Experience of persistent psychological symptoms and perceived stigma among people with HIV on antiretroviral therapy (ART): A systematic review

The impact of antiretroviral therapy on symptom burden among HIV outpatients with low CD4 count in rural Uganda: nested longitudinal cohort study

BACKGROUND

Individuals with HIV have a high prevalence of physical and psychological symptoms throughout their disease course. Despite the clinical and public health implications of unresolved pain and symptoms, little is known about the effect of anti-retroviral therapy (ART) on these outcomes. This study aimed to assess the impact on symptom burden for the year after ART initiation in individuals with a CD4 count <200 cells/uL in Uganda.

METHODS

HIV-infected, ART-naıve adults referred from voluntary testing and counseling services in rural Uganda for enrollment into a randomized controlled trial to test fluconazole as primary prophylaxis against cryptococcal disease were invited to complete the Memorial Symptom Assessment Scale-Short Form (MSAS-SF) prior to commencing ART and at two subsequent follow up visits. This tool measures self-reported 7-day period prevalence and associated burden of physical and psychological symptoms. Changes in the total number of symptoms and distress indices with time on ART and trial arm were investigated through fitting Linear Mixed Models for repeated measures.

RESULTS

During the first year of ART initiation the prevalence of most individual symptoms remained constant. The notable exceptions which improved after commencing ART are as follow; prevalence of pain (prevalence changed from 79% to 60%), weight loss (67% to 31%), lack of appetite (46% to 28%), feeling sad (52% to 25%) and difficulty sleeping (35% to 23%). The total number of symptoms and distress indices reduced after treatment commenced. Of concern was that half or more study participants remained with symptoms of pain (60%), itching (57%), skin changes (53%) and numbness in hands and feet (52%) after starting ART. Sixteen symptoms remained with a burden of 25% or more.

CONCLUSION

Despite the beneficial effect of ART on reducing symptoms, some patients continue to experience a high symptom burden. It is essential that HIV services in sub-Saharan Africa integrate management of symptoms into their programmes.

TRIAL REGISTRATION

CRYPTOPRO [ISRCTN 76481529 ], November 2004.

Psychiatric Symptoms in Patients Receiving Dolutegravir

INTRODUCTION

Psychiatric symptoms (PSs) are reported to occur frequently in people living with HIV and may be associated with specific antiretrovirals. We analyzed PSs observed with dolutegravir (DTG) and other frequently prescribed anchor drugs.

METHODS

Selected PSs (insomnia, anxiety, depression, and suicidality) occurring in HIV-positive patients during DTG treatment across 5 randomized clinical trials (3 double-blind), in the Observational Pharmaco-Epidemiology Research & Analysis (OPERA) cohort, and among cases spontaneously reported to ViiV Healthcare were analyzed.

RESULTS

In clinical trials, PSs were reported at low and similar rates in patients receiving DTG or comparators [atazanavir, darunavir, efavirenz, or raltegravir (RAL)]. Insomnia was most commonly reported. The highest rates were observed in SINGLE (DTG 17%, efavirenz 12%), with consistently lower rates in the other trials (DTG: 3%-8% versus comparator: 3%-7%). More efavirenz-treated patients withdrew because of PSs than patients treated with other anchor drugs. In OPERA, history of PSs at baseline was lowest in efavirenz-treated patients compared with patients treated with DTG, RAL, or darunavir. Despite baseline differences, prevalence and incidence during treatment were similar across the 4 anchor drugs. Withdrawal rates for PSs were lowest for DTG (0%-0.6%) and highest for RAL (0%-2.5%). Spontaneously reported events were similar in nature to clinical trial data.

CONCLUSIONS

Analysis of 3 different data sources shows that, similar to other frequently prescribed anchor drugs to treat HIV infection, PSs are also reported in DTG-treated patients. These events are reported with low frequency and rarely necessitate DTG discontinuation.

AIDS and jail: social representations of women in freedom deprivation situations

OBJECTIVE

To graspthe AIDS social representations built by freedom-deprived women.

METHOD

Descriptive study with a quali-quantitative approach that involved 174 convicted women in a women's prison in a capital city of the Brazilian northeastern region. Aword-association test was applied in October and November 2014, using AIDS as a stimulus. The corpuswas processed usingIramuteq software. Descending Hierarchical Classification and Correspondence Factor Analysis were applied.

RESULTS

The content that comprises the social representation of AIDS was influenced by the prison context, which was pervaded by a lack of assistance, lack of knowledge, discrimination, and suffering that disclosed vulnerability to HIV/AIDS factors such as unprotected sex and object sharing. This underlines the stigma and fear of the illness, in addition to favoring and supporting negative feelings and a sense of rejection.

CONCLUSION

To consider the use of this representational amalgam to ensure a comprehensive, contextualized care can help redirect practices, motivate self-care practices, and reduce prejudiced attitudes.

OBJETIVO

Apreenderas representações sociais sobre a aids construídas por mulheres privadas de liberdade.

MÉTODO

Estudo descritivo, com abordagem quali-quantitativa que envolveu 174 apenadas de Presídio Feminino situado em capital do nordeste brasileiro. Aplicou-se o Teste de Associação Livre de Palavras, em outubro e novembro de 2014, utilizando-se do estímulo aids. O corpus foi processado pelo software Iramuteq, sendo efetuadas a Classificação Hierárquica Descendente e Análise Fatorial de Correspondência.

RESULTADOS

Os conteúdos que compõem a representação social sobre aids são influenciados pelo contexto prisional, permeado dedesassistência, desconhecimento, discriminação e condições de sofrimento, revelando fatores de vulnerabilidade ao HIV/Aids como atividade sexual desprotegida e compartilhamento de objetos; reiterando o estigma e o temor à doença; e favorecendo e sustentando sentimentos negativos e de rejeição.

CONCLUSÃO:

Considerar este amálgama representacional na garantia de um cuidado integral e contextualizado pode contribuir para redirecionar práticas, motivar condutas de autocuidado e reduzir atitudes preconceituosas.

Effects of depression and anxiety on antiretroviral therapy adherence among newly diagnosed HIV-infected Chinese MSM

OBJECTIVE

Our objective was to explore the effect of depression and anxiety on adherence to antiretroviral therapy (ART) among MSM with newly diagnosed HIV infections.

DESIGN

We conducted a prospective study of Chinese MSM with newly diagnosed HIV infections.

METHODS

The Hospital Anxiety and Depression Scale was used to measure depression and anxiety at baseline, 6 and 12 months, separately. ART adherence was self-reported once every 3 months ('perfect' or no missing dose in the past 3 months vs. 'imperfect' adherence or at least one missing dose in the past 3 months). We utilized a priori substantial knowledge guided by causal models to identify confounding covariates, and performed mixed-effect logistic regression to assess the effects of depression and anxiety on ART adherence.

RESULTS

We included 228 participants who initiated ART after HIV diagnosis and before the end of study. A one-unit increase in the depression and anxiety score was associated with a 16% increase [adjusted odds ratio (aOR), 1.16; 95% confidence interval (CI), 1.02-1.32] and a 17% increase (aOR, 1.17; 95% CI, 1.03-1.33) in the odds of reporting imperfect ART adherence, respectively. When depression and anxiety were categorized (normal, borderline, and likely), only likely anxiety had a significant association with imperfect ART adherence (aOR, 4.79; 95% CI, 1.12-20.50).

CONCLUSION

Depression and anxiety are risk factors for imperfect ART adherence among Chinese MSM with newly diagnosed HIV infections. Intensive intervention on depression and/or anxiety beyond regular post-HIV-testing counseling may increase adherence to ART, and improve HIV treatment outcomes.

Hair Measurements of Cortisol, DHEA, and DHEA to Cortisol Ratio as Biomarkers of Chronic Stress among People Living with HIV in China: Known-Group Validation

Background

Existing literature suggests that endocrine measures, including the steroid hormones of cortisol and Dehydroepiandrosterone (DHEA), as well as the DHEA to cortisol ratio in the human hair can be used as promising biomarkers of chronic stress among humans. However, data are limited regarding the validity of these measures as biomarkers of chronic stress among people living with HIV (PLWH), whose endocrine system or hypothalamic pituitary adrenal (HPA) axis may be affected by HIV infection and/or antiretroviral therapy (ART) medications.

Method

Using hair sample data and self-reported survey from 60 PLWH in China, we examined the validity of three endocrine measures among Chinese PLWH using a known-groups validation strategy. High-stress group (n = 30) and low-stress group (n = 30) of PLWH were recruited through individual assessment interviews by a local licensed psychologist. The endocrine measures in hair were extracted and assessed by LC-APCI-MS/MS method. Both bivariate and multivariate analyses were conducted to examine the associations between the endocrine measures and the stress level, and to investigate if the associations differ by ART status.

Results

The levels of endocrine measures among Chinese PLWH were consistent with existing studies among PLWH. Generally, this pilot study confirmed the association between endocrine measures and chronic stress. The high stress group showed higher level hair cortisol and lower DHEA to cortisol ratio. The higher stress group also reported higher scores of stressful life events, perceived stress, anxiety and depression. Hair cortisol level was positively related to anxiety; DHEA was negatively associated with stressful life events; and the DHEA to cortisol ratio was positively related to stressful life events and perceived stress. ART did not affect the associations between the endocrine measures and stress level.

Conclusions

Our findings suggest that hair cortisol and DHEA to cortisol ratio can be used as promising biomarkers of chronic stress among PLWH. Clarifying the role of steroid hormones in the psychoimmunology of PLWH may yield important implications for clinical practice and psychological intervention.

Health and mood among HIV-positive outpatients attending an ART Clinic of a University Hospital

AIMS AND OBJECTIVES

To evaluate how individuals at different stages of infection with HIV perceive their health status and its association with mood states.

BACKGROUND

With the introduction of Highly Active Antiretroviral Therapy in 1996, the quality of life of people living with HIV has improved. However, the literature emphasises the negative effects of the disease on the mental health of individuals suffering from this condition and the high incidence of depression among infected individuals. Although people diagnosed and living with HIV are overwhelmed by emotions, we found that various emotional manifestations are understudied within this group of patients.

DESIGN

A cross-sectional study was conducted in an outpatient unit of a University Hospital (antiretroviral therapy clinic), with a consecutive sample composed of 152 patients.

METHODS

Data were collected through a questionnaire used to assess the sociodemographic and clinical characteristics, the Short Form (36) Health Survey, and the Profile of Mood States scale.

RESULTS AND CONCLUSIONS

The health status negatively affects the role at the emotional and mental health dimensions. The participants showing a worse health condition than in the previous year had higher levels of tension/anxiety, depression/dejection, fatigue/inertia and confusion/bewilderment. The stage of disease and the profile of mood state emerged as independent phenomena.

RELEVANCE TO CLINICAL PRACTICE

The results of this study indicate that nurses worldwide should be aware of the emotional aspects (negative emotions strongly impact health) related to the subjective perception of a worsening health status, regardless of the stage of the disease.

Depression and anxiety were low amongst virally suppressed, long-term treated HIV-infected individuals enrolled in a public sector antiretroviral program in Thailand

HIV/AIDS and anxiety/depression are interlinked. HIV-infected patients suffering from depression may be at risk for poor adherence which may contribute to HIV disease progression. Additionally, an HIV diagnosis and/or using certain antiretroviral agents may trigger symptoms of anxiety/depression. The objective of the study was to assess the prevalence and factors associated with anxiety and depression in HIV-infected patients from the Thai National HIV Treatment Program. This cross-sectional study was performed from January 2012 to December 2012 in HIV-infected out-patients, aged ≥18 years, from three HIV referral centers. Symptoms of anxiety and depression were measured using the Thai-validated Hospital Anxiety and Depression Scale (HADS). A score of ≥11 was defined as having anxiety and depression. Associated factors were assessed by multivariate logistic regression. Totally 2023 (56% males) patients were enrolled. All patients received antiretroviral therapy (ART) for a mean duration of 7.7 years. Median CD4 was 495 cells/mm³. Ninety-five percent had HIV-RNA < 50 copies/ml. Thirty-three percent were currently on efavirenz (EFV)-based ART. The prevalence of anxiety and depression were 4.8% and 3.1%, respectively. About 1.3% had both anxiety and depression. In multivariate logistic models, the female sex [OR = 1.6(95%CI 1.1-2.3), p = .01], having adherence <90% [OR = 2.2(95%CI 1.5-3.4), p < .001], fair/poor quality of life (QOL) [OR = 7.2 (95%CI 3.6-14.2), p < .001] and EFV exposure [OR = 1.6(95%CI 1.1-2.3), p = .01], were independently associated with having anxiety or depression. Our findings demonstrated that prevalence of depression and anxiety was low amongst virally suppressed, long-term antiretroviral-treated HIV-infected individuals. Some key characteristics such as the female sex, poor adherence, poor/fair QOL and EFV exposure are associated with anxiety and depression. These factors can be used to distinguish who would need a more in-depth evaluation for these psychiatric disorders.

The impact of a livelihood program on depressive symptoms among people living with HIV in Cambodia

Background

Psychological and social problems are major concerns in this era of successful antiretroviral therapy. Although livelihood programs have been implemented extensively to improve the daily living conditions of people living with HIV in Cambodia, no studies have yet investigated the impacts of these programs on the mental health of this vulnerable population. Therefore, we examined the impact of a livelihood program on depressive symptoms and associated factors among people living with HIV in Cambodia.

Design

A quasi-experimental, nonequivalent comparison group study was conducted in six provinces of Cambodia in 2014. Data were collected from an intervention group comprising 357 people living with HIV who had participated in the livelihood program and a comparison group comprising 328 people living with HIV who had not participated in this program. Multiple logistic regression analysis was carried out to examine the association between livelihood-program participation and depressive symptoms as measured by the depressive symptoms subscale of the 25-item Cambodian version of the Hopkins Symptom Checklist. A propensity score matching was used to examine the effect of the livelihood program on depressive symptoms while controlling for selection bias.

Results

Overall, 56.0% and 62.7% of the participants in the intervention and comparison groups, respectively, met the Hopkins Symptom Checklist threshold for depressive symptoms. The multiple logistic regression analysis showed that the participants in the intervention group had significantly lower odds of having depressive symptoms (adjusted odds ratio 0.68, 95% confidence interval 0.52–0.88). The analysis from propensity score matching indicated that the livelihood program helped mitigate depressive symptoms among the participants in the intervention group (T=−1.99).

Conclusions

The livelihood program appeared to help mitigate the burden of depressive symptoms among people living with HIV in Cambodia. Thus, this program should be scaled up and modified to better improve participants’ mental health.

HIV-related stigma and universal testing and treatment for HIV prevention and care: design of an implementation science evaluation nested in the HPTN 071 (PopART) cluster-randomized trial in Zambia and South Africa

BACKGROUND

Stigma and discrimination related to HIV and key populations at high risk of HIV have the potential to impede the implementation of effective HIV prevention and treatment programmes at scale. Studies measuring the impact of stigma on these programmes are rare. We are conducting an implementation science study of HIV-related stigma in communities and health settings within a large, pragmatic cluster-randomized trial of a universal testing and treatment intervention for HIV prevention in Zambia and South Africa and will assess how stigma affects, and is affected by, implementation of this intervention.

METHODS/DESIGN

A mixed-method evaluation will be nested within HIV prevention trials network (HPTN) 071/PopART (Clinical Trials registration number NCT01900977), a three-arm trial comparing universal door-to-door delivery of HIV testing and referral to prevention and treatment services, accompanied by either an immediate offer of anti-retroviral treatment to people living with HIV regardless of clinical status, or an offer of treatment in-line with national guidelines, with a standard-of-care control arm. The primary outcome of HPTN 071/PopART is HIV incidence measured among a cohort of 52 500 individuals in 21 study clusters. Our evaluation will include integrated quantitative and qualitative data collection and analysis in all trial sites. We will collect quantitative data on indicators of HIV-related stigma over 3 years from large probability samples of community members, health workers and people living with HIV. We will collect qualitative data, including in-depth interviews and observations from members of these same groups sampled purposively. In analysis, we will: (1) compare HIV-related stigma measures between study arms, (2) link data on stigma to measures of the success of implementation of the PopART intervention and (3) explore changes in the dominant drivers and manifestations of stigma in study communities and the health system.

DISCUSSION

HIV-related stigma may impede the successful implementation of HIV prevention and treatment programmes. Using a novel study-design nested within a large, community randomized trial we will evaluate the extent to which HIV-related stigma affects and is affected by the implementation of a comprehensive combination HIV prevention intervention including a universal test and treatment approach.

Improved long-term antiretroviral treatment outcomes amongst patients receiving community-based adherence support in South Africa

Retaining high levels of patients in care who are virally suppressed over long treatment periods has been an important challenge for antiretroviral treatment (ART) programmes in sub-Saharan Africa, the region having the highest HIV burden globally. Clinic-linked community-based adherence support (CBAS) programmes provide home-based adherence and psychosocial support for ART patients. However, there is little evidence of their longer-term impact. This study assessed the effectiveness of CBAS after eight years of ART. CBAS workers are lay healthcare personnel providing regular adherence and psychosocial support for ART patients and their households through home visits addressing household challenges affecting adherence. A multicentre cohort study using routinely collected data was undertaken at six public ART sites in a high HIV-prevalence South African district. Patient retention, loss to follow-up (LTFU), viral suppression and CD4 cell restoration were compared between patients with and without CBAS, using competing-risks regression, linear mixed models and log-binomial regression. 3861 patients were included, of whom 1616 (41.9%) received CBAS. Over 14,792 patient-years of observation, the cumulative incidence of LTFU was 37.3% and 46.2% amongst patients with and without CBAS, respectively, following 8 years of ART; adjusted subhazard ratio (CBAS vs. no CBAS) = 0.74 (95% CI: 0.66-0.84; P < .0001). Amongst patients on ART for 6.5-8 years, proportions not achieving viral suppression were 11.4% and 19.4% in patients with and without CBAS, respectively; adjusted risk ratio = 0.47 (95% CI: 0.26-0.86; P = .015). Annual CD4 cell increases from baseline were 62.8 cells/µL/year and 51.5 cells/µL/year amongst patients with and without CBAS, respectively, after 6.5 years or more (P = .034). After adjustment, annual CD4 cell recovery was 15.1 cells/µL/year (95% CI: 2.7-27.6) greater in CBAS patients (P = .017). ART patients who received CBAS had improved long-term patient retention, viral suppression and immunological restoration. CBAS is an intervention that can improve longer-term ART programme outcomes in resource-limited settings.

'Treating Africans differently': using skin colour as proxy for HIV risk

AIMS AND OBJECTIVES

This paper examines the qualitative results of two studies of Black African new settler communities in New Zealand. The analysis investigates the issues of stigma and microaggressions and their effects on Black African communities.

BACKGROUND

Previous work that investigated experiences of stigma faced by relatively early Black African new settlers to New Zealand found that new settlers experienced stigma, and their resulting isolation had negative implications for access to health and social services, regardless of HIV status.

DESIGN

This paper is a meta-analysis of two published studies, using original qualitative data from each.

METHODS

Researchers for the first study, Standing in the Fire, interviewed 13 Black Africans living with HIV who were new settlers to New Zealand. The second study, AfricaNZ Care, was a national mixed method study which surveyed 703 Black African new settlers, and included 131 participants in 23 different focus groups. The present analysis includes only the qualitative data from the second study. Some, but not most, participants of the second study were living with HIV.

RESULTS

Black African identity is used as a proxy for HIV status among non-HIV specialist health care workers. Participants reported experiences of stigma and microaggressions based on their race, and a lack of knowledge about HIV in non-HIV specialist nurses and other health care workers. They also experienced poor health care and education practices, professional prejudice against colleagues living with HIV and institutional challenges including failure to protect patient confidentiality.

CONCLUSIONS

HIV-related stigma and microaggressions remain significant problems, not only for people living with HIV but also for those perceived to be at high risk for HIV.

RELEVANCE TO CLINICAL PRACTICE

Experiences of stigmatising behaviour by health care professionals have a broad and significant range of impacts on patients' health outcomes.

Physical activity levels and perceived benefits and barriers to physical activity in HIV-infected women living in the deep south of the United States

Engaging in regular physical activity (PA) is important in maintaining health and increasing the overall quality of life of people living with HIV (PLWH). The deep south of the USA is known for its high rate of sedentary behavior although data on the activity levels and perceptions of the benefits and barriers to exercise in women living with HIV in the deep south are lacking. Understanding the perceived benefits and barriers to exercise can guide the development of PA interventions. We conducted a cross-sectional study to determine the PA levels and perceived benefits and barriers to exercise associated with both age and depression level in a group of HIV+ women living in the deep south. We recruited a total of 50 participants from a cohort site for the Women's Interagency HIV Study. Depression was assessed using the Center for Epidemiological Studies Depression Scale (CES-D) and benefits/barriers to exercise were measured using the Exercise Benefits and Barriers Scale (EBBS). We measured PA both subjectively and objectively using the International Physical Activity Questionnaire (IPAQ) and a Fitbit PA monitor, respectively. Our sample was predominantly African-American (96%) and the mean ±SD age, body mass index, and CES-D score were 42 ± 8.8 years, 36.6 ± 11.5 kg/m(2), and 15.6 ± 11.4, respectively. Both subjective and objective measures of PA indicated that our participants were sedentary. The greatest perceived benefit to exercise was physical performance and the greatest barrier to exercise was physical exertion. Higher overall perceived benefits were reported by women ≥43 years and women reporting higher levels of depression. There was no difference in overall barriers associated with age and depression level, but women with depression felt more fatigued by exercise. The results of this study can be helpful when designing and implementing PA interventions in women living with HIV in the deep south.

Food insecurity, mental health and quality of life among people living with HIV commencing antiretroviral treatment in Ethiopia: a cross-sectional study

BACKGROUND

Studies from high-income settings show that both food insecurity and common mental disorders (CMDs) are associated with lower quality of life among people living with HIV (PLHIV). However, there is limited research among PLHIV in sub-Saharan Africa. In this study we tested the hypothesis that food insecurity and CMDs would be associated with poorer quality of life of PLHIV in Ethiopia.

METHODS

A cross-sectional study was carried out with 348 PLHIV who were initiating antiretroviral therapy recruited from two primary care centers and a tertiary Hospital in southwest Ethiopia. Food insecurity, CMD, and quality of life were measured using instruments adapted and validated in Ethiopia (Household Food Insecurity Access Scale, Kessler-6, and WHOQOL-HIV-BREF-ETH, respectively). Multiple linear regression analysis was used to identify factors associated with quality of life after adjusting for confounders.

RESULTS

The prevalence of severe household food insecurity among PLHIV was 38.7 %. After adjusting for confounders, severe food insecurity (β = -3.24, 95 % CI: -6.19; -0.29) and higher levels of CMD symptoms (β = -1.72 for each 1 point increase, 95 % CI: -1.94; -1.49) were associated with lower quality of life. Other factors associated with lower quality of life were advanced HIV disease (β = -3.80, 95 % CI: -6.18; -1.42), and being underweight (BMI = 17.0 - 18.5 kg/m(2)) (β = -3.45, 95 % CI: -6.18; -0.71). Owning more household assets was associated with higher quality of life (β = 0.99 for owning one more asset, 95 % CI: 0.09; 1.89).

CONCLUSION

Poor mental health and food insecurity are associated with lower quality of life in PLHIV. There is a need for longitudinal studies to elucidate the pathways linking CMD, food insecurity and quality of life.

Conducting experimental research in marginalised populations: clinical and methodological implications from a mixed-methods randomised controlled trial in Kenya

Experimental studies to test interventions for people living with HIV in low- and middle-income countries are essential to ensure appropriate and effective clinical care. The implications of study participation on outcome data in such populations have been discussed theoretically, but rarely empirically examined. We aimed to explore the effects of participating in a randomised controlled trial conducted in an HIV clinic in Mombasa, Kenya. We report qualitative data from the Treatment Outcomes in Palliative Care trial, which evaluated the impact of a nurse-led palliative care intervention for HIV positive adults on antiretroviral therapy compared to standard care. Participants in both arms attended five monthly quantitative data collection appointments. Post-trial exit, 10 control and 20 intervention patients participated in semi-structured qualitative interviews, analysed using thematic analysis. We found benefit attributed to the compassion of the research team, social support, communication, completion of patient reported outcome measures (PROMs) and material support (transport reimbursement). Being treated with compassion and receiving social support enabled participants to build positive relationships with the research team, which improved mental health and well-being. Open and non-judgmental communication made participants feel accepted. Participants described how repeated completion of the PROMs was a prompt for reflection, through which they began to help themselves and self-care. Participant reimbursements relieved financial hardship and enabled them to fulfil their social responsibilities, enhancing self-worth. These findings emphasise the importance of compassion, support and effective communication in the clinical encounter, particularly in stigmatised and isolated populations, and the potential of the integration of simple PROMs to improve patient outcomes. Participation in research has unexpected positive benefits for participants, which should be taken into account when designing research in similar populations. Researchers should be aware of the effects of financial reimbursement and contact with researchers in isolated and impoverished communities.

The Association of HIV-Related Stigma to HIV Medication Adherence: A Systematic Review and Synthesis of the Literature

This paper provides a review of the quantitative literature on HIV-related stigma and medication adherence, including: (1) synthesis of the empirical evidence linking stigma to adherence, (2) examination of proposed causal mechanisms of the stigma and adherence relationship, and (3) methodological critique and guidance for future research. We reviewed 38 studies reporting either cross-sectional or prospective analyses of the association of HIV-related stigma to medication adherence since the introduction of antiretroviral therapies (ART). Although there is substantial empirical evidence linking stigma to adherence difficulties, few studies provided data on psychosocial mechanisms that may account for this relationship. Proposed mechanisms include: (a) enhanced vulnerability to mental health difficulties, (b) reduction in self-efficacy, and (c) concerns about inadvertent disclosure of HIV status. Future research should strive to assess the multiple domains of stigma, use standardized measures of adherence, and include prospective analyses to test mediating variables.

Sexual inactivity and sexual satisfaction among women living with HIV in Canada in the context of growing social, legal and public health surveillance

INTRODUCTION

Women represent nearly one-quarter of the 71,300 people living with HIV in Canada. Within a context of widespread HIV-related stigma and discrimination and on-going risks to HIV disclosure, little is known about the influence of growing social, legal and public health surveillance of HIV on sexual activity and satisfaction of women living with HIV (WLWH).

METHODS

We analyzed baseline cross-sectional survey data for WLWH (≥16 years, self-identifying as women) enrolled in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS), a multisite, longitudinal, community-based research study in British Columbia (BC), Ontario (ON) and Quebec (QC). Sexual inactivity was defined as no consensual sex (oral or penetrative) in the prior six months, excluding recently postpartum women (≤6 months). Satisfaction was assessed using an item from the Sexual Satisfaction Scale for Women. Multivariable logistic regression analysis examined independent correlates of sexual inactivity.

RESULTS

Of 1213 participants (26% BC, 50% ON, 24% QC), median age was 43 years (IQR: 35, 50). 23% identified as Aboriginal, 28% as African, Caribbean and Black, 41% as White and 8% as other ethnicities. Heterosexual orientation was reported by 87% of participants and LGBTQ by 13%. In total, 82% were currently taking antiretroviral therapy (ART), and 77% reported an undetectable viral load (VL<40 copies/mL). Overall, 49% were sexually inactive and 64% reported being satisfied with their current sex lives, including 49% of sexually inactive and 79% of sexually active women (p<0.001). Sexually inactive women had significantly higher odds of being older (AOR=1.06 per year increase; 95% CI=1.05-1.08), not being in a marital or committed relationship (AOR=4.34; 95% CI=3.13-5.88), having an annual household income below $20,000 CAD (AOR: 1.44; 95% CI=1.08-1.92), and reporting high (vs. low) HIV-related stigma (AOR=1.81; 95% CI=1.09-3.03). No independent association was found with ART use or undetectable VL.

CONCLUSIONS

Approximately half of WLWH in this study reported being sexually inactive. Associations with sexual dissatisfaction and high HIV-related stigma suggest that WLWH face challenges navigating healthy and satisfying sexual lives, despite good HIV treatment outcomes. As half of sexually inactive women reported being satisfied with their sex lives, additional research is required to determine whether WLWH are deliberately choosing abstinence as a means of resisting surveillance and disclosure expectations associated with sexual activity. Findings underscore a need for interventions to de-stigmatize HIV, support safe disclosure and re-appropriate the sexual rights of WLWH.

Living with AIDS in Uganda: a qualitative study of patients' and families' experiences following referral to hospice

Background

Globally, the majority of people with HIV/AIDS live in sub-Saharan Africa. While the increasing availability of antiretroviral therapy is improving the outlook for many, its effects are yet to reach all of those in need and patients still present with advanced disease. This paper reports findings from qualitative interviews with patients living with AIDS and their caregivers who were receiving palliative care from Hospice Africa Uganda (HAU). We aimed to understand what motivated patients and their families to seek formal healthcare, whether there were any barriers to help- seeking and how the help and support provided to them by HAU was perceived.

Methods

We invited patients with AIDS and their relatives who were newly referred to HAU to participate in qualitative interviews. Patients and carers were interviewed in their homes approximately four weeks after the patient’s enrolment at HAU. Interviews were translated, transcribed and analysed using narrative and thematic approaches.

Results

Interviews were completed with 22 patients (10 women and 12 men) and 20 family caregivers, nominated by patients. Interviews revealed the extent of suffering patients endured and the strain that family caregivers experienced before help was sought or accessed. Patients reported a wide range of severe physical symptoms. Patients and their relatives reported worries about the disclosure of the AIDS diagnosis and fear of stigma. Profound poverty framed all accounts. Poverty and stigma were, depending on the patient and family situation, both motivators and barriers to help seeking behaviour. Hospice services were perceived to provide essential relief of pain and symptoms, as well as providing rehabilitative support and a sense of caring. The hospice was perceived relieve utter destitution, although it was unable to meet all the expectations that patients had.

Conclusion

Hospice care was highly valued and perceived to effectively manage problems such as pain and other symptoms and to provide rehabilitation. Participants noted a strong sense of being “cared for”. However, poverty and a sense of stigma were widespread. Further research is needed to understand how poverty and stigma can be effectively managed in hospice care for patients for advanced AIDS and their families.

Implementation Process of a Canadian Community-based Nurse Mentorship Intervention in HIV Care

We describe salient individual and organizational factors that influenced engagement of registered nurses in a 12-month clinical mentorship intervention on HIV care in Canada. The intervention included 48 nurses and 8 people living with HIV (PLWH) who were involved in group-based and one-on-one informal mentorship informed by transformative learning theory. We evaluated the process of implementing the mentorship intervention using qualitative content analysis. The inclusion of PLWH as mentors, the opportunities for reciprocal learning, and the long-term commitment of individual nurses and partner organizations in HIV care were major strengths. Challenges included the need for multiple ethical approvals, the lack of organizational support at some clinical sites, and the time commitment required by participants. We recommend that clinical mentorship interventions in HIV care consider organizational support, adhere to the Greater Involvement of People Living with HIV/AIDS principles, and explore questions of professional obligations.

Quality of life assessment among HIV-positive persons entering the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial

OBJECTIVES

With HIV treatment prolonging survival and HIV infection now managed as a chronic illness, quality of life (QOL) is important to evaluate in persons living with HIV (PLWH). We assessed at study entry the QOL of antiretroviral-naïve PLWH with CD4 counts > 500 cells/μL in the Strategic Timing of AntiRetroviral Treatment (START) clinical trial.

METHODS

QOL was assessed with: (1) a visual analogue scale (VAS) for self-assessment of overall current health; (2) the Short-Form 12-Item Version 2 Health Survey(®) (SF-12V2), for which responses are summarized into eight individual QOL domains plus component summary scores for physical health [the Physical Health Component Summary (PCS)] and mental health [the Mental Health Component Summary (MCS)]. The VAS and eight domain scores were scaled from 0 to 100. Mean QOL measures were calculated overall and by demographic, clinical and behavioural factors.

RESULTS

A total of 4631 participants completed the VAS and 4119 the SF-12. The mean VAS score (with standard deviation) was 80.9 ± 15.7. Mean SF-12 domain scores were lowest for vitality (66.3 ± 26.4) and mental health (68.6 ± 21.4), and highest for physical functioning (89.3 ± 23.0) and bodily pain (88.0 ± 21.4). Using multiple linear regression, PCS scores were lower (P < 0.001) for Asians, North Americans, female participants, older participants, and those with less education, longer duration of known HIV infection, alcoholism/substance dependence and body mass index ≥ 30 kg/m(2) . MCS scores were highest (P < 0.001) for Africans, South Americans and older participants, and lowest for female participants, current smokers and those with alcoholism/substance dependence.

CONCLUSIONS

In this primarily healthy population, QOL was mostly favourable, emphasizing that it is important that HIV treatments do not negatively impact QOL. Self-assessed physical health summary scores were higher than mental health scores. Factors such as older age and geographical region had different effects on perceived physical and mental health.

A Social-Ecological View of Barriers and Facilitators for HIV Treatment Adherence: Interviews with Puerto Rican HIV Patients

Purpose

To identify perceived barriers and facilitators for HAART adherence among people living with HIV/AIDS in Southern Puerto Rico using a Social Ecological framework.

Patients and Methods

Individual in-depths interviews were conducted with 12 HIV patients with a history of HAART non-adherence. Interviews were audio-taped and transcribed. Content analysis was performed for each transcribed interview by three independent coders using a codebook. Using Atlas TI, super-codes and families were generated to facilitate the categorization tree as well as grounded analyses and density estimates

Results

Most participants reported a monthly income of $500 or less (n = 7), a high school education level (n = 7), being unemployed (n = 9) and being recipients of government health insurance (n = 11). Three out of six women reported living alone with their children and most men informed living with their parents or other relatives (n = 4). For the grounded analyses, the top four sub-categories linked to high number of quotations were mental health barriers (G = 32) followed by treatment regimen (G = 28), health system (G = 24) and interpersonal relations (G = 16). The top four sub-categories linked to high number of codes are treatment regimen (D = 4), health status perception (D = 3), interpersonal relations (D = 3) and health system (D = 3).

Conclusion

The results of this study suggest the interconnection of HIV treatment adherence barriers at various system levels. Future studies on HIV treatment barriers should explore these interactions and investigate the possible synergistic effect on non-adherent behavior

Shame among people living with HIV: a literature review

Shame is consistently associated with poor adjustment (e.g., depressive symptoms) among community samples but, surprisingly, has rarely been directly examined among people living with HIV/AIDS (PLWH). This limited research on shame is likely due, in part, to shame's having been subsumed within measures of internalized stigma, an imprecise construct with varied definitions in the HIV literature. The current review summarizes research directly examining the correlates of shame among PLWH. Findings indicate that shame is associated with greater depressive symptoms, less healthcare utilization, and poorer physical health among PLWH. Directions for future research examining shame among PLWH are highlighted, including the need for more prospective research examining shame as a predictor of future adjustment.

Nurse-led palliative care for HIV-positive patients taking antiretroviral therapy in Kenya: a randomised controlled trial

BACKGROUND

People with HIV accessing antiretroviral therapy (ART) have persistent physical, psychological, social, and spiritual problems, which are associated with poor quality of life and treatment outcomes. We assessed the effectiveness of a nurse-led palliative care intervention on patient-reported outcomes.

METHODS

We did this randomised controlled trial at a clinic in Kenya for adults with HIV, established on ART, and reporting moderate-to-severe pain or symptoms. We randomly assigned participants (1:1) either to a palliative care intervention (including assessments of physical, emotional, and spiritual wellbeing and quality of life) given six times over 4 months, or to usual care. Participants and investigators were not masked to allocation. The primary outcome was pain (scored on the African Palliative Care Association's African Palliative Outcome Scale). This trial is registered with ClinicalTrials.gov, number NCT01608802.

FINDINGS

We screened 2070 patients, of whom we enrolled 120: 60 allocated to each group. In the control group, median pain score improved from 1·0 (IQR 0·0-2·0) at baseline to 5·0 (3·0-5·0) at 4 months; in the intervention group, it improved from 1·0 (0·0-2·0) at baseline to 4·5 (3·0-5·0) at 4 months. Compared with standard care, the intervention had no significant effect on pain (coefficient -0·01, 95% CI -0·36 to 0·34, p=0·95).

INTERPRETATION

A nurse-led palliative care intervention was not effective in reducing pain. However, person-centred assessment and care delivered by staff who have received additional training had positive effects on self-reported mental health related quality of life and psychosocial wellbeing.

FUNDING

Diana Princess of Wales Memorial Fund.

Symptom Clusters in People Living with HIV Attending Five Palliative Care Facilities in Two Sub-Saharan African Countries: A Hierarchical Cluster Analysis

Background

Symptom research across conditions has historically focused on single symptoms, and the burden of multiple symptoms and their interactions has been relatively neglected especially in people living with HIV. Symptom cluster studies are required to set priorities in treatment planning, and to lessen the total symptom burden. This study aimed to identify and compare symptom clusters among people living with HIV attending five palliative care facilities in two sub-Saharan African countries.

Methods

Data from cross-sectional self-report of seven-day symptom prevalence on the 32-item Memorial Symptom Assessment Scale-Short Form were used. A hierarchical cluster analysis was conducted using Ward’s method applying squared Euclidean Distance as the similarity measure to determine the clusters. Contingency tables, X² tests and ANOVA were used to compare the clusters by patient specific characteristics and distress scores.

Results

Among the sample (N=217) the mean age was 36.5 (SD 9.0), 73.2% were female, and 49.1% were on antiretroviral therapy (ART). The cluster analysis produced five symptom clusters identified as: 1) dermatological; 2) generalised anxiety and elimination; 3) social and image; 4) persistently present; and 5) a gastrointestinal-related symptom cluster. The patients in the first three symptom clusters reported the highest physical and psychological distress scores. Patient characteristics varied significantly across the five clusters by functional status (worst functional physical status in cluster one, p<0.001); being on ART (highest proportions for clusters two and three, p=0.012); global distress (F=26.8, p<0.001), physical distress (F=36.3, p<0.001) and psychological distress subscale (F=21.8, p<0.001) (all subscales worst for cluster one, best for cluster four).

Conclusions

The greatest burden is associated with cluster one, and should be prioritised in clinical management. Further symptom cluster research in people living with HIV with longitudinally collected symptom data to test cluster stability and identify common symptom trajectories is recommended.

Substance-related coping, HIV-related factors, and mental health among an HIV-positive sexual minority community sample

HIV-positive status poses a unique set of social stressors, especially among lesbian, gay, and bisexual (LGB) persons. Among these difficulties are the internalization of HIV-related stigma and poor mental health. Unfortunately, substance use as a coping mechanism is also common, dependent on other demographic factors, among HIV-positive and LGB samples. The present study integrates these bodies of literature by examining main and interactive effects of HIV-related experiences (i.e., disclosure of HIV-positive status, fear of disclosure, HIV-related victimization, and internalized HIV-related stigma) and substance-related coping with discrimination as they impact mental health (i.e., stress, anxiety, depressive symptoms, and suicide and self-injury proneness). Participants were 216 HIV-positive LGB community members from an urban community medical clinic. Prominent results included: (1) robust negative effects of internalized HIV-related stigma on all mental health indicators when controlling for other HIV-related experiences and (2) a significant interaction in which substance-related coping significantly increases suicide proneness, only for those who have disclosed HIV-positive status to family or friends. Results are discussed with respect to theoretical perspectives of internalized stigma, implications for clinical work with LGB persons of HIV-positive status, and future research.

Do Web-based and clinic samples of gay men living with HIV differ on self-reported physical and psychological symptoms? A comparative analysis

Background

Although the Internet is commonly used to recruit samples in studies of human immunodeficiency virus (HIV)-related risk behaviors, it has not been used to measure patient-reported well-being. As the burden of long-term chronic HIV infection rises, the Internet may offer enormous potential for recruitment to research and interventions.

Objective

This study aimed to compare two samples of gay men living with HIV, one recruited via the Web and the other recruited in outpatient settings, in terms of self-reported physical and psychological symptom burden.

Methods

The Internet sample was recruited from a UK-wide Web-based survey of gay men with diagnosed HIV. Of these, 154 respondents identified themselves as resident in London and were included in this analysis. The HIV clinic sample was recruited from five HIV outpatient clinics. Of these participants, 400 gay men recruited in London clinics were included in this analysis.

Results

The Web-based sample was younger than the clinic sample (37.3 years, SD 7.0 vs 40.9 years, SD 8.3), more likely to be in paid employment (72.8%, 99/136 vs 60.1%, 227/378), less likely to be on antiretroviral therapy (ART) (58.4%, 90/154 vs 68.0%, 266/391), and had worse mean psychological symptom burden compared to the clinic sample (mean scores: 1.61, SD 1.09 vs 1.36, SD 0.96) but similar physical symptom burden (mean scores: 0.78, SD 0.65 vs 0.70, SD 0.74). In multivariable logistic regression, for the physical symptom burden model, adjusted for age, ethnicity, employment status, and ART use, the recruitment setting (ie, Web-based vs clinic) was not significantly associated with high physical symptom score. The only variable that remained significantly associated with high physical symptom score was employment status, with those in employment being less likely to report being in the upper (worst) physical symptom tertile versus the other two tertiles (adjusted OR 0.41, 95% CI 0.28-0.62, P<.001). For the psychological symptom burden model, those recruited via the Web were significantly more likely to report being in the upper (worst) tertile (adjusted OR 2.20, 95% CI 1.41-3.44, P=.001). In addition, those in employment were less likely to report being in the upper (worst) psychological symptom tertile compared to those not in employment (adjusted OR 0.32, 95% CI 0.21-0.49, P<.001).

Conclusions

Our data have revealed a number of differences. Compared to the clinic sample, the Web-based sample had worse psychological symptom burden, younger average age, higher prevalence of employment, and a lower proportion on ART. For future research, we recommend that Web-based data collection should include the demographic variables that we note differed between samples. In addition, we recognize that each recruitment method may bring inherent sampling bias, with clinic populations differing by geographical location and reflecting those accessing regular medical care, and Web-based sampling recruiting those with greater Internet access and identifying survey materials through specific searches and contact with specific websites.

"Was it a mistake to tell others that you are infected with HIV?": factors associated with regret following HIV disclosure among people living with HIV in five countries (Mali, Morocco, Democratic Republic of the Congo, Ecuador and Romania). Results from a community-based research

This study examined regret following HIV serostatus disclosure and associated factors in under-investigated contexts (Mali, Morocco, Democratic Republic of the Congo, Ecuador and Romania). A community-based cross-sectional study was implemented by a mixed consortium [researchers/community-based organizations (CBO)]. Trained CBO members interviewed 1,500 PLHIV in contact with CBOs using a 125-item questionnaire. A weighted multivariate logistic regression was performed. Among the 1,212 participants included in the analysis, 290 (23.9 %) declared that disclosure was a mistake. Female gender, percentage of PLHIV's network knowing about one's seropositivity from a third party, having suffered rejection after disclosure, having suffered HIV-based discrimination at work, perceived seriousness of infection score, daily loneliness, property index and self-esteem score were independently associated with regret. Discrimination, as well as individual characteristics and skills may affect the disclosure experience. Interventions aiming at improving PLHIV skills and reducing their social isolation may facilitate the disclosure process and avoid negative consequences.

Depression in HIV infected patients: a review

Depression is the most common neuropsychiatric complication in HIV-infected patients and may occur in all phases of the infection. Accurately, diagnosing major depressive disorder in the context of HIV is an ongoing challenge to clinicians and researchers, being complicated by the complex biological, psychological, and social factors associated with the HIV illness. Evidences exist to support the importance of improving the identification of depressive symptoms and their adequate treatment. Depression has long been recognized as a predictor of negative clinical outcomes in HIV-infected patients, such as reducing medication adherence, quality of life, and treatment outcome, and possibly worsening the progression of the illness and increasing mortality. By analyzing the most relevant studies (MEDLINE, EMBASE, PsycLit, Cochrane Library), the review discusses the epidemiology and the main clinical features of depression in HIV-infected patients, the causal pathways linking depression and HIV infection, the validity of screening tools, and the efficacy of different treatment approaches, including psychosocial interventions, psychopharmacology as well as HIV-specific health psychology health service models.

Effectiveness of Psycho-Educational Intervention in HIV Patients' Treatment

Adherence to Highly Active Antiretroviral Therapy (HAART) is the main prognostic factor associated with HIV disease progression and death. The aim was to evaluate the effectiveness of a psycho-educational program to promote adherence to HAART in HIV patients. A longitudinal study (n = 102) over 9 months in an Infectious Diseases Hospital was carried out. Adherence to HAART was measured with standardized scales and values of viral load. Two groups were defined: adherents and non-adherents. In the latter, a psycho-educational program was implemented and 6 months later measured adherence to HAART. Knowledge about the infection, CD4 T lymphocytes and HIV-ribonucleic acid values were measured before and after this program. The sample was predominantly male (70%), heterosexual (78%), with a mean age of 49 (SD = 12.7) years, and 48% of participants were not adhering to HAART. After the program, non-adherence decreased to 21.6%. Knowledge about the infection increased from 79 to 97%. A significant increase in CD4 T lymphocytes (mean 540-580) and a decrease in viral load (mean 5411-3052) were observed, the latter of statistical significance. This program seems to be feasible and efficient, improving adherence to HAART.