Depression is common among people living with HIV/AIDS in sub-Saharan Africa. Yet, little is known about how depression influences physical health and socioeconomic well-being in the context of antiretroviral therapy (ART). Semi-structured interviews with 40 adult HIV clients receiving ART in Uganda were conducted to assess experiences prior to and after HIV diagnosis and initiation of ART. Content analysis revealed themes that were suggestive of the following patterns: 1) functioning decreased after patients were diagnosed with HIV, but improved following ART, 2) depression is associated with lower physical health functioning and work status levels after both HIV diagnosis and ART, and 3) antidepressant medication is associated with better functioning compared to depressed patients not receiving depression treatment. These findings suggest that depression plays a role in the deleterious effects of HIV on functioning, and that antidepressant treatment provided alongside ART may serve to help individuals regain functioning, particularly employment. These findings highlight the potential value of integrating depression treatment into HIV care.
depression treatment; work functioning; antiretroviral treatment; HIV
Little research has examined gender differences in reporting of condom use, which is the goal of our analysis. A baseline study was conducted in two urban clinics and we examined data from sexually active clients entering HIV care who enrolled in a prospective longitudinal cohort study. The primary outcome was consistent condom use and determinant variables were demographics, physical health and immune status, economic well-being, relationship characteristics, psychosocial functioning, and self-efficacy. Of 280 participants, 129 were males and 151 females, and 41.7% had at least some secondary education; 60.7% did not always use condoms. Nearly half (48.1%) of men reported always using condoms compared to 31.8% of females. In bivariate analyses, men who consistently use condoms were more likely to be working, have a primary partner who was HIV negative, to have disclosed their HIV status to their primary partner, and to have higher general self-efficacy and condom use self-efficacy compared to men who did not always use condoms. Higher general self-efficacy and condom use self-efficacy were the only variables associated with reported consistent condom use among women. In regression analysis, working in the last 7 days, general self efficacy, and condom use self-efficacy were associated with consistent condom use among men. These findings reveal low rates of consistent condom use among people living with HIV, and a gender difference with men more likely to report consistent condom use. These data suggest the need for gender sensitive prevention programs and strategies, including programs that can provide women with greater control and self-efficacy regarding use of protective methods.
To pilot the Adherence Readiness Program, 60 patients planning to start HIV antiretrovirals were assigned to usual care (n=31) or the intervention (n=29), of whom 54 started antiretrovirals and were followed for up to 24 weeks. At Week 24, the intervention had a large effect (50.0% vs. 16.7%, d=.75) on optimal dose-timing (85+% doses taken on time) and small effect (54.2% vs. 43.3%, d=.22) on optimal dose-taking (85+% doses taken) electronically monitored adherence, and medium effect on undetectable viral load (62%.5% vs. 43.4%, d= .41), compared to usual care. These intervention benefits on adherence and viral suppression warrant further investigation.
HIV; adherence; readiness; practice trials; intervention
This qualitative study sought to explore the sexual identity development of men who have sex with men (MSM) in Beirut, the stigma experienced by these men, and how their psychological well-being and social engagement are shaped by how they cope with this stigma. Semi-structured interviews were conducted with 31 MSM, and content analysis was used to identify emergent themes. While many men reported feeling very comfortable with their sexual orientation and had disclosed their sexual orientation to family, most men struggled at least somewhat with their sexuality, often because of perceived stigma from others and internal religious conflict about the immorality of homosexuality. Most participants described experiencing verbal harassment or ridicule, or being treated as different or lesser than in social relationships with friends or family. Mechanisms for coping with stigma included social avoidance (trying to pass as heterosexual; limiting interaction with MSM to the internet) or withdrawal from relationships in an attempt to limit exposure to stigma. Our findings suggest that effective coping with both internal and external sexual stigma is central to the psychological well-being and social engagement of MSM in Beirut, much like what has been found in Western gay communities.
Men who have sex with men; Stigma; well-being; Lebanon
This study determined whether motivational interviewing-based cognitive behavioral therapy (MI-CBT) adherence counseling combined with modified directly observed therapy (MI-CBT/mDOT) is more effective than MI-CBT counseling alone or standard care (SC) in increasing adherence over time. A three-armed randomized controlled 48-week trial with continuous electronic drug monitored adherence was conducted by randomly assigning 204 HIV-positive participants to either 10 sessions of MI-CBT counseling with mDOT for 24 weeks, 10 sessions of MI-CBT counseling alone, or SC. Poisson mixed effects regression models revealed significant interaction effects of intervention over time on non-adherence defined as percent of doses not-taken (IRR = 1.011, CI = 1.000–1.018) and percent of doses not-taken on time (IRR = 1.006, CI = 1.001–1.011) in the 30 days preceding each assessment. There were no significant differences between groups, but trends were observed for the MI-CBT/mDOT group to have greater 12 week on-time and worse 48 week adherence than the SC group. Findings of modest to null impact on adherence despite intensive interventions highlights the need for more effective interventions to maintain high adherence over time.
Adherence; HIV/AIDS; ART; Motivational Interviewing; Directly Observed Therapy
Some people living with HIV/AIDS (PLHIV) want to have children while others want to prevent pregnancies; this calls for comprehensive services to address both needs. This study explored decisions to have or not to have children and contraceptive preferences among PLHIV at two clinics in Uganda.
This was a qualitative cross-sectional study. We conducted seventeen focus group discussions and 14 in-depth interviews with sexually active adult men and women and adolescent girls and boys, and eight key informant interviews with providers. Overall, 106 individuals participated in the interviews; including 84 clients through focus group discussions. Qualitative latent content analysis technique was used, guided by key study questions and objectives. A coding system was developed before the transcripts were examined. Codes were grouped into categories and then themes and subthemes further identified.
In terms of contraceptive preferences, clients had a wide range of preferences; whereas some did not like condoms, pills and injectables, others preferred these methods. Fears of complications were raised mainly about pills and injectables while cost of the methods was a major issue for the injectables, implants and intrauterine devices. Other than HIV sero-discordance and ill health (which was cited as transient), the decision to have children or not was largely influenced by socio-cultural factors. All adult men, women and adolescents noted the need to have children, preferably more than one. The major reasons for wanting more children for those who already had some were; the sex of the children (wanting to have both girls and boys and especially boys), desire for large families, pressure from family, and getting new partners. Providers were supportive of the decision to have children, especially for those who did not have any child at all, but some clients cited negative experiences with providers and information gaps for those who wanted to have children.
These findings show the need to expand family planning services for PLHIV to provide more contraceptive options and information as well as expand support for those who want to have children.
Family planning; Fertility; HIV; Contraception
Treatment advocacy (TA) programs, based in AIDS service organizations and clinics, aim to engage clients into care and support antiretroviral treatment (ART) adherence through client-centered counseling; advocate for patients with providers; and provide social service referrals. Systematic evaluations of TA are lacking. We conducted a non-randomized evaluation examining relationships of TA participation to adherence, care engagement, social services utilization, unmet needs, patient self-advocacy, and adherence self-efficacy among 121 HIV-positive clients (36 in TA, 85 not in TA; 87% male, 34% African American, 31% White, 19% Latino). In multivariate models, TA participants (vs. non-TA participants) showed higher electronically monitored [85.3% vs. 70.7% of doses taken; b(SE)=13.16(5.55), p<.05] and self-reported [91.1% vs. 75.0%; b(SE)=11.60(5.65), p<.05] adherence; utilized more social service programs [Ms = 5.2 vs. 3.4; b(SE)=1.97(0.48), p<.0001]; and had fewer unmet social-service needs [Ms = 1.8 vs. 2.7; b(SE)=−1.06(0.48), p<.05]. Findings suggest the need for a randomized controlled trial of TA.
Research is needed to identify culturally relevant factors that may contribute to sexual risk among African Americans. We investigated HIV-specific medical mistrust as one such cultural factor, often exhibited as conspiracy beliefs about HIV (e.g., “AIDS was produced in a government laboratory”), which may be indicative of general suspicion of HIV treatment and prevention messages. Over a 6-month time-period, we measured endorsement of HIV conspiracy beliefs three times and frequency of condom use monthly among 181 HIV-positive African American males. A hierarchical multivariate repeated-measures logistic random effects model indicated that greater belief in HIV conspiracies was associated with a higher likelihood of reporting unprotected intercourse across all time-points. An average of 54% of participants who endorsed conspiracies reported unprotected intercourse, versus 39% who did not endorse conspiracies. Secondary prevention interventions may need to address medical mistrust as a contributor to sexual risk among African Americans living with HIV.
African American/Black; HIV/AIDS Conspiracy Beliefs; Sexual Behavior
People living with HIV (PLWH) exhibit more severe mental health symptoms than do members of the general public (including depression and post-traumatic stress disorder/PTSD symptoms). We examined whether perceived discrimination, which has been associated with poor mental health in prior research, contributes to greater depression and PTSD symptoms among HIV-positive Black men who have sex with men (MSM), who are at high risk for discrimination from multiple stigmatized characteristics (HIV-serostatus, race/ethnicity, sexual orientation).
A total of 181 Black MSM living with HIV completed audio computer-assisted self-interviews (ACASI) that included measures of mental health symptoms (depression, PTSD) and scales assessing perceived discrimination due to HIV-serostatus, race/ethnicity, and sexual orientation.
In bivariate tests, all three perceived discrimination scales were significantly associated with greater symptoms of depression and PTSD (i.e., re-experiencing, avoidance, and arousal subscales) (all p-values < .05). The multivariate model for depression yielded a three-way interaction among all three discrimination types (p < .01), indicating that perceived racial discrimination was negatively associated with depression symptoms when considered in isolation from other forms of discrimination, but positively associated when all three types of discrimination were present. In multivariate tests, only perceived HIV-related discrimination was associated with PTSD symptoms (p < .05).
Findings suggest that some types of perceived discrimination contribute to poor mental health among PLWH. Researchers need to take into account intersecting stigmas when developing interventions to improve mental health among PLWH.
African American/Black; discrimination; HIV/AIDS; men who have sex with men; mental health
Posttraumatic stress disorder (PTSD) is relatively common among people living with HIV/AIDS (PLHA) and may be associated with antiretroviral therapy (ART) adherence. We examined the relationship between PTSD symptom severity and adherence among 214 African American males. Because PLHA may experience discrimination, potentially in the form of traumatic stress (e.g., hate crimes), we also examined whether perceived discrimination (related to race, HIV status, sexual orientation) is an explanatory variable in the relationship between PTSD and adherence. Adherence, monitored electronically over 6 months, was negatively correlated with PTSD total and re-experiencing symptom severity; all 3 discrimination types were positively correlated with PTSD symptoms and negatively correlated with adherence. Each discrimination type separately mediated the relationship between PTSD and adherence; when both PTSD and discrimination were included in the model, discrimination was the sole predictor of adherence. Findings highlight the critical role that discrimination plays in adherence among African American men experiencing posttraumatic stress.
HIV; adherence; posttraumatic stress; discrimination; mediation
Depression consistently predicts nonadherence to human immunodeficiency virus (HIV) antiretroviral therapy, but which aspects of depression are most influential is unknown. Such knowledge could inform assessments of adherence readiness and the type of depression treatment to utilize.
We examined how depression severity, symptom type and change over time relate to adherence.
Microelectronic adherence and self-reported depression data from 1374 participants across merged studies were examined with cross-sectional and longitudinal analyses. Depression variables included a continuous measure, categorical measure of severity, cognitive and vegetative subscales, and individual symptoms.
At baseline, mean adherence was 69%, and 25% had mild/moderate and 18% had severe depression. In cross-sectional multivariate analyses, continuous depression, cognitive depressive symptoms and severe depression were associated with lower adherence. In longitudinal analysis, reductions in both continuous and categorical depression predicted increased adherence.
The relationship between global continuous depression and nonadherence was statistically significant, but relatively weak compared to that of cognitive depressive symptoms and severe depression, which appear to pose strong challenges to adherence and call for the need for early detection and treatment of depression.
depression; cognitive depressive symptoms; HIV/AIDS; antiretroviral adherence
African–Americans show worse HIV disease outcomes compared to Whites. Health disparities may be aggravated by discrimination, which is associated with worse health and maladaptive health behaviors. We examined longitudinal effects of discrimination on antiretroviral treatment adherence among 152 HIV-positive Black men who have sex with men. We measured adherence and discrimination due to HIV-serostatus, race/ethnicity, and sexual orientation at baseline and monthly for 6 months. Hierarchical repeated-measures models tested longitudinal effects of each discrimination type on adherence. Over 6 months, participants took 60% of prescribed medications on average; substantial percentages experienced discrimination (HIV-serostatus, 38%; race/ethnicity, 40%; and sexual orientation, 33%). Greater discrimination due to all three characteristics was significantly bivariately associated with lower adherence (all p’s<0.05). In the multivariate model, only racial discrimination was significant (p<0.05). Efforts to improve HIV treatment adherence should consider the context of multiple stigmas, especially racism.
Adherence; Black/African–American race/ethnicity; Discrimination; HIV/AIDS
Prior research on adherence to Hepatitis C treatment has documented rates of dose reductions and early treatment discontinuation, but little is known about patients' dose-taking adherence.
To assess the prevalence of missed doses of pegylated interferon and ribavirin and examine the correlates of dose-taking adherence in clinic settings.
180 patients on treatment for Hepatitis C (23% co-infected with HIV) completed a cross-sectional survey at the site of their Hepatitis C care.
Seven percent of patients reported missing at least one injection of pegylated interferon in the last four weeks and 21% reported missing at least one dose of ribavirin in the last 7 days. Dose-taking adherence was not associated with HCV viral load.
Self-reported dose nonadherence to Hepatitis C treatment occurs frequently. Further studies of dose nonadherence (assessed by method other than self-report) and its relationship to HCV virologic outcome are warranted.
Adherence; HCV; HIV; co-infection; interferon; ribavirin
Men who have sex with men (MSM) may account for most new HIV infections in Lebanon, yet little is known about the factors that influence sexual risk behavior and HIV testing in this population. Qualitative interviews were conducted with 31 MSM living in Beirut, and content analysis was used to identify emergent themes. Mean age of the participants was 28.4 years, and all identified as either gay (77%) or bisexual (23%). Half reported not using condoms consistently and one quarter had not been HIV-tested. Many described not using condoms with a regular partner in the context of a meaningful relationship, mutual HIV testing, and a desire to not use condoms, suggesting that trust, commitment and intimacy play a role in condom use decisions. Condoms were more likely to be used with casual partners, partners believed to be HIV-positive, and with partners met online where men found it easier to candidly discuss HIV risk. Fear of infection motivated many to get HIV tested and use condoms, but such affect also led some to avoid HIV testing in fear of disease and social stigma if found to be infected. Respondents who were very comfortable with their sexual orientation and who had disclosed their sexuality to family and parents tended to be more likely to use condoms consistently and be tested for HIV. These findings indicate that similar factors influence the condom use and HIV testing of MSM in Beirut as those observed in studies elsewhere of MSM; hence, prevention efforts in Lebanon can likely benefit from lessons learned and interventions developed in other regions, particularly for younger, gay-identified men. Further research is needed to determine how prevention efforts may need to be tailored to address the needs of men who are less integrated into or do not identify with the gay community.