HIV-positive individuals seek support for medication adherence from a variety of sources—spouses, family and friends. We conducted a qualitative study of twenty same sex male couples where we asked men to give narratives of support received for medication adherence from their partner, family and friends. Men in couple relationships did not routinely seek tangible or practical assistance for adherence from friends and family but almost exclusively from partners. These men did seek and receive informational and emotional support from friends and family. These results have implications for designing interventions for medication support when an individual is in a relationship.
social support; gay couples; antiretroviral adherence; HIV/AIDS
There is growing evidence that early treatment with antiretroviral therapy (ART) confers benefit to HIV-infected persons and may reduce the risk of transmission. Among an urban poor sample living with HIV who meet guidelines for but are not taking ART, we explored treatment beliefs at baseline and subsequent ART uptake over the following 12 months. Most demographic/background characteristics did not differ between ART initiators and non-initiators, but baseline beliefs of expectancies about treatment ease, efficacy, and readiness sensitively predicted ART initiation. Treatment-related stigma/social concerns did not. Results offer direction for interventions to optimize treatment among those most in need.
Treatment uptake; readiness; expectancies; IDU
The Model of Health Care Empowerment (HCE) defines HCE as the process and state of being engaged, informed, collaborative, committed, and tolerant of uncertainty regarding health care. We examined the hypothesized antecedents and clinical outcomes of this model using data from ongoing human immunodeficiency virus (HIV)-related research. The purpose of this paper is to explore whether a new measure of HCE offers direction for understanding patient engagement in HIV medical care. Using data from two ongoing trials of social and behavioral aspects of HIV treatment, we examined preliminary support for hypothesized clinical outcomes and antecedents of HCE in the context of HIV treatment.
This was a cross-sectional analysis of 12-month data from study 1 (a longitudinal cohort study of male couples in which one or both partners are HIV-seropositive and taking HIV medications) and 6-month data from study 2, a randomized controlled trial of HIV-seropositive persons not on antiretroviral therapy at baseline despite meeting guidelines for treatment. From studies 1 and 2, 254 and 148 participants were included, respectively. Hypothesized antecedents included cultural/social/environmental factors (demographics, HIV-related stigma), personal resources (social problem-solving, treatment knowledge and beliefs, treatment decision-making, shared decision-making, decisional balance, assertive communication, trust in providers, personal knowledge by provider, social support), and intrapersonal factors (depressive symptoms, positive/negative affect, and perceived stress). Hypothesized clinical outcomes of HCE included primary care appointment attendance, antiretroviral therapy use, adherence self-efficacy, medication adherence, CD4+ cell count, and HIV viral load.
Although there was no association observed between HCE and HIV viral load and CD4+ cell count, there were significant positive associations of HCE scores with likelihood of reporting a recent primary care visit, greater treatment adherence self-efficacy, and higher adherence to antiretroviral therapy. Hypothesized antecedents of HCE included higher beliefs in the necessity of treatment and positive provider relationships.
human immunodeficiency virus; acquired immune deficiency syndrome; health care empowerment; adherence; compliance
This qualitative study examines received social support by analyzing relationship dynamics concerning antiretroviral therapy (ART) adherence among HIV+ seroconcordant and serodiscordant male couples. Using narrative data from forty participants (20 couples interviewed separately), we describe patterns of relationship dynamics and support preferences. One group viewed adherence as a Personal Responsibility. A second group viewed adherence as a Couple Responsibility and integrated support for medication adherence into the relationship. A third group was in the process of ending their relationships and adherence support was one-sided or withdrawn altogether. Examining support exchanges contexts at cultural, situational, relational, and personal levels illuminated adherence processes. Qualitative methods provided a framework for investigating these complex relationships and their associations with HIV treatment adherence.
Adherence; Antiretroviral Therapy; Gay Couples; HIV Infection; Social Support
Unprotected sexual intercourse remains a primary mode of HIV transmission in the United States. We found that receipt of services to reduce HIV transmission-risk behaviors was low among 3787 HIV-infected individuals and that men who have sex with men were especially unlikely to receive these services even though they were more likely to report unprotected sexual intercourse with seronegative and unknown serostatus casual partners. Greater efforts should be made to ensure that prevention counseling is delivered to all HIV-infected persons, especially men who have sex with men.
Side effects from antiretroviral therapy (ART) for HIV disease can deter treatment, impact quality of life, and impede medication adherence. Individual differences in neuroticism may account for variations in the experience of side effects and perceptions of health status. Cross-sectional assessments were conducted with 258 HIV-infected participants with confirmed HIV infection and current ART regimen. Structural equation modeling (SEM) was used to evaluate a model of self-reported ART side effect frequency and severity and perceived health status, as related to symptoms of neuroticism. Symptoms of neuroticism were associated with greater reports of ART side effects and poorer perceived health but unrelated to reported CD4 count and viral load. A structural model was supported in which greater symptoms of neuroticism are linked to poorer perceived health through greater side effect frequency and severity. Individual differences in symptoms of neuroticism can explain variations in side effect reporting and consequential impairments in perceived health in the context of HIV treatment. Identification and intervention with individuals high in symptoms of neuroticism may be warranted to alleviate side effect-related concerns and maximize treatment benefit.
Neuroticism; HIV; AIDS; Adherence; Compliance; Symptom Reporting; Structural Equation Modeling
Adherence to HIV treatment, including adherence to antiretroviral (ART) medication regimens, is paramount in the management of HIV. Self-efficacy for treatment adherence has been identified as an important correlate of medication adherence in the treatment of HIV and other medical conditions. This paper describes the validation of the HIV Treatment Adherence Self-Efficacy Scale (HIV-ASES) with two samples of HIV+ adults on ART. Factor analyses support subscales measuring Adherence Integration (eigenvalue = 6.12) and Adherence Perseverance (eigenvalue = 1.16), accounting for 61% of the variance in scale items. The HIV-ASES demonstrates robust internal consistency (ρs > .90) and 3-month (rs > .70) and 15-month (rs > .40) test-retest reliability. Concurrent validity analyses revealed relationships with psychosocial measures, ART adherence, clinical status, and healthcare utilization. Findings support the use of the HIV-ASES and provide guidance for further investigation of adherence self-efficacy in the context of treatment for HIV and other diseases.
HIV; AIDS; Adherence; Self-Efficacy
We sought to understand patient perceptions of the emergency department/urgent care (ED/UC) HIV diagnosis experience as well as factors that may promote or discourage linkage to HIV care. We conducted in-depth interviews with patients (n=24) whose HIV infection was diagnosed in the ED/UC of a public hospital in San Francisco at least six months prior and who linked to HIV care at the hospital HIV clinic. Key diagnosis experience themes included physical discomfort and limited functionality, presence of comorbid diagnoses, a wide spectrum of HIV risk perception, and feelings of isolation and anxiety. Patients diagnosed with HIV in the ED/UC may not have their desired emotional supports with them, either because they are alone or they are with family members or friends to whom they do not want to immediately disclose. Other patients may have no one they can rely on for immediate support. Nearly all participants described compassionate disclosure of test results by ED/UC providers, although several noted logistical issues that complicated the disclosure experience. Key linkage to care themes included the importance of continuity between the testing site and HIV care, hospital admission as an opportunity for support and HIV education, and thoughtful matching by linkage staff to a primary care provider. ED/UC clinicians and testing programs should be sensitive to the unique roles of sickness, risk perception, and isolation in the ED/UC diagnosis experience, as these things may delay acceptance of HIV diagnosis. The disclosure and linkage to care experience is crucial in forming patient attitudes towards HIV and HIV care, thus staff involved in disclosure and linkage activities should be trained to deliver compassionate, informed, and thoughtful care that bridges HIV testing and treatment sites.
Sleep disturbances have been reported to be higher in human immunodeficiency virus (HIV)-infected individuals compared to the general population. Despite the consequences of poor quality of sleep (QOS), research regarding sleep disturbances in HIV infection is lacking and many questions regarding correlates of poor QOS, especially in marginalized populations, remain unanswered. We conducted one-on-one qualitative interviews with 14 marginalized HIV-infected individuals who reported poor QOS to examine self-reported correlates of sleep quality and explore the relationship between QOS and antiretroviral adherence. Findings suggest a complex and multidimensional impact of mental health issues, structural factors, and physical conditions on QOS of these individuals. Those reporting poor QOS as a barrier to antiretroviral adherence reported lower adherence due to falling asleep or feeling too tired to take medications in comparison to those who did not express this adherence barrier. These interviews underscore the importance of inquiries into a patient’s QOS as an opportunity to discuss topics such as adherence, depression, suicidal ideation, and substance use.
adherence; HIV/AIDS; interviews; qualitative research; sleep
To identify factors associated with antiretroviral therapy (ART) adherence and virologic control among HIV-positive men on ART in primary relationships, data were collected from 210 male couples (420 men). Dyadic actor–partner analyses investigated associations with three levels of adherence-related dependent variables: self-efficacy (ASE), self-reported adherence, and virologic control. Results indicated that higher patient ASE was related to his own positive beliefs about medications, higher relationship autonomy and intimacy, and fewer depressive symptoms. Fewer depressive symptoms and less relationship satisfaction in the partner were linked to higher ASE in the patient. Better self-reported adherence was related to the patient’s positive appraisal of the relationship and the partner’s positive treatment efficacy beliefs. Greater medication concerns of both patient and partner were associated with less adherence. The partner’s higher relationship commitment was associated with lower viral load in the patient. Findings suggest that depressive symptoms, treatment beliefs, and relationship quality factors of both partners may influence adherence-related outcomes.
HIV; AIDS; Adherence; Compliance; Couples; Depression; Primary relationships; HIV treatment adherence; Virologic control
Human immunodeficiency virus (HIV) treatment self-efficacy is the confidence held by an individual in her or his ability to follow treatment recommendations, including specific HIV care such as initiating and adhering to antiretroviral therapy (ART). The purpose of this study was to explore the potential mediating role of treatment adherence self-efficacy in the relationships between Social Cognitive Theory constructs and self- reported ART adherence.
Cross-sectional and descriptive. The study was conducted between 2009 and 2011 and included 1,414 participants who lived in the United States or Puerto Rico and were taking antiretroviral medications.
Social cognitive constructs were tested specifically: behaviors (three adherence measures each consisting of one item about adherence at 3-day and 30-day along with the adherence rating scale), cognitive or personal factors (the Center for Epidemiology Studies Depression Scale to assess for depressive symptoms, the 12-Item Short Form Health Survey (SF-12) to assess physical functioning, one item about physical condition, one item about comorbidity), environmental influences (the Social Capital Scale, one item about social support), and treatment self-efficacy (HIV Adherence Self-Efficacy Scale). Analysis included descriptive statistics and regression.
The average participant was 47 years old, male, and a racial or ethnic minority, had an education of high school or less, had barely adequate or totally inadequate income, did not work, had health insurance, and was living with HIV/acquired immunodeficiency syndrome for 15 years. The model provided support for adherence self-efficacy as a robust predictor of ART adherence behavior, serving a partial mediating role between environmental influences and cognitive or personal factors.
Although other factors such as depressive symptoms and lack of social capital impact adherence to ART, nurses can focus on increasing treatment self-efficacy through diverse interactional strategies using principles of adult learning and strategies to improve health literacy.
Adherence to ART reduces the viral load thereby decreasing morbidity and mortality and risk of transmission to uninfected persons. Nurses need to use a variety of strategies to increase treatment self-efficacy.
HIV/AIDS; social cognitive theory; self-efficacy; adherence
Advances in antiretroviral therapy (ART) for HIV offer life-extending benefit; however, the side effects associated with ART use negatively impact quality of life and medication adherence among people living with HIV.
This study tested the efficacy of mindfulness-based stress reduction (MBSR) for reducing ART symptoms and bother/distress related to ART side effects. Secondary aims were to test the impact of MBSR on medication adherence and psychological functioning.
Seventy-six people living with HIV who were actively taking ART and reported distress from ART-related side effects were randomly assigned to MBSR or a wait-list control standard care condition. We measured side effects, ART adherence, perceived stress, depression, positive and negative affect, and mindfulness at three time points: baseline, three-month follow-up, and six-month follow-up. Side effects and related distress were assessed separately from other symptoms.
Compared to a wait-list control, participants in the MBSR condition experienced a reduction in the frequency of symptoms attributable to antiretroviral therapies at three months post intervention (mean difference = 0.33; 95% confidence interval [CI] = 0.01, 0.66; t(132) = 2.04, P = 0.044) and at six months post intervention (mean difference = 0.38; 95% CI = 0.05, 0.71; t(132) = 2.27, P = 0.025). MBSR participants also experienced a reduction in distress associated with those symptoms at three months post intervention (mean difference = 0.47; 95% CI = 0.003, 0.94; t(132) = 1.99, P = 0.048) compared with the wait-list control condition.
Mindfulness-based stress reduction is a promising approach for reducing HIV treatment-related side effects.
Mindfulness-based stress reduction; HIV; antiretroviral therapy; side effects; symptoms; adherence
In the era of anti-retroviral therapy (ART), depression and substance use predict hastened HIV disease progression but the underlying biological or behavioral mechanisms that explain these effects are not fully understood.
Using outcome data from 603 participants enrolled in a randomized controlled trial of a behavioral intervention, binary logistic and linear regression were employed to examine whether inconsistent patterns of ART utilization partially mediated the effects of depression and substance use on higher HIV viral load over a 25-month follow-up.
Elevated affective symptoms of depression independently predicted ART discontinuation (Adjusted OR [AOR] = 1.39, 95% CI = 1.08 – 1.78), and use of stimulants at least weekly independently predicted intermittent ART utilization (AOR = 2.62, 95% CI = 1.45 – 4.73). After controlling for the average self-reported percentage of ART doses taken and baseline T-helper (CD4+) count, elevated depressive symptoms predicted a 50% higher mean viral load, and weekly stimulant use predicted a 137% higher mean viral load. These effects became non-significant after accounting for inconsistent patterns of ART utilization, providing evidence of partial mediation.
Inconsistent patterns of ART utilization may partially explain the effects of depression and stimulant use on hastened HIV disease progression.
Access; Adherence; Antiretroviral; Cocaine; Depression; Disease Progression; Highly Active; HIV/AIDS; HIV Viral Load; Methamphetamine; Substance Use; Utilization
The purpose of this paper is to explore more comprehensive methods to analyze antiretroviral non-adherence data. Using illustrative data and simulations, we investigated the value of using binary logistic regression (LR; dichotomized at 0% non-adherence) versus a hurdle model (combination of LR plus generalized linear model for >0% non-adherence) versus a zero-inflated negative binomial (ZINB) model (simultaneously modeling 0% non-adherence and >0% non-adherence). In simulation studies, the hurdle and ZINB models had similar power but both had higher power in comparison to LR alone. The hurdle model had higher power than ZINB in settings where covariate effects were restricted to one or the other part of the model (0% non-adherence or degree of non-adherence). Use of the hurdle and ZINB models are powerful and valuable approaches in analyzing adherence data which yield a more complete picture than LR alone. We recommend adoption of this methodology for future antiretroviral adherence research.
HIV; medication adherence; analysis; zero-inflated negative binomial model; hurdle model
The Health Care Empowerment Model offers direction for the investigation of patient-controlled engagement and involvement in health care. At the core of the model is the construct of Health Care Empowerment (HCE), for which there exist no validated measures. A set of 27 candidate self-report survey items was constructed to capture five hypothesized inter-related facets of HCE (informed, engaged, committed, collaborative, and tolerant of uncertainty). The full item set was administered to 644 HIV-infected persons enrolled in three ongoing research studies. Exploratory and confirmatory factor analyses resulted in a two factor solution comprising four items each on two subscales: (1) HCE: Informed, Committed, Collaborative, and Engaged HCE ICCE) and (2) HCE Tolerance of Uncertainty (HCE TU). Subscale scores were evaluated for relationships with relevant constructs measured in the three studies, including depression, provider relationships, medication adherence, and HIV-1 viral load. Findings suggest the utility of this 8-item Health Care Empowerment Inventory (HCEI) in efforts to measure, understand, and track changes in the ways in which individuals engage in health care.
Poor quality of sleep (QOS) is frequently reported in HIV-positive individuals; however, despite its clinical and public health significance, few studies have examined the correlation between QOS and antiretroviral (ARV) adherence. The objective of this study was to estimate the prevalence of sleep disturbances, determine the characteristics of those with poor QOS, and establish the relationship between QOS and ARV nonadherence among HIV-positive individuals. We conducted a cross-sectional secondary data analysis of 2845 HIV-positive adults taking ARV therapy from the Healthy Living Project baseline cohort. Mean self-reported ARV nonadherence was estimated using a 3-day measure. QOS was assessed using three questions regarding sleep pattern changes, amount of bother from difficulty falling/staying asleep, and amount of bother from vivid dreams. Over 68% of individuals reported sleep pattern changes, 50.3% reported difficulty falling/staying asleep, and 20.5% reported bother from vivid dreams. Depression, suicidal ideation, unemployment, use of illicit substances, history of incarceration, and HIV viral load were all independently associated with poor QOS. Individuals reporting feeling bothered about difficulty falling/staying asleep had a 1.66 higher odds of nonadherence (95% confidence interval [CI]=1.18, 2.33; p=0.004). Those reporting the highest degree of bother from difficulty falling/staying asleep and from vivid dreams had a 1.42 (95% CI=1.13, 1.78; p=0.002) and 1.31 (95% CI=0.98, 1.75; p=0.07) higher odds of nonadherence, respectively. With higher incremental reports of poor QOS there were considerable increases in ARV nonadherence. Recognition and timely treatment of sleep difficulties may result in reduced ARV nonadherence with beneficial clinical and public health implications.
Due to the rapid proliferation of human immunodeficiency virus (HIV) treatment options, there is a need for health care providers with knowledge of antiretroviral therapy intricacies. In a HIV multidisciplinary care team, the HIV pharmacist is well-equipped to provide this expertise. We conducted a systematic review to assess the impact of HIV pharmacists on HIV clinical outcomes.
We searched six electronic databases from January 1, 1980 to June 1, 2011 and included all quantitative studies that examined pharmacist’s roles in the clinical care of HIV-positive adults. Primary outcomes were antiretroviral adherence, viral load, and CD4+ cell count and secondary outcomes included health care utilization parameters, antiretroviral modifications, and other descriptive variables.
Thirty-two publications were included. Despite methodological limitation, the involvement of HIV pharmacists was associated with statistically significant adherence improvements and positive impact on viral suppression in the majority of studies.
This systematic review provides evidence of the beneficial impact of HIV pharmacists on HIV treatment outcomes and offers suggestions for future research.
pharmacist; HIV/AIDS; clinical; adherence; impact
Second generation electronic medication adherence monitors provide real-time data on pill bottle opening behavior. Feasibility, validity, and acceptability, however, have not been established. Med-eMonitor is a multi-compartment adherence device with reminder and education capacity that transmits data through a telephone connection. Monthly adherence levels were measured for 52 participants over approximately three months using the Med-eMonitor (unadjusted and adjusted for participant confirmed dosing) and unannounced pill counts. HIV RNA was assessed before and after the three-month period. Acceptability of Med-eMonitor was determined. Over 92% of Med-eMonitor data was transmitted daily. Unannounced pill counts significantly correlated with adjusted Med-eMonitor adherence (r=0.29, p=0.04). HIV RNA significantly correlated with unannounced pill counts (r=−0.34, p=0.02), and trended toward a significant correlation with unadjusted Med-eMonitor adherence (r=−0.26; p=0.07). Most, but not all, participants liked using the Med-eMonitor. Med-eMonitor allows for real-time adherence monitoring and potentially intervention, which may be critical for prolonging treatment success.
As HIV infection has shifted to a chronic condition, self-care practices have emerged as an important topic for HIV-positive individuals in maintaining an optimal level of health. Self-care refers to activities that patients undertake to maintain and improve health, such as strategies to achieve and maintain high levels of antiretroviral adherence.
Technology-based methods are increasingly used to enhance antiretroviral adherence; therefore, we systematically reviewed the literature to examine technology-based self-care methods that HIV-positive individuals utilize to improve adherence. Seven electronic databases were searched from 1/1/1980 through 12/31/2010. We included quantitative and qualitative studies. Among quantitative studies, the primary outcomes included ARV adherence, viral load, and CD4+ cell count and secondary outcomes consisted of quality of life, adverse effects, and feasibility/acceptability data. For qualitative/descriptive studies, interview themes, reports of use, and perceptions of use were summarized. Thirty-six publications were included (24 quantitative and 12 qualitative/descriptive). Studies with exclusive utilization of medication reminder devices demonstrated less evidence of enhancing adherence in comparison to multi-component methods.
This systematic review offers support for self-care technology-based approaches that may result in improved antiretroviral adherence. There was a clear pattern of results that favored individually-tailored, multi-function technologies, which allowed for periodic communication with health care providers rather than sole reliance on electronic reminder devices.
Despite disproportionate rates of HIV among transgender women and evidence that medication adherence is necessary for treatment success and increased likelihood of survival, there has been little investigation into antiretroviral treatment (ART) adherence issues among transgender women. This study examined rates of self-reported ART adherence among transgender women on ART (n = 35) and well-established correlates of nonadherence including depression, adherence self-efficacy, patient perceptions of interactions with their providers, and perceived adverse side effects of ART compared to other respondents (n = 2,770). Transgender women on ART were less likely to report 90% adherence rates or higher and reported less confidence in their abilities to integrate treatment regimens into their daily lives. When transgender women were compared to other respondents, regardless of the current medication regimen, they reported significantly fewer positive interactions with their health care providers. Training for providers and integration of hormone therapy into HIV care is recommended.
adherence; AIDS; antiretroviral therapy; HIV; transgender; women
The creation of the Clinical Translational Science Awards for academic health sciences campuses in 2006 was implicitly accompanied by a call for a new paradigm of faculty development and mentoring to train the next generation of researchers and leaders in this new approach to research. Effective mentoring is critical to help early career investigators become successful, independent researchers, and a new approach to mentoring is vital to recruit, advance, and retain fellows and junior faculty engaged in clinical and translational research. However, in addition to the many rewards of mentoring, there are numerous substantive barriers to effective mentoring. These barriers include a lack of training in how to be a mentor, lack of time and structural and financial support for mentoring, and competing personal, administrative and clinical demands.
The authors describe an innovative program, the University of California, San Francisco (UCSF) Mentor Development Program (MDP), established in 2006 and designed to train mid-career academic health sciences researchers to be more effective as clinical and translational research mentors. Using a framework for presenting innovations in academic research, they present the rationale, design, implementation, and mechanisms being used to evaluate and sustain the MDP. Specific details of the objectives and content of the MDP sessions are provided as well as evaluation criteria and a link to specific curriculum materials.
The University of California, San Francisco (UCSF) Clinical Translational Science Institute (CTSI), created in 2006 as a result of the Clinical Translational Science Awards given by the National Institutes of Health, was charged with the creation of a new mentor training program for clinical translational research (CTR) faculty members. Using a framework for presenting innovations in academic research,10 we present the rationale, design, implementation, and mechanisms to evaluate and sustain the resulting program, the UCSF Mentor Development Program (MDP).
Risk reductions behaviors are especially important during acute/early HIV infection, a period of high transmission risk. We examined how sexual behaviors changed following diagnosis of acute/early HIV infection. Twenty-eight individuals completed structured surveys and in-depth interviews shortly after learning of their infection and two months later. Quantitative analyses revealed significant changes after diagnosis, including reductions in total partners and decreases in the proportion of unprotected sex acts occurring with uninfected partners (serosorting). Qualitative findings indicated that these changes were motivated by concerns about infecting others. However, participants were less successful at increasing the frequency with which they used condoms. These results suggest that the initial diagnosis with HIV may constitute an important component of interventions to promote risk reduction during the acute/early stages of the disease.
acute HIV; serosorting; behavior change; HIV prevention
Human immunodeficiency virus (HIV) treatment side effects have a deleterious impact on treatment adherence, which is necessary to optimize treatment outcomes including morbidity and mortality.
To examine the effect of the Balance Project intervention, a five-session, individually delivered HIV treatment side effects coping skills intervention on antiretroviral medication adherence.
HIV+ men and women (N = 249) on antiretroviral therapy (ART) with self-reported high levels of ART side effect distress were randomized to intervention or treatment as usual. The primary outcome was self-reported ART adherence as measured by a combined 3-day and 30-day adherence assessment.
Intent-to-treat analyses revealed a significant difference in rates of nonadherence between intervention and control participants across the follow-up time points such that those in the intervention condition were less likely to report nonadherence. Secondary analyses revealed that intervention participants were more likely to seek information about side effects and social support in efforts to cope with side effects.
Interventions focusing on skills related to ART side-effects management show promise for improving ART adherence among persons experiencing high levels of perceived ART side effects.
Side effects; Antiretroviral therapy; Adherence; Compliance; RCT