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\"She lived in a savage world in an uncivilized age - a world ruled by men and governed by the sword. The[y] called her... Red Sonja - for her flame red hair, and for the smoldering fire of her pride, which gave her sword-arm a strength that few men could match, and none had ever defeated. This collection contains a variety of issues from the original Marvel Comics series 'The Savage Sword of Conan,' as well as Sonja Tales from 'Kull and the Barbarians,' with each page re-mastered for this volume. Also included is a gallery of pin-ups by Frank Thorne, Howard Chaykin, and more. These tales are where it all began, and set the stage for the current Red Sonja series from Dynamite Entertainment\"--back cover.

Background New patients are a particularly vulnerable population because they are at high risk of missing a subsequent visit or dropping out of care completely. However, few data exist on what new patients value in the beginning of a relationship with a new provider. Persons with HIV infection may be an ideal population to study the drivers of a positive initial patient-provider relationship, as it is a chronic and serious condition that requires a reliable, ongoing relationship with a provider. Informed by patients’ real experiences, this study aims to identify what patients see as the most critical elements for building trust and rapport from the outset. Methods We conducted longitudinal, in-person interviews with 21 patients new to the HIV clinic at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, from August 2013 to March 2015. Patients were interviewed across three time points: once before their first provider visit, a second time within two weeks after the first visit, and a third time at 6 to 12 months after the first provider visit. Results We conducted 61 h of patient interviews. The mean age was 53 years; 52% were non-Hispanic white, 23% were non-Hispanic black and 19% were Hispanic. Patients described significant anxiety and vulnerability not just from HIV itself, but also in starting a relationship as a new patient to a new provider. Our analysis of these experiences revealed five actions providers can take to reduce their patients’ anxiety and build trust early in the first visit: 1) provide reassurance to patients, 2) tell patients it’s okay to ask questions, 3) show patients their lab results and explain what they mean, 4) avoid language and behaviors that are judgmental of patients, and 5) ask patients what they want [i.e., treatment goals and preferences]. Conclusions Our study incorporates direct input from patients and highlights the unique psychological challenges that patients face in seeking care from a new provider. The actionable opportunities cited by patients have the potential to mitigate patients’ feelings of anxiety and vulnerability, and thereby improve their overall health care experience.

Background Wait time, defined as time spent in the waiting and exam rooms waiting to see a provider, is a key quality metric in a number of national patient experience surveys. However, the literature on wait time does not show a consistent correlation between long waits and worse overall patient care experiences. Herein, we examine contextual factors that can shape the manner in which patients may respond to different wait times. We also identify actions providers and clinics can take to promote positive wait experiences and mitigate negative ones. Methods We conducted over 130 h of semi-structured interviews with patients new to two HIV primary care clinics in Houston, Texas. We interviewed patients before the first provider visit, again within two weeks of the first visit, and again at 6–12 months. We analyzed the interviews using directed and conventional content analysis. Results Our study showed that patients’ “willingness to wait” is the product of the actual wait time, individual factors, such as the perceived value of the visit and cost of a long wait, and clinic and provider factors. Analyses revealed key steps providers and clinics can take to improve the wait time experience. These include: 1) proactively informing patients of delays, 2) explicitly apologizing for delays, and 3) providing opportunities for diversion. Patients noted the importance of these steps in curtailing frustrations that may result from a long wait. Conclusions Our study highlights key steps cited by patients as having the potential to improve the wait time experience. These steps are practical and of particular interest to clinics, where waits are oftentimes inevitable.

Background. Contemporary antiretroviral treatment regimens are simpler than in the past, with lower pill burden and once-daily dosing frequency common. We performed a meta-analysis of randomized controlled trials (RCTs) to investigate the impact of pill burden and once-daily vs twice-daily dosing on ART adherence and virological outcomes. Methods. A literature search of 4 electronic databases through 31 March 2013 was used. RCTs comparing once-daily vs twice-daily ART regimens that also reported on adherence and virological suppression were included. Study design, study population characteristics, intervention, outcome measures, and study quality were extracted. Study quality was rated using the Cochrane risk-of-bias tool. Results. Nineteen studies met our inclusion criteria (N = 6312 adult patients). Higher pill burden was associated with both lower adherence rates (P = .004) and worse virological suppression (P < .0001) in both once-daily and twice-daily subgroups, although the association with adherence in the once-daily subgroup was not statistically significant. The average adherence was modestly higher in once-daily regimens than twice-daily regimens (weighted mean difference = 2.55%; 95% confidence interval [CI], 1.23 to 3.87; P = .0002). Patients on once-daily regimens did not achieve virological suppression more frequently than patients on twice-daily regimens (relative risk [RR] = 1.01; 95% CI, 0.99 to 1.03; P = .50). Both adherence and viral load suppression decreased over time, but adherence decreased less with once-daily dosing than with twice-daily dosing. Conclusions. Lower pill burden was associated with both better adherence and virological suppression. Adherence, but not virological suppression, was slightly better with once- vs twice-daily regimens.

Analogous to the business model of customer satisfaction and retention, patient satisfaction could serve as an innovative, patient-centered focus for increasing retention in HIV care and adherence to HAART, and ultimately HIV suppression. To test, through structural equation modeling (SEM), a model of HIV suppression in which patient satisfaction influences HIV suppression indirectly through retention in HIV care and adherence to HAART. We conducted a cross-sectional study of adults receiving HIV care at two clinics in Texas. Patient satisfaction was based on two validated items, one adapted from the Consumer Assessment of Healthcare Providers and Systems survey (\"Would you recommend this clinic to other patients with HIV?) and one adapted from the Delighted-Terrible Scale, (\"Overall, how do you feel about the care you got at this clinic in the last 12 months?\"). A validated, single-item question measured adherence to HAART over the past 4 weeks. Retention in HIV care was based on visit constancy in the year prior to the survey. HIV suppression was defined as plasma HIV RNA <48 copies/mL at the time of the survey. We used SEM to test hypothesized relationships. The analyses included 489 patients (94% of eligible patients). The patient satisfaction score had a mean of 8.5 (median 9.2) on a 0- to 10- point scale. A total of 46% reported \"excellent\" adherence, 76% had adequate retention, and 70% had HIV suppression. In SEM analyses, patient satisfaction with care influences retention in HIV care and adherence to HAART, which in turn serve as key determinants of HIV suppression (all p<.0001). Patient satisfaction may have direct effects on retention in HIV care and adherence to HAART. Interventions to improve the care experience, without necessarily targeting objective clinical performance measures, could serve as an innovative method for optimizing HIV outcomes.

Background. Patients with human immunodeficiency virus (HIV) infection need lifelong medical care, but many do not remain in care. The effect of poor retention in care on survival is not known, and we sought to quantify that relationship. Methods. We conducted a retrospective cohort study involving persons newly identified as having HIV infection during 1997–1998 at any United States Department of Veterans Affairs hospital or clinic who started antiretroviral therapy after 1 January 1997. To be included in the study, patients had to have seen a clinician at least once after receiving their first antiretroviral prescription and to have survived for at least 1 year. Patients were divided into 4 groups on the basis of the number of quarters in that year during which they had at least 1 HIV primary care visit. Survival was measured through 2002. Because data were available for only a small number of women, female patients were excluded from the study. Results. A total of 2619 men were followed up for a mean of >4 years each. The median baseline CD4+ cell count and median log10 plasma HIV concentration were 228 × 106 cells/L and 4.58 copies/mL, respectively. Thirty-six percent of the patients had visits in <4 quarters, and 16% died during follow-up. In Cox multivariate regression analysis, compared with persons with visits in all 4 quarters during the first year, the adjusted hazard ratio of death was 1.42 (95% confidence interval, 1.11–1.83; P < .01), 1.67 (95% confidence interval, 1.24–2.25; P < .001), and 1.95 (95% confidence interval, 1.37–2.78; P < .001) for persons with visits in 3 quarters, 2 quarters, and 1 quarter, respectively. Conclusions. Even in a system with few financial barriers to care, a substantial portion of HIV-infected patients have poor retention in care. Poor retention in care predicts poorer survival with HIV infection. Retaining persons in care may improve survival, and optimal methods to retain patients need to be defined.

People with HIV with co-occurring substance use and mental health diagnoses who are unstably housed have poorer outcomes for retention in care and viral suppression. Navigation models are a potential strategy to help this vulnerable population obtain the necessary medical and non-medical services across multiple service systems. The Health Resources and Services Administration's Special Projects of National Significance: \"Building a Medical Home for Multiply-Diagnosed HIV-positive Homeless Populations initiative 2012-2017 found that navigation models may be an effective intervention to support people with HIV with unstable housing improve HIV health outcomes. However, there is limited information about the mechanisms by which this intervention works. In this article, we explore the participant and program factors for achieving stable housing at 6 months and how these factors influence HIV health outcomes. This was a prospective study of 471 unstably housed people with HIV enrolled in a navigation intervention across nine sites in the United Stated from 2013-2017. All sites provided HIV primary medical care. Eight sites were located in urban areas and one site served a predominantly rural population. Two sites were federally qualified health centers, three were city or county health departments, one site was a comprehensive HIV/AIDS service organization, and three sites were outpatient or mobile clinics affiliated with a university -based or hospital system. Data were collected via interview and medical chart review at baseline, post 6 and 12 months. Type and dose of navigation activities were collected via a standardized encounter form. We used a path analysis model with housing stability at 6 months as the mediator to examine the direct and indirect effects of participant's socio-demographics and risk factors and navigation on viral suppression and retention in care at 12 months. Housing stability at 6 months was associated with male gender, younger age, viral suppression at baseline, having a lower risk for opiate use, recent homelessness, lower risk of food insecurity, and a longer length of time living with HIV. Participants who increased self-efficacy with obtaining help by 6 months had significantly higher odds of achieving housing stability. Stable housing, fewer unmet needs, moderate to high risk for opiate use, and viral suppression at baseline had a direct effect on viral suppression at 12 months. The intensity of navigation contact had no direct effect on housing stability and a mixed direct effect on viral suppression. Recent diagnosis with HIV, women, greater social support, increased self-efficacy and higher intensity of navigation contact had a direct effect on improved retention in HIV primary care at 12 months. In this sample of people with HIV who are experiencing homelessness, housing stability had a significant direct path to viral suppression. Navigation activities did not have a direct effect on the path to housing stability but were directly related to retention in care. These results identify key populations and factors to target resources and policies for addressing the health and social unmet needs of people with HIV to achieve housing stability and HIV health outcomes.

Background/Objectives: Effective HIV treatment and prevention rely heavily on patient adherence to the prescribed regimen. Therapeutic drug monitoring (TDM), which involves measuring medication concentrations in blood circulation, offers an objective method to evaluate toxic or ineffective drug levels. TDM is not routinely used in HIV treatment in clinical practice. Therefore, the purpose of this study is to survey infectious disease providers’ attitudes and barriers toward therapeutic drug monitoring for antiretroviral therapy in people living with HIV. Materials and Methods: A 15-item online survey was distributed to infectious disease providers in the Greater Houston area, including physicians, pharmacists, and mid-level practitioners involved in HIV patient care. The survey was disseminated via the Houston Citywide Infectious Disease Provider Network and the Houston AIDS Education and Training Center. The survey employed close-ended questions to evaluate providers’ attitudes, perceptions, practices, and barriers toward antiretroviral drug level monitoring. Responses were recorded using a five-point Likert scale. Demographic characteristics and information regarding research involvement were collected to contextualize the findings. The survey results were analyzed using descriptive statistics, with categorical variables expressed as frequencies and percentages using SAS software. Results: A total of 139 responses were received, with 89 participants meeting the inclusion criteria; the majority were female (62.9%), nearly half were aged 34 or younger (53.4%), 50% were physicians and 36.3% pharmacists, and most worked in hospitals (52.3%) or clinics (35.2%). The findings demonstrate participants’ predominantly positive attitudes toward TDM. Nearly 70% agree (agree or strongly agree) that TDM will be helpful and will positively impact improving drug efficacy and medication adherence. The results revealed barriers to implementing TDM, including a lack of evidence supporting TDM’s impact on HIV outcomes, and the absence of clinical guidelines. The results indicated that >90% were ambivalent or agreed that there was not enough evidence to support the use of TDM, and nearly all recognized that the guidelines do not endorse it or did not know if they do not endorse it. Conclusions: This study highlighted positive attitudes and significant barriers to implementing therapeutic drug monitoring, including a lack of evidence supporting TDM’s impact on HIV outcomes and the absence of clinical guidelines supporting TDM’s widespread use. The findings emphasize the need for clinical trials and longitudinal studies to establish definitive evidence on the effectiveness of TDM in improving HIV treatment outcomes.

Individuals with human immunodeficiency virus (HIV) infection are at increased risk for human papillomavirus—related squamous cell cancer of the anus. Screening HIV-infected patients for squamous cell cancer of the anus and human papillomavirus—related anal dysplasia may prevent excess morbidity and mortality. We have conducted a systematic review of the indirect evidence in the literature regarding the utility of anal Papanicolau (Pap) smear screening of HIV-infected individuals in the highly active antiretroviral therapy era. Although there are no published studies evaluating the efficacy of anal Pap smear screening for preventing squamous cell cancer of the anus or anal intraepithelial neoplasia, we reviewed data regarding the burden of disease, anal Pap smear sensitivity and specificity, the prevalence of anal dysplasia, and 1 cost effectiveness study. The available evidence demonstrates that HIV-infected individuals have an increased risk for squamous cell cancer of the anus and anal intraepithelial neoplasia. This review identifies important areas for further study before routine anal Pap smear screening can be recommended.

Little is known about the treatment outcomes of undocumented Hispanic immigrants with HIV infection. We sought to compare the treatment outcomes of undocumented and documented patients 12-months after entering HIV care. We conducted a retrospective cohort study of antiretroviral-naive patients 18 years and older attending their first visit at Thomas Street Health Center in Houston, Texas, between 1/1/2003 and 6/30/2008. The study population of 1,620 HIV-infected adults included 186 undocumented Hispanic, 278 documented Hispanic, 986 Black, and 170 White patients. The main outcome measures were retention in care (quarter years with at least one completed HIV primary care provider visit) and HIV suppression (HIV RNA <400 copies/mL), both measured 12-months after entering HIV care. Undocumented Hispanic patients had lower median initial CD4 cell count (132 cells/mm(3)) than documented Hispanic patients (166 cells/mm(3); P = 0.186), Black patients (226 cells/mm(3); P<0.001), and White patients (264 cells/mm(3); P = 0.001). However, once in care, undocumented Hispanic patients did as well or better than their documented counterparts. One year after entering HIV care, undocumented Hispanics achieved similar rates of retention in care and HIV suppression as documented Hispanic and White patients. Of note, black patients were significantly less likely to have optimal retention in care (adjusted odds ratio [aOR] 0.65, CI = 0.45-0.94) or achieve HIV suppression (aOR 0.32, CI = 0.17-0.61) than undocumented Hispanics. Undocumented Hispanic persons with HIV infection enter care with more advanced disease than documented persons, suggesting testing and/or linkage to care efforts for this difficult-to-reach population need intensification. Once diagnosed, however, undocumented Hispanics have outcomes as good as or better than other racial/ethnic groups. Safety net providers for undocumented immigrants are vital for maintaining individual and public health.