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1.  The Association between Poor Antiretroviral Adherence and Unsafe Sex: Differences by Gender and Sexual Orientation and Implications for Scale-Up of Treatment as Prevention 
AIDS and behavior  2014;18(8):1541-1547.
Non-adherence to safer sex and non-adherence to ART can each have adverse health consequences for HIV-infected individuals and their sex partners, but little is known about the association of these behaviors with each other. This “dual risk” has potential negative public health consequences since non-adherence can lead to the development of resistant virus that can then be transmitted to sex partners.
Among participants in the Multi-site Adherence Collaboration in HIV (MACH14) we examined, at study baseline, the association between the frequency of unprotected sex (assessed by self-report) and ART adherence (assessed by Medication Event Monitoring System, Aardex) among the sexually active participants in the five studies (N=459) that collected sexual risk behavior. The bivariate association between sexual risk behaviors and ART adherence was assessed by Pearson correlations; subsequently ANOVAs were used to evaluate the role of demographic characteristics, depression and substance use in explaining the “dual risk” outcome (sexual risk and non-adherence).
Among participants who had been sexually active, more unprotected anal/vaginal sex was weakly associated with poorer ART adherence (r = −.12, p=0.01 for the overall sample). Further analysis showed this association was driven by the heterosexual men in the sample (r = −.29, p<0.001), and was significant only for this group, and not for gay/bisexual men or for women (heterosexual and homosexual). Neither substance use nor depression accounted for the association between sexual risk and ART adherence.
HIV-infected heterosexual men who are having difficulty adhering to ART are also more likely to engage in risky sexual behaviors and therefore may benefit from counseling about these risk behaviors. We must identify procedures to screen for these risk behaviors and develop interventions, appropriately tailored to specific populations and identified risk factors, that can be integrated into routine clinical care for people living with HIV. This will become increasingly important in the context of wider access to treatment globally, including new recommendations for ART initiation earlier in a patients’ disease course (e.g., “Test and Treat” paradigms).
PMCID: PMC4016192  PMID: 24213215
ART adherence; sexual risk behavior; test-and-treat; depression; substance use
2.  Conceptualisations of Masculinity and Self-Reported Medication Adherence among HIV-Positive Latino Men in Los Angeles, California, USA 
Culture, health & sexuality  2014;16(6):697-709.
HIV-positive Latino men have been found to have poorer medication adherence compared to Whites. This study sought to identify how cultural conceptualisations of masculinity are associated with self-reported medication adherence among Latino men. 208 HIV-positive men reported the number of doses of antiretroviral medication missed in the previous seven days (dichotomised at 100% adherence versus less). Conceptualisations of masculinity consisted of traditional machismo (e.g., power and aggressive attitudes, which are normally associated with negative stereotypes of machismo) and caballerismo (e.g., fairness, respect for elders and the importance of family). Multivariate logistic regression was used to identify factors associated with adherence. The mean adherence was 97% (SD 6.5%; range = 57%–100%). 100% adherence in the previous seven days was reported by 77% of the participants. Caballerismo was associated with a greater likelihood (OR: 1.77; 95% CI: 1.08–2.92; p = 0.03) and machismo with a lower likelihood (OR: 0.60; 95% CI: 0.38–0.95; p = 0.03) of medication adherence. In addition, higher medication side effects were found to be associated with a lower likelihood (OR: 0.59; 95% CI: 0.43–0.81; p = 0.001) of medication adherence. These findings reinforce the importance of identifying cultural factors which may affect medication adherence among HIV-positive Latino men resident in the USA.
PMCID: PMC4061155  PMID: 24730591
HIV; medication adherence; Latinos; masculinity; machismo
3.  Short Message Service (SMS)-Based Intervention to Improve Treatment Adherence among HIV-Positive Youth in Uganda: Focus Group Findings 
PLoS ONE  2015;10(4):e0125187.
This paper presents one of the first qualitative studies to discuss programmatic barriers to SMS-based interventions for HIV-positive youth and discusses pathways through which youth perceive them to work. We conducted six focus groups with 20 male and 19 female HIV-positive youths in two clinics in Kampala, Uganda. We find that youth commonly use SMS as over 90% of this study’s youths knew how to read, write and send messages and almost three-fourths of them had phones. Youth strongly felt that the success of this intervention hinged on ensuring confidentiality about their HIV-positive status. Key programmatic challenges discussed where restrictions on phone use and phone sharing that could exclude some youth. Participants felt that the intervention would improve their adherence by providing them with needed reminders and social support. Youths’ suggestions about intervention logistics related to content, frequency, timing and two-way messages will be helpful to practitioners in the field.
PMCID: PMC4400100  PMID: 25881059
4.  The Role of Depression in Work-Related Outcomes of HIV Treatment in Uganda 
The primary goal of this analysis was to examine the influence of depression above and beyond the effects of HIV treatment on work activity and function.
We combined data from three longitudinal studies of patients starting antiretroviral therapy (ART) and/or entering HIV care in Uganda. Assessments were conducted at baseline and months 6 and 12. The 9-item Patient Health Questionnaire (PHQ-9) was used to assess depressive symptoms, as well as Major (scores > 9) and Minor (scores 5–9) Depression status; work functioning was assessed using a sub-scale of the Medical Outcomes Study HIV Health Survey (MOS-HIV). Multivariate random-effects logistic regression models for longitudinal data were used to examine the impact of treatment on work status and optimal work functioning, with measures of both baseline and change in physical health functioning, cognitive functioning and depression in the models, controlling for baseline demographics and CD4 cell count.
The sample of 1,731 participants consisted of 1,204 starting ART and 527 not yet eligible for ART. At baseline, 35% were not working and 37% had sub-optimal work functioning. Intention-to-treat analyses revealed that those on ART experienced greater improvement in both work outcomes over 12 months relative to non-ART patients, and that baseline and change in physical health functioning, continuous and categorical depression were all independently associated with improvement in both work outcomes, even after accounting for the direct effect of ART.
Improvement in physical and mental health plays a key role in the positive impact of HIV treatment on work activity and function, suggesting potential economic benefits of integrating depression treatment into HIV care.
PMCID: PMC4337391  PMID: 24402775
5.  Fertility desires and unmet need for family planning among HIV infected individuals in two HIV clinics with differing models of family planning service delivery 
BMC Women's Health  2015;15:5.
Eliminating family planning (FP) unmet need among HIV-infected individuals (PLHIV) is critical to elimination of mother-to-child HIV transmission. We assessed FP unmet need among PLHIV attending two clinics with differing models of FP services. Nsambya Home Care provided only FP information while Mulago HIV clinic provided information and contraceptives onsite.
In a cross-sectional study conducted between February-June 2011, we documented pregnancies, fertility desires, and contraceptive use among 797 HIV-infected men and women (408 in Mulago and 389 in Nsambya). FP unmet need was calculated among women who were married, unmarried but had sex within the past month, did not desire the last or future pregnancy at all or wished to postpone for ≥ two years and were not using contraceptives. Multivariable analyses for correlates of FP unmet need were computed for each clinic.
Overall, 40% (315) had been pregnant since HIV diagnosis; 58% desired the pregnancies. Of those who were not pregnant, 49% (366) did not desire more children at all; 15.7% wanted children then and 35.3% later. The unmet need for FP in Nsambya (45.1%) was significantly higher than that in Mulago at 30.9% (p = 0.008). Age 40+ compared to 18–29 years (OR = 6.05; 95% CI: 1.69, 21.62 in Mulago and OR = 0.21; 95% CI: 0.05, 0.90 in Nsambya), other Christian denominations (Pentecostal and Seventh Day Adventists) compared to Catholics (OR = 7.18; 95% CI: 2.14, 24.13 in Mulago and OR = 0.23; 95% CI: 0.06, 0.80 in Nsambya), and monthly expenditure > USD 200 compared to < USD40 in Nsambya (OR = 0.17; 95% CI: 0.03, 0.90) were associated with FP unmet need.
More than half of the pregnancies in this population were desired. Unmet need for FP was very high at both clinics and especially at the clinic which did not have contraceptives onsite. Lower income and younger women were most affected by the lack of contraceptives onsite. Comprehensive and aggressive FP programs are required for fertility support and elimination of FP unmet need among PLHIV, even with integration of FP information and supplies into HIV clinics.
PMCID: PMC4320597  PMID: 25627072
Family planning; Unmet need; Fertility; HIV; PMTCT
6.  Fertility Desires and Intentions and the Relationship to Consistent Condom Use and Provider Communication Regarding Childbearing Among HIV Clients in Uganda 
ISRN infectious diseases  2013;2013:478192.
HIV prevention and reproductive health programs emphasize consistent condom use and preventing unplanned pregnancies, but do not account for the childbearing desires of many HIV clients. We examined the correlates of fertility desires and intentions, including condom use, among HIV clients in Uganda.
Baseline data from a prospective cohort study of clients starting antiretroviral therapy were analyzed. All measures were self-report, except abstracted CD4 count.
The sample included 767 clients; 34% were men and 50% had a primary sex partner. Among those with a desire (31%) or intention (24%) for having a child in the near future, 60% had not discussed this with providers. A majority (61%) had received advise about family planning, and 27% were told by their provider that they should not bear a child because of their HIV status. In regression analysis, male gender, younger age, higher CD4, having fewer children, and having a primary partner were significantly associated with fertility desires and intentions; having been told by one’s provider not to have a child was associated with intentions but not desires. Among participants with a primary partner, consistent condom use was greater among those with no fertility intentions, as was receipt of advise about family planning, while HIV disclosure to partner was greater among those with intentions. Partner HIV status was not associated with fertility desires or intentions.
These findings highlight the need for HIV care and reproductive health programs to incorporate safer conception counseling and improve provider/patient communication regarding childbearing.
PMCID: PMC4219363  PMID: 25379322
7.  Changes in Condom Use During the First Year of HIV Treatment in Uganda and the Relationship to Depression 
We examined the effect of antiretroviral therapy (ART), and the predictive role of depression, on condom use with primary partners.
Data from three studies in Uganda were combined into a sample of 750 patients with a primary sex partner, with 502 starting ART and 248 entering HIV care, and followed for 12 months. Random-effects logistic regression models were used to examine the impact of ART, and the influence of baseline level and change in depression, on condom use with primary partners.
At Month 12, 61% ART and 67% non-ART patients were consistent condom users, compared to 44% and 41% at baseline, respectively. Multivariate analysis revealed that consistent condom use increased similarly for ART and non-ART patients, and that Minor Depression at baseline and increased depression over time predicted inconsistent condom use.
Improved depression diagnosis and treatment could benefit HIV prevention.
PMCID: PMC4125566  PMID: 24504978
depression; HIV; antiretroviral therapy; condom use; primary partner; Uganda
8.  AIDS Treatment and Mental Health: Evidence from Uganda 
Increased access to antiretroviral therapy (ART) in developing countries over the last decade is believed to have contributed to reductions in HIV transmission and improvements in life expectancy. While numerous studies document the effects of ART on physical health and functioning, comparatively less attention has been paid to the effects of ART on mental health outcomes. In this paper we study the impact of ART on depression in a cohort of patients in Uganda entering HIV care. We find that twelve months after beginning ART, the prevalence of major and minor depression in the treatment group had fallen by approximately 15 and 27 percentage points respectively relative to a comparison group of patients in HIV care but not receiving ART. We also find some evidence that ART helps to close the well-known gender gap in depression between men and women.
PMCID: PMC3713499  PMID: 23849276
HIV; Antiretroviral therapy; Mental health; Africa
9.  HIV Prevalence and Demographic Determinants of Unprotected Anal Sex and HIV Testing Among Men Who Have Sex with Men in Beirut, Lebanon 
Archives of sexual behavior  2014;43(4):779-788.
The limited epidemiological data in Lebanon suggest that HIV incident cases are predominantly among men who have sex with men (MSM). We assessed the prevalence of HIV and demographic correlates of condom use and HIV testing among MSM in Beirut. Respondent-driven sampling was used to recruit 213 participants for completion of a behavioral survey and an optional free rapid HIV test. Multivariate regression analysis was used to examine demographic correlates of unprotected anal sex and any history of HIV testing. Nearly half (47%) were under age 25 years and 67% self-identified as gay. Nearly two-thirds (64%) reported any unprotected anal intercourse (UAI) with men in the prior 3 months, including 23% who had unprotected anal intercourse with men whose HIV status was positive or unknown (UAIPU) to the participant. Three men (1.5% of 198 participants tested) were HIV-positive; 62% had any history of HIV testing prior to the study and testing was less common among those engaging in UAIPU compared to others (33% vs. 71%). In regression analysis, men in a relationship had higher odds of having UAI but lower odds of UAIPU and any university education was associated with having UAI; those with any prior history of HIV testing were more likely to be in a relationship and have any university education. HIV prevention efforts for MSM need to account for the influence of relationship dynamics and promotion of testing needs to target high-risk MSM.
PMCID: PMC4134874  PMID: 24752791
HIV testing; men who have sex with men (MSM); social determinants; unprotected anal intercourse (UAI); Lebanon
10.  INtegration of DEPression Treatment into HIV Care in Uganda (INDEPTH-Uganda): study protocol for a randomized controlled trial 
Trials  2014;15:248.
Despite 10 to% of persons living with HIV in sub-Saharan Africa having clinical depression, and the consequences of depression for key public health outcomes (HIV treatment adherence and condom use), depression treatment is rarely integrated into HIV care programs. Task-shifting, protocolized approaches to depression care have been used to overcome severe shortages of mental health specialists in developing countries, but not in sub-Saharan Africa and not with HIV clients. The aims of this trial are to evaluate the implementation outcomes and cost-effectiveness of a task-shifting, protocolized model of antidepressant care for HIV clinics in Uganda.
INDEPTH-Uganda is a cluster randomized controlled trial that compares two task-shifting models of depression care - a protocolized model versus a model that relies on the clinical acumen of trained providers to provide depression care in ten public health HIV clinics in Uganda. In addition to data abstracted from routine data collection mechanisms and supervision logs, survey data will be collected from patient and provider longitudinal cohorts; at each site, a random sample of 150 medically stable patients who are depressed according to the PHQ-2 screening will be followed for 12 months, and providers involved in depression care implementation will be followed over 24 months. These data will be used to assess whether the two models differ on implementation outcomes (proportion screened, diagnosed, treated; provider fidelity to model of care), provider adoption of treatment care knowledge and practices, and depression alleviation. A cost-effectiveness analysis will be conducted to compare the relative use of resources by each model.
If effective and resource-efficient, the task-shifting, protocolized model will provide an approach to building the capacity for sustainable integration of depression treatment in HIV care settings across sub-Saharan Africa and improving key public health outcomes.
Trial registration
INDEPTH-Uganda has been registered with the National Institutes of Health sponsored clinical trials registry (3 February 2013) and has been assigned the identifier NCT02056106.
PMCID: PMC4083331  PMID: 24962086
Depression; Task-shifting; HIV; Uganda
12.  Association of Discrimination-Related Trauma with Sexual Risk among HIV-Positive African-American Men Who Have Sex with Men 
American journal of public health  2013;103(5):875-880.
HIV disproportionately affects African-American men who have sex with men (MSM). High levels of traumatic stress among African American MSM may be associated with poor health behaviors, including sexual risk, and thus may be a promising target for HIV prevention. We investigated whether one form of traumatic stress, discrimination-related trauma (e.g., physical assault due to race), was associated with unprotected anal intercourse (UAI), especially when compared to non-discrimination-related trauma, among African-American MSM.
A convenience sample of 131 HIV-positive African-American MSM receiving antiretroviral treatment completed audio computer-assisted-self-interviews that covered UAI; interpersonal trauma; and whether trauma was due to discrimination based on race/ethnicity, HIV-serostatus, or sexual orientation.
60% reported at least one interpersonal trauma; they attributed at least one trauma to being gay (47%), African-American (17%), and/or HIV-positive (9%). In a multivariate regression, experiencing discrimination-related trauma was significantly associated with UAI (AOR=2.4,95%CI=1.0-5.7,p=0.04), whereas experiencing non-discrimination-related trauma was not (AOR=1.3,95%CI=0.6-3.1,p=0.53).
HIV-positive African-American MSM experience high levels of discrimination-related trauma, a stressor that was associated with greater risk. HIV prevention interventions should consider the potential damaging effects of discrimination in the context of trauma.
PMCID: PMC3625518  PMID: 23488499
13.  Perceived Discrimination and Physical Health among HIV-Positive Black and Latino Men who have Sex with Men 
AIDS and behavior  2013;17(4):1431-1441.
We conducted the first study to examine health correlates of discrimination due to race/ethnicity, HIV-status, and sexual orientation among 348 HIV-positive Black (n=181) and Latino (n=167) men who have sex with men. Participants completed audio computer-assisted self-interviews. In multivariate analyses, Black participants who experienced greater racial discrimination were less likely to have a high CD4 cell count [OR=0.7, 95%CI=(0.5, 0.9), p=.02], and an undetectable viral load [OR=0.8, 95%CI=(0.6, 1.0), p=.03], and were more likely to visit the emergency department [OR=1.3, 95%CI=(1.0, 1.7), p=.04]; the combined three types of discrimination predicted greater AIDS symptoms [F (3,176)=3.8, p<0.01]. Among Latinos, the combined three types of discrimination predicted greater medication side effect severity [F (3,163)=4.6, p<0.01] and AIDS symptoms [F (3,163)=3.1, p<0.05]. Findings suggest that the stress of multiple types of discrimination plays a role in health outcomes.
PMCID: PMC3631464  PMID: 23297084
African American/Black; HIV/AIDS; Latino/Hispanic; men who have sex with men; perceived discrimination
14.  Depression and its Relationship to Work Status and Income Among HIV Clients in Uganda 
World journal of AIDS  2012;2(3):126-134.
Despite high levels of depression among persons living with HIV (PLWHIV), little research has investigated the relationship of depression to work status and income in PLWHIV in sub-Saharan Africa, which was the focus of this analysis.
Baseline data from a prospective longitudinal cohort of 798 HIV patients starting antiretroviral therapy in Kampala, Uganda were examined. In separate multivariate analyses, we examined whether depressive severity and symptom type [as measured by the Patient Health Questionnaire (PHQ-9)] and major depression [diagnosed with the Mini International Neuropsychiatric Interview (MINI)] were associated with work status and income, controlling for demographics, physical health functioning, work self-efficacy, social support and internalized HIV stigma.
14% of the sample had Major Depression and 66% were currently working. Each measure of depression (PHQ-9 total score, somatic and cognitive subscales; Major Depression diagnosis) was associated with not working and lower average weekly income in bivariate analysis. However, none of the depression measures remained associated with work and income in multivariate analyses that controlled for other variables associated with these economic outcomes.
These findings suggest that while depression is related to work and income, its influence may only be indirect through its relationship to other factors such as work self-efficacy and physical health functioning.
PMCID: PMC3957320  PMID: 24653946
depression; HIV/AIDS; work; income; physical health functioning; work self-efficacy
We investigated depression in relationship to sexual risk behavior with primary partners among HIVclients in Uganda.
Baseline data were analyzed from a cohort of clients starting ART. The Patient Health Questionnaire (PHQ-9) was used to classify depressive severity (none, minor and major depression) and symptom type (cognitive and somatic). Condom use was assessed over the past 6 months and during the last episode of sexual intercourse.
386 participants had a primary sex partner, with whom 41.6% always used condoms during sex over the past 6 months, and 62.4% during last sex. Use of a condom during last sex was associated with having no depression and lower PHQ-9 total and cognitive and somatic subscale scores in bivariate analyses; most of these relationships were marginally significant for sex over the past 6 months. Controlling for demographics, HIV disclosure and partner HIV status, only minor depression was associated with unprotected sex.
Depressive symptoms, even if not a clinical disorder, warrant early detection and treatment for promoting HIV prevention among HIV-affected couples.
PMCID: PMC3841244  PMID: 23970636
depression; HIV; Uganda; sexual risk behavior; condom use
16.  Strategies for Optimizing Clinic Efficiency in a Community-Based Antiretroviral Treatment Programme in Uganda 
AIDS and behavior  2013;17(1):10.1007/s10461-012-0199-9.
We address a critical aspect of antiretroviral therapy (ART) scale-up: poor clinic organization leading to long waiting times and reduced patient retention. Using a before and after study design, time and motion studies and qualitative methods we evaluated the impact of triage and longer clinic appointment intervals (triage) on clinic efficiency in a community-based program in Uganda. We compared time waiting to see and time spent with providers for various patient categories and examined patient and provider satisfaction with the triage. Overall, median time spent at the clinic reduced from 206 to 83 min. Total median time waiting to see providers for stable-ART patients reduced from 102 to 20 min while that for patients undergoing ART preparation reduced 88–37 min. Improved patient flow, patient and provider satisfaction and reduced waiting times allowed for service delivery to more patients using the same staff following the implementation of triage.
PMCID: PMC3887144  PMID: 22610422
Clinic efficiency; Waiting time; Time and motion; Triage; Antiretroviral therapy
17.  Electronic Medical Records and Same Day Patient Tracing Improves Clinic Efficiency and Adherence to Appointments in a Community Based HIV/AIDS Care Program, in Uganda 
AIDS and behavior  2012;16(2):10.1007/s10461-011-9996-9.
Patients who miss clinic appointments make unscheduled visits which compromise the ability to plan for and deliver quality care. We implemented Electronic Medical Records (EMR) and same day patient tracing to minimize missed appointments in a community-based HIV clinic in Kampala. Missed, early, on-schedule appointments and waiting times were evaluated before (pre-EMR) and 6 months after implementation of EMR and patient tracing (post-EMR). Reasons for missed appointments were documented pre and post-EMR. The mean daily number of missed appointments significantly reduced from 21 pre-EMR to 8 post-EMR. The main reason for missed appointments was forgetting (37%) but reduced significantly by 30% post-EMR. Loss to follow-up (LTFU) also significantly decreased from 10.9 to 4.8% The total median waiting time to see providers significantly decreased from 291 to 94 min. Our findings suggest that EMR and same day patient tracing can significantly reduce missed appointments, and LTFU and improve clinic efficiency.
PMCID: PMC3872059  PMID: 21739285
Clinic efficiency; Electronic medical records (EMR); Patient tracing; Clinic appointments; Patient waiting time
18.  A Qualitative Analysis of the Effects of Depression and Antidepressants on Physical and Work Functioning among ART Clients in Uganda 
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.
PMCID: PMC3830664  PMID: 23442495
depression treatment; work functioning; antiretroviral treatment; HIV
19.  Gender Differences in Determinants of Condom Use Among HIV Clients in Uganda 
AIDS Patient Care and STDs  2012;26(11):694-699.
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.
PMCID: PMC3495108  PMID: 23066699
20.  Pilot Controlled Trial of the Adherence Readiness Program: An Intervention to Assess and Sustain HIV Antiretroviral Adherence Readiness 
AIDS and behavior  2013;17(9):10.1007/s10461-013-0550-9.
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.
PMCID: PMC3812249  PMID: 23904145
HIV; adherence; readiness; practice trials; intervention
21.  Sexual Stigma, Psychological Well-Being and Social Engagement among Men Who Have Sex with Men in Beirut, Lebanon 
Culture, health & sexuality  2013;15(5):570-582.
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.
PMCID: PMC3742541  PMID: 23730919
Men who have sex with men; Stigma; well-being; Lebanon
22.  A Randomized Controlled Trial Examining the Efficacy of Motivational Counseling with Observed Therapy for Antiretroviral Therapy Adherence 
AIDS and Behavior  2013;17(6):1992-2001.
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.
PMCID: PMC3672512  PMID: 23568228
Adherence; HIV/AIDS; ART; Motivational Interviewing; Directly Observed Therapy
23.  Fertility and contraceptive decision-making and support for HIV infected individuals: client and provider experiences and perceptions at two HIV clinics in Uganda 
BMC Public Health  2013;13:98.
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.
PMCID: PMC3568663  PMID: 23374175
Family planning; Fertility; HIV; Contraception
24.  Community HIV Treatment Advocacy Programs May Support Treatment Adherence 
AIDS Education and Prevention  2012;24(1):1-14.
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.
PMCID: PMC3286035  PMID: 22339141
25.  A Qualitative Exploration of Sexual Risk and HIV Testing Behaviors among Men Who Have Sex with Men in Beirut, Lebanon 
PLoS ONE  2012;7(9):e45566.
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.
PMCID: PMC3445492  PMID: 23029103

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