This study examined the impact of motivational interviewing (MI) counseling time on self-efficacy to practice safer sex for people living with HIV/AIDS (PLWHA).
In 4 month intervals we followed a cohort of 490 PLWHA for 12 months. We conducted hierarchical linear regression models to examine changes in safer sex self-efficacy when participants received zero, low to moderate (5–131 minutes) and high (132–320 minutes) doses of MI time. We conducted a similar analysis using number of counseling sessions as the predictor variable.
Participants with low to moderate doses of MI counseling had 0.26 higher self-efficacy scores than participants with zero MI time (p=0.01). Also, they had 0.26 lower self-efficacy scores than participants with high amounts of MI time (p=0.04). Participants with high doses of MI had a 0.5 higher self-efficacy score than participants with zero amount of MI time (p<0.0001). Participants who received 3–4 counseling sessions had 0.41 greater self-efficacy scores than participants who did not receive any sessions (p<0.0001) but did not differ from participants receiving 1–2 sessions.
MI time is a key to enhancing safer sex self-efficacy among PLWHA.
Safer sex self-efficacy improves the more MI counseling time and sessions PLWHA receive.
HIV; Motivational Interviewing; Self-efficacy; Safer Sex
To assess factors associated with having a Trichomonas vaginalis (TV) infection among persons receiving care for HIV and estimate the number of transmitted HIV infections attributable to TV.
HIV clinic patients were recruited from two secondary prevention studies, screened by urine nucleic-acid amplification tests for sexually transmitted infections (STIs) and interviewed about risk factors (baseline, 6 and 12 months). We conducted mathematical modeling of the results to estimate the number of transmitted HIV infections attributable to TV among a cohort of HIV-infected patients receiving medical care in North Carolina.
TV was prevalent in 7.4%, and incident in 2% – 3% of subjects at follow-up. Individuals with HIV RNA less than 400 copies/ml (OR 0.32, 95% CI: 0.14 – 0.73) and at least 13 years of education (OR 0.24, 95% CI: 0.08 –0.70) were less likely to have TV. Mathematical modeling predicted that 0.062 HIV transmission events occur per 100 HIV infected women in the absence of TV infection and 0.076 HIV infections per 100 HIV and TV-infected women (estimate range: 0.070 – 0.079), indicating that 23% of the HIV transmission events from HIV-infected women may be attributable to TV infection when 22% of women are co-infected with TV.
The data suggest the need for improved diagnosis of TV infection and suggest that HIV-infected women in medical care may be appropriate targets for enhanced testing and treatment.
HIV; Secondary prevention; Trichomonas infections; Sexually transmitted diseases
Programs to help people living with HIV/AIDS practice safer sex are needed to prevent transmission of HIV and other sexually transmitted infections. We sought to assess the impact of SafeTalk, a multicomponent motivational interviewing-based safer sex program, on HIV-infected patients’ risky sexual behavior. We enrolled sexually active adult HIV-infected patients from one of three clinical sites in North Carolina and randomized them to receive the 4-session SafeTalk intervention versus a hearthealthy attention-control. There was no significant difference in the proportion of people having unprotected sex between the two arms at enrollment. SafeTalk significantly reduced the number of unprotected sex acts with at-risk partners from baseline, while in controls the number of unprotected sex acts increased. Motivational interviewing can provide an effective, flexible prevention intervention for a heterogeneous group of people living with HIV.
AIDS; HIV; Motivational interviewing; Safer sex; SafeTalk
The epidemiology of HIV infection in the US in general, and in the southeast, in particular, has shifted dramatically over the past two decades, increasingly affecting women and minorities. The site for our intervention was an infectious diseases clinic based at a university hospital serving over 1,300 HIV-infected patients in North Carolina. Our patient population is diverse and reflects the trends seen more broadly in the epidemic in the southeast and in North Carolina. Practicing safer sex is a complex behavior with multiple determinants that vary by individual and social context. A comprehensive intervention that is client-centered and can be tailored to each individual’s circumstances is more likely to be effective at reducing risky behaviors among clients such as ours than are more confrontational or standardized prevention messages. One potential approach to improving safer sex practices among people living with HIV/AIDS (PLWHA) is Motivational Interviewing (MI), a non-judgmental, client-centered but directive counseling style. Below, we describe: (1) the development of the Start Talking About Risks (STAR) MI-based safer sex counseling program for PLWHA at our clinic site; (2) the intervention itself; and (3) lessons learned from implementing the intervention.
HIV prevention; Motivational interviewing; Sexual behavior
Rationale and Purpose
Motivational interviewing (MI) is a counseling technique that has been used effectively to change a number of health-related behaviors. We sought to assess the impact on patients’ antiretroviral therapy (ART) adherence of a multicomponent, MI-based ART adherence intervention compared with that of an HIV informational control program.
Two-arm, randomized, controlled trial.
One hundred forty adult HIV-infected patients attending a large, academic center infectious diseases clinic who were either failing or newly initiating an ART regimen.
(1) Mean adherence level (% of prescribed doses take in the prior month) at the week 12 visit, (2) change in mean adherence, (3) percentage of patients achieving >95% adherence in the third 4-week block, and (4) change in viral load.
The MI group’s mean adherence improved by 4.5% compared with a decrease in the control group’s adherence by 3.83% (P = 0.10). In the treatment group, 29% achieved >95% adherence compared with only 17% in the control group (P = 0.13). When we controlled for ethnicity, the intervention group had 2.75 times higher odds of achieving more than 95% adherence than did the controls (P = 0.045; 95% confidence interval: 1.023, 7.398). Although a number of mediating variables (beliefs about ART, coping style, social support, and goals set) had statistically significant changes in the expected direction in the MI group compared with controls, in the intent-to-treat analysis, the mean adherence at study exit for the intervention group was 76% (SD = 27%) and 71% (SD = 27%) for the control group (P = 0.62).
Although not definitive, this study provides some evidence that MI offers an effective approach to improving adherence. Future studies able to build MI into the intervention for longer than 3 months may have a greater impact.
antiretroviral adherence; motivational interviewing; medication compliance
We identified factors associated with testing HIV positive in a prison system performing voluntary HIV testing on inmates and estimated the number of undetected HIV cases to evaluate the efficacy of risk-factor–based HIV testing.
We used logistic regression to estimate associations between HIV serostatus and HIV risk behaviors, mental health, coinfection status, and socio-demographic characteristics for prisoners entering the North Carolina Department of Correction from January 2004 through May 2006. We estimated the number of undetected HIV cases on the basis of age-, gender-, and race-specific HIV prevalences among prisoners and in the state.
Nearly 3.4% (718/21419) of tested prisoners were HIV positive. The strongest risk factors for infection among men were having sex with men (odds ratio [OR]=8.0), Black race (OR=6.2), other non-White race (OR=7.4), and being aged 35 to 44 years (OR=4.1). The strongest risk factor among women was Black race (OR=3.8). Among HIV-positive prisoners, 65% were coinfected with HCV. We estimated that between 24% (223) and 61% (1101) of HIV cases remained undetected.
The associations between HIV serostatus and a variety of factors highlight the potential limitations of risk-factor–based HIV testing in prisons, as do the high number of potential undetected HIV cases.
We examined the use of voluntary HIV testing among state prisoners in the North Carolina prison system.
We calculated system-wide and facility-specific proportions and rates of adult inmates tested for HIV and estimated associations between testing status and inmate characteristics for prisoners in North Carolina.
Of the 54016 inmates who entered prison between January 2004 and May 2006, 20820 (38%) were tested for HIV; of those tested, 18574 (89%) were tested at admission. Across the 8 intake prisons, more than 80% of inmates in both female facilities but less than 15% of inmates in 4 of 6 male facilities were tested. Prisoners with a documented history of heroin use, crack or cocaine use, conventional HIV risk behavior, or tuberculosis were at least 10% more likely to be tested than were inmates without these characteristics. However, more than 60% of men reporting conventional risk behaviors were not tested. Before covariate adjustment, Black men were 30% less likely than White men to be tested; in the multivariable regression model, this difference was attenuated to 13%.
Rates of HIV testing varied widely across intake prisons, and many male inmates with documented risk of infection were never tested.
HIV/AIDS trends in the United States depict a concentrated epidemic with hot spots that vary by location, poverty, race/ethnicity, and transmission mode. HIV/AIDS is a leading cause of death among US women of color; two thirds of new infections among women occur in black women, despite the fact that black women account for just 14% of the US female population. The gravity of the HIV epidemic among US women is often not appreciated by those at risk as well as by the broader scientific community. We summarize the current epidemiology of HIV/AIDS among US women and discuss clinical, research, and public health intervention components that must be brought together in a cohesive plan to reduce new HIV infections in US women. Only by accelerating research and programmatic efforts will the hidden epidemic of HIV among US women emerge into the light and come under control.
HIV in women; HIV prevention science; racial disparity
This study aimed to determine the level of antiretroviral (ART) adherence and factors associated with adherence among patients receiving free ART at one clinic in Tanzania. Adult patients were recruited into the cross-sectional study and completed a survey that included self-reported adherence over four days and over one month. Less than 95% adherence on either measure was considered “poor”. Factors associated with adherence in unadjusted analyses (α=0.10) were included in a logistic regression model. 340 patients participated in the study, and 5.9% (20/340) reported poor adherence. The final model found poor adherence associated with: being young (OR=4.03) or old (OR=6.68); having lower perceived quality of patient-provider interaction (OR=2.75); and ever missing a clinic appointment (OR=3.13). Results highlight good adherence, but suggest the importance of addressing: 1) age-specific challenges of adherence through counseling and support; 2) client-focused care and quality of patient-provider interaction; and 3) clinic appointment reminder systems.
HIV; adherence; antiretroviral therapy; Tanzania
Imprisonment provides opportunities for the diagnosis and successful treatment of HIV, however, the benefits of antiretroviral therapy are frequently lost following release due to suboptimal access and utilization of health care and services. In response, some have advocated for development of intensive case-management interventions spanning incarceration and release to support treatment adherence and community re-entry for HIV-infected releasees. We conducted a randomized controlled trial of a motivational Strengths Model bridging case management intervention (BCM) beginning approximately 3 months prior to and continuing 6 months after release versus a standard of care prison-administered discharge planning program (SOC) for HIV-infected state prison inmates. The primary outcome variable was self-reported access to post-release medical care. Of the 104 inmates enrolled, 89 had at least 1 post-release study visit. Of these, 65.1% of BCM and 54.4% of SOC assigned participants attended a routine medical appointment within 4 weeks of release (P >0.3). By week 12 post-release, 88.4% of the BCM arm and 78.3% of the SOC arm had at attended at least one medical appointment (P = 0.2), increasing in both arms at week 24–90.7% with BCM and 89.1% with SOC (P >0.5). No participant without a routine medical visit by week 24 attended an appointment from weeks 24 to 48. The mean number of clinic visits during the 48 weeks post release was 5.23 (SD = 3.14) for BCM and 4.07 (SD = 3.20) for SOC (P >0.5). There were no significant differences between arms in social service utilization and re-incarceration rates were also similar. We found that a case management intervention bridging incarceration and release was no more effective than a less intensive pre-release discharge planning program in supporting health and social service utilization for HIV-infected individuals released from prison.
Prisoners; Access to care; Case management
Although HIV-positive patients’ adherence to antiretroviral therapy (ART) is relatively high in African nations, as compared with industrialized nations, few studies have explored why. In the research presented here we aimed to understand the dynamics of good adherence to ART among patients receiving free ART and HIV-related services from a clinic in Arusha, Tanzania. We conducted individual semi-structured interviews with 6 health care providers and 36 patients at the study site. Interviews were conducted in Swahili using interview guides informed by social cognitive theory. All interviews were audio-recorded, transcribed in Kiswahili, translated into English and coded for themes and patterns with Atlas t.i. Of the 36 patients interviewed (mean time on ART 9.8 months; range 1–23 months), 32 reported perfect adherence in the previous month. Self-reported adherence was high despite economic hardship, depression, low rates of HIV disclosure and high perceived HIV-associated stigma. Five factors emerged to explain excellent adherence in the face of such barriers. First, all respondents experienced substantial improvements in their health after starting ART; this supported their confidence in the medication and motivated them to adhere. Second, their perceived need to be able to meet their family responsibilities motivated respondents to stay healthy. Third, respondents developed specific strategies to remember to take pills, particularly routinizing pill-taking by linking it with daily activities or events. Fourth, material and emotional support received from others facilitated adherence. Finally, respondents trusted the advice and instructions of their health care providers, who regularly emphasized adherence. The facilitating factors identified were consistent with the constructs of social cognitive theory and highlighted the importance of interventions that address multiple levels of influence on adherence.
To know the perceptions regarding barriers and facilitators to cART adherence among people living with HIV/AIDS
Materials and Methods:
To adapt U.S. based SAFETALK “prevention with positives” intervention to be culturally relevant in Gujarat, India in assisting PLWHA, a formative study was conducted. We conducted 30 in-depth interviews with PLWHA in the local language, assessing the experiences, perceived barriers, and facilitators to combination antiretroviral therapy (cART) among PLWHA in Gujarat. PLWHA were selected from the Voluntary Counseling and Testing Centre (VCTC) in Gujarat. To triangulate interview findings, we conducted two focus group discussions (FGDs) with medical and non-medical providers, respectively.
Travel and commuting to clinic, fear of possible physical reactions, high cost of ART from private practitioners, CD4 count being in normal limits and resistance to medication acted as barriers to cART adherence. Initiation of cART was facilitated by family members′ suggestion, advice of treating doctors and counselors, appropriate counseling before starting cART, belief that cART would aid in living a better and longer life and due to lowering of the CD4 count.
Interpretation and Conclusions:
Our study suggests that several issues need to be considered when providing cART. Further research is needed to study interactions between patients and their health care providers.
Barriers; cART; facilitators; HIV positive people; qualitative study
Human immunodeficiency virus (HIV) disclosure offers important benefits to people living with HIV/AIDS. However, fear of discrimination, blame, and disruption of family relationships can make disclosure a difficult decision. Barriers to HIV disclosure are influenced by the particular culture within which the individuals live. Although many studies have assessed such barriers in the U.S., very few studies have explored the factors that facilitate or prevent HIV disclosure in India. Understanding these factors is critical to the refinement, development, and implementation of a counseling intervention to facilitate disclosure.
Materials and Methods:
To explore these factors, we conducted 30 in-depth interviews in the local language with HIV- positive individuals from the Integrated Counselling and Testing Centre in Gujarat, India, assessing the experiences, perceived barriers, and facilitators to disclosure. To triangulate the findings, we conducted two focus group discussions with HIV medical and non-medical service providers, respectively.
Perceived HIV-associated stigma, fear of discrimination, and fear of family breakdown acted as barriers to HIV disclosure. Most people living with HIV/AIDS came to know of their HIV status due to poor physical health, spousal HIV-positive status, or a positive HIV test during pregnancy. Some wives only learned of their husbands’ HIV positive status after their husbands died. The focus group participants confirmed similar findings. Disclosure had serious implications for individuals living with HIV, such as divorce, maltreatment, ostracism, and decisions regarding child bearing.
Interpretation and Conclusion:
The identified barriers and facilitators in the present study can be used to augment training of HIV service providers working in voluntary counseling and testing centers in India.
Disclosure; fear; human immunodeficiency virus; people living with HIV/AIDS; social stigma
Colon cancer screening recommendations for patients aged 75 years and older should account for variation in older adults’ health states, life expectancies, and potential to benefit from screening.
To assess if resident physicians incorporate health state and life expectancy information when making recommendations about colon cancer screening for adults aged 75 years and older.
Resident physicians at a university internal medicine program completed a survey in which they made life expectancy estimates and screening recommendations for hypothetical 75- and 85-year-old women patients with good, fair, or poor health states. Outcomes of interest included accuracy of residents’ life expectancy estimates (compared with life table data), effect of health state and life expectancy on screening recommendations, and whether providing life table information affected the initial screening recommendation for the 85-year-old hypothetical patients.
Residents’ life expectancy estimates demonstrated moderate agreement with life table estimates. Their recommendations for colon cancer screening for the 75-year-old patient vignettes varied appropriately by health state and by their estimates of life expectancy. Receiving information about life expectancy from life tables affected residents’ recommendations for one of the three 85-year-old hypothetical patients, the woman in good health. Many resident physicians reported uncertainty about the potential to benefit from screening for each patient scenario.
Resident physicians appropriately used life expectancy and health state to make colon cancer screening recommendations for older adults. Residents reported substantial uncertainty with regard to the potential benefit of screening.
decision making; aged; aged 80 and older; mass screening; colorectal cancer
With the continued transmission of HIV each year, novel approaches to HIV prevention are needed. Since 2003, the U.S. HIV prevention focus has shifted from primarily targeting HIV-negative at-risk persons to including safer sex programs for people already infected with HIV. At least 20–30% of people infected with HIV engage in risky sexual practices. Based on these data, policymakers have recommended that interventionists develop strategies to help HIV-infected people reduce their risky sexual behaviors. In the past, the few safer sex interventions that targeted HIV-infected people met with limited success because they basically adapted strategies previously used with HIV-uninfected individuals. In addition, often these adaptations did not address issues of serostatus disclosure, HIV stigma, or motivation to protect others from HIV. We had previously tested, in a demonstration project named the Start Talking About Risks (STAR) Program, a monthly three-session motivational interviewing (MI)-based intervention to help people living with HIV practice safer sex. In this study, we refined that program by enhancing its frequency and intensity and adding written and audio components to support the counseling. We theorized that an intervention such as MI, which is tailored to each individual's circumstances more than standardized prevention messages, would be more successful when supplemented with other components. We qualitatively assessed participants' perceptions, reactions, and preferences to the refined prevention with positives counseling program we called SafeTalk and learned that participants found the SafeTalk MI counseling and educational materials appealing, understandable, and relevant to their lives.
Identifying and counseling individuals with Acute HIV Infection (AHI) offers a critical opportunity to avert preventable HIV transmission, however opportunities to recognize these individuals may be missed. We surveyed 32 adults diagnosed with AHI during voluntary HIV testing from 1/1/03 to 2/28/05 in publicly funded testing sites in NC to describe their clinical, social, and behavioral characteristics. Eighty-one percent of participants were men; 59% were African American. Seventy-five percent experienced symptoms consistent with acute retroviral syndrome; although 83% sought medical care for these symptoms, only 15% were appropriately diagnosed at that initial medical visit, suggesting opportunities to diagnose these individuals earlier were missed. Eighty-five percent of the men engaged in sex with men. More than 50% of the participants thought they were infected with HIV by a steady partner. This study yields important information to assist in identifying populations at risk for or infected with AHI and designing both primary and secondary prevention interventions.
Acute HIV Infection (AHI); North Carolina (NC); HIV/AHI screening; AHI Epidemiology; HIV Risk Factors
Competing causes of mortality in the elderly decrease the potential net benefit from colorectal cancer screening and increase the likelihood of potential harms. Individualized decision making has been recommended, so that the elderly can decide whether or not to undergo colorectal cancer (CRC) screening. The objective is to develop and test a decision aid designed to promote individualized colorectal cancer screening decision making for adults age 75 and over.
We used formative research and cognitive testing to develop and refine the decision aid. We then tested the decision aid in an uncontrolled trial. The primary outcome was the proportion of patients who were prepared to make an individualized decision, defined a priori as having adequate knowledge (10/15 questions correct) and clear values (25 or less on values clarity subscale of decisional conflict scale). Secondary outcomes included overall score on the decisional conflict scale, and preferences for undergoing screening.
We enrolled 46 adults in the trial. The decision aid increased the proportion of participants with adequate knowledge from 4% to 52% (p < 0.01) and the proportion prepared to make an individualized decision from 4% to 41% (p < 0.01). The proportion that preferred to undergo CRC screening decreased from 67% to 61% (p = 0. 76); 7 participants (15%) changed screening preference (5 against screening, 2 in favor of screening)
In an uncontrolled trial, the elderly participants appeared better prepared to make an individualized decision about whether or not to undergo CRC screening after using the decision aid.
More than a quarter of human immunodeficiency virus (HIV)-infected persons are undiagnosed and therefore unaware of their HIV+ status. African Americans are disproportionately infected. Although perceived racism influences their attitudes toward HIV prevention, how racism influences their behaviors is unknown. We sought to determine whether perceiving everyday racism and racial segregation influence African American HIV testing behavior.
This was a clinic-based, multi-level study. Eligibility was limited to African Americans (N=373) seeking sexually transmitted disease diagnoses or screening. We collected survey data, block group characteristics, and lab-confirmed HIV testing behavior. We estimated associations using logistic regression with generalized estimating equations (GEE).
More than 90% of the sample perceived racism, which was associated with higher odds of HIV testing (OR=1.64, 95% CI=1.07, 2.52) controlling for residential segregation and other covariates. Neither patient satisfaction nor mechanisms for coping with stress explained the association.
African Americans are not merely victims of racism but also exercise agency within their social contexts. Those who perceive everyday racism may draw upon health promoting assets relative to their behaviors. How segregation influences testing warrants further research.
Current national guidelines recommend that all HIV care providers routinely counsel their HIV-infected patients about reducing HIV transmission behaviors. In this article we identify the challenges and lessons learned from implementing a provider-delivered HIV transmission risk-reduction intervention for HIV-infected patients (Positive Steps). Based on a multi-site Centers for Disease Control and Prevention (CDC) initiative, we integrated the Positive Steps program into an infectious diseases clinic in North Carolina. Of the nearly 1200 HIV-infected patients, 59% were African American, 44% were white, 33% were women, and over 50% were between 25 and 44 years of age. We obtained feedback from a community advisory board, input from clinic staff, and conducted formative interviews with clinic patients and providers to achieve overall acceptance of the program within the clinic. Clinic providers underwent training to deliver standardized prevention counseling. During program implementation we conducted a quality assessment of program components, including reviewing whether patients were screened for HIV transmission risk behaviors and whether providers counseled their patients. Once Positive Steps was implemented, on average, 69% of patients were screened and 77% of screened patients were counseled during the first 12 months. In analyses of quarterly exit surveys of patients after their medical exams, on average, 73% of respondents reported being asked about safer sex and 51% reported having safer-sex discussions with their providers across six quarterly periods. Of those who had discussions, 91% reported that those discussions were “very” or “moderately helpful.” Providers reported time and competing medical priorities as barriers for discussing prevention with patients, however, provider-delivered counseling was routinely performed for 12 months. Overall, the findings indicate that the Positive Steps program was successfully integrated in an infectious diseases clinic and received well by patients.
OBJECTIVES: The purpose of this study was to determine the effect of release from prison and subsequent re-incarceration on the viral loads of HIV-infected individuals receiving highly active antiretroviral therapy (HAART). METHODS: Fifteen re-incarcerated HIV-infected prisoners on HAART were identified from a retrospective cohort of HIV-infected prison inmates released from January 1, 1997, to August 31, 1999. The re-incarcerated prisoners were matched (1:2) to 30 HIV-infected incarcerated prisoners on HAART who remained incarcerated during the re-incarcerated participants' release time period. The outcomes measured were plasma HIV RNA levels, CD4+ lymphocyte counts, percentage of re-incarcerated and incarcerated participants with plasma HIV RNA levels <400 copies/mL, and the median change in plasma HIV RNA levels of the re-incarcerated and incarcerated participants at the end of the study. RESULTS: At the beginning of the study, 8/15 re-incarcerated participants had plasma HIV RNA levels <400 copies/mL, compared with 15/30 incarcerated participants. At the end of the study, only three of those eight re-incarcerated participants had plasma HIV RNA levels <400 copies/mL, compared with 14/15 incarcerated participants (p=0.0086). The median change in plasma HIV RNA levels of the re-incarcerated participants was 1.29 log10 copies/mL (interquartile range 0.04 to 1.70), compared with -0.03 log10 copies/mL (interquartile range -0.65 to 0.09) in the incarcerated participants (p=0.0183). CONCLUSIONS: Release from prison was associated with a deleterious effect on virological and immunological outcomes. These data suggest that comprehensive discharge planning efforts are required to make certain that HIV-infected inmates receive access to quality care following incarceration.
National guidelines recommend that practitioners assess and reinforce patient adherence when prescribing antiretroviral (ART) medications, but the extent to which physicians do this routinely is unknown.
To assess the adherence counseling practices of physicians caring for patients with HIV/AIDS in North Carolina and to determine characteristics associated with providing routine adherence counseling.
A statewide self-administered survey.
SETTING AND PARTICIPANTS
All physicians in North Carolina who prescribed a protease inhibitor (PI) during 1999. Among the 589 surveys sent, 369 were returned for a response rate of 63%. The 190 respondents who reported prescribing a PI in the last year comprised the study sample.
MAIN OUTCOME MEASURES
Physicians reported how often they carried out each of 16 adherence counseling behaviors as well as demographics, practice characteristics, and attitudes.
On average, physicians reported spending 13 minutes counseling patients when starting a new 3-drug ART regimen. The vast majority performed basic but not more extensive adherence counseling; half reported carrying out 7 or fewer of 16 adherence counseling behaviors “most” or “all of the time.” Physicians who reported conducting more adherence counseling were more likely to be infectious disease specialists, care for more HIV-positive patients, have more time allocated for an HIV visit, and to perceive that they had enough time, reimbursement, skill, and office space to counsel. After also controlling for the amount of reimbursement and availability of space for counseling, physicians who were significantly more likely to perform a greater number of adherence counseling practices were those who 1) cared for a greater number of HIV/AIDS patients; 2) had more time allocated for an HIV physical; 3) felt more adequately skilled; and 4) had more positive attitudes toward ART.
This first investigation of adherence counseling practices in HIV/AIDS suggests that physicians caring for patients with HIV/AIDS need more training and time allocated to provide antiretroviral adherence counseling services.
adherence; antiretroviral; HIV/AIDS; medication compliance; physicians
Because career satisfaction among general internists is relatively low, we sought to understand the impact on satisfaction of general internists managing patients both in and outside of the hospital. Using data from a national survey, we asked, “Among outpatient-oriented general internists (i.e., internists who spend less than 50% of their clinical time caring for inpatients), what effect does time spent in the hospital have on physician satisfaction, stress, and burnout?”
The Physician Worklife Study, in which 5,704 physicians in primary and specialty nonsurgical care selected from the American Medical Association's Masterfile were surveyed (adjusted response rate = 52%), was used. Our analyses focused on clinically active outpatient-oriented general internists (N = 339).
MEASUREMENTS AND MAIN RESULTS
We constructed multivariate linear models to test for statistically significant associations between the amount of time spent seeing inpatients and physician satisfaction as measured by several satisfaction scales. Even after controlling for total hours worked and other possible confounding variables, we found that increased time working in the hospital was significantly associated with decreases in satisfaction with administration, specialty, autonomy, and personal time, and significantly associated with an increase in life stress. There was also a significant association between increased time spent in the hospital and burnout.
Our findings imply that there may be a tension between the practice of inpatient and outpatient medicine by general internists, and suggest that fewer hospital duties may increase career satisfaction for outpatient-oriented internists. Although additional studies are warranted in order to better understand why these relationships exist, our data suggest that the hospitalist model of inpatient care might be one approach to alleviate stress and improve satisfaction for many general internists.
job satisfaction; hospitalists; burnout, professional; primary health care; professional practice
Adherence to complex antiretroviral therapy (ART) is critical for HIV treatment but difficult to achieve. The development of interventions to improve adherence requires detailed information regarding barriers to adherence. However, short follow-up and inadequate adherence measures have hampered such determinations. We sought to assess predictors of long-term (up to 1 year) adherence to newly initiated combination ART using an accurate, objective adherence measure.
A prospective cohort study of 140 HIV-infected patients at a county hospital HIV clinic during the year following initiation of a new highly active ART regimen.
MEASURES AND MAIN RESULTS
We measured adherence every 4 weeks, computing a composite score from electronic medication bottle caps, pill count and self-report. We evaluated patient demographic, biomedical, and psychosocial characteristics, features of the regimen, and relationship with one's HIV provider as predictors of adherence over 48 weeks. On average, subjects took 71% of prescribed doses with over 95% of patients achieving suboptimal (<95%) adherence. In multivariate analyses, African-American ethnicity, lower income and education, alcohol use, higher dose frequency, and fewer adherence aids (e.g., pillboxes, timers) were independently associated with worse adherence. After adjusting for demographic and clinical factors, those actively using drugs took 59% of doses versus 72% for nonusers, and those drinking alcohol took 66% of doses versus 74% for nondrinkers. Patients with more antiretroviral doses per day adhered less well. Participants using no adherence aids took 68% of doses versus 76% for those in the upper quartile of number of adherence aids used.
Nearly all patients' adherence levels were suboptimal, demonstrating the critical need for programs to assist patients with medication taking. Interventions that assess and treat substance abuse and incorporate adherence aids may be particularly helpful and warrant further study.
adherence; antiretroviral; medication compliance; HIV
Adherence to combination antiretroviral therapy is critical for clinical and virologic success in HIV-infected patients. To combat poor adherence, clinicians must identify nonadherent patients so they can implement interventions. However, little is known about the accuracy of these assessments. We sought to describe the accuracy of clinicians' estimates of patients' adherence to combination antiretroviral therapy.
Public HIV clinic.
Prospective cohort study. During visits, we asked clinicians (nurse practitioners, residents and fellows, and their supervising attending physicians) to estimate the percentage of antiretroviral medication taken by patients over the last 4 weeks and predicted adherence over the next 4 weeks. Adherence was measured using electronic monitoring devices, pill counts, and self-reports, which were combined into a composite adherence measure.
PATIENTS AND PARTICIPANTS
Clinicians estimated 464 episodes of adherence in 82 patients.
Among the 464 adherence estimates, 264 (57%) were made by principal care providers (31% by nurse practitioners, 15% by fellows, 6% by residents, and 5% by staff physicians) and 200 (43%) by supervising attending physicians. Clinicians' overestimated measured adherence by 8.9% on average (86.2% vs 77.3%). Greater clinician inaccuracy in adherence prediction was independently associated with higher CD4 count nadir (1.8% greater inaccuracy for every 100 CD4 cells, P = .005), younger patient age (3.7% greater inaccuracy for each decade of age, P = .02), and visit number (P = .02). Sensitivity of detecting nonadherent patients was poor (24% to 62%, depending on nonadherence cutoff). The positive predictive value of identifying a patient as nonadherent was 76% to 83%.
Clinicians tend to overestimate medication adherence, inadequately detect poor adherence, and may therefore miss important opportunities to intervene to improve antiretroviral adherence.
adherence; compliance; HIV; clinician assessment; antiretroviral therapy
The integration of original data from multiple antiretroviral (ARV)
adherence studies offers a promising, but little used method to generate
evidence to advance the field. This paper provides an overview of the design and
implementation of MACH14, a collaborative, multi-site study in which a large
data system has been created for integrated analyses by pooling original data
from 16 longitudinal ARV adherence studies. Studies selected met specific
criteria including similar research design and data domains such as adherence
measured with medication event monitoring system, psychosocial factors related
to adherence behavior, and virologic and clinical outcomes. The data system
created contains individual data (collected between 1997 and 2009) from 2,860
HIV patients. Collaboration helped resolve the challenges inherent in pooling
data across multiple studies, yet produced a data system with strong statistical
power and potentially greater capacity to address key scientific questions than
possible with single-sample studies or even meta-analytic designs.
HIV/AIDS; Adherence; MEMS Multi-site Antiretroviral medication; Individual participant data