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Background Some persons who achieve viral suppression may later experience viral rebound, potentially putting them at risk for transmitting HIV. We estimate the prevalence of, and describe factors associated with, viral rebound among adults with diagnosed HIV in the United States who had ≥2 viral load tests in a 12-month period. Setting The Medical Monitoring Project is an annual cross-sectional survey about the experiences and needs of adults with diagnosed HIV sampled from the National HIV Surveillance System. Methods We analyzed interview and medical record data from 3 Medical Monitoring Project cycles spanning June 2015-May 2018. We analyzed viral load results from the 12-month period before the interview among persons with ≥2 viral load tests who achieved viral suppression. Data were weighted based on known probabilities of selection, adjusted for patient nonresponse, and poststratified to known population totals from the National HIV Surveillance System. Results Among those with ≥2 viral load tests who achieved viral suppression, 7.5% demonstrated viral rebound. In multivariable analyses, viral rebound was higher among non-Hispanic blacks, persons ages 18-39, persons with public insurance, persons recently experiencing homelessness, persons with higher numbers of viral load tests, persons who missed HIV care appointments, and persons with suboptimal adherence to antiretroviral therapy. Conclusions Viral rebound varied by sociodemographic and clinical characteristics. HIV providers can monitor persons at greatest risk for viral rebound and link patients with ancillary services or evidence-based interventions to help them remain virally suppressed. Our findings can inform strategies and interventions implemented under the Ending the HIV Epidemic initiative.

National guidelines recommend that HIV providers systematically monitor retention in care to identify and re-engage persons suboptimally in care. We described (1) U.S.-based outpatient HIV care facilities that systematically monitor retention in care, and (2) characteristics of patients attending facilities that monitored retention in care. We used data collected during 6/2014–5/2015 from the Medical Monitoring Project, an annual, cross-sectional survey that produces nationally representative estimates of characteristics of HIV-positive persons in medical care. We described systematic monitoring of retention in care among facilities and patients attending facilities providing this service using weighted percentages and 95% confidence intervals, and used Rao-Scott chi-square tests (p < .05) to assess differences by selected characteristics. Overall, 67% of facilities systematically monitored retention in care, and 81% of patients attended these facilities. Federally qualified health centers, community-based organizations, health departments, non-private practices, and Ryan White HIV/AIDS Program (RWHAP)-funded facilities were more likely to systematically monitor retention in care. Persons living in poverty, and those who were homeless or incarcerated, or injected drugs were more likely to attend facilities with this service. Although systematic monitoring of retention in care is accessible for many patients, improvements at other, non-RWHAP-funded facilities may help in reaching national prevention goals.

BACKGROUND: People living with HIV are prescribed opioids more often and at higher doses than people who do not have HIV, and disproportionately experience risk factors for substance use disorder, which suggests they could be at increased risk of the misuse of opioids. Researchers also suggest that opioid misuse negatively affects various HIV clinical outcomes, increasing the risk of transmission to partners with an HIV-negative status. METHODS: We calculated weighted percentages and 95% confidence intervals to estimate substance use characteristics among a probability sample of 28,162 HIV-positive adults receiving medical care in the United States who misused opioids (n = 975). Then, we used Rao-Scott χ(2) tests to assess bivariate associations between opioid misuse and selected characteristics. RESULTS: In all, 3.3% misused opioids. Misuse was more common among young adults, males, and non-Hispanic whites. Persons who misused opioids were less likely to: have been prescribed antiretroviral therapy (ART) (88.7%), report being adherent to ART medications in the past 3 days (78.1%), and have durable viral suppression (54.3%) than persons who did not misuse opioids (92.5%, 87.7%, and 64.7%, respectively). Persons who misused opioids were more likely to report condomless sex with partners of negative or unknown HIV status while not durably virally suppressed (11.7% vs 3.4%) than persons who did not misuse opioids. CONCLUSIONS: Opioid misuse among adults receiving HIV medical care is associated with inadequate ART adherence, insufficient durable viral suppression, and higher risk of HIV transmission to sexual partners.

Objectives: Evidence-based guidelines recommend that HIV care providers offer retention-in-care services, but data are needed to assess service provision. Methods: We surveyed a probability sample of 1234 HIV care providers to estimate the percentage of providers whose practices offered 5 recommended retention services and describe providers’ perceptions of barriers to care among patients. Results: An estimated 21% of providers’ practices offered all 5 retention services. Providers at smaller (400 patients), private, and non-Ryan White HIV/AIDS Program (RWHAP)-funded practices, and practices without on-site case management were significantly less likely to provide patient navigation services or do systematic monitoring of retention. Providers’ most commonly perceived barriers to care among patients were mental health (40%), substance abuse (36%), and transportation (34%) issues. Conclusion: Deficiencies in the provision of key retention services are substantial. New strategies may be needed to increase the delivery of recommended retention services, especially among private, non-RWHAP-funded, and smaller facilities.

BACKGROUND Data to care (D2C) is a public health strategy that uses HIV surveillance and other data to identify persons in need of HIV medical care. The Medical Monitoring Project (MMP), which uses similar methods to contact and recruit HIV-positive persons, may inform predictors of successful contact for D2C programs. SETTING MMP is a Centers for Disease Control and Prevention-funded surveillance system that collects nationally representative data on adults with diagnosed HIV in the United States and Puerto Rico. METHODS Using MMP's 2016 data collection cycle, we present contact rates (ie, proportion of HIV-positive persons successfully contacted for MMP) by the age of contact information and age of laboratory test results available from HIV surveillance data. RESULTS Nationally, 27.6% of eligible persons did not have a recorded laboratory test performed within the past year (project area range: 10.8%-54.6%). The national contact rate among persons with laboratory tests older than 1 year was 37.0% (project area range: 16.5%-67.1%). Higher contact rates were found among persons with more recent laboratory tests. Similar results were found by the age of contact information. Nationally, the most common reason for MMP ineligibility was that the person was deceased; the most common reason for not being contacted was lack of correct contact information. CONCLUSIONS MMP findings suggest that D2C programs would benefit from efforts to improve the quality of HIV surveillance data and local surveillance practices-in particular, death ascertainment, the completeness of laboratory reporting, and the routine updating of contact information. Strengthening collaboration and integration with existing MMP programs may be beneficial.

Background The Medical Monitoring Project (MMP) is a national population-based behavioral and clinical surveillance system of adults with diagnosed HIV in the United States, and it is sponsored by the Centers for Disease Control and Prevention (CDC). Its purpose is to provide locally and nationally representative estimates of factors affecting HIV transmission risk and clinical outcomes. Objective This study aimed to describe the rationale for and methodology of the MMP, in addition to its contribution to evaluating and monitoring HIV prevention, care, and treatment efforts in the United States. Methods MMP employs a stratified 2-stage sample design to select annual samples of persons living with diagnosed HIV from the National HIV Surveillance System and conducts interviews and medical record abstractions with participating persons. Results MMP data are published routinely via annual reports, conference presentations, and scientific publications. Data may be accessed upon request from the CDC, contingent on the guidelines established for the security and confidentiality of HIV surveillance data. Conclusions MMP is the only source of annual population-based data on the behaviors and clinical care of persons with diagnosed HIV in the United States. It provides essential information for monitoring progress toward national treatment and prevention goals and guiding efforts to improve the health of persons with diagnosed HIV and prevent HIV transmission. International Registered Report Identifier (IRRID) RR1-10.2196/15453

Background A new HIV diagnostic algorithm has been proposed which replaces the use of the HIV-1 Western blot and HIV-1 immunofluorescence assays (IFA) as the supplemental test with an HIV-1/HIV-2 antibody differentiation assay. Objectives To compare an FDA-approved HIV-1/HIV-2 antibody differentiation test (Multispot) as a confirmatory test with the HIV-1 Western blot and IFA. Study design Participants were screened with an HIV-1/HIV-2 combination Antigen/Antibody (Ag/Ab) screening assay. Specimens with repeatedly reactive results were tested with Multispot and either Western blot or IFA. Specimens with discordant screening and confirmatory results were resolved with HIV-1 RNA testing. Results Individuals (37,876) were screened for HIV infection and 654 (1.7%) had a repeatedly reactive Ag/Ab assay result. On Multispot, 554 (84.7%) were HIV-1 reactive, 0 (0%) were HIV-2 reactive, 1 (0.2%) was reactive for both HIV-1 and HIV-2 (undifferentiated), 9 (1.4%) were HIV-1 indeterminate, and 90 (13.8%) were non-reactive. HIV-1 RNA was detected in 47/90 Multispot non-reactive (52.2%) specimens. Among specimens confirmed to have HIV infection (true positives), Multispot and Western blot detected HIV-1 antibody in a similar proportion of cases (93.7% vs. 94.4% respectively) while Multispot and IFA also detected HIV-1 antibody in a similar proportion of cases (84.5% vs. 83.4% respectively). Conclusions In this study, Multispot confirmed HIV infections at a similar proportion to Western blot and IFA. Multispot, Western blot, and IFA, however, did not confirm all of the reactive Ag/Ab assay results and underscores the importance of HIV NAT testing to resolve discordant screening and confirmatory results.

Background U.S. health departments have not historically used HIV surveillance data for disease control interventions with individuals, but advances in HIV treatment and surveillance are changing public health practice. Many U.S. health departments are in the early stages of implementing “Data to Care” programs to assists persons living with HIV (PLWH) with engaging in care, based on information collected for HIV surveillance. Stakeholder engagement is a critical first step for development of these programs. In Seattle-King County, Washington, the health department conducted interviews with HIV medical care providers and PLWH to inform its Data to Care program. This paper describes the key themes of these interviews and traces the evolution of the resulting program. Methods Disease intervention specialists conducted individual, semi-structured qualitative interviews with 20 PLWH randomly selected from HIV surveillance who had HIV RNA levels >10,000 copies/mL in 2009–2010. A physician investigator conducted key informant interviews with 15 HIV medical care providers. Investigators analyzed de-identified interview transcripts, developed a codebook of themes, independently coded the interviews, and identified codes used most frequently as well as illustrative quotes for these key themes. We also trace the evolution of the program from 2010 to 2015. Results PLWH generally accepted the idea of the health department helping PLWH engage in care, and described how hearing about the treatment experiences of HIV seropositive peers would assist them with engagement in care. Although many physicians were supportive of the Data to Care concept, others expressed concern about potential health department intrusion on patient privacy and the patient-physician relationship. Providers emphasized the need for the health department to coordinate with existing efforts to improve patient engagement. As a result of the interviews, the Data to Care program in Seattle-King County was designed to incorporate an HIV-positive peer component and to ensure coordination with HIV care providers in the process of relinking patients to care. Conclusions Health departments can build support for Data to Care efforts by gathering input of key stakeholders, such as HIV medical and social service providers, and coordinating with clinic-based efforts to re-engage patients in care.

Background. Retention in care for human immunodeficiency virus (HIV)–infected patients is a National HIV/AIDS Strategy priority. We hypothesized that retention could be improved with coordinated messages to encourage patients' clinic attendance. We report here the results of the first phase of the Centers for Disease Control and Prevention/Health Resources and Services Administration Retention in Care project. Methods. Six HIV-specialty clinics participated in a cross-sectionally sampled pretest-posttest evaluation of brochures, posters, and messages that conveyed the importance of regular clinic attendance. 10 018 patients in 2008–2009 (preintervention period) and 11 039 patients in 2009–2010 (intervention period) were followed up for clinic attendance. Outcome variables were the percentage of patients who kept 2 consecutive primary care visits and the mean proportion of all primary care visits kept. Stratification variables were: new, reengaging, and active patients, HIV RNA viral load, CD4 cell count, age, sex, race or ethnicity, risk group, number of scheduled visits, and clinic site. Data were analyzed by multivariable log-binomial and linear models using generalized estimation equation methods. Results. Clinic attendance for primary care was significantly higher in the intervention versus preintervention year. Overall relative improvement was 7.0% for keeping 2 consecutive visits and 3.0% for the mean proportion of all visits kept (P

The present study sought to identify demographic, structural, behavioral, and psychological subgroups for which the Antiretroviral Treatment Access Study (ARTAS) intervention had stronger or weaker effects in linking recently diagnosed HIV-positive persons to medical care. The study, carried out from 2001 to 2003, randomized 316 participants to receive either passive referral or a strengths-based linkage intervention to facilitate entry into HIV primary care. The outcome was attending at least one HIV primary care visit in each of two consecutive 6-month periods. Participants (71% male; 29% Hispanic; 57% black non-Hispanic), were recruited from sexually transmitted disease clinics, hospitals and community-based organizations in four U.S. cities. Thirteen effect modifier variables measured at baseline were examined. Subgroup differences were formally tested with interaction terms in unadjusted and adjusted log-linear regression models. Eighty-six percent (273/316) of participants had complete 12-month follow-up data. The intervention significantly improved linkage to care in 12 of 26 subgroups. In multivariate analysis of effect modification, the intervention was significantly (p0.05) stronger among Hispanics than other racial/ethnic groups combined, stronger among those with unstable than stable housing, and stronger among those who were not experiencing depressive symptoms compared to those who were. The ARTAS linkage intervention was successful in many but not all subgroups of persons recently diagnosed with HIV infection. For three variables, the intervention effect was significantly stronger in one subgroup compared to the counterpart subgroup. To increase its scope, the intervention may need to be tailored to the specific needs of groups that did not respond well to the intervention.

Objective The Antiretroviral Treatment Access Study-II (ARTAS-II) evaluated a brief case management intervention delivered in health departments and community-based organizations (CBOs) to link recently diagnosed HIV-infected persons to medical care rapidly. Methods Recently diagnosed HIV-infected persons were recruited from 10 study sites across the United States during 2005 to 2006. The intervention consisted of up to 5 sessions with an ARTAS linkage case manager over a 90-day period. The outcome measure was whether or not the participant had seen an HIV medical care provider at least once within 6 months of enrollment. Multivariate logistic regression was used to identify significant predictors of receiving HIV medical care. Results Seventy-nine percent (497 of 626) of participants visited an HIV clinician at least once within the first 6 months. Participants who were older than 25 years of age, Hispanic, and stably housed; had not recently used noninjection drugs; had attended 2 or more sessions with the case manager; and were recruited at a study site that had HIV medical care colocated on its premises were all significantly more likely to have received HIV care. Conclusions The ARTAS linkage case management intervention provides a model that health departments and CBOs can use to ensure that recently diagnosed HIV-infected persons attend an initial HIV care encounter.

HIV RNA viral load (VL) is a pivotal outcome variable in studies of HIV infected persons. We propose and investigate two frameworks for analyzing VL: (1) a single-measure VL (SMVL) per participant and (2) repeated measures of VL (RMVL) per participant. We compared these frameworks using a cohort of 720 HIV patients in care (4,679 post-enrollment VL measurements). The SMVL framework analyzes a single VL per participant, generally captured within a "window" of time. We analyzed three SMVL methods where the VL binary outcome is defined as suppressed or not suppressed. The omit-participant method uses a 8-month "window" (-6/+2 months) around month 24 to select the participant's VL closest to month 24 and removes participants from the analysis without a VL in the "window". The set-to-failure method expands on the omit-participant method by including participants without a VL within the "window" and analyzes them as not suppressed. The closest-VL method analyzes each participant's VL measurement closest to month 24. We investigated two RMVL methods: (1) repeat-binary classifies each VL measurement as suppressed or not suppressed and estimates the proportion of participants suppressed at month 24, and (2) repeat-continuous analyzes VL as a continuous variable to estimate the change in VL across time, and geometric mean (GM) VL and proportion of participants virally suppressed at month 24. Results indicated the RMVL methods have more precision than the SMVL methods, as evidenced by narrower confidence intervals for estimates of proportion suppressed and risk ratios (RR) comparing demographic strata. The repeat-continuous method had the most precision and provides more information than other considered methods. We generally recommend using the RMVL framework when there are repeated VL measurements per participant because it utilizes all available VL data, provides additional information, has more statistical power, and avoids the subjectivity of defining a "window."

Background The objective of this analysis was to determine the ways in which patients’ legal statuses at hospital admission and discharge are associated with select sociodemographic and clinical variables. This study specifically investigated differences between patients who were voluntary during both admission and discharge, patients who were involuntary on admission but voluntary on discharge (having converted to voluntary status during hospitalization), and patients who were involuntary during both admission and discharge. Method Data were collected from the charts and treating clinicians of 227 consecutively discharged patients from two psychiatric units in a large, urban, county hospital in the southeastern United States. Based on results of bivariate tests, sociodemographic and clinical factors were entered into a polytomous logistic regression model to determine effect estimates (adjusted odds ratios). Results In the bivariate analyses, 15 variables were significantly associated with the trichotomous legal status. In the model, three factors were independently significantly associated with legal status, while controlling for four potential confounders: (1) whether or not the patient was experiencing psychotic symptoms at discharge, (2) whether or not the patient had documented medical problems requiring medication at discharge, and (3) the number of psychiatric medications. Conclusions A generalized lack of treatment engagement and adherence among involuntary patients likely underlies significant differences between the groups in terms of psychotic symptoms, diagnosed medical problems requiring medications, and number of psychiatric medications at discharge. Studying legal status (and the process of legal status conversion from involuntary to voluntary) and its correlates is an important topic for further research.

BACKGROUND Retaining HIV patients in medical care promotes access to antiretroviral therapy, viral load suppression, and reduced HIV transmission to partners. We estimate the programmatic costs of a US multisite randomized controlled trial of an intervention to retain HIV patients in care. METHODS Six academically affiliated HIV clinics randomized patients to intervention (enhanced personal contact with patients across time coupled with basic HIV education) and control [standard of care (SOC)] arms. Retention in care was defined as 4-month visit constancy, that is, at least 1 primary care visit in each 4-month interval over a 12-month period. We used microcosting methods to collect unit costs and measure the quantity of resources used to implement the intervention in each clinic. All fixed and variable labor and nonlabor costs of the intervention were included. RESULTS Visit constancy was achieved by 45.7% (280/613) of patients in the SOC arm and by 55.8% (343/615) of patients in the intervention arm, representing an increase of 63 patients (relative improvement 22.1%; 95% confidence interval: 9% to 36%; P < 0.01). The total annual cost of the intervention at the 6 clinics was $241,565, the average cost per patient was $393, and the estimated cost per additional patient retained in care beyond SOC was $3834. CONCLUSIONS Our analyses showed that a retention in care intervention consisting of enhanced personal contact coupled with basic HIV education may be delivered at fairly low cost. These results provide useful information for guiding decisions about planning or scaling-up retention in care interventions for HIV-infected patients.

Poor engagement in HIV care is common in the United States and worsens HIV treatment outcomes. In addition, poor engagement in care is likely to drastically reduce the effectiveness of “test and treat” HIV prevention strategies.

quantitative results from clients participating in the Antiretroviral Treatment Access Studies-II (ARTAS-II) intervention have previously been published. The current report provides qualitative data from providers (agency staff who referred clients to ARTAS-II) concerning how the introduction of ARTAS-II case managers affected referrals to HIV care.referring providers from agencies that conducted HIV counseling and testing (community organizations, health care clinics, hospitals, and public health agencies) that had been asked to refer recently diagnosed HIV-positive individuals to ARTAS-II participated. Five ARTAS-II sites interviewed a total of 18 providers using a survey instrument of 11 open-ended questions. The questions covered interviewee characteristics (e.g., how long have you been in this position, job title) and questions related to the ARTAS-II project (e.g., before ARTAS-II, how did you link clients? what benefits have come from being part of the ARTAS-II program?)prior to the ARTAS-II project, the referring providers described the referral process as ranging from uncertain to disorganized and chaotic. Referring providers reported the process improved dramatically following implementation of the project, with the transition from HIV testing to medical care becoming less complicated and less prone to delays. Recommendations from the providers for further improvement included increasing the number of ARTAS-II case managers, having the program staff use direct, face-to-face communication with staff at referring agencies, and increasing system integration by having ARTAS-II program staff be co-located in clinic settings.the introduction of ARTAS-II case managers to receive referrals from HIV counseling and testing programs was widely viewed as a success by referring providers. ARTAS-II case managers were reported to fill a much needed role that strengthened the HIV service delivery system.

Objective A 'test and treat' strategy to reduce HIV transmission hinges on linking and retaining HIV patients in care to achieve the full benefit of antiretroviral therapy. We integrated empirical findings and estimated the percentage of HIV-positive persons in the United States who entered HIV medical care soon after their diagnosis; and were retained in care during specified assessment intervals. Methods We comprehensively searched databases and bibliographic lists to identify studies that collected data from May 1995 through 2009. Separate meta-analyses were conducted for entry into care and retention in care (having multiple HIV medical visits during specified assessment intervals) stratified by methodological variables. All analyses used random-effects models. Results Overall, 69% [95% confidence interval (CI) 66-71%, N = 53 323, 28 findings] of HIV-diagnosed persons in the United States entered HIV medical care averaged across time intervals in the studies. Seventy-two percent (95% CI 67-77%, N = 6586, 12 findings) entered care within 4 months of diagnosis. Seventy-six percent (95% CI 66-84%, N = 561, 15 findings) entered care after testing HIV-positive in emergency/urgent care departments and 67% (95% CI 64-70%, N = 52 762, 13 findings) entered care when testing was done in community locations. With respect to retention in care, 59% (95% CI 53-65%, N = 75 655, 28 findings) had multiple HIV medical care visits averaged across assessment intervals of 6 months to 3-5 years. Retention was lower during longer assessment intervals. Conclusion Entry and retention in HIV medical care in the United States are moderately high. Improvement in both outcomes will increase the success of a test and treat strategy.

Background Implementation of linkage to HIV care programs in the U.S. is poorly described in the literature despite the central role of these programs in delivering clients from HIV testing facilities to clinical care sites. Models demonstrating success in linking clients to HIV care from testing locations that do not have co-located medical care are especially needed. Methods Data from the Antiretroviral Treatment Access Studies-II project ('ARTAS-II') as well as site visit and project director reports were used to describe structural factors and best practices found in successful linkage to care programs. Successful programs were able to identify recently diagnosed HIV-positive persons and ensure that a high percentage of persons attended an initial HIV primary care provider visit within six months of enrolling in the linkage program. Results Eight categories of best practices are described, supplemented by examples from 5 of 10 ARTAS-II sites. These five sites highlighted in the best practices enrolled a total of 352 HIV+ clients and averaged 85% linked to care after six months. The other five grantees enrolled 274 clients and averaged 72% linked to care after six months. Sites with co-located HIV primary medical care services had higher linkage to care rates than non-co-located sites (87% vs. 73%). Five grantees continued linkage to care activities in some capacity after project funding ended. Conclusions With the push to expand HIV testing in all U.S. communities, implementation and evaluation of linkage to care programs is needed to maximize the benefits of expanded HIV testing efforts

This study investigated predictors of length of stay (LOS) for two inpatient psychiatric units (a crisis stabilization unit and a longer-stay milieu unit) in a large, urban, university-affiliated, county hospital. It was hypothesized that three variables would be independently associated with shorter LOS: (1) higher Global Assessment of Functioning (GAF) scale scores, (2) not requiring the use of seclusion or restraints, and (3) the presence of a comorbid substance use disorder. Data were collected on consecutive discharges (n=234) from the two inpatient units. Bivariate tests were conducted, and multiple linear regression models assessed the independent effects of potential determinants of LOS. The presence of a comorbid personality disorder or substance use disorder was predictive of shorter LOS on the crisis stabilization unit (n=88). Several variables were found to be predictive of shorter LOS on the longer-stay milieu unit (n=146), including: involuntary legal status on discharge, not requiring seclusion or restraints, higher admission GAF scale score, female gender, and the presence of a comorbid substance use disorder. Findings indicate that a substantial portion of the variance in LOS in this setting can be predicted from basic sociodemographic and clinical factors available in hospital medical charts.

Objective: This study was conducted to determine the practical, readily accessible predictors of missed first outpatient appointments in a community mental health setting after psychiatric hospitalization. Methods: Data were collected from treatment team members and from charts of 234 consecutively discharged patients from two inpatient units in a large, urban, county hospital. Data on whether the patient attended the first scheduled outpatient community mental health appointment were gathered by telephone contact with outpatient clinics. Outcome data were available for 221 patients. Bivariate tests examined a variety of demographic, psychosocial, and clinical characteristics that may be associated with nonadherence. Significant predictors were entered into a logistic regression model to determine effect estimates (adjusted odds ratios). Results: In bivariate tests, a number of variables were predictive of nonadherence with the first scheduled outpatient appointment. In the logistic regression model, the four characteristics that were independently significant predictors included involuntary legal status at discharge or leaving against medical advice, not having an established outpatient clinician, axis IV problems related to the primary support group (for example, death of a family member or health problems in the family), and number of days from hospital discharge to the follow-up appointment. Conclusions: Clinical, policy, and programmatic implications may be elaborated by studying risk factors for nonadherence in a community mental health setting. Given the multitude of problems associated with nonadherence, interventions should be tailored around specific characteristics that elevate the risk of nonadherence, especially nonadherence in the form of failure to attend the first appointment after psychiatric hospitalization. (Psychiatric Services 57:531–537, 2006)