Barriers to care among persons living with HIV/AIDS in urban and rural areas

Depressive symptoms as a link between barriers to care and sexual risk behavior of HIV-infected individuals living in non-urban areas

HIV-infected individuals living in non-urban areas have been proposed to be particularly vulnerable for sexual risk behavior because of barriers to adequate care. The current study examined the association of barriers to care and sexual risk behavior with a focus on depressive symptoms as a link between the two variables. One-hundred-and-one sexually active HIV-infected individuals living in non-urban areas in New England participated by completing self-report measures in a computer-administered format. Four barriers to care were examined: geographical barriers and distance to services; access to and quality of medical and psychological services; community stigma; and personal resources. The results indicated barriers to care, and in particular those pertaining to access to and quality of medical and psychological services were related to depressive symptoms, which, in turn, were related to sexual risk behavior. The findings suggest that interventions to reduce sexual risk behavior in non-urban settings could include not only increasing the availability of quality services but targeting depressive symptoms of HIV-infected individuals.

Trauma, mental health, distrust, and stigma among HIV-positive persons: implications for effective care

Individuals living with HIV often have complicated histories, including negative experiences such as traumatic events, mental illness, and stigma. As the medical community in the United States adapts to managing HIV as a chronic disease, understanding factors such as these negative experiences that may be associated with poorer adherence to treatment regimens, greater HIV risk behavior, and lower patient quality of life becomes critical to HIV care and prevention. In less wealthy nations, these issues are also critical for addressing quality of life as well as medication adherence in the areas where antiretroviral therapies are being made available. This article presents a review of the literature regarding the following psychosocial factors as they relate to HIV/AIDS in the US and globally: traumatic events; mental illness, including depression, anxiety, and posttraumatic stress disorder; lack of trust in the healthcare system and government; and experiences of stigma among individuals with HIV disease. These factors have been found to be prevalent among individuals with HIV/AIDS, regardless of gender or race/ethnicity. Traumatic events, mental illness, distrust, and stigma have also been linked with poorer adherence to medication regimens and HIV risk behavior.

Barriers and facilitators to medication adherence in a southern minority population with HIV disease

Adherence to HIV medications has been an important focus over the past decade, but little is known about adherence barriers and facilitators specifically in that part of the United States known as the Deep South. Characteristics of the region may affect factors associated with adherence related to the patient, the patient-provider relationship, and the environment. A total of 20 HIV-infected clients of a large public infectious diseases clinic in the Deep South participated in one of three focus groups; themes were identified by content analysis. Barriers included the perceived burden of extra planning, denial, life stress, difficult characteristics of the medicines, social stigma, and shame. Facilitators included acceptance of the diagnosis, thinking about the consequences of not taking the medicines, prayer and spirituality, improvements in the medicines, and support from family and friends. In the South, faith and prayer may be strong facilitators that need to be considered when adapting existing adherence interventions.

Risk behaviours and blood borne virus exposure for transient workers in rural Victoria

OBJECTIVE

To investigate risk behaviours associated with the transmission of blood borne viruses (BBVs) and sexually transmitted infections (STIs) among transient rural workers in Victoria.

DESIGN

Cross-sectional study using a convenience sampling frame.

SETTING

Between June and August 2006, 89 participants were recruited from sites located in three rural centres in Victoria's Loddon and Mallee regions. Data were collected using a short questionnaire that asked about history of transient work, sexual history, condom use, alcohol and illicit drug use, and BBV history and testing. Finger-prick blood samples were collected in order to determine prevalence of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) exposure.

RESULTS

Eighty-nine individuals completed a questionnaire, and 85 (96%) provided a finger-prick blood sample for antibody testing. Twenty-seven participants (30%) were consuming alcohol at levels risky to health. Thirty per cent of participants with new partners reported infrequent condom use. Illicit drug use (mainly marijuana) was widespread with more than 46% of the sample reporting recent use of illicit drugs. An HCV exposure prevalence of 2.4% was measured; no samples tested reactive for HIV antibodies.

CONCLUSIONS

Compared with nationally representative data, our study sample reported high rates of alcohol consumption at levels risky to health, illicit drug use and infrequent use of condoms. These results suggest that transient workers and their contacts would benefit from the targeted provision of harm-reduction services, with a particular focus on sexual behaviour and alcohol and drug use.

Predicting ongoing adherence to disease modifying therapies in multiple sclerosis: utility of the health beliefs model

OBJECTIVE

To evaluate ongoing adherence to disease modifying therapies (DMT) among individuals with multiple sclerosis and test the utility of the Health Beliefs Model (HBM) to predict adherence.

DESIGN

Telephone survey completed at baseline with monthly telephone follow-up for 6 months.

SETTING

Veterans Health Administration.

PARTICIPANTS

Eighty-nine veterans with MS actively enrolled in a regional VA MS outpatient clinic currently prescribed DMT.

MEASURES

Demographic information. Selected items from the Adherence Determinants Questionnaire (ADQ) and Barriers to Care Scale (BACS).

RESULTS

Adherence in this population of ongoing DMT users was relatively high (over 80% achieved 80% adherence at follow-up time points). Logistic regression and hierarchical multiple regression analyses controlling for demographics and disease duration were employed to examine the relationship of HBM constructs of perceived susceptibility, severity, benefits, and barriers to DMT adherence and satisfaction at 2-, 4- and 6-month follow-up. Of the four HBM constructs, only perceived benefits uniquely predicted both outcomes across multiple time points.

CONCLUSION

Sustained adherence to DMT remains a challenge for an important minority of individuals with MS. The Health Beliefs Model provides insight into psychosocial mechanisms that maintain adherence behavior. In particular, focus upon the perceived benefits of ongoing DMT therapy may be a promising focus for future interventions.

Health care services for HIV-positive substance abusers in a rural setting: an innovative program

Agencies that deliver health care services to HIV-positive substance abusers living in rural areas of the United States face particular treatment challenges and barriers to care. Rural consumers of HIV/AIDS health care-related services identified long travel distances to medical facilities, lack of transportation, lack of availability of HIV-specific medical personnel, a shortage of mental health and substance abuse services, community stigma, and financial problems as leading barriers to access to care. This article discusses barriers to care for rural HIV-positive substance abusers, and challenges for rural health care providers. In addition, it presents a case study of Health Services Center, a model program that has devised innovative practices in the delivery of health care services to HIV-positive substance abusers in rural northeastern Alabama.

Measurement of stigma in people with HIV: a reexamination of the HIV Stigma Scale

Stigma associated with HIV infection can unfavorably impact the lives and behavior of people living with HIV/AIDS. The HIV Stigma Scale was designed to measure the perception of stigma by those who are HIV infected. Reanalysis of the psychometric properties of this scale was conducted in a new sample of 157 individuals living with HIV/AIDS in rural New England. This resulted in revision of the scale: shortening it from 40 to 32 items and retaining the original four factors but renaming one: Enacted Stigma (formerly Personalized Stigma), Disclosure Concerns, Negative Self-image, and Concern With Public Attitudes. These four subscales have been refined such that each consists of unique items. Cronbach's alphas for the subscales ranged from .90 to .97, and .95 for the overall scale, indicating internal consistency. Correlations with other scales confirmed the validity of the HIV Stigma Scale in another sample of people living with HIV/AIDS.

Characteristics of HIV-infected adults in the Deep South and their utilization of mental health services: A rural vs. urban comparison

Insufficient utilization of mental health services has been described among HIV-infected individuals in urban areas; however, little is known about utilization of mental health services among rural-living HIV-infected individuals. This article examines use of mental health services by HIV-infected adults in the Southern U.S., where approximately two-thirds of rural HIV cases reside, and compares mental health services use between those in rural and urban areas. Data were obtained from surveys of HIV-infected individuals receiving care at tertiary Infectious Diseases clinics in the Southern U.S. (n = 474). Study findings indicated that participants living in areas with a higher proportion of rural-living individuals were less likely to report seeing a mental health provider (p < .001) in the last year even though there were no differences in level of psychological distress by degree of rurality. Participants living in more rural areas also reported significantly fewer mental health visits in the previous month (p = .025). Furthermore, rural living was significantly associated with being African-American, heterosexual, less educated, and having minor children in the home. Due to differences in characteristics and mental health services use by degree of rurality, efforts are needed to assess and address the specific mental health and other needs of HIV-infected individuals in rural areas.

Barriers to accessing HIV/AIDS care in North Carolina: Rural and urban differences

Many HIV-positive individuals face multiple barriers to care and therefore frequently experience unmet medical and support services needs. Rural areas often lack the infrastructure to support the delivery of comprehensive HIV services; however, few studies have examined service barriers faced by rural residents with HIV/AIDS, particularly in the South where two-thirds of people living with HIV/AIDS in rural areas reside. We surveyed North Carolina HIV/AIDS case managers (N = 111) employed at state-certified agencies regarding barriers to medical and support services that influence medication adherence for their rural and urban-living clients. For each of the seven barriers assessed (long travel for care, HIV-related stigma, and a lack of transportation; HIV-trained medical practitioners; housing; mental health services and substance abuse treatment), a substantial proportion of case managers (29-67%) reported it was a 'major problem'. For five of the seven barriers, rural case managers were significantly more likely to identify the barrier as a 'major problem'. Multivariate analysis revealed that rural case managers and case managers with more female clients reported a greater number of barriers. Because unmet medical and support service needs may result in poorer outcomes for HIV-positive individuals, barriers to these services must be identified and addressed, particularly in rural areas which may be highly underserved.

A randomized clinical trial of two telephone-delivered, mental health interventions for HIV-infected persons in rural areas of the United States

Through December 2003, more than 55,300 persons were living in small towns and rural areas of the United States at the time of their AIDS diagnosis. Many HIV-infected rural persons experience elevated levels of depression, suicidal ideation, and anxiety. This research tested if two telephone-delivered, mental health interventions could facilitate the adjustment efforts of persons living with HIV/AIDS in rural areas of the United States. Participants (N=299) were recruited through AIDS service organizations in 13 states and assigned to a Usual Care Condition (n=107), an 8-session Information Support Group Intervention (n=84), or an 8-session Coping Improvement Group Intervention (n=108). Participants completed self-administered surveys at pre-intervention, post-intervention, and 4- and 8-month follow-ups. ANCOVA revealed that no treatment condition produced reductions in the main outcome measures of depressive and psychological symptoms; however, Information Support participants received significantly more support from friends at 4- and 8-month follow-ups and reported fewer barriers to health care and social services at 4-month follow-up compared to participants in the other two conditions. Telephone-delivered, information-support groups have potential to increase perceptions of support and reduce barriers to health care and social services in this population, but the practical significance of these intervention-related changes is limited.

Predictors of post-release primary care utilization among HIV-positive prison inmates: a pilot study

The primary aims of this exploratory pilot study were (1) to determine the proportion of a sample of HIV-positive inmates utilizing primary care after recent release, and (2) to identify variables associated with utilization of primary care at the time of a post-release interview. Sixty HIV-positive, male and female state prison inmates were interviewed approximately three months prior to release, and 30 were interviewed again between seven and 21 days after release. Variables associated with having utilized primary care at the time of a post-release interview (chi(2) p-values < 0.20) included: taking anti-HIV medications at the time of release, no alcohol use since release, living in the same place as before incarceration and rating of housing situation as 'comfortable' or 'very comfortable'. For exploratory purposes, these variables were entered into a logistic regression model. The model correctly classified 80% of cases overall. Future studies are required to ascertain whether these results would obtain with a statistically adequate sample size.

Individual, interpersonal, and structural correlates of effective HAART use among urban active injection drug users

Among individuals receiving highly active antiretroviral therapy (HAART), injection drug users (IDUs) are less likely to achieve HIV suppression. The present study examined individual-level, interpersonal, and structural factors associated with achieving undetectable plasma viral load (UVL) among US IDUs receiving recommended HAART. Data were from baseline assessments of the INSPIRE (Interventions for Seropositive Injectors-Research and Evaluation) study, a 4-site, secondary HIV prevention intervention for heterosexually active IDUs. Of 1113 study participants at baseline, 42% (n = 466) were currently taking recommended HAART (34% were female, 69% non-Hispanic black, 26% recently homeless; median age was 43 years), of whom 132 (28%) had a UVL. Logistic regression revealed that among those on recommended HAART, adjusted odds of UVL were at least 3 times higher among those with high social support, stable housing, and CD4 > 200; UVL was approximately 60% higher among those reporting better patient-provider communication. Outpatient drug treatment and non-Hispanic black race and an interaction between current drug use and social support were marginally negatively significant. Among those with high perceived support, noncurrent drug users compared with current drug users had a greater likelihood of UVL; current drug use was not associated with UVL among those with low support. Depressive symptoms (Brief Symptom Inventory) were not significant. Results suggest the major role of social support in facilitating effective HAART use in this population and suggest that active drug use may interfere with HAART use by adversely affecting social support. Interventions promoting social support functioning, patient-provider communication, stable housing, and drug abuse treatment may facilitate effective HAART use in this vulnerable population.

Psychosocial differences between whites and African Americans living with HIV/AIDS in rural areas of 13 US states

CONTEXT

Acquired immunodeficiency syndrome (AIDS) prevalence rates are increasing rapidly in rural areas of the United States. As rural African Americans are increasingly affected by human immunodeficiency virus (HIV), it is important to identify psychosocial factors unique to this group so that AIDS mental health interventions can be culturally contextualized to meet their unique needs.

PURPOSE

The current study characterized psychosocial functioning in 43 rural African Americans living with HIV/AIDS and compared their levels of functioning to those of 196 HIV-infected rural white persons.

METHODS

All participants were recruited through AIDS service organizations in 13 US states. Surveys were completed as part of a preintervention phase of a randomized clinical trial evaluating 2 mental health interventions for HIV-infected rural persons.

FINDINGS

Compared to their white counterparts, fewer African Americans had progressed to AIDS. African American participants also reported higher levels of coping self-efficacy, more support from family members, and marginally fewer depressive symptoms, and they engaged in more active coping. African Americans who had greater HIV disease severity also received less support from family members and experienced more loneliness.

CONCLUSIONS

Study findings caution that rural African Americans and whites living with HIV disease should not be considered a homogeneous group.

HIV Infection and AIDS in the Deep South

We examine epidemiological and demographic data documenting the HIV/AIDS epidemic in the Deep South region of the United States. These data document substantial increases in AIDS cases in the Deep South from 2000 to 2003. In contrast, other US regions are experiencing stable rates or small increases in new AIDS cases. Furthermore, the AIDS epidemic in the Deep South is more concentrated than in other regions among African Americans, women, and rural residents. The Deep South also has some of the highest levels of poverty and uninsured individuals, factors that complicate the prevention and treatment of HIV infection. Further research is needed to determine the cause of the disproportionate rise in AIDS incidence and to develop effective means of preventing HIV infection and providing care of those infected in this region.

Mapping the social demography and location of HIV services across Toronto neighbourhoods

In this paper we map the location and distribution of HIV service providers across Toronto neighbourhoods. Our analysis identified an uneven distribution of services across Toronto and a number of communities that are less accessible to HIV-related services. We subsequently identified three neighbourhood-level characteristics of the populations living within these communities (i.e. concentrated economic disadvantage, concentrated immigration, and residential instability). Our findings suggest a significant overlap in the location of HIV service providers and the clustering of neighbourhood-level demographic and socioeconomic factors. Some inaccessible neighbourhoods overlap with clusters of neighbourhoods with higher levels of concentrated disadvantage, immigration and percentage of black Canadians. Accessible neighbourhoods are located within the downtown core of Toronto and overlap with clusters of highly dense, younger neighbourhoods (with a high proportion of 15- to 34-year-olds who are unmarried). Our findings point to the need for policy-makers to integrate spatial analytic techniques into their examination of the types of neighbourhoods, and subsequently the community members that live within those neighbourhoods, that are potentially underserved with respect to health and social services.

Mental Health Differences Between Rural and Urban Men Living with HIV Infection in Various Age Groups

Despite the disproportionate increase in rural, Southern residents and older persons during the third era of the HIV/AIDS epidemic, no known study has examined whether older, rural men living with HIV infection face a double jeopardy and have poorer psychosocial profiles than other subgroups of men. We investigated whether area of residence (rural, urban), age (young, middle-age, old), and the interaction of residence and age would be related to mental health factors by using two measurement methods to categorize rural and urban residence (US Census Bureau classification and The Office of Rural Health Policy's, Rural Urban Commuting Area Codes [RUCAs]). We conducted 2-3 hour-long, face-to-face interviews with all but 43 patients who met the study criteria and kept their clinic appointments at three different types of healthcare facilities (i.e., VA, university clinic, public health department) over a 20-month period. The sample consisted of 226 men living in the southeastern US. Rural and urban men of various age groups did not differ in socioeconomic factors, travel distance to clinics, use of medications, satisfaction with care, types of severe stressors, and confidentiality concerns. Using two methods to categorize area of residence, we found that rural men as compared to urban men had similar levels of total stress, AIDS-related stress, social support, active coping and avoidance coping, but higher rates of risk for depression. Rural men had higher levels of non-AIDS-related stress only when the US Census Bureau's categorization was used, which highlights the importance of carefully selecting and describing methods to categorize rural versus urban residence.

Review: use of health care services among persons living with HIV infection: state of the science and future directions

Health care services for persons living with HIV have broadened from short-term, crisis-oriented, and palliative care to include preventive, acute, and long-term services because of advances in HIV treatment and earlier detection. This integrated literature review on utilization of HIV-related health care services provides information on barriers to access, disparities in treatments, and factors contributing to wasteful use of services. Early research focused on describing and quantifying use of in-hospital care. As HIV transformed into a chronic disease, research on utilization expanded into outpatient settings. Predisposing factors such as race, gender, and injection drug use, and enabling factors (i.e., insurance, social support systems, housing) were strong predictors of utilization patterns. Clinical factors, such as immune status, symptoms, and depression, as well as contextual factors (i.e., characteristics of clinicians, urban/rural residence) determined the amounts of services obtained. Additional research is recommended on the utilization of nursing and preventive services and care in rehabilitation settings, home health, and nursing homes. Understanding the patterns and predictors of resource use can facilitate health professionals' efforts in improving the health care delivery system for individuals with HIV infection.

Mapping and visualizing the location HIV service providers: an exploratory spatial analysis of Toronto neighborhoods

Efforts have been made to identify, reduce and ultimately eliminate health disparities, yet variation in access to health services continues to be an important concern. As with large American cities, Toronto has been particularly hard hit by the AIDS epidemic, representing 68% of Ontario's HIV diagnoses (Health Canada, 2000). The accessibility of healthcare in terms of the geographic location and spatial distribution of health services are important factors in healthcare utilization. In this descriptive paper we map the location of HIV-related services and use exploratory spatial data analysis to visualize and examine the distribution of HIV service providers. In examining the location of HIV service providers we map the minimum distance to the nearest service provider. Our analyses also map and analyze five separate categories of HIV-related services. These include: (1) Diagnostic and preventive services; (2) Health and social services for initial HIV diagnosis; (3) Emotional and social support; (4) Emergency services; and (5) Medical and end-of-life services. While our findings point to significant clustering of some types of HIV-related services (such as emergency and preventive services), other services are more evenly distributed across Toronto (this includes medical and end-of-life services). Our findings point to the need for policy makers and researchers to integrate mapping, GIS and spatial analytic techniques into their analyses of the neighborhoods and subsequently the populations in those neighborhoods that are underserved in terms of accessibility of some categories of HIV-related services.

Focus on Women: Linking HIV Care and Treatment with Reproductive Health Services in the MTCT-Plus Initiative

Despite important advances in expanding access to antiretroviral therapy in the countries most heavily affected by HIV/AIDS, there has been little consideration of the connections between HIV prevention, care and treatment programmes and reproductive health services. In this paper, we explore the integration of reproductive health services into HIV care and treatment programmes. We review the design and progress of the MTCT-Plus Initiative, which provides HIV care and treatment services to HIV positive women as well as their HIV positive children and partners. By emphasising the long-term follow-up of families and the provision of comprehensive care across the spectrum of HIV disease, MTCT-Plus highlights the potential synergies in linking reproductive health services to HIV care and treatment programmes. While HIV care and treatment programmes in resource-limited settings may not be able to integrate all reproductive health services into a single service delivery model, there is a clear need to include basic reproductive health services, such as access to appropriate contraception and counselling and management of unplanned pregnancies. The integration of these services would be facilitated by greater insight into the reproductive choices of HIV positive women and men, and into how health care providers influence access to reproductive health services of people with HIV and AIDS.

Access and equity in HIV/AIDS palliative care: a review of the evidence and responses

The high prevalence of pain and other symptoms throughout the HIV disease trajectory, the need for management of side effects related to antiretroviral therapy, the continuing incidence of cancers and new emerging co-morbidities as a result of extended life expectancy under new therapeutic regimes, and the ongoing need for terminal care all prove the curative versus palliative dichotomy to be inappropriate. Although there is evidence for both need and effectiveness of palliative care in HIV patient care, access is often poor and care less than optimal. This review aimed to identify evidence of barriers and inequalities in HIV palliative care in order to inform policy and service development. Biomedical databases were searched using a specific strategy, and evidence extracted into the barrier and inequity categories of patient, clinician, service and disease factors. A model of the barriers and inequalities is presented from the evidence. Recommendations are made from the evidence for promoting access and outcomes through integrated palliative care from diagnosis to end-of-life, alongside antiretroviral therapy when initiated. Service responses that have attempted to increase access to palliative care are presented.

Substance Abuse and Symptoms of Mental Illness Among HIV-positive Persons in the Southeast

OBJECTIVES

Mental illness and substance abuse have been consistently associated with poor HIV-medication adherence and other negative health outcomes.

METHODS

A brief mental health and substance use screening instrument was administered to 1,362 HIV-infected individuals receiving care at two academic medical center Infectious Diseases Clinics in North Carolina.

RESULTS

Study results indicated high frequencies of symptoms of mental illness (60%), substance abuse (32%), and co-occurring symptoms of mental illness and substance abuse (23%). Younger age (P = 0.03), male sex (P < 0.001), and higher viral load (P < 0.001) were associated with substance use problems. White race (P = 0.001), younger age (P = 0.023), and higher viral load (P = 0.042) were associated with symptoms of mental illness.

CONCLUSIONS

In the Southeast, mental health and substance abuse services are sparse and stigma is high; thus, innovative treatment strategies are needed to address the high levels of co-occurring mental illness and substance abuse. Antiretroviral therapies will not reach their potential for slowing the HIV/AIDS epidemic and prolonging survival if comorbidities that influence patient behavior are not addressed.

Developing consumer involvement in rural HIV primary care programmes

OBJECTIVES

As part of a broader medical and psychosocial needs assessment in a rural region of northern California, USA, five focus groups were conducted to explore innovative approaches to creating a system of consumer involvement in the delivery of HIV primary care services in the region.

DESIGN

A total of five focus groups (n = 30) were conducted with clients from three of five counties in the region with the highest number of HIV patients receiving primary care.

SETTING AND PARTICIPANTS

Participants were recruited by their HIV case managers. They were adults living with HIV, who were receiving health care, and who resided in a rural mountain region of northern California.

VARIABLES STUDIED

Group discussions explored ideas for new strategies and examined traditional methods of consumer involvement, considering ways they could be adapted for a rural environment.

RESULTS

Recommendations for consumer involvement included a multi-method approach consisting of traditional written surveys, a formal advisory group, and monthly consumer led social support/informal input groups. Specific challenges discussed included winter weather conditions, transportation barriers, physical limitations, confidentiality concerns, and needs for social support and education.

CONCLUSIONS

A multiple-method approach would ensure more comprehensive consumer involvement in the programme planning process. It is also evident that methods for incorporating consumer involvement must be adapted to the specific context and circumstances of a given programme.

Adherence to antiretroviral therapy in rural persons living with HIV disease in the United States

The current study delineated patterns and predictors of adherence to antiretroviral therapy in 329 persons living with HIV disease in rural areas of 12 US states. Participants provided self-report data on patterns of HIV medication adherence, reasons for missing medication doses, psychological symptomatology, life-stressor burden, social support, ways of coping, coping self-efficacy, the quality of their relationship with their main physician, and barriers to health care and social services. Based on adherence data collected via retrospective, self-report assessment instruments, only 50% of participants adhered consistently to antiretroviral therapy regimens in the past week. Consistent adherence was more common in White participants, persons who had progressed to AIDS, and 'native infections' (i.e. persons who were born, raised, and infected in their current place of residence). Logistic regression analyses indicated that consistent adherence was reported by persons who drank less alcohol, had a good relationship with their main physician, and engaged in more active coping in response to HIV-related life stressors. As the number of rural persons living with HIV disease continues to increase, research that identifies correlates of non-adherence and conceptualizes approaches to optimize adherence in this group is urgently needed.

Emotional Distress in Nonmetropolitan Persons Living With HIV Disease Enrolled in a Telephone-Delivered, Coping Improvement Group Intervention

The study delineated depressive symptoms and modeled emotional distress in persons living with HIV disease in nonmetropolitan areas of 13 U.S. states. Participants (N=329) were enrolled in a randomized clinical trial of a telephone-delivered, coping improvement group intervention, and 60% reported moderate or severe levels of depressive symptomatology on the Beck Depression Inventory. Structural equation modeling indicated that participants who experienced more severe HIV symptomatology, received less social support, and engaged in more avoidant coping also experienced more emotional distress (a latent construct comprising depressive symptoms and emotional well-being). Greater HIV-related stigma and rejection by family led to more emotional distress, with social support and avoidant coping mediating almost entirely the effects of the former 2 variables. The model accounted for 72% of the variance in emotional distress in nonmetropolitan persons living with HIV disease.

An HIV Self-Care Symptom Management Intervention for African American Mothers

BACKGROUND

Human immunodeficiency virus (HIV) infection has become a serious health problem for low-income African American women in their childbearing years. Interventions that help them cope with feelings about having HIV and increase their understanding of HIV as a chronic disease in which self-care practices, regular health visits, and medications can improve the quality of life can lead to better health outcomes.

OBJECTIVE

This study aimed to determine the efficacy of an HIV self-care symptom management intervention for emotional distress and perceptions of health among low-income African American mothers with HIV.

METHOD

Women caregivers of young children were randomly assigned to self-care symptom management intervention or usual care. The intervention, based on a conceptual model related to HIV in African American women, involved six home visits by registered nurses. A baseline pretest and two posttests were conducted with the mothers in both groups. Emotional distress was assessed as depressive symptoms, affective state, stigma, and worry about HIV. Health, self-reported by the mothers, included the number of infections and aspects of health-related quality of life (i.e., perception of health, physical function, energy, health distress, and role function).

RESULTS

Regarding emotional distress, the mothers in the experimental group reported fewer feelings of stigma than the mothers in the control group. Outcome assessments of health indicated that the mothers in the experimental group reported higher physical function scores than the control mothers. Within group analysis over time showed a reduction in negative affective state (depression/dejection and tension/anxiety) and stigma as well as infections in the intervention group mothers, whereas a decline in physical and role function was found in the control group.

CONCLUSIONS

The HIV symptom management intervention has potential as a case management or clinical intervention model for use by public health nurses visiting the home or by advanced practice nurses who see HIV-infected women in primary care or specialty clinics.

The chronic illness quality of life (CIQOL) model: explaining life satisfaction in people living with HIV disease

The chronic illness quality of life (CIQOL) model theorizes that life satisfaction in persons living with a chronic illness such as HIV disease is a function of illness-related discrimination, barriers to health care and social services, physical well-being, social support, and coping. The CIQOL model was evaluated using data from 275 persons living with HIV disease. Women reported less life satisfaction and confronted more barriers to health care and social services than men, and White participants reported higher perceptions of AIDS-related discrimination than non-White participants. The CIQOL model provided an excellent fit to study data (root-mean-square error of approximation = .03) and accounted for almost a third of the variance in life satisfaction scores. Barriers to health care and social services played a particularly prominent role in the model.

Access to services and maintenance of safer sex practices among people living with HIV/AIDS

Access to services and their relationship to the maintenance of long-term safer sex practices are addressed in this study of 360 HIV+ adults recruited from outpatient medical facilities. Protease inhibitors, antiviral therapies, and entitlements were reported as the most needed services, while entitlements and money to pay for housing were reported as the largest unmet needs. Differences across ethnic and gender groups were observed. One-third of all respondents reported at least one occasion of unprotected anal or vaginal intercourse in the previous six months. The practice of unsafe sex was found to be significantly related to both the number of needed services and the number of unmet needs, even after controlling for demographic variables. In addition, a higher proportion of those who engaged in unsafe sex reported a higher need for psychological counseling and social support. These findings underscore the important linkage between access to services with avoidance of high-risk sexual behavior in HIV+ persons. Implications for the delivery of culturally appropriate, gender-specific and community-based interventions are discussed.

Prejudice, clinical uncertainty and stereotyping as sources of health disparities

Disparities in health can result from the clinical encounter between a doctor and a patient. This paper studies three possible mechanisms: prejudice of doctors in the form of being less willing to interact with members of minority groups, clinical uncertainty associated with doctors' differential interpretation of symptoms from minority patients or from doctor's distinct priors across races, and stereotypes doctors hold about health-related behavior of minority patients. Within a unified conceptual framework, we show how all three can lead to disparities in health and health services use. We also show that the effect of social policy depends critically on the underlying cause of disparities.

Thoughts of suicide among HIV-infected rural persons enrolled in a telephone-delivered mental health intervention

This study characterized rates and predictors of suicidal thoughts among HIV-infected persons living in rural communities of eight U.S. states. Self-administered surveys were completed by 201 HIV-infected persons living in communities of 50,000 or fewer that were located at least 20 miles from a city of 100,000 or more. All participants were clients of rural AIDS service organizations and had recently enrolled into a randomized clinical trial of a telephone-delivered, coping improvement-group intervention designed specifically for HIV-infected rural persons. At baseline, participants reported on thoughts of suicide, psychological symptomatology, life-stressor burden, ways of coping, coping self-efficacy, social support, and barriers to health care and social services. Thirty-eight percent of HIV-infected rural persons had engaged in thoughts of suicide during the past week. A logistic regression analysis revealed that participants who endorsed thoughts of suicide also reported more depressive symptoms (odds ratio [OR] = 2.19; 95% confidence interval [CI] = 1.32-3.63, p < .002), less coping self-efficacy (OR = 0.70; 95% CI = 0.56-0.88, p < .002), more frequently worried about transmitting their HIV infection to others (OR = 1.66, 95% CI = 1.14-2.40, p < .008), and experienced more stress associated with AIDS-related stigma (OR = 1.58, 95% CI = 1.07-2.35, p < .03). As AIDS prevalence rates increase in rural areas, interventions that successfully identify and treat geographically isolated HIV-infected persons who experience more frequent or serious thoughts of suicide are urgently needed.

Variations in rural AIDS epidemiology and service delivery models in the United States

This article reviews AIDS surveillance data and the rural health literature to summarize what is known about the rural AIDS epidemic, characteristics of rural environments that affect HIV service delivery, and approaches that rural areas are using to address the health and support service needs of HIV-positive residents. During 1999, nonmetropolitan (non-MSA) adult/adolescent AIDS rates were highest in the South (11 per 100,000) and Northeast (9 per 100,000). The South had the highest non-MSA proportion of adult/adolescent AIDS cases (12%), followed by the North Central region (9%), the West (4%), and the Northeast (3%). Variations in rural HIV/AIDS epidemiologic patterns and the demographic, socio-economic, and cultural characteristics of rural environments are likely to require different levels of resource investment and different methods of organizing and delivering HIV services. Currently, many HIV-positive rural residents are traveling to metropolitan areas for medical care because of concerns about confidentiality or a lack of confidence in the HIV management capabilities of local physicians. Rural communities are attempting to address these problems by developing the HIV care capacity of existing clinics, building local networks of physicians with HIV management experience, and cultivating "shared care" arrangements with urban-based specialists.

Where to seek care: an examination of people in rural areas with HIV/AIDS

Though HIV/AIDS has spread to rural areas, little empirical evidence is available on where patients living in these areas receive care. This article presents estimates of rural residents in care for HIV/AIDS, their demographic and health-related characteristics, information about whether they receive care in a rural or urban setting, and data on the drug therapies prescribed. The estimates come from the HIV Cost and Services Utilization Study (HCSUS), a nationally representative probability sample of HIV-infected adults receiving care in the contiguous United States. Regardless of the definition used--enrollment site, usual source of HIV care, or site of most recent hospitalization--almost three quarters of rural residents with HIV/AIDS obtained their health care in urban areas. The authors find that differences in the demographic characteristics of those using urban vs. rural care do not drive the decision on where to obtain care, with the primary difference being that people with a rural provider tend to be older. Rural residents with an urban usual source of HIV care incurred significant inconvenience in obtaining care--the majority said their care was not conveniently located, they had substantially longer mean travel times, and over 25% had put off obtaining care in the past 6 months because they did not have a way to get to their provider. Given the considerable burden this places on a chronically ill population,further research is needed to explore how provider supply and provider experience affect the decision to travel for care and how quality of care is affected.

Delayed pursuit of health care among HIV-positive gay men enrolled in a longitudinal research study

The aim of this qualitative article is to describe the reasons HIV-positive gay men who are enrolled in a longitudinal research project give for not initiating health care. Extreme sampling techniques were used to recruit four HIV-positive gay men who are enrolled in a research project that is examining factors related to disease progression in HIV infection but who do not otherwise receive any health care. Intensive, open-ended interviews were conducted, and the interviews were analyzed for recurring themes. Results indicate that the participants did not have an accurate perception of health care and therefore were hesitant in seeking health care. Part of this hesitation involved their strong reluctance to begin antiretroviral therapy. Enrollment in a longitudinal study allowed the participants to have some monitoring of their HIV infection. However, not having a primary care provider resulted in a lack of preparedness when they encountered changes in their health status. The end result of this process was progression in their HIV disease. Implications for clinicians and researchers are discussed.

Psychological symptoms among persons 50 years of age and older living with HIV disease

Although persons 50 years of age and older account for 10% of all US AIDS cases, the mental health needs of this growing group remain largely overlooked. The current study delineated patterns and predictors of psychological symptoms amongst late middle-aged and older adults living with HIV/AIDS in two large US cities. In late 1998, 83 HIV-infected individuals 50-plus years of age (M = 55.2, Range = 50-69) completed self-report surveys eliciting data on psychological symptomatology, HIV-related life-stressor burden, social support, barriers to health care and social services, and sociodemographic characteristics. Based on the Beck Depression Inventory, 25% of participants reported 'moderate' or 'severe' levels of depression. HIV-infected older adults also evidenced an elevated number of symptoms characteristic of somatization. A hierarchical multiple regression analysis revealed that HIV-infected older adults who endorsed more psychological symptoms also reported more HIV-related life-stressor burden, less support from friends, and reduced access to health care and social services due to AIDS-related stigma. As the impact of HIV on older communities continues to increase, geropractitioners must be prepared to provide care to greater numbers of HIV-infected older adults, a substantial minority of whom will present with complex comorbid physical and mental health conditions.

Internet use among people living with HIV/AIDS: association of health information, health behaviors, and health status

The telecommunications revolution provides open access to health information that can inform and empower people living with chronic illnesses. However, many people living with HIV may not access the Internet and are not benefiting from available health information. This study investigated Internet access among people living with HIV/AIDS and its relation to health. Results of a survey of men (n = 175) and women (n = 84) living with HIV/AIDS recruited from infectious disease clinics and community-based AIDS services showed that 51% (n = 116) of participants reported ever using the Internet, of which 59% (n = 68) had used the Internet to access health-related information. As expected, Internet users were significantly more likely to be better educated and of higher incomes. Internet users, including those who used the Internet for general purposes and those who reported health-related use, also demonstrated significantly greater knowledge of HIV disease and greater confidence in their ability to adhere to medications. Persons who used the Internet for general purposes were more likely to have an undetectable viral load compared to persons who had not used the Internet. The disparities in Internet use identified in this study suggest that individuals who access the Internet, particularly for health information, are among the better resourced and healthier persons living with HIV/AIDS.

Effectiveness of highly active antiretroviral therapy among HIV-1 infected women

STUDY OBJECTIVE

To describe the impact of highly active antiretroviral therapy (HAART) on mortality, morbidity, and markers of HIV disease progression in HIV infected women.

DESIGN

Data collected from the Women's Interagency HIV Study, a prospective cohort study that enrolled women between October 1994 and November 1995.

SETTING

Six clinical consortia based in five cities in the United States (New York, NY; Washington, DC; Los Angeles, CA; San Francisco, CA; and Chicago, IL).

PARTICIPANTS

A total of 1691 HIV seropositive women with a study visit after April 1996.

MAIN RESULTS

Beginning in April 1996, the self reported use of HAART increased over time, with more than 50% of the cohort reporting HAART use in 1999. There was a 23% decline per semester in the incidence of AIDS from April 1996 (95% confidence intervals (CI) -29% to -16%). Furthermore, there was a 21% decline of the semiannual mortality rates among those with AIDS at baseline (95% CI -27% to -14%) and an 11% decline among those AIDS free at baseline (95% CI -3% to -18%). CD4+ lymphocyte counts either increased (women with baseline AIDS) or stabilised (women without baseline AIDS) after April 1996, and HIV RNA levels dramatically declined in both groups, although the percentage of women with HIV RNA above 4000 cps/ml remained stable at approximately 40% since mid-1997.

CONCLUSIONS

Despite concerns regarding the use of antiretroviral therapies in this population, the use of therapies led to improved immunological function, suppressed HIV disease activity, and dramatic declines in morbidity and mortality.

Condom use, power and HIV/AIDS risk: sex-workers bargain for survival in Hillbrow/Joubert Park/Berea, Johannesburg

Through interviews with 50 female sex-workers in the Hillbrow/Berea/Joubert Park area of Johannesburg, this paper explores sexual negotiations between men and women in the sex industry. This paper focuses on factors that affect sexual decision-making including safer sex practices. In moving beyond approaches that emphasize women's 'powerlessness' in sexual negotiation, this article focuses on ways in which sex-workers capitalize on clients' reluctance to use condoms in sexual exchanges. We emphasize sex-worker's agency and use a broader, Foucauldian understanding of power, which couples power with resistance. Further, this paper examines other elements of the sex industry that contribute to unsafe sex such as competition between women for clients and violence in the industry. Finally, this paper suggests that HIV-prevention programs take cognizance that power negotiations between men and women cannot be simplistically understood as men having power and women being powerless. Rather, this article contributes to a growing body of literature in medical anthropology, which elucidates the complexities of sexual negotiations between men and women. This focus on agency is important in trying to lessen the stigma and discrimination that sex-workers face at the hands of clients, pimps/managers, police and health care workers.

Issues for women with heterosexually transmitted HIV disease

The encouraging outcome of new antiretroviral therapies has not been accompanied by a decrease in the incidence of HIV disease. There are reports of increases in AIDS in select geographical areas, minorities, and women. In 1997, 39% of cases in women were from heterosexual contact, whereas in men 7% of cases were from heterosexual contact. It is the most common mode of transmission in women globally and the only category of transmission in which the incidence of opportunistic infection has increased in the United States. Female anatomy, physiology, and sexual practices contribute to increasing risk of transmission, although there are no major biomedical differences in development of the disease related to gender. Two case examples illustrate the vulnerabilities, life-settings, pressures, and methods of coping for this population. Extensive discussion and review of the literature on the epidemiology, testing, disclosure, health care services, and prevention of transmission in women bring into focus strategies for improved education, diagnosis, care, and treatment.