.63) and for posters of stigma-related content versus other content (- 5.1 vs - 3.3). Preliminary evidence suggests that a supportive virtual community, accessed through a clinic-affiliated ...

Southern Medical Journal, 2016

The Affordable Care Act (ACA), signed into law in 2010, is expected to expand insurance coverage ... more The Affordable Care Act (ACA), signed into law in 2010, is expected to expand insurance coverage for millions of people in the United States, including people with HIV infection. While several provisions of the ACA have implications for people with HIV, two are expected to have the most far reaching effects on coverage-the expansion of Medicaid eligibility and the creation of new Health Insurance Marketplaces where individuals can purchase private coverage. This issue brief, based on analysis of nationally representative data from the Centers for Disease Control and Prevention's (CDC's) Medical Monitoring Project (MMP), provides the first national estimates of how many people with HIV who are receiving medical care may gain new insurance coverage due to the ACA through both Medicaid expansion and the state Marketplaces. It finds that of the approximately 407,000 people with HIV between the ages of 19-64 in care, most (87%) have incomes below 400% FPL. While Medicaid is their single largest source of coverage (covering about 4 in 10), close to 70,000 (17%) are currently uninsured. Of these, almost 23,000 would gain coverage through the Marketplace (most of whom would be eligible for financial assistance), and approximately 46,910 would be eligible for Medicaid, if all states were to expand Medicaid. However, only 26 states plan to expand their Medicaid programs as of October 2013, which could reduce the number gaining coverage through Medicaid expansion by more than 40%. For individuals left out of coverage expansions, the Ryan White HIV/AIDS Program will continue to be critical; it will also likely continue to remain critical in filling the gaps in insurance coverage for HIV care for many insured people with HIV, as it does today. Lastly, while this analysis focuses on the approximately 407,000 people with HIV between the ages of 19-64 who are already in care, more than 700,000 people with HIV are not yet in care. Based on the findings presented here, an additional 124,000 could gain new coverage due to the ACA, removing one obstacle to care seeking and bringing the total estimated number of people with HIV who could gain new coverage close to 200,000.

AIDS research and therapy, 2017

Immune reconstitution inflammatory syndrome (IRIS) can manifest with initiation or reintroduction... more Immune reconstitution inflammatory syndrome (IRIS) can manifest with initiation or reintroduction of antiretroviral therapy (ART) in persons living with HIV (PLWH). In 2012, updated United States treatment guidelines recommended initiation of ART for all PLWH regardless of CD4 count. The objectives of this study were to quantify hospital usage attributable to IRIS and assess the reasons for hospitalization in PLWH before and after the guideline update. Subjects were PLWH between 18-89 years of age who were hospitalized between November 1, 2009 and July 31, 2014. Equivalent time periods before and after updated treatment guidelines were considered, and designated as Time Period 1 and Time Period 2, respectively. IRIS-attributable hospitalizations were identified by ICD9 codes and electronic medical record searches with subsequent review and confirmation. For hospitalizations that were not confirmed as being IRIS-attributable, primary discharge diagnoses were reviewed. A total of 278 ...

AIDS research and therapy, 2017

Following publication of this article [1], it has come to our attention that one of the authors s... more Following publication of this article [1], it has come to our attention that one of the authors should have had their middle initial included, Kathleen A. McManus. The original article has been updated to reflect this. Furthermore, it was reported in the Methods section that the ages of patients involved in this study were "8-89" when in fact the correct range was 18-89. The original version of the article has been revised to reflect this.

Open Forum Infectious Diseases, 2015

Background. Before the Affordable Care Act (ACA), state AIDS Drug Assistance Programs (ADAPs) wer... more Background. Before the Affordable Care Act (ACA), state AIDS Drug Assistance Programs (ADAPs) were the safety net providing antiretroviral therapy to uninsured/ underinsured people living with HIV (PLWH). Many ADAPs, including Virginia, shifted their healthcare delivery model from a focus on direct medication provision to the purchase of insurance with the advent of ACA in 2014. Virginia ADAP helped enroll clients in ACA insurance plans and paid monthly premiums, medication

Open Forum Infectious Diseases, 2016

JMIR mHealth and uHealth, 2021

Background Mobile health (mHealth) apps can provide support to people living with a chronic disea... more Background Mobile health (mHealth) apps can provide support to people living with a chronic disease by offering resources for communication, self-management, and social support. PositiveLinks (PL) is a clinic-deployed mHealth app designed to improve the health of people with HIV. In a pilot study, PL users experienced considerable improvements in care engagement and viral load suppression. To promote its expansion to other HIV clinics, we developed an implementation strategy consisting of training resources and on-demand program support. Objective The objective of our study was to conduct an interim analysis of the barriers and facilitators to PL implementation at early adopting sites to guide optimization of our implementation strategy. Methods Semistructured interviews with stakeholders at PL expansion sites were conducted. Analysis of interviews identified facilitators and barriers that were mapped to 22 constructs of the Consolidated Framework for Implementation Research (CFIR)....

Background Most people diagnosed with Hepatitis C virus (HCV) have not linked to care. The patien... more Background Most people diagnosed with Hepatitis C virus (HCV) have not linked to care. The patient perspective on decision-making regarding linkage to care (LTC) in the direct acting antivirals treatment era is limited. We assess perceptions that impacted the choice not to pursue care among non-urban patients in the South who failed to attend an HCV clinic appointment. Methods We conducted a demographic survey and semi-structured interview with participants referred to our HCV clinic between 2014 and 2018 who did not attend an appointment. Data collection and analyses were guided by the Health Belief Model. Results Twelve participants enrolled, including 7 men and 5 women. Barriers to care were common including being uninsured (33%), having unreliable transportation (42%), unstable housing (33%), and a history of substance use disorder requiring treatment (58%). Participants demonstrated good knowledge of HCV disease, complications, and treatment. Emerging themes regarding failure o...

Open Forum Infectious Diseases, 2020

Background The Affordable Care Act’s (ACA’s) major reforms started in 2014. In addition to assess... more Background The Affordable Care Act’s (ACA’s) major reforms started in 2014. In addition to assessing HIV clinicians’ ACA knowledge and attitudes, this study aims to evaluate HIV clinicians’ perspectives on whether the ACA has impacted the quality of HIV care and whether it addresses the main barriers to HIV care. Methods HIV clinicians were emailed a survey weblink in 2018. Descriptive statistics, Mann-Whitney U tests, and binary logistic regression were performed. Results Of the 211 survey participants, the majority (70%) answered all 4 knowledge questions correctly. About 80% knew correctly whether their state had expanded Medicaid. Participants from Medicaid expansion states were more likely to report an improved ability to provide high-quality care compared with participants from Medicaid nonexpansion states (50% vs 34%; P = .01). The average response to whether the ACA addresses the main barriers to HIV care was neutral and did not differ based on Medicaid status. The top 3 mai...

Open Forum Infectious Diseases, 2019

Background Direct-acting antivirals (DAAs) have simplified and expanded access to Hepatitis C vir... more Background Direct-acting antivirals (DAAs) have simplified and expanded access to Hepatitis C virus (HCV) treatment. Only 17% of the estimated 2.4 million Americans currently infected with HCV have linked to HCV specialty care. We evaluated linkage to care (LTC) in a non-urban hepatitis C referral clinic with a nurse navigator model of care and identified disparities in LTC during the DAA era. Methods A single-center retrospective cohort analysis was performed among all patients referred to an infectious diseases HCV clinic between 2014 and 2018. The primary outcome was LTC, defined as attendance at a clinic appointment. A multivariable Poisson regression model estimated associations of patient characteristics with LTC. Results Among 824 referred patients, 624 (76%) successfully linked to care and 369 (45%) achieved sustained virologic response. The mean age was 48.5 years (SD 13.5 years) and 46% (382 of 824) were uninsured. Common reasons for failure of LTC included no-shows (26.5%...

Open Forum Infectious Diseases, 2019

Background mHealth (mobile health) is a promising tool to deliver healthcare interventions to und... more Background mHealth (mobile health) is a promising tool to deliver healthcare interventions to underserved populations. Across low- and middle-income countries (LMIC), the prevalence of smartphones has risen to 42%. Effective mHealth deployment in LMIC requires an understanding of how LMIC populations use mobile technology. We characterized the use of mobile devices in rural KwaZulu-Natal, South Africa to tailor mHealth interventions for people living with HIV and at risk for acquiring HIV. Methods We surveyed participants in community settings and offered free HIV counseling and testing. Participants self-reported their gender, age, relationship status, living distance from preferred clinic, receipt of monthly grant, condomless sex frequency, and circumcision status (if male). Outcomes included cell phone and smartphone ownership, private data access, health information seeking, and willingness to receive healthcare messages. We performed multivariable logistic regression to assess ...

The American Journal of Tropical Medicine and Hygiene, 2019

In this study, we report on the prevalence of 19 virulence genes in enteroaggregative Escherichia... more In this study, we report on the prevalence of 19 virulence genes in enteroaggregative Escherichia coli (EAEC) isolates from northern South Africa. Stool samples obtained prospectively from 97 children from 1 to 12 months of age were analyzed, and EAEC isolates were confirmed based on the presence of aaiC or aatA genes. We investigated 177 enteroaggregative Escherichia coli isolates for the prevalence of virulence genes using multiplex polymerase chain reaction. The chromosomal gene aaiC was detected at higher frequency (48.0%) compared with aatA (26.0%). The gene encoding the open reading frame Orf61 was the most prevalent putative virulence trait detected among the isolates (150/ 177; 84.7%). None of the genes was statistically associated with diarrhea (P > 0.05). Detection rates were higher during 7-12 month of life with an association observed for the pic gene and the age group 7-12 months (P = 0.04). Winter was the season with the highest detection rates. Our data reveal a high prevalence of Orf61, Orf3, and astA in South African EAEC isolates. Specific genes may provide additional markers for the study of disease associations with age and season of sample collection.

AIDS Research and Human Retroviruses, 2019

Many AIDS drug assistance programs (ADAPs) purchased Affordable Care Act (ACA) qualified health p... more Many AIDS drug assistance programs (ADAPs) purchased Affordable Care Act (ACA) qualified health plans (QHPs) for low-income people living with HIV. To date, little has been written about this from the client perspective. The study's objective was to gain information about the experience of Virginia ADAP-funded QHP enrollment and the impact of this change. English-speaking clients who were eligible for ADAP-funded QHPs were recruited at three HIV clinics in Virginia. The goal was to enroll ‡5% of those who were eligible for ADAP-funded QHPs in two Virginia Department of Health planning districts. Participants were surveyed about demographic characteristics, and semi-structured interviews were performed. Descriptive analyses were performed for cohort characteristics. Using an open coding strategy, codebooks were generated for the interviews and themes were identified. The cohort (n = 53) met our recruitment goal. Two-thirds gained their ACA knowledge at HIV clinics from case managers and social workers. Many barriers to enrollment were identified, including internet access/literacy. Almost 9 out of 10 participants had concerns about privacy, which centered on QHP's mandated use of mail-order pharmacies. Except for medication concerns, most participants had positive perceptions of the impact of QHP enrollment on their health care. HIV clinic case managers and social workers are often the primary source of knowledge for patients about insurance options and their assistance is crucial for QHP enrollment. Our findings indicate that reducing identified barriers and addressing privacy concerns by allowing people to opt out of mail order pharmacies may encourage QHP enrollment.

Telemedicine and e-Health, 2019

Purpose: Secure messaging between patients and their health care team can facilitate chronic care... more Purpose: Secure messaging between patients and their health care team can facilitate chronic care management. Positive-Links Ò (PL) is a clinic-affiliated smartphone application designed for patients living with HIV that includes a secure messaging feature for patients, PL staff, and clinic providers to communicate. Our aim was to examine the content and function of messaging within PL. Methodology: We examined messages exchanged through PL from November 2017 through January 2018. Qualitative analysis included categorization of topics as: related to the app, medical care, or social needs. Messaging functions were categorized as information exchange or rapport building. Results: Of the 1,474 PL messages analyzed, 44% were sent by PL staff, 38% by patients, and 18% by providers, whereas 61% were received by patients, 22% by providers, and 17% by PL staff. Message topics included app-related (57.6%), medical care (34.3%), and social concerns (12.4%). Apprelated messages addressed technical difficulties, software updates, or coordinating phone payments. Medical messages included medical information, medications, appointments, outreach, and care coordination for physical and mental health. Social messages related to insurance, transportation, housing, food, utilities, disability, finances, and work absences. Message function coding showed that 87.3% of messages contained information exchange and 33.8% contained rapport building. Messages sent by providers were most likely to contain rapport building at 54.8%. Conclusion: PL messaging was used to handle medical and social needs with potential impact on patients' health and offers an opportunity to strengthen patient-provider relationships through responsiveness and rapport building. Secure messaging through a clinic-affiliated smartphone app could enhance patient-centered care between clinical visits.

The Journal of Nutrition, 2019

Background Child cognitive development is influenced by early-life insults and protective factors... more Background Child cognitive development is influenced by early-life insults and protective factors. To what extent these factors have a long-term legacy on child development and hence fulfillment of cognitive potential is unknown. Objective The aim of this study was to examine the relation between early-life factors (birth to 2 y) and cognitive development at 5 y. Methods Observational follow-up visits were made of children at 5 y, previously enrolled in the community-based MAL-ED longitudinal cohort. The burden of enteropathogens, prevalence of illness, complementary diet intake, micronutrient status, and household and maternal factors from birth to 2 y were extensively measured and their relation with the Wechsler Preschool Primary Scales of Intelligence at 5 y was examined through use of linear regression. Results Cognitive T-scores from 813 of 1198 (68%) children were examined and 5 variables had significant associations in multivariable models: mean child plasma transferrin rece...

BMC Infectious Diseases, 2018

Background: Injection drug use (IDU) is a growing public health threat in Virginia, though there ... more Background: Injection drug use (IDU) is a growing public health threat in Virginia, though there is limited knowledge of related morbidity. The purpose of this study was to describe the temporal, geographic and clinical trends and characteristics of infective endocarditis associated with IDU (IDU-IE) and to identify opportunities for better-quality care of people who inject drugs (PWID). Methods: We reviewed charts for all admissions coded for both IE and drug use disorders at the University of Virginia Medical Center (UVA) from January 2000 to July 2016. A random sample of 30 admissions coded for IE per year were reviewed to evaluate temporal trends in the proportion of IDU associated IE cases. Results: There were a total of 76 patients with IDU-IE during the study period, 7.54-fold increase (prevalence ratio: 8.54, 95% CI 3.70-19.72) from 2000 to 2016. The proportion of IE that was IDU-associated increased by nearly 10% each year (prevalence ratio of IDU per year: 1.09, 95% CI: 1.05-1.14). Patients with IDU-IE had longer hospital stays [median days (interquartile range); IDU-IE, 17 (10-29

Water, 2018

Consumption of microbial-contaminated water can result in diarrheal illnesses and enteropathy wit... more Consumption of microbial-contaminated water can result in diarrheal illnesses and enteropathy with the heaviest impact upon children below the age of five. We aimed to provide a comprehensive analysis of water quality in a low-resource setting in Limpopo province, South Africa. Surveys were conducted in 405 households in rural communities of Limpopo province to determine their water-use practices, perceptions of water quality, and household water-treatment methods. Drinking water samples were tested from households for microbiological contamination. Water from potential natural sources were tested for physicochemical and microbiological quality in the dry and wet seasons. Most households had their primary water source piped into their yard or used an intermittent public tap. Approximately one third of caregivers perceived that they could get sick from drinking water. All natural water sources tested positive for fecal contamination at some point during each season. The treated municipal supply never tested positive for fecal contamination; however, the treated system does not reach all residents in the valley; furthermore, frequent shutdowns of the treatment systems and intermittent distribution make the treated water unreliable. The increased water quantity in the wet season correlates with increased treated water from municipal taps and a decrease in the average contaminant levels in household water. This research suggests that wet season increases in water quantity result in more treated water in the region and that is reflected in residents' water-use practices.

Open Forum Infectious Diseases, 2018

Background Injection drug use disorder (IDD) is a growing public health threat in Virginia, altho... more Background Injection drug use disorder (IDD) is a growing public health threat in Virginia, although there is limited knowledge of related morbidity. The purpose of this study was to describe the temporal, geographic, and clinical trends and characteristics of infective endocarditis associated with IDD (IDD-IE) and to identify opportunities for better-quality care of people with IDD. Methods We reviewed charts for all admissions coded for both IE and drug use disorders at the University of Virginia Medical Center (UVA) from January 2000 to July 2016. A random sample of 30 admissions coded for IE per year were reviewed to evaluate temporal trends in the proportion of IDD associated IE cases. Results There were a total of 76 patients with IDD-IE during the study period, with a 7-fold increase in cases of IDD-IE from the early 2000s to 2016. The proportion of IE that was IDD-associated increased by nearly 10% each year (prevalence ratio of IDD per year: 1.09, 95% CI: 1.05–1.14). Patien...

AIDS and behavior, Jan 7, 2018

Stigma has negative consequences for quality of life and HIV care outcomes. PositiveLinks is a mo... more Stigma has negative consequences for quality of life and HIV care outcomes. PositiveLinks is a mobile health intervention that includes a secure anonymous community message board (CMB). We investigated discussion of stigma and changes in stigma scores. Of 77 participants in our pilot, 63% were male, 49% Black, and 72% had incomes below the federal poverty level. Twenty-one percent of CMB posts (394/1834) contained stigma-related content including negative (experiencing stigma) and positive (overcoming stigma) posts addressing intrapersonal and interpersonal stigma. Higher baseline stigma was positively correlated with stress and negatively correlated with HIV care self-efficacy. 12-month data showed a trend toward more improved stigma scores for posters on the CMB versus non-posters (- 4.5 vs - 0.63) and for posters of stigma-related content versus other content (- 5.1 vs - 3.3). Preliminary evidence suggests that a supportive virtual community, accessed through a clinic-affiliated ...

Southern Medical Journal, 2016

The Affordable Care Act (ACA), signed into law in 2010, is expected to expand insurance coverage ... more The Affordable Care Act (ACA), signed into law in 2010, is expected to expand insurance coverage for millions of people in the United States, including people with HIV infection. While several provisions of the ACA have implications for people with HIV, two are expected to have the most far reaching effects on coverage-the expansion of Medicaid eligibility and the creation of new Health Insurance Marketplaces where individuals can purchase private coverage. This issue brief, based on analysis of nationally representative data from the Centers for Disease Control and Prevention's (CDC's) Medical Monitoring Project (MMP), provides the first national estimates of how many people with HIV who are receiving medical care may gain new insurance coverage due to the ACA through both Medicaid expansion and the state Marketplaces. It finds that of the approximately 407,000 people with HIV between the ages of 19-64 in care, most (87%) have incomes below 400% FPL. While Medicaid is their single largest source of coverage (covering about 4 in 10), close to 70,000 (17%) are currently uninsured. Of these, almost 23,000 would gain coverage through the Marketplace (most of whom would be eligible for financial assistance), and approximately 46,910 would be eligible for Medicaid, if all states were to expand Medicaid. However, only 26 states plan to expand their Medicaid programs as of October 2013, which could reduce the number gaining coverage through Medicaid expansion by more than 40%. For individuals left out of coverage expansions, the Ryan White HIV/AIDS Program will continue to be critical; it will also likely continue to remain critical in filling the gaps in insurance coverage for HIV care for many insured people with HIV, as it does today. Lastly, while this analysis focuses on the approximately 407,000 people with HIV between the ages of 19-64 who are already in care, more than 700,000 people with HIV are not yet in care. Based on the findings presented here, an additional 124,000 could gain new coverage due to the ACA, removing one obstacle to care seeking and bringing the total estimated number of people with HIV who could gain new coverage close to 200,000.

AIDS research and therapy, 2017

Immune reconstitution inflammatory syndrome (IRIS) can manifest with initiation or reintroduction... more Immune reconstitution inflammatory syndrome (IRIS) can manifest with initiation or reintroduction of antiretroviral therapy (ART) in persons living with HIV (PLWH). In 2012, updated United States treatment guidelines recommended initiation of ART for all PLWH regardless of CD4 count. The objectives of this study were to quantify hospital usage attributable to IRIS and assess the reasons for hospitalization in PLWH before and after the guideline update. Subjects were PLWH between 18-89 years of age who were hospitalized between November 1, 2009 and July 31, 2014. Equivalent time periods before and after updated treatment guidelines were considered, and designated as Time Period 1 and Time Period 2, respectively. IRIS-attributable hospitalizations were identified by ICD9 codes and electronic medical record searches with subsequent review and confirmation. For hospitalizations that were not confirmed as being IRIS-attributable, primary discharge diagnoses were reviewed. A total of 278 ...

AIDS research and therapy, 2017

Following publication of this article [1], it has come to our attention that one of the authors s... more Following publication of this article [1], it has come to our attention that one of the authors should have had their middle initial included, Kathleen A. McManus. The original article has been updated to reflect this. Furthermore, it was reported in the Methods section that the ages of patients involved in this study were "8-89" when in fact the correct range was 18-89. The original version of the article has been revised to reflect this.

Open Forum Infectious Diseases, 2015

Background. Before the Affordable Care Act (ACA), state AIDS Drug Assistance Programs (ADAPs) wer... more Background. Before the Affordable Care Act (ACA), state AIDS Drug Assistance Programs (ADAPs) were the safety net providing antiretroviral therapy to uninsured/ underinsured people living with HIV (PLWH). Many ADAPs, including Virginia, shifted their healthcare delivery model from a focus on direct medication provision to the purchase of insurance with the advent of ACA in 2014. Virginia ADAP helped enroll clients in ACA insurance plans and paid monthly premiums, medication

Open Forum Infectious Diseases, 2016