N = 25) as part of a community-based HIV testing study with heterosexuals in a high-poverty, high-HIV-incidence urban area. A sequential explanatory mixed-methods design was used. We described linkage to HIV care and clinical outcomes  over 1 year, and then addressed qualitative research questions about the experience of receiving a new HIV diagnosis, its effects on timely engagement in HIV care, and other barriers and facilitators. Participants were assessed five times, receiving a structured interview battery, laboratory tests, data extraction from the medical record, a post-test counseling session, and in-person/phone contacts to foster linkage to care. Participants were randomly selected for qualitative interviews (N = 15/25) that were recorded and transcribed, then analyzed using systematic content analysis. Participants were 50 years old, on average (SD = 7.2 years), mostly male (80%), primarily African-American/Black (88%), and low socioeconomic status. At the first follow-up, rates of engagement in care were high (78%), but viral suppression was modest (39%). Rates improved by the final follow-up . Two-thirds (69%) were adequately retained in care over 1 year. Qualitative results revealed multi-faceted responses to receiving an HIV diagnosis. Problems accepting and internalizing one’s HIV status were common. Reaching acceptance of one’s HIV-infected status was frequently a protracted and circuitous process, but acceptance is vital for engagement in HIV care. Fear of stigma and loss of important relationships were potent barriers to acceptance. Thus, partially as a result of difficulties accepting HIV status, delays in achieving an undetectable VL are common in this population, with serious potential negative consequences for individual and public health. Interventions to foster acceptance of HIV status are needed.After HIV diagnosis, heterosexuals in high-poverty urban areas evidence delays in linkage to care and antiretroviral therapy initiation compared to other groups. Yet barriers to/facilitators of HIV care among these high-risk heterosexuals are understudied. Under the theory of triadic influence, putative barriers to HIV care engagement include individual/attitudinal-level , social-level , and structural-level influences . Participants were African-American/Black and Hispanic adults found newly diagnosed with HIV ( To eliminate HIV transmission in the United States, persons living with HIV (PLWH) must be aware of their diagnoses, engage in regular HIV medical care, initiate antiretroviral therapy (ART), and adhere well to ART, in order to achieve viral suppression , 2. AlthThe present study focuses on African-American/Black and Hispanic heterosexuals newly diagnosed with HIV infection as part of a community-based HIV testing study. Consistent with the National HIV Behavioral Surveillance system of the CDC, we define high-risk heterosexuals as those socially connected to urban geographical areas with elevated rates of both socioeconomic disadvantage and HIV prevalence . In factTheoretical barriers to engagement in HIV primary care and uptake of ART among newly diagnosed high-risk heterosexuals can be conceptualized using the theory of triadic influence , a sociaMoreover, a small number of recent studies have focused on an additional individual/attitudinal-level factor among vulnerable populations—acceptance of a new HIV diagnosis. In a qualitative study of MSM and women, Baumgartner and David  describeThe present mixed-methods study focuses on high-risk heterosexuals newly diagnosed with HIV. In response to the gaps in the literature described above, we first describe patterns of linkage to HIV care and clinical outcomes (CD4 counts and VL levels) over a 1-year period, to identify both successes and gaps, using quantitative data. Then, in response to these quantitative findings, we address a set of qualitative research questions focused on how individuals experience a new HIV diagnosis and the effects of this experience and other multi-level factors on timely engagement along the HIV care continuum. Finally, we discuss how findings that emerged from the qualitative data can be used to provide a deeper understanding of the patterns of engagement in HIV care after initial diagnosis and of barriers to such engagement.http://ClinicalTrials.gov (NCT01607541).The present study used a sequential explanatory mixed-methods design  with a sN = 25), and these newly diagnosed individuals are the focus of the present study.Participants were those identified as newly diagnosed with HIV in a larger study designed to seek out high-risk heterosexuals with undiagnosed HIV. Participants were recruited using respondent-driven sampling (RDS), a peer-to-peer recruitment method, and provided with confidential HIV counseling and testing, as described in brief below and in detail elsewhere . The ratEligibility criteria were as follows: age 18–60 years, sexually active with at least one opposite-sex partner in the past year, African-American/Black or Hispanic race/ethnicity, resides in a defined high-risk urban geographical area with elevated rates of prevalent HIV and poverty, comprehends English or Spanish, not actively psychotic, and found newly diagnosed with HIV in the larger study’s first phase .N = 115 participants with past HIV diagnosis entered the study, as shown in Figure In recent research, we reported on the first phase of the larger study designed to locate high-risk heterosexuals with undiagnosed HIV infection in New York City, using a “Seek, Test, Treat, and Retain” approach . In the N = 25; 5 intervention arm, 20 control arm) was lower than hypothesized based on past surveillance studies  and post-test counseling were provided, following the CDC and local  guidelines for post-test counseling. These guidelines included an initial risk reduction and disclosure plan and an appointment for HIV care made for participants. Participants received compensation for the session ($30), plus local round-trip public transportation. After this session, those assigned to the intervention arm received patient navigation (3 months of intensive navigation and 3 months of maintenance navigation). Navigation is an efficacious, flexible, individualized, strengths-based approach to assist PLWH in identifying and overcoming barriers to health services , 35. It Primary study outcomes for the quantitative study component included time to an HIV clinic appointment , time to initiating ART, HIV VL suppression, and retention in care among the newly diagnosed. Participants were considered retained in care if they saw an HIV care provider at least three times in the year after diagnosis, with two visits at least 90 days apart .Participants received a structured assessment battery at five time points: baseline in the larger study’s first phase, the time of initial diagnosis [called the Time 2 (T2) assessment], and 3 (T3), 6 (T4), and 12 months post-diagnosis (T5). The T2, T3, and T4 interviews assessed the prior quarter, and the T5 interview assessed the prior 6 months. All assessments were conducted using audio computer-assisted self-interviewing (ACASI) software and lasted approximately an hour. Participants received $30 in compensation for assessments. For parsimony in analysis, we combined the T2 and T3 assessments and T4 and T5 assessments. Retention rates were high: most completed T2 and/or T3 , and T4 and/or T5 , as shown in Figure From the 25 participants found newly diagnosed with HIV, 15 were selected at random for participation in qualitative interviews . We conducted one-on-one, semi-structured, in-depth qualitative interviews in a confidential location at the study’s community-based field site. Interviews were conducted by experienced qualitative researchers, lasted 60–90 min and were audio-recorded and professionally transcribed verbatim. Identifying information was removed from transcripts. Interviews were conducted 8–11 months post-enrollment. Participants were compensated $30 and provided with funds for round-trip local public transportation.Qualitative interviews followed a semi-structured guide that included main questions and probes linked to domains of the theory of triadic influence and known or hypothesized barriers to linkage to HIV care , and also allowed for emergent themes . Questions focused on the experience of receiving the new HIV diagnosis, experiences of linkage to HIV care, barriers to and facilitators of linkage to HIV care, retention in care, and initiation of and adherence to ART.Clinical case notes from intervention sessions, navigation, and phone contacts with participants with respect to barriers to and facilitators of linkage to care and related issues were recorded in a confidential database and included in the qualitative data set. The number of navigation contacts, both in-person and phone, ranged from 6 to 51 contacts , some of them brief.Participants provided a blood specimen at T2 and T5 for testing of CD4 count and VL. Participants received $25 in compensation for blood draws. Blood specimens were processed by commercial laboratories. VL was tested using the COBAS Amplicor Ultrasensitive HIV-1 RNA PCR assay (Version 2.0), viral suppression/undetectable VL was defined as VL < 50 copies/ml. Most participants provided blood specimens at T2 (84%) and T5 (80%), as shown in Figure At T5, a medical report form was completed by the participant’s health-care provider, extracting data on attendance at care appointments, to assess retention in care, CD4 values, and VL values over the past year. An MRF was received for 64% of participants Figure . When boThe measures used in the present study were drawn primarily from a set of harmonized instruments used for the set of Seek, Test, Treat, and Retain studies sponsored by the National Institute on Drug Abuse (NIDA) at the National Institutes of Health . These mCharacteristics such as age, race/ethnicity, gender, education level, insurance, housing status, employment, and financial insecurity  were measured using a structured NIDA-harmonized instrument .We assessed general health on a five-point Likert-type scale [scores were collapsed to indicate whether general health was “good” or better (yes/no) ]. DepresFrequency of drug and alcohol use in the past month was assessed , 43, aloThe National HIV Behavioral Surveillance System measure , 47 was HIV health behavior, including engagement in HIV care, where care was received, initiation and continuation of ART, and whether CD4 and VL tests were received, were assessed with a measure from the HIV Cost and Services Utilization Study (HCSUS) .Descriptive statistics including counts, percentages, means, and SDs are presented in analyses. Figures showing CD4 and HIV VL over time were constructed using the ggplot2 R package . All anaWe applied a systematic content analysis approach that was both theory-driven and inductive , 52. DatWe evaluated concordance between specific case study participants’ descriptions of their engagement in HIV care and ART and quantitative ratings derived from MRFs and T2 and T5 biomarker test results collected by the study. Thus qualitative data, case notes, and medical data were triangulated to enhance data quality . FindingTable n = 19) already had a regular health-care provider (84%) and usually received care in a hospital clinic (47%), other clinic (21%), or private doctor’s office (16%). Regarding the first follow-up period (T2/T3), MRFs and data from the assessment battery indicate 80% were linked to care within 90 days of diagnosis and/or by T2/T3. The mean CD4 count was 569 cells/mm3 (SD = 364 cells/mm3), based on MRF or blood draw, and the mean log10 transformed VL was 2.9 (SD = 1.4), by MRF or blood draw. About half (52%) had taken ART in that period; 82% of these participants had continued with ART. At the T4/T5 follow-up interview(s), 96% had seen a health-care provider for their HIV diagnosis. Most (96%) reported completing CD4 and VL testing at least once, with an average CD4 result of 559 cells/mm3 (SD = 357 cells/mm3) and an average log10 transformed VL of 2.4 (SD = 1.4 log10 transformed VL), based on MRF or blood draw. Approximately two-thirds (69%) were retained in HIV care over the previous 12-month period. At the first follow-up period, 39% had undetectable VL, and 62% had undetectable VL by the final follow-up period. Most had taken ART by the final follow-up point (87.0%). In 7 out of 16 MRFs, we found evidence of an HIV diagnosis prior to study involvement .Table Overall, these quantitative data show good engagement in HIV care and clinical outcomes but suggest that a substantial minority (~20%) were slow to engage in HIV care, and most experienced delays in achieving good adherence to ART in order to achieve undetectable VL (~60%). Yet these gaps in HIV care engagement and ART uptake were reduced by the final follow-up point. Further, we found a substantial proportion of the cohort had been previously diagnosed with HIV, but had not elected to disclose their HIV status to the study at enrollment. Thus, guided by the theoretical model and the review of the literature described above, the answers to a number of main qualitative research questions seem relevant to understanding these results: how did participants experience and adapt to the receipt of the HIV diagnosis, whether it was new to them or not, and how did this experience influence their motivation and/or abilities to engage in HIV care and/or initiate ART? Embedded in this question is an exploration of the reasons why participants did not disclose their HIV status to the study at enrollment. In addition, what other factors promoted or impeded engagement in HIV care and uptake of ART with good adherence over the study period?Drawing on both prospective and retrospective reports, we found acceptance of a new HIV diagnosis was often not a simple, binary phenomenon whereby participants thought of themselves as not being infected with HIV one moment, were tested and told of their positive test result, and then accepted that diagnosis as true or accurate in the next. Instead, we found the state of “knowing” one was infected with HIV at the time of receiving the new diagnosis, whether in the course of the present study or prior to it, was complex, multi-faceted, and evolving over time. With respect to prior knowledge of the HIV diagnosis provided in the study, some participants reported no previous knowledge of the diagnosis, and others reported having concerns and suspicions they were infected . Some participants had been informed of an HIV diagnosis in the past but had not personally accepted that diagnosis as accurate, while a small number had been previously diagnosed and had integrated and accepted the diagnosis into their self-concept, which allowed for HIV-related risk reduction, disclosure, and health-care behaviors. Indeed, regardless of whether they had accepted their HIV status during the course of the study, we found it was common, if not typical, for participants who had been told in the past they were HIV infected to have found themselves unable to accept or integrate that knowledge into their sense of self, sometimes for as long as a decade or more. Yet even these participants, who could be described as “in denial” and whom we characterize as experiencing “delayed acceptance,” at the same time often evidenced some level of “knowing” they were HIV infected, as we describe below. Thus, we found some participants reported both knowing and not knowing about their HIV-infected status simultaneously.Thus, we characterized the primary reactions to a new HIV diagnosis evident in the present study as falling into the following typologies: (1) there was no expectation of an HIV diagnosis, the diagnosis precipitated a crisis, and acceptance of the new diagnosis was slow; (2) there was suspicion of an HIV diagnosis, and the information was met with acceptance; (3) the new diagnosis revealed a combination of denial and some level of knowing about the diagnosis; and (4) the participant was, in fact, already aware of the past diagnosis, but chose not to disclose it to the study. Below, we present case studies that illuminate the main aspects of each of the first three typologies, including their implications for engagement in HIV care and uptake of ART, as well as the cases’ relationships to themes found more broadly in the qualitative analysis. For parsimony, we do not describe the fourth typology, but attend to this group in the Section “The case studies presented below describe male participants, because almost all enrolled in the study were men. We attend to commonalities among men and women and themes specific to women in a brief section below. The names used below are pseudonyms, and identifying details have been changed to protect participants’ confidentiality. For context, the case studies include some description of participants’ experiences in the study’s first phase, when HIV testing was provided, as well as the second, which focused on providing post-test counseling and linkage to HIV care. Further, cases reflect participants’ natural histories, as well as their engagement with the research project, which provided navigation (intervention arm) or standard care (control arm).Jerry was a 34-year-old African-American/Black man in an on-again/off-again relationship with a woman who was the mother of the youngest of his three children. Jerry had been incarcerated for varying lengths of time in the past, and partly as a result of these incarcerations, he was unemployed and in need of stable housing when he entered the study, residing only temporarily with his mother.Upon consenting to the rapid HIV test  and receiving a preliminary positive test result, Jerry expressed what he later described as an almost overpowering sense of fear, shock, and disbelief, as well as an inability to accept the veracity of the test results. In an effort to facilitate his acceptance of the new diagnosis, he was offered the opportunity to view the actual HIV test device that indicated the positive result, but he declined. He was then asked if he would agree to participate in post-test counseling with the study interventionist, despite his inability to accept the HIV test result as accurate. While his first impulse was to flee from the room and leave the facility, with great reluctance he did elect to stay and discuss the test result. In keeping with the study protocol and ethos, his autonomy was respected as study activities were offered to him, and his choices were solicited and respected.During the course of the post-test counseling session, the interventionist sought to help Jerry manage these powerful negative reactions to the diagnosis, prevent escalation to a larger crisis, and encourage Jerry to stay engaged with the research study. In fact, despite Jerry’s severe negative emotional reactions, he did agree to stay in touch with his interventionist and to ask questions and seek support from her and others as needed. At the end of the second intervention session (the last activity in the study’s first phase), Jerry was still unable to accept the HIV diagnosis as true or accurate. However, Jerry consented to a confirmatory HIV test  and provided a blood specimen for CD4 and VL testing. He agreed to schedule his post-test counseling intervention session, which would take place 2 weeks later, where he would receive confirmatory HIV test results. During this interim period, the confirmatory test results were received, which indicated that consistent with the rapid HIV test results, Jerry was indeed infected with HIV.HIV is another level. It’s not like gonorrhea, syphilis, chlamydia, crabs, it’s a whole ’nother level. You know what I’m saying? I was nervous.Over the next 5 weeks, Jerry repeatedly canceled appointments for his post-test counseling intervention session, and reported to his interventionist he was not yet emotionally prepared to meet and discuss his HIV diagnosis. He was, in fact, still feeling overwhelmed by the prospect of an HIV diagnosis. As he later recalled,Like I said, I still wanna get the results from the blood first before everything. I really didn’t do nothing yet about [confirming my diagnosis]. Like I said, I’m scared, but at the end of the day I’m still gonna have to—I have to accept it and just go up in there [to the primary care provider] and see what’s goin’ on. But, I ain’t really doin’ it yet.Five weeks passed. Jerry was still not ready to receive his confirmatory test results from the research study. Yet, during that period, he stayed in touch with his study interventionist. He informed her he sought advice from his primary care physician and consented to a blood-based laboratory HIV test from him. However, Jerry delayed receiving the test results from the primary care provider as well, as he reported:Consistent with the motivational interviewing approach, the study interventionist did not pressure him to accept the diagnosis, but instead encouraged him to explore his personal reactions to the test results she had provided, make decisions about the steps he would take to regain emotional equilibrium, evaluate his sexual behavior in light of this information, and seek out support.I put it like this, I’m not saying nothing to no one [about the diagnosis] until I take that blood test. ’Cause even though by swab, it could be in your saliva, it doesn’t mean it’s in your system. So, when I go do that blood work, and I find out the real results, then I could be able to open up about it. Right now, I don’t wanna say nothing ’bout it.Especially during the times when Jerry wished to disavow the positive test results he received from the research study, he would return to the hope that the results were inaccurate because he received a test using oral fluids during the research study, but not a blood specimen. In fact, he cited this as a reason for the delays he experienced accepting the truth of his diagnosis:Cause I don’t wanna know the full answer … I’m saying I’ll go do it, I just wanna take it one step at a time. You know what I’m sayin’? I’ll do it by myself, but I’m just not ready right now. But Imma go. Eventually, Imma go.Yet Jerry also continued to express apprehension regarding receiving his HIV blood tests results from his primary care provider. He acknowledged that he was waiting to feel “ready” to receive these test results before acknowledging to himself and others that he was infected with HIV, and then seeking HIV care. Jerry understood that eventually he would need to do so. But, he would do so in his own time, as he explained:death sentence” that Jerry associated with HIV infection, he also noted fears of stigma surrounding being infected with HIV. For example, although Jerry was in need of housing, and the local social services administration provides housing for people living with HIV, Jerry’s fear of HIV-related stigma prevented him from accessing those services, as he recalled:I don’t wanna go to no HIV housing. ’Cause once you go to HIV housing, everyone already knows you—what it is.Furthermore, in addition to reporting anxiety around the potential “Despite not accepting or, at least, not fully accepting the diagnosis, Jerry began to evaluate his sexual behavior. Indeed, Jerry had an active sex life with a substantial number of different partners. Jerry expressed concern about how HIV might negatively affect this important aspect of his life. In particular, Jerry was concerned about the effectiveness of condoms and how to negotiate safer sex. He reported a lack of confidence about his understanding of HIV infection and how HIV is transmitted to partners. Again, although the study interventionist was, in theory, able to refer him to sexual health services to bolster his personal secondary prevention efforts, his difficulty accepting the HIV diagnosis limited his willingness to do so. Yet he continued to engage with his study interventionist by phone, and consider changes he might need to make–if and when he was ready to accept the diagnosis.Throughout his time enrolled in the study, Jerry continued to struggle to accept that he was, in fact, infected with HIV. Jerry did not agree to receive confirmatory results of his HIV test from the study or participate in the post-test counseling intervention session, although, notably, he did return phone calls from the interventionist, engage in discussions with her, and agree to participate in other project activities including the in-depth qualitative interview, blood draws, and a structured assessment battery.At the time he concluded his participation in the study, Jerry evidenced only very modest progress in his abilities to accept and adapt to his new diagnosis. Because his fears and anxieties surrounding the meaning of an HIV-positive status seemed insurmountable to him, he could not bring himself to receive either his confirmatory test results from the research study or his blood test results from his primary care provider. Given that he could not accept that he was HIV infected, he did not seek HIV primary care. HIV biomarker data collected from him at two time points over the course of the study Figure  showed dIn the sample more generally, we found, in both retrospective and prospective reports, slow acceptance of a new HIV diagnosis was common in this cohort. Further, Jerry’s case highlighted a number of themes found more broadly in this study; for example, that HIV may be considered a “death sentence,” even in the context of current highly tolerable and effective ART regimens. Further, participants commonly reported they had insufficient knowledge surrounding HIV transmission and HIV prevention. Finally, fears regarding the ways in which an HIV diagnosis might interfere with or even foreclose upon future intimate relationships, the importance of maintaining sexual and romantic relationships, and the critical role of stigma, were potent barriers to acceptance of HIV status. Certainly, we found that learning one has a life changing and stigmatized diagnosis does not always result in timely acceptance of that knowledge, and a lack of acceptance can be a powerful barrier to the receipt of HIV care.Carl was a 58-year-old African-American/Black man staying in a homeless shelter at the time he enrolled in the study, where, instead of a bed, he slept upright in a chair because of overcrowding. Carl reported he had not been engaged in any type of medical care for as long as he could remember, only visiting an emergency department if it was unavoidable. Further, he indicated he suffered from some cognitive impairment due to an earlier traumatic brain injury, making it difficult for him, for example, to plan or enact sequences of new activities. Moreover, at the time he entered the study, Carl felt run-down and sick. He had trouble walking and had been drinking heavily over the last several months. Carl reported he had never been tested for HIV, but that he suspected that he might be HIV infected. He noted that after the death of his wife 15 years prior, he had started to drink daily and engage in what he considered risky sexual behaviors with a number of partners. When Carl was offered an HIV test in the study’s first phase, he began to prepare himself emotionally for the possibility of receiving an HIV diagnosis.It really hurt when I found out I had it. It was a big blow. But I’m gonna take one step at a time. It’s a long, long road.After receiving his preliminary positive HIV test results from the rapid test, Carl was upset, but remained calm and maintained perspective. He later recalled,Immediately after learning his status, Carl stated he was willing to obtain HIV primary care, but explained that he was unable to do so because he had no phone and no means of transportation—common barriers to HIV care among this population. After providing him with the confirmatory test results and post-test counseling in session 3, he was also given a phone and funds for round-trip local public transportation—simple and practical, yet critical, forms of assistance.Moreover, cognitive challenges related to the traumatic brain injury compounded the difficulties Carl faced linking to HIV care and other social services. Yet, with concrete guidance from his study interventionist, including assistance with paperwork to apply for public insurance (Medicaid), Carl was referred by the study to a comprehensive care social service agency, which provided case management, nutrition support, support groups, housing assistance, and HIV primary care—a setting that seemed optimal given Carl’s needs.I always take my medication. I feel healthy [now], like I was 17.”Soon after, Carl attended his initial HIV primary care appointment at this multi-service organization. Much to his surprise, in addition to HIV infection, he was also diagnosed with diabetes. He then initiated ART and treatment for diabetes and reported being pleased with a rapid and dramatic improvement in his health. He noted, “However, at times it was challenging for Carl to adhere to his HIV medications. For example, at one point he took a trip to visit family who did not know about his HIV status. Because Carl was not yet prepared to disclose his HIV status to these family members, he left his HIV medication at home rather than risk his family members’ accidently learning of his HIV status. Consequently, Carl’s VL, which had dropped dramatically in response to the ART regimen, rebounded, as shown in Figure (I) just take my medicine, take one pill. When I miss a lot of days … [my viral load] goes back up. My [viral load] when I first went in, was like, over 100,000. Now I got it down low. I think it’s down to 22,000. But I got to get it back to 40 (undetectable). Because, see once I get it to 40 again, I get $150 bonus card.Periodic contacts during the navigation period were used to help him identify barriers to maintaining good adherence to ART and making good decisions about his health behaviors. Upon learning of the effect his non-adherence to the ART regimen had on his VL levels, Carl was upset and re-committed to adhering well to the medication. Further, Carl enrolled in a conditional economic incentive program at the organization; that is, an intervention that reinforces adherence to HIV medication regimens with economic incentives provided when participants achieve undetectable VL. Carl found the program beneficial, as he stated:complete faith” in the information they provided to him regarding management of his HIV infection. Further, Carl moved from the shelter into an apartment with a life-long friend. In navigation contacts, he weighed the pros and cons of sharing his HIV status with this person and decided to do so. In fact, this friend was an ongoing source of support and was the only person to whom Carl disclosed his status during the study. Further, through the social service organization where he received services and HIV care, Carl applied for supplemental security income and housing for HIV-infected persons. Unfortunately, though, before his city-sponsored HIV housing came through, Carl had to leave his friend’s apartment. He acknowledged this was stressful for him, saying, “I lost weight. Probably stress. Because I got to go back to the shelter.” Carl asserted, however, that he was able to maintain his health and good ART adherence while waiting for housing, even if he had to live in a shelter, noting, “no, I’ll take my medication with me. I still see my doctor.”Importantly, over the course of his participation in the study, Carl developed positive relationships with his doctor and case manager, and reported having “Because I wouldn’t give them the HIV. You don’t want nobody to give you that, right?”Carl stated he was motivated to reduce his chances of transmitting HIV to others by taking ART, and by refraining from sexual behavior at this point. He was still considering how he might negotiate condom use and disclosure to sexual partners in the future, as he stated, “Over the course of the study, Carl’s physical health showed improvement. His CD4 increased. Yet consistent with his reports of inconsistent adherence, his VL data were variable Figure .No, I didn’t know [I was infected with HIV]. I really didn’t. So, in a way that guy like saved my life when he give me the card to come here.Carl’s case highlights a number of themes common among participants receiving a new diagnosis. First, while Carl may have been concerned he was infected with HIV, he had never been tested for HIV. He was brought to the study through active outreach from a peer as part of RDS and agreed to be tested. With respect to the peer recruitment component of the study he noted,Further, like many participants in the study, Carl was faced with a number of potent structural barriers to his timely engagement in HIV medical care, including lack of transportation and difficulties applying for public health insurance. There is growing awareness in HIV testing and clinical settings regarding the need to resolve or circumvent such barriers to health care, similar to the approach taken in the present study. Once linked to a multi-service organization, Carl developed an open and trusting relationship with his health-care and social service providers. This setting provided him with high-quality HIV care and assisted him with managing his other significant life stressors, in particular his diabetes and housing instability. Moreover, similar to Jerry’s experiences, and results in the sample more broadly, fear of stigma was a primary theme. Finally, Carl lacked confidence in his ability to negotiate safer sex and struggled to find a way to have a satisfactory sexual and romantic life while living with HIV.Lawrence, a 42-year-old African-American/Black man, entered the project in the midst of a marital crisis. Lawrence and his wife, Brenda, had been married for 10 years and had three children together. He was employed by the local transit authority, while she stayed home with the children. Lawrence was recruited into the study by Brenda, who, 7 months pregnant with their fourth child, tested positive for HIV during the course of her own participation in the first phase of this research study. Although Brenda had been tested for HIV early in her pregnancy and found to be uninfected, she had seroconverted by the time she reached her seventh month.Prior to her being tested in the study, Brenda had asked Lawrence to participate in the research project, as part of her peer recruitment activities. However, Lawrence was non-committal and put her off. But after Brenda was found infected with HIV, she again asked Lawrence to present to the study. Under these circumstances, Lawrence agreed to enroll. He participated in HIV counseling and testing and received confirmation that he also was living with HIV.vaguely remembered” was found HIV infected after they had ended their relationship. She contacted him at the time she was diagnosed, and he was tested soon after. Lawrence reported he found it difficult to remember the details of this period of his life with any specificity, but recalled he was told at this time was HIV infected. But, as he went on to explain, he did not tell anyone of his status, and did not engage in HIV care. Lawrence could not bring himself to fully accept the diagnosis. He reported on the one hand, he “knew” he had HIV because he had been told by a medical provider he was HIV infected. At the same time, for reasons he had difficulty articulating, he could not allow himself to know that he was HIV infected.Lawrence’s initial reactions were guilt and concern for his wife and children. In fact, he was not surprised by Brenda’s test results. He reported, with hesitation and distress, that over a decade earlier he had a former female partner who he “Like I said, I’m lucky because how I got contacted with [HIV] was like about 10 years ago, after the girl I was with [and before] I met my wife. But before I met [my wife] I got hit, you know what I mean? But it somehow, some way it was in a cocoon or something like that, or whatever in my body. It recently burst. Now if it had been opened [before], God only knows how bad it would have really gotten.Lawrence kept his HIV diagnosis largely, but not entirely, out of his own awareness over the next 10 years, as well as he could, in part by drawing on a misconception that if someone had no discernable symptoms of HIV, there was no need for concern regarding HIV’s impact on the body. Lawrence believed his HIV infection existed in a “cocoon” in his body, which would only affect him when it “burst,” which he believed only took place around the time that Brenda became infected with HIV. As he recounted:Lawrence relied on the fact that Brenda had tested HIV negative during her previous pregnancies as another rationale for not disclosing his HIV status to her or integrating the diagnosis into his sense of self. In other words, as time went on, and Brenda remained uninfected with HIV, he became increasingly convinced that he would not transmit HIV to her. Yet, a sense of guilt ate at him, and he lived in fear she would find out about his HIV status and leave him. This fear of the marriage ending appeared to be the primary reason Lawrence did not disclose his HIV status to her, or fully acknowledge it to himself.But her, it counted more, you know what I am saying, because she got [it] through me, so I thought the worst, I thought she was gonna leave me, take the kids and all that … I was shocked, because I thought she wanted to kill me. You know what I am saying, I thought she wanted to kill me at first, I was like, oh, can I sleep with you, can I live in this house—can I stay in here?Thus at the time he was diagnosed, Lawrence’s primary concerns were regarding his marriage, as he was certain Brenda would leave him once their HIV statuses were revealed. As he recalled,Yet Lawrence’s fears did not become reality. Brenda and Lawrence did not end their marriage, and in fact relied on one another as they weathered one health decision after another. Brenda received timely medical intervention to prevent mother-to-child transmission of HIV to their child, gave birth by Cesarean section, and stayed on ART after the pregnancy. Because the diagnosis was made late in the pregnancy, the baby was put on ART after birth for a period of time, and Brenda could not breastfeed, which caused her sadness. However, the baby was eventually pronounced free of HIV infection. One by one, the other children received HIV testing, and all were found uninfected.open-minded,” “like a family,” “giving (him) hope,” and “caring,” played an important role in helping Lawrence manage this painful, critical period in his life.Lawrence reported being highly motivated to engage in HIV care on a consistent schedule, initiate ART, and adhere to his ART regimen, in part in response to the guilt he felt over how things transpired, and due to his newfound perspective on his HIV infection. In fact, he described his HIV diagnosis as a life-changing experience and suggested he felt relief at not having to hide his status from himself and others. Based on HIV biomarker data collected over the course of his enrollment in the study, Lawrence’s physical health showed marked improvement: his VL decreased over his time in the study, and his CD4 cell count increased Figure . The stuLawrence’s fears surrounding the potentially negative effects of an HIV disclosure on his intimate relationships served as an impediment to his accepting his own HIV diagnosis over a long period of time, with significant costs to his sense of self and well-being. As noted above, a long and difficult trajectory to accepting one’s diagnosis was common in this sample. Thus, Lawrence’s case highlights how accepting an HIV diagnosis can be a lengthy and complex process for many PLWH, sometimes with serious negative consequences for one’s health and the health of loved ones. Further, low HIV health literacy, such as the idea that HIV lives in a cocoon, may impede acceptance of a new HIV diagnosis, as many PLWH who feel healthy express misconceptions about HIV, such as a lack of a need for treatment until one is ill.The analyses presented above focused primarily on the experiences of men, given the nature of the data set, and congruent with local epidemiology where more men than women are diagnosed with HIV. Nonetheless, we found a number of results specific to high-risk heterosexual women.When I found out [I had HIV], I was in denial for a long time. But I had to grasp myself because I got children …. I went down to 90 pound with bricks in my pocket. And then, I got tired of my kids worrying about me. All the nurses and everybody kept calling, and I got tired of the way I looked at myself. I really looked in the mirror at myself and I thought, damn [Jonelle], you like 55-years old, you look like you’re 90-years old. And I just had the crap scared out of me, scared right? That’s all, I had to get right.As we described above, men commonly feared the loss of their sexuality and sexual relationships, and this caused distress and impeded their accepting their diagnoses. Yet, interestingly, this theme did not arise among female participants. Instead, women commonly described their responsibilities caring for children and family members as primary motivators for self-care. Moreover, they described a number of challenges related to disclosing their HIV status to their children, such as if, when, and how to disclose. Men, on the other hand, did not reference either caregiving or children as aspects of their adaptation to HIV. For example, as Jonelle, a 57-year-old African-American/Black woman described,I found out that person that I was with had HIV. And he was sayin’ that he didn’t know that he had it. He told me he didn’t know and then, when the red flag went up [and I was suspicious about his status], he knew. He knew.”Finally, the theme of betrayal arose for both sexes. However, women more commonly than men described being “betrayed” by male partners who transmitted HIV to them, either unknowingly, or in some cases, and consistent with the cases described above, in the context of the male partner’s knowledge, at least on some level, that he was infected with HIV. As Jonelle described, “Among high-risk heterosexuals, reactions to receiving a new HIV diagnosis are complex and multi-faceted. We found difficulty accepting and internalizing one’s HIV status is frequently a challenge and is often a central reason for non-disclosure of HIV status to friends, family, sexual partners, and even researchers. Indeed, drawing on both prospective and retrospective qualitative data, we found knowledge of one’s HIV status in this population is not typically a simple binary phenomenon after diagnosis, even for months or years after diagnosis. That is, participants typically do not think of themselves as uninfected with HIV one moment, then after being informed the HIV test is positive, immediately understand, accept, and/or “know” that they are infected. Rather, we identified four main ways in which high-risk heterosexuals react to receiving an HIV diagnosis . These reactions, for the most part, can be placed on a continuum of acceptance of HIV status, ranging from no acceptance at all  to full knowledge and acceptance of HIV infection. Moreover, years might pass while individuals struggle to become ready to accept an HIV diagnosis. Yet not accepting one’s HIV diagnosis has serious potential adverse public health consequences, because such acceptance is typically a prerequisite for engagement in HIV care, uptake of ART, disclosure to others, and minimizing the risk of transmission to sexual and injection drug using partners.The sequential explanatory mixed-methods design is useful in describing and uncovering the complexities that underlie reactions to a new HIV diagnosis in a vulnerable population; data sources, while addressing different research questions, shed light on complementary aspects of the phenomena under study. Thus, the present study advances research on adaptation to a new HIV diagnosis in a vulnerable population by uncovering the complexities high-risk heterosexuals experience in the process of acceptance, as well as some of the specific barriers to acceptance, most notably fear of stigma and of the potential loss of vital intimate relationships. Interestingly, Horter and colleagues  found maMoitra and colleagues  have devWe found a substantial proportion of participants, at least 44%, were not newly diagnosed in the course of the study, and some of these with past HIV diagnoses had already engaged in HIV care, although they did not elect to disclose their HIV status at the time they enrolled. As Marzinke and colleagues  have desIn the sections that follow, we refer to participants in the present study as newly diagnosed, but with the understanding that a substantial proportion had at least some level of previous knowledge of their HIV infection, and some were already in HIV care. Nonetheless, they were “newly diagnosed” in that they presented to the larger study with self-reported HIV-uninfected/unknown status and were informed over the course of the study they were infected with HIV.Participants in the present study were primarily male and African-American/Black. Consistent with the understanding that HIV is a disease of low socioeconomic status and structural inequality , they evOverall, the cohort evidenced satisfactory rates of engagement in HIV care and uptake of ART by the final follow-up period, and clinical indicators were generally stable. Approximately two-thirds (68.8%) were adequately retained in HIV care over the nearly 1 year post-diagnosis follow-up period, based on reports from the medical record. These rates are higher than found nationally , but a tAlthough we cannot say definitively due to a lack of a control group and small sample size, these generally positive clinical outcomes point to the potential importance of integrated culturally appropriate seek, test, treat, and retain approaches, such as the program described in the present paper. Further, these findings underscore the potential utility of providing ongoing linkage services in HIV testing sites to bring newly diagnosed individuals to HIV care and provide support during the transition to care, which can be lengthy, particularly for those with multiple barriers to accessing medical services , 68.The qualitative study component findings highlight the success of the study’s intervention components in engaging and retaining highly vulnerable participants through times of crisis. In particular, the intervention’s ethos of non-judgment, anti-stigma, and acceptance, grounded in motivational interviewing , was criStudy limitations include the small sample size of newly diagnosed individuals in comparison to estimates derived at the time the study was planned . This smThe present study extends the literature on the experience of receiving a new HIV diagnosis, focusing on a population at high-risk, and highlighting the complex and often-lengthy processes involved in accepting and adapting to a new HIV diagnosis. Yet, as we found, such acceptance is a necessary step toward engaging in HIV care and reducing sexual and drug use behaviors that might transmit HIV to others. Thus, attention to these processes in clinical settings has potential to identify PLWH with barriers to acceptance, address these psychosocial issues, and thereby improve HIV-related outcomes. Finally, the present study highlights the utility of the mixed-methods approach for complex phenomena such as reactions to an HIV diagnosis.The study was approved by the New York University School of Medicine Institutional Review Board.AK directed the study, developed study procedures, developed the research questions, and conducted data analyses and writing. MG conceived of the overall study concept and design and played a primary role in writing the manuscript. CC participated in the design of the study, planned the statistical analyses, and helped draft the manuscript. NL participated in the design of the study and study implementation procedures, and assisted with conceptualizing and writing the manuscript. RF and AR analyzed qualitative data. TM-G, KH, and BM developed study procedures and participated in interpretation of data. All the authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Background: The advanced access (AA) model is a highly recommended innovation to improve timely access to primary healthcare. Despite that many studies have shown positive impacts for healthcare professionals, and for patients, implementing this model in clinics with a teaching mission for family medicine residents poses specific challenges.Objective: To identify these challenges within these clinics, as well as potential strategies to address them.Design: The authors adopted a qualitative multiple case study design, collected data in 2016 using semi-structured interviews (N = 40) with healthcare professionals and clerical staff in four family medicine units in Quebec, and performed a thematic analysis. They validated results through a discussion workshop, involving many family physicians and residents practicing in different regionsResults: Five challenges emerged from the data: 1) choosing, organizing residents’ patient; 2) managing and balancing residents’ appointment schedules; 3) balancing timely access with relational continuity; 4) understanding the AA model; 5) establishing collaborative practices with other health professionals. Several promising strategies were suggested to address these challenges, including clearly defining residents’ patient panels; adopting a team-based care approach; incorporating the model into academic curriculum and clinical training; proactive and ongoing education of health professionals, residents, and patients; involving residents in the change process and in adjustment strategies.Conclusions: To meet the challenges of implementing AA, decision-makers should consider exposing residents to AA during academic training and clinical internships, involving them in team work on arrival, engaging them as key actors in the implementation and in intra- and inter-professional collaborative models. Advanced access (AA) is a highly recommended innovation for improving timely access to primary healthcare services ,2. It isAA ensures patients obtain an appointment at the date and time that suits them, within a period of time appropriate to their condition, while responding in an optimal way to their expected needs ,5.Among the organizational settings experimenting with implementation of this model in Canada, the USA, and internationally, are family medicine clinics with a teaching mission. Such clinics have great potential for spreading innovation among future healthcare professionals , as theyHowever, international research has shown that clinics, medical teams, and residents in particular face sizeable challenges when implementing AA ,9. DespiThese studies have documented the lack of availability and variation in family physician supply ,10 resulMany countries attempting to achieve the goals of improved access and patient-centered care are increasingly implementing AA, as a component of the patient-centered medical model. However, evaluation is still under development. In addition, the challenges faced by residents remain under-investigated . A recenobjective of this article is to identify the challenges associated with implementing AA for residents in family medicine, as well as potential strategies to overcome these challenges.Given the inherent contextual characteristics of teaching units ,14,15  and the Ministry of Health and Social Services (MSSS), to address the long-standing problem of accessing services . Many FaParticipants were recruited through the FMUs’ medical directors, who were contacted to identify key stakeholders involved in the change process and using the AA model. A purposeful and diversified sampling strategy targeted five categories, composed of health professionals  and clerical staff [CS]. An interview guide was used, which covered perceptions of the challenges, modalities for adapting the AA model, and suggestions on organizing the AA model for residents.N = 40), lasting from 40 to 60 min, were conducted between May 2015 and February 2016. They were carried out face-to-face or by telephone when constrained by distance (distance ≥ 150 km). Data saturation was attained by the tenth interview within each FMU.Semi-structured interviews . The first author has conducted (SAM) coding and reverse-coding using an iterative process, and one co-author (MB) reviewed a random sample. All themes emerging from the respondents’ verbatim statements were validated with all co-authors.An inductive approach was adopted to conduct an intra- and inter-case analysis that highlighted mainly commonalities (similarities) and some differences regarding the challenges of implementing AA at the different sites under study. A coding grid developed during the analysis was used for this purpose. In this article, transversal analysis is the core focus of the results.N = 20) practicing in six different FMUs across several regions. The three-hour workshop provide the opportunity to: 1) gather written and oral data on users’ experiences implementing this model in a teaching unit in general and among residents in particular; and 2) verify the results and validate promising strategies for facilitating implementation of the model by residents. A dynamic interactive approach was adopted involving group work and plenary discussion. A researcher observed and audio-recorded the discussions, with the consent of participants, and took summary notes. Sharing results with stakeholders corroborated our findings and enhanced our understanding of the challenges and possible solutions.Credibility was ensured through a reflective triangulation strategy , which cResults are discussed in terms of the study’s two objectives.Although the level of implementation of AA principles varied across the four study practices, all FMUs reported four similar challenges: 1) choosing and managing the residents’ patient panel; 2) concurrently ensuring a balance between timely access and relational continuity of care 3) managing and balancing the residents’ appointment schedules; and 4) getting residents to understand and appropriate the model. A fifth challenge, establishing collaborative practice, was reported at two FMUs (cases 2 and 3) that had failed to implement some of the AA principles, as compared to others  Table 3.C“There is going to be an adjustment challenge. It will involve reorienting the patients, yes, but then we also want it to be balanced for the residents to learn. We want a variety of pathologies, so that each resident can follow a few diabetics, a few COPDs [chronic obstructive pulmonary diseases], […] Yes, that’s it. So, it has to be balanced” (MD-FMU2)Across the sites, participants had quite similar perceptions overall. The method and criteria for assigning patients to a new cohort of residents, meeting both their learning needs and the clients’ demand for services, represented important challenges. Several supervisors reported the challenge of ensuring a balanced distribution of patients with complex health issues  among different residents, while adapting the type of patients to residents’ year of residency and to their heterogeneous educational needs.“But of course we try to balance things so that one resident won’t have all the severe cases. I think the follow-up for more severe cases is somewhat evenly distributed among all the residents” (FP1-FMU1)Providing access to services in a timely manner requires sharing complex and severe cases among the various residents, which remains a challenge.“For residents who have just arrived, it’s not so feasible during the first year, because after all they have to be set up with a list of patients. On the other hand, I would say that, from about nine months in, we can get them started with advanced access.” (CS1-FMU4)Some stressed the difficulty of preparing the patient caseload for the incoming first-year residents to practice the AA model.“The question is, what the result is. Do we assign them a patient who has come as a walk-in and who isn’t their patient? Or do we assign more patients who are their patients and who need to be seen quickly.” (FP1-FMU2)Another challenge reported by several participants was choosing the type of patients to be followed by residents , while responding promptly to the demand for services. Some physicians (FMU 2) raised questions around this issue, namely, how to operate in an AA model that responds optimally to residents’ learning needs and level of competence.“I think that, at the beginning, we hadn’t set up fast appointments, then just in terms of unit operations, they weren’t seeing enough patients that way. That’s why I think that keeping slots that are really open, not just for their patients but to everyone, I think that’s a good idea for FMUs” (FP2-FMU1)Others (FMU 1) have tried to diversify the clientele, avoiding empty appointment slots by providing quick appointments to other patients.“So, already that creates a problem in FMUs, because doctors don’t have much office availability, it’s the same thing for residents, who change over, or are at the hospital for the week, […] at a transitional functional rehabilitation unit, or at a geriatric unit and, in any case, if patients try to see them, well, they can be absent for 2 weeks with all the specialized activities that they have in Quebec City. They are often absent, and their presence is irregular. So, there are access problems.” (FP2-FMU2)A significant challenge reported by most participants in the four FMUs was the residents’ ability to provide timely access to patients and to meet their needs at all times, given their limited availability at the FMU. The main causes underlying the lack of availability, as identified by participants, were the fragmentation of training from one setting to another, the extensive mobilization of residents, and the diversification of clinical settings imposed on residents .“But they [residents] also experience frustration due to not being at the clinic often. It’s more difficult to work in advanced access when you’re not around that much. You have to be there to make it work properly.” (FP1-FMU3)Access problems due to lack of availability often led to frustration among residents and discontent among patients.“Maintaining relational continuity is always difficult for residents and then because [….] they’re not always at the FMU, they leave for two months to remote areas, or three months on training, so basically they’re not always there either. For AA, I was saying that it was great [for patients] to see their own doctors for 48 hours, for two weeks, it was their doctor, which allowed a more long-term follow-up, but in the case of residents, if they’ve gone off to a rural area, the patient has again to see another resident again, I think it’s difficult.” (FP1-FMU1)According to several participants, this not only disrupted the relational continuity with patients, but also led to deviation from the skills required by their pedagogical curriculum.“It’s maybe about managing time, because, well, we have a schedule with allocated time slots. For example, a resident is assigned an additional patient in his office. Well, the case may be more complex than he expected, so he may run over time, so the other patients are going to be delayed […] It could be harder for the residents because sometimes they will have patients with whom they’re not familiar. When they are in their office, they get prepared, they know their patients, they do everything, ‘my plan with this patient’ […]. which means it can be difficult for them.” (NP-FMU1)A particular challenge in residency programs is the varying availability of appointments from 1 week to another, due to the multi-site training required by the programs. The participants reported that residents’ variable schedules made it particularly challenging to manage, plan, and especially standardize their appointment schedules . Organizing schedules to increase patient access, while avoiding empty slots and minimizing their negative consequences, was a particular challenge. For example, filling residents’ empty time slots with patients, whom they are not used to following, can sometimes lead to difficulty in managing the follow-up time for complex cases  and consequently a greater delay for the patients booked later in the resident’s daily schedule.“It is about the residents’ highly variable schedules. More or less everyone’s in clinic, so it’s really about setting up the residents’ schedules and knowing that they do have available time slots. Residents also have to be paired with a physician who is available to supervise them. So, it’s mostly about schedule management […]. Implementation challenges, yes, yes, that’s it. In my opinion, it’s mainly on the organizational side.” (R1-FMU1)In these teaching settings, another challenge reported is organizing and managing the residents’ schedules to match supervising physicians’ schedules, so that the latter can assume their teaching and clinical supervision responsibilities.“I really mainly learned about that once I got to my residency training. During my clerkship, we did many specialty courses, so it was not really conveyed as a principle. It was really when I arrived in the family medicine residency that I heard about it. So, in any case, I personally had not been exposed to that at all.” (R2-FMU4)A challenge unanimously reported by residents in all four FMUs was operating in AA when they had not been prepared nor exposed to the model during their academic training.“Yes, well, you heard a little about it during the clerkship, but no, no one had really explained to me how it worked or how to set it up.” (R1-FMU1)Participants also pointed out the lack of supervision during residency internships in family medicine and the lack of adequate training strategies to understand the principles of AA and its operational modalities. The data revealed that most residents had received superficial and very limited information related only to the appointment review principle.“But also the bosses who had had training, well, in any case, I think they might have had more meetings than we did, so they were able to tell us, ‘Such-and-such a patient, you could put into advanced access,’ or they would make us think it over, telling us, ‘This patient here, do you think he should be in advanced access, or do you think he should be seen again in two months?’ […]. So, it was often pretty much like that, the bosses would challenge us a lot to see whether we, as residents, do we put our patients in adapted access or not, and for what reasons.” (R2-FMU4)However, this challenge appeared to have been diminished at one FMU (case 4), where reflective learning exercises had been adopted to facilitate appropriation of the model.Some participants pointed out that the challenge of implementing a joint follow-up model  arose in two FMUs due to the lack of availability of financial and human resources (nurses) (FMU 3) and the lack of involvement in the implementation process (FMU 2).“Of course if we were the same four residents with the same nurse and we were following the same pool of 200 patients, which would be good. That would be very good. That way, the nurse could do some triage of what’s urgent, what is not urgent, then dispatch to the residents. That would be really wonderful. I feel that for the time being that’s somewhat wishful thinking, because… The fact is, it would require additional nursing resources.” (R2-1-FMU2)An unfavorable organizational context in terms of financial and human resources, among other factors, can influence the implementation of AA for residents. Collaborative practice, in terms of interdisciplinary follow-up to optimize care, is a characteristic of a favorable context.Identifying and revising the residents’ patient panels to balance demand for care with residents’ learning needs. This incorporates adapting the caseload according to the learning objectives and preparing a patient list for each resident that matches the level of residents’ skills at the beginning of the training. This step will be followed by a regular re-evaluation of the number of patients in residents’ caseloads throughout the training period, considering on one hand the patient demands, the diversity of health problems of the assigned patients, and on the other hand the trainees’ needs, their learning obligations and the complexity of follow-up.Pairing up residents or developing resident care teams, each consisting of 2 or 4 residents (with different rotation schedules), who assume a collective responsibility towards a group of patients and ensure provision continuity of care.a joint follow-up of a group of patients by the residents and the clinical nurse or the nurse practitioner, who will work in partnership and carry out coordinated follow-up visits for a diverse clientele ; or a small team composed of multiple health care professionals  who will work collaboratively and follow-up a group of patients in a way that any provider within this sub-team would be able to respond to their needs.Implementing group practice models such as Establishing new collaborative models: A variety of models can be implemented such asPreparing and training health professionals and residents on the various key principles of AA so they can integrate it into their practice: such as integrating a course in the curriculum related to the AA model that contributes to initiating them to different practice models during their academic program. Also, upon entering their residency training, they can be trained through attending workshops and also through exposing them to many cases seen under this practice redesign and providing them the appropriate supervision using quality improvements tools. Moreover, it would be essential to standardize AA learning concepts for supervisors to enable delivery of a unified lesson for residents, to clearly convey its key principles and bring the whole supervising members to work in the same direction.Educating patients, using many methods , should be performed on a regular basis to change their habits in using primary care services.Involving residents and the whole team in a collective approach to change, within the limits of their availability and their academic obligations: Essential steps would be engaging residents in regular staff follow-up meetings, and involving them in co-constructing work tools and in adjustment strategies of AA. It would be also useful to develop key performance indicators relevant to the roles of residents and all health care professionals in achieving practice quality and efficiency.Although implementing AA for residents is challenging, solutions seem to exist to facilitate it in an educational setting . They foOur findings shed much-needed light on a subject that has not been thoroughly investigated thus far. Research in this area has focused mainly on the challenges faced in a teaching context by the team in general. Few studies have addressed the challenges faced specifically by residents and how to overcome them . AlthougOur results are in line with those reported by the Accessibility Committee of the Department of Family Medicine and Emergency Medicine at the University of Sherbrooke, which highlighted the same challenges that may compromise development of the key competencies required in the ‘CanMEDS-Family Medicine Competency Framework’  related to family medicine roles: management ; collaboration ; and, erudition . Consequently, educational directors should pay particular attention to these findings to attain educational goals and prepare residents to provide high-quality, safe, patient-centered care.Our results suggest concrete and proactive strategies to address these challenges and to facilitate implementation success. The strategies need to be implemented at an early stage in order to anticipate, minimize, or overcome the challenges.Training residents, the entire health and clerical staff as well as patients; assigning residents an active role within a collective approach to change; and optimizing team work by establishing new collaborative models with residents were all put forward as promising strategies by key informants.These strategies emerging from the field echo the findings of existing studies. For example, some authors have focused not only on resident involvement in implementing AA but also on strategies for improving and adapting the model through regular follow-up meetings throughout the entire change process ,7. Such Some authors have also recommended integrating AA in resident training, without, however, focusing on the modalities of pedagogical learning required to achieve this ,8. Regarp ˂0.0001). The potential of such a model in the context of AA remains to be explored.Optimizing the role of other professionals through joint monitoring with nurses has also been raised ,16 as a Our results, which draw on several international scientific papers that emphasize the need to adapt this model for family medicine residents  as well This qualitative study has certain limitations. Results reported by participants sampled in four FMUs may not be transferable to other clinical settings with a teaching mission. They should be further validated by conducting other studies in different settings to identify the full range of challenges to consider when implementing AA. Moreover, considering that the AA model is in constant adaptation, without a longitudinal study design, the evolution of the challenges over time cannot be identified. Further studies, investigating the challenges encountered during the change process and the strategies put in place by team members and supervising physicians to overcome them, would be relevant. It is important to mention that the strategies identified and, in some cases, adopted by the actors in this study  have not yet been evaluated. It would be interesting to pursue research and discussion of this issue until a certain level of consensus regarding the solutions will be reached between the various actors involved.As patients, essential users of the AA model may influence acceptance of this new organizational model and its integration into everyday practice of family physicians and residents in particular, we have explored their perceptions and attitudes regarding implementing AA in an academic unit, in a separate paper.Finally, evaluation studies would be needed, to test these various strategies to expose future family physicians to best practices during the course of their training; to facilitate the ongoing implementation and adaptation process of this model in their future practice according to the realities of their contexts; and to determine the effects of strategies after they have been adapted to the characteristics of each context and to the particular needs of various professionals.Implementing AA in a teaching setting calls for an adaptation of the model according to pedagogical needs. More specifically, the process entails numerous challenges for residents, which require a proactive change approach. Rethinking the training of residents, their role as an active member of the team in implementing AA, and the modalities of their intra- and inter-professional collaboration are strategies to consider, given their potential capacity to anticipate such challenges.These strategies must be applied in a favorable organizational context, in a primary healthcare organization with an adequate level of available resources, while adopting a dynamic team and collective learning approach.


In previous work, we have assessed the structural similarities between marketed drugs (‘drugs’) and endogenous natural human metabolites (‘metabolites’ or ‘endogenites’), using ‘fingerprint’ methods in common use, and the Tanimoto and Tversky similarity metrics, finding that the fingerprint encoding used had a dramatic effect on the apparent similarities observed. By contrast, the maximal common substructure (MCS), when the means of determining it is fixed, is a means of determining similarities that is largely independent of the fingerprints, and also has a clear chemical meaning. We here explored the utility of the MCS and metrics derived therefrom. In many cases, a shared scaffold helps cluster drugs and endogenites, and gives insight into enzymes (in particular transporters) that they both share. Tanimoto and Tversky similarities based on the MCS tend to be smaller than those based on the MACCS fingerprint-type encoding, though the converse is also true for a significant fraction of the comparisons. While no single molecular descriptor can account for these differences, a machine learning-based analysis of the nature of the differences (MACCS_Tanimoto vs MCS_Tversky) shows that they are indeed deterministic, although the features that are used in the model to account for this vary greatly with each individual drug. The extent of its utility and interpretability vary with the drug of interest, implying that while MCS is neither ‘better’ nor ‘worse’ for every drug–endogenite comparison, it is sufficiently different to be of value. The overall conclusion is thus that the use of the MCS provides an additional and valuable strategy for understanding the structural basis for similarities between synthetic, marketed drugs and natural intermediary metabolites.The online version of this article (doi:10.1186/s13321-017-0198-y) contains supplementary material, which is available to authorized users. It is becoming increasingly clear that the transmembrane transport of drugs and xenobiotics via any trans-phospholipid bilayer diffusion is probably negligible, and thus that they have to “hitchhike” on the transporters of intermediary metabolism in order to get into cells –19. ConsFollowing an earlier sortie , we haveHowever, there are many different similarity coefficients even for (binary) bitstrings (Todeschini and colleagues compared 51 ), and juOne scoring that is resistant to the detailed encoding used is based on the simple presence or absence of a given substructure, and assessing the frequencies and presence of some 600 common substructures provided a novel and useful metric, even with Tanimoto . Again, All of these have been of value in recognising that approved, marketed drugs did share structural similarities with endogenous metabolites. A related question surrounds the “natural” substrates of particular transporters that transport pharmaceutical drugs, but this could not directly be answered from similarity considerations alone.One structural feature that is largely  indepenhttp://rdkit.org/) MCS nodes for the MCS calculations. To provide a metric for the MCS, we followed the recent analyses of Bajorath and colleagues  the MCS SMARTS string, the a,b, and MCS Atom counts; as well as the Tanimoto-like MCSS.Specifically, the MCS algorithm used in this study was the fast connected MCS algorithm fMCS, as implemented in RDKit , and quinolone antibiotics (rosoxacin) whose basic scaffold is really nothing like that of a benzodiazepine. Note that Fig. 2.) The simplest interpretation is really that the MCS is much more discriminating for what it says, i.e. the maximum common substructure or scaffold, but that this leads to a more natural and useful clustering. Finally, here, Fig. In our previous work , where wWhile this was considerably more demanding in computer time than our previous similarity analyses based on various fingerprints coupled to Tanimoto or Tversky similarity –22, 88, While the calculation of the MCS values was quite demanding, the calculation of other similarities see “” sectionIt seems that the MCS method of molecular comparison, when all rings are included intact, gives much more reliable measurements of useful similarity as judged by scaffolds. As ever, the different metrics give different indications of how similar two molecules seem to be. To this end, we interrogated the endogenites with a few drugs carefully chosen to illustrate the kinds of variation observable, first illustrating their differences with (1) an MCS-based similarity with Tversky α 0.2 and β 0.8 and (2) a MACCS encoding and a Tanimoto similarity as in .++-channel blocker with multiple disease indications . It is also considered one of the more rapidly transported drugs in Caco-2 cells . Ac. Ac++-chhttps://www.ebi.ac.uk/chembldb/index.php/compound/inspect/CHEMBL27 it has 166 known targets, including 9 uptake transporters. Its structural similarity to noradrenaline means that unsurprisingly these include the very active serotonin, dopamine and noradrenaline transporters. Finally, we show a drug that is among the least obviously metabolite-like, viz. clozapine . Overall, though, it is clear that the use of the MCS adds significantly to the armoury of similarity strategies for those seeking to compare the structural similarities between synthetic drugs and natural biomolecules.The extent to which two molecules are to be seen as ‘similar’ in purely (2D) structural terms depends strongly on both their encoding and the similarity metric used, and this was the case for our drug–endogenite analyses as performed previously –22. In tOne strategy to ensure that we pick up pertinent similarities is to use as many methods as possible for encoding them, and we here sought to assess the maximal common substructure (MCS) as an additional useful similarity measure. MCS also has the advantage of having a clear chemical meaning in terms of a linked set of atoms. Although, again, the extent to which the MCS showed up similarities observable via the MACCS fingerprint varied significantly between drugs, the corresponding conclusion was precisely that, as a consequence of this, the MCS was valuable as an additional method in such comparisons. To reiterate, we do not imply that MCS is ‘better’ or ‘worse’ than other methods, but we do think that the evidence shows that it is different and correspondingly valuable, and should thus be used in parallel with fingerprinting methods, whether separately or , v


Post-war medical debates about the psychiatric consequences of married women’s economic behaviour witnessed far more divergence and collision between perspectives than has often been acknowledged. Practitioners who approached women primarily as facilitators of family health—as wives and mothers—were mistrustful of the competing demands presented by paid employment. They were faced by a growing spectrum of opinion, however, which represented women as atrophying in the confines of domestic life, and which positioned work as a therapeutic act. Advocates of work tapped into anxieties about family instability by emphasizing the dangers posed by frustrated housewives, shifting clinical faith away from full-time motherhood, but nevertheless allowing responsibilities towards husbands and children to continue to frame argument about women’s behaviour. Doctors, researchers and social critics, in this context, became preoccupied with questions of balance, mapping a path which sought to harmonize public and private fulfilment, identity and responsibility. This article traces this discursive shift through a series of conferences held by the Medical Women’s International Association during the early-to-mid 1950s, connecting debates in Britain with systems of broader intellectual exchange. It enriches and complicates historical knowledge of post-war relationships between medicine and feminism, at the same time as offering a conceptual and linguistic context for modern discussion about work-life balance and gender. This article is published as part of a collection entitled “On balance: lifestyle, mental health and wellbeing”. New Statesman on 14 February 2016, the feminist author and journalist Laurie Penny set out a persuasive array of reasons for women to think about the twice about the supposed benefits of heterosexual monogamous relationships. Echoing the pioneering sociologist Ann Coupledom, for men, is not supposed to involve a surrendering of the self, as it is for women. Young men do not worry about how they will achieve a “work-life balance”, nor does the “life” aspect of that equation translate to “partnership and childcare”. When commentators speak of women’s “work-life balance”, they’re not talking about how much time a woman will have, at the end of the day, to work on her memoirs, or travel the world, or spend time with her friends. “Life”, for women, is envisioned as a long trajectory towards marriage. “Life”, for men, is meant to be bigger than that. Writing in the Sixty years earlier, doctors, researchers and social critics were voicing comparable concerns about the effects of lifestyle on women’s selfhood and growth. Similarly engaged with questions of balance, commentators began to equate individual, familial and social health with a dual role for women, which divided their time and energy between home and workplace. As Claire In Britain, in common with much of Western Europe and North America, a steep and steady rise in part-time employment for younger married women provoked and defied conservative anxieties about the stability and security of childhood and marriage : 74. WriFemale practitioners were at the forefront of post-war discussions about the medical implications of women’s working behaviour. This article follows the Medical Women’s International Association (MWIA), an umbrella organization for national associations and regional caucuses including the British Medical Women’s Federation (MWF), through a series of conferences and related publications in the early-to-mid 1950s. The meetings of the MWIA were one of many intellectual spaces in which women made use of sociological and medical interpretive frameworks to articulate dissatisfaction with domesticity, to dissent from suffocating models of motherhood, and to map a path which integrated a nascent clinical, ethical and practical case for work with widespread concerns about the breakdown of family life. Their deliberations repay careful study by challenging persistent simplifications of the role of post-war psychiatry in governing women’s attitudes to work, assumptions about the interplay between medicine and patriarchy that have been complicated by other research . Social Following a substantive introduction to the formation, work, and self-conceptualization of the MWIA, the first section of this article investigates growing post-war apprehensions about the ill-effects of housework on women’s bodies and minds. Although industrial medicine provided a methodological and aetiological toolset to interpret housewives’ distress, the conceptualization of home environments as workplaces to be rationalized brought the limits of occupational analogies and the specificity of domestic experience into clearer focus. Meeting in Vichy in 1952, MWIA delegates used cyclical connections between physical ailments, psychological disorder, the rhythm and pace of household labour, and subjective feelings of unhappiness and frustration to question whether domesticity under any guise could provide the stimulation and self-fulfilment required by women . The secThe engagements of MWIA members in debates about women’s working practices were, up to a point, self-referential. Surveys taken by the MWF in Britain reported that 57% of the affiliated doctors qualifying between 1933 and 1948 were married, with a lower rate among older women. Although women in medicine faced a number of professional and personal obstacles, the highest cause of occupational wastage was the difficulty involved in finding positions that could fit plausibly around family responsibilities . As in smatris animo curant; “they cure in a motherly spirit” , writers who presented the menopause as an opportunity for personal renaissance underestimated the danger of this “insuperable psychological block”.In fact, A shift in attention beyond inevitable biological processes and towards psychosocial understandings of the menopause in relation to constructed gender identity enabled a reappraisal of the specific challenges faced by working women. Inger Haldorssen, a Norwegian physician, delivered a brief survey of attitudes to the impact of the menopause on working ability. Despite “climacteric complaints” only accounting for a small proportion of sickness absence, she argued, doctors, employers and patients were still likely to regard the “dangerous years” as the beginning of a decline in professionalism, health and aptitude : 99. AccChatelaine, a Canadian women’s magazine, have been construed as prescient and provocative warnings about the fragility of women’s health in traditional roles  had each addressed identical themes in 1955, as attention to the issue within international medical networks gained ground. Odlum, the British representative who had spoken in Vichy on the difficulties of applying occupational methods to domestic work, had attended both. Reporting on the deliberations of the ELMH, she drew together the commonalities in approach between that organization and the MWIA audience in Burgenstock. ELMH delegates had made similar observations about the medical impact of domestic boredom, linking health with occupational emancipation : 26. ChiFamily Doctor, the magazine of the British Medical Association, that “the wishes, and even to some extent the needs, of the baby must be modified to fit in with her needs too”. Children in receipt of constant maternal attention were by no means guaranteed healthy psychological development, but could fall prey to a divergent strain of pathological motherhood, the overbearing “mom” who recurred frequently in American debate (n debate : 55. A fn debate : 54. OdlBritish Medical Journal highlighted the attitudes of the “Far Eastern” working group. Delegates from India and China, while admitting little experience of the problems under discussion, claimed to be “looking forward to the day when [they] would have” (Men, ld have” : 1297. TOnly one of the speakers struck a discordant note. A paediatrician who founded the Institute for Mental Health in Childhood in Zurich, Marie Nation and Family, had recast the question of married women’s right to a job as one of working women’s right to a family. An advocate of contraception and women’s health specialist in Copenhagen, Inge Jespersen, reported to the MWIA on innovations in Denmark, Norway and Sweden. Women were empowered to balance work and family without negative implications for either health or family life, she explained, by a series of initiatives; prohibition of night work; maternity leave; flexible working hours; job security on pregnancy or marriage; nurseries and crèches; permissive taxation; and means tested domestic help for working mothers. The problems women faced, however, could not be said to have been entirely solved, necessitating further legislation, increased male participation in housework and parenthood, and changes to sexist employment cultures which disadvantaged all workers, married and single (In contrast to Switzerland, Scandinavian legislative measures were broadly supportive of women’s choices. d single : 3–4. Ald single , Odlum (Like all rapid social change it gives birth to conflicts and could therefore be pathological. In the interests of the mental health of the family it is essential to find solutions to establish an equilibrium between the traditional demands and these changing tendencies in order to preserve the stability of the family group and the satisfactory development of the personality of the child. : 25Stepping outside of the nuanced ethical and medical case for work presented by the majority of speakers, both Odlum and Ruys emphasized that doctors in and beyond the association would be increasingly required to assist women in navigating the complexities of dual roles whether they approved of the development or not. For Ruys developed Odlum’s analogy, situating the medical consequences of emancipation as “part of the dynamic process of the evolution of mankind”. Female vitality, she argued, was growing with an “astonishing rapidity” which “cannot be arrested”. Like a river bursting from its banks, it could cause damage, but was “also fertilizing new grounds” : 36. TheThe work of the MWIA to contest and criticize reductive and inflexible models of femininity formed one strand in hitherto overlooked feminist medical discourses in the 1950s. Although patterns of resistance to the clinical rationales underpinning a rigid sexual division of labour have been identified, they have usually been located within the social sciences or in women’s own actions : 394. ThPrefiguring arguments made by second wave feminists, women in the home were depicted as incomplete or “damaged selves” for whom paid work was essential for resilience or recovery : 27. TheSteeped in linguistic conventions which used balance as a signifier for health in emotional : 60, endData sharing is not applicable to this article, as no datasets were generated or analysed during the current study.