HIV-infected women and infants. Social and health factors impeding utilization of health care

The impact of marital status on health care utilization among Medicare beneficiaries

To explain prior literature showing that married Medicare beneficiaries achieve better health outcomes at half the per person cost of single beneficiaries, we examined different patterns of healthcare utilization as a potential driver.Using the Medicare Current Beneficiary Survey (MCBS) data, we sought to understand utilization patterns in married versus currently-not-married Medicare beneficiaries. We analyzed the relationship between marital status and healthcare utilization (classified based on setting of care utilization into outpatient, inpatient, and skilled nursing facility (SNF) use) using logistic regression modeling. We specified models to control for possible confounders based on the Andersen model of healthcare utilization.Based on 13,942 respondents in the MCBS dataset, 12,929 had complete data, thus forming the analytic sample, of whom 6473 (50.3%) were married. Of these, 58% (vs. 36% of those currently-not-married) were male, 45% (vs. 47%) were age >75, 24% (vs. 70%) had a household income below $25,000, 18% (vs. 14%) had excellent self-reported general health, and 56% (vs. 36%) had private insurance. Compared to unmarried respondents, married respondents had a trend toward higher odds of having a recent outpatient visit (unadjusted odds ratio (OR) 1.11, 95% confidence interval (CI) 1.04-1.19, adjusted odds ratio (AOR) 1.10, (CI) 0.99-1.22), and lower odds in the year prior to have had an inpatient stay (AOR 0.84, CI 0.72-0.99) or a SNF stay (AOR 0.55, CI 0.40-0.75).Based on MCBS data, odds of self-reported inpatient and SNF use were lower among married respondents, while unadjusted odds of outpatient use were higher, compared to currently-not-married beneficiaries.

Overlooked, Ignored, and Forgotten

This article explores the experience of mature women in the HIV/AIDS epidemic,especially in terms of their vulnerability to infection and lack of AIDS-relatedknowledge. Demographic trends illustrate the increase of AIDS diagnoses amongmidlife women and women of color. The proportion of adolescent and adult femalecases among women age 50 and older has been 9% to 10% since 1989. However, theproportion of those mature women who are age 65 and older when diagnosed hasdeclined from 36% in 1989 to 20% in 1997. Lack of accurate knowledge amongwomen in older cohorts is shown with data from the 1994 National Health InterviewSurvey. Increased age is related to not having accurate information, including knowledge necessary to protect oneself from high-risk behavior such as the effectivenessof condoms or that someone with AIDS can look well and healthy. Finally, researchrecommendations are made along with the suggestion to employ a life-courseperspective when developing education, intervention, and treatment programs forwomen.

HIV-infected mothers' experiences during their infants' HIV testing

Both survival with HIV and rates of perinatal HIV infection have significantly declined during the past decade, due to antiretroviral therapies that interrupt HIV transmission to the fetus and newborn. Although HIV is no longer routinely fatal to mothers or transmitted to fetuses, and the testing of newborns for HIV has been improved, evidence about HIV-infected mothers' experiences during the months of their infants' HIV testing predates these improvements. This qualitative study on 16 mothers was an analysis of interviews conducted several weeks after testing was completed and all infants had been determined to be uninfected. Mothers reported that their experiences evolved during the months of testing. Initial reactions included maternal trauma and guilt associated with infant testing. They then reported learning to cope with the roller coaster ride of repeated testing with the help of information from clinicians. By the end of the testing period, ambiguity began to resolve as they engaged in tentative maternal-infant attachment and expressed desire for a sense of normalcy. Need for support and fear of stigma persisted throughout. These findings expand current knowledge about this experience and suggest clinical strategies to guide HIV-infected women during this stressful period.

HIV-infected mothers' foci of concern during the viral testing of their infants

The objective of this study was to explore HIV-infected mothers' most worrisome concerns during their infants' HIV viral testing. A total of 20 HIV-infected women consented to one antepartum and five postpartum study visits clustered around infant HIV viral testing time points. Content analysis was used to categorize maternal responses about their concerns. The majority (80%) of mothers identified infant health as the most worrisome concern during the prenatal and early postpartum periods. This concern declined after the second infant viral test result but rebounded before obtaining the final viral test. Once the final viral test result was known, the majority (60%) of mothers identified psychosocial issues as most worrisome. Maternal health did not surpass infant health or psychosocial issues as a primary concern. The primary concern of the HIV-infected mothers in this study was infant health during the infant viral testing period. Maternal health issues remained secondary to infant health and psychosocial issues as major concerns several months after infant viral testing was completed.

Pregnancy decisions among women with HIV

Nearly 80% of women currently infected with HIV are of childbearing age. As women of childbearing age continue to be at risk of contracting HIV, there will be an increased need for choices about whether or not to have biological children. The purpose of this exploratory study was to investigate the influence of partners, physicians, and family members on pregnancy decisions, as well as the impact of HIV stigma on these decisions. Results indicated that most women chose not to become pregnant since learning their HIV diagnosis and the woman's age at the time of diagnosis is significantly associated with this decision. Additional factors included fear of transmitting HIV to their child, personal health-related concerns, and desire to have children. Women with a procreative inclination were more likely to choose to become pregnant which outweighed social support and personal health concerns. Implications and suggestions for future research are noted.

Immunisation coverage among children born to HIV-infected women in Rakai district, Uganda: effect of voluntary testing and counselling (VCT)

To evaluate the impact of maternal HIV-infection on routine childhood Immunisation coverage, we compared the Immunisation status of children born to HIV-infected and HIV-uninfected women in rural Uganda. The study population was 214 HIV(+) and 578 HIV(-) women with children aged 6 to 35 months previously enrolled in a community study to evaluate maternal and child health in Rakai District, Uganda. Sampling of subjects for interview was stratified by the use of voluntary counselling and testing (VCT) service so that the final sample was four groups: HIV + /VCT+ (n = 98); HIV + /VCT- (n = 116); HIV - /VCT+ (n= 348); HIV - /VCT- (n = 230). The main outcome measure was the percent of complete routine childhood Immunisations recommended by the WHO as assessed from Immunisation cards or maternal recall during household interviews. We found that Immunisation coverage in the overall sample was 26.1%. For all vaccines, children born to HIV-infected mothers had lower Immunisation coverage than children born to HIV-negative mothers (21.3 vs. 27.7%). There was a statistically significant interaction between maternal HIV-infection and maternal knowledge of HIV-infection (p = 0.034). The children of mothers who were HIV-infected and knew their serostatus (HIV + /VCT + ) had a more than two-fold odds of underImmunisation (OR = 2.21, 95% CI: 1.14, 4.29) compared to children of mothers who were HIV - /VCT-. We conclude that maternal HIV-infection was associated with childhood underImmunisation and this was mediated by a mother's knowledge of her HIV status. HIV VCT programmes should encourage HIV-infected mothers to complete childhood Immunisation. Improving access to Immunisation services could benefit vulnerable populations such as children born to HIV-infected mothers.

Gender differences in knowledge and perceptions of HIV resources among individuals living with HIV in the Southeast

OBJECTIVES

Ancillary services have been associated with beneficial health utilization outcomes among individuals infected with the human immunodeficiency virus (HIV), including greater retention in medical care and greater likelihood of antiretroviral use. Our primary objectives were to examine gender differences in barriers to ancillary services among people living with HIV in the Southeastern United States.

METHODS

Survey and chart abstraction data were collected from six tertiary infectious diseases clinics in the Southeast. Using multivariate analyses, we examined the relationship between gender and 1) knowledge of how to access HIV and acquired immunodeficiency syndrome (AIDS) resource information and 2) opinions about the helpfulness of local services for people with HIV/AIDS.

RESULTS

Women were less knowledgeable about HIV/AIDS resources and rated local services less favorably than men. Middle-aged and older African-American women rated local services as less helpful than other survey participants did.

CONCLUSIONS

These findings indicate a need for outreach services that are designed to address the specific needs of older African-American women, and women in general.

Individual and system level factors associated with treatment nonadherence in human immunodeficiency virus-infected men and women

Antiretroviral treatment nonadherence is complex, implicating more than a patient's ability and motivation to be compliant. The bulk of the research to date focuses on individual level barriers with less emphasis on the many system level factors that potentially impact patients' adherence behaviors. This study examined the effects of system enabling factors in addition to the frequently studied individual predisposing and enabling factors upon nonadherence to treatment. One hundred eighty-two patients from five community-based clinics were interviewed and their medical charts examined. Patients' self-reported nonadherence was correlated with clinicians' assessments of medication and appointment nonadherence. Seven individual predisposing factors (gender, ethnicity, birthplace, years of education, HIV Overview of Problems-Evaluation System [HOPES] psychosocial, Hospital Anxiety and Depression Scale [HADS] anxiety, and HADS depression scores) were found to be significantly associated with treatment adherence/nonadherence. Individual enabling factors (hopefulness and access to health care), as well as treatment by clinic staff, a system enabling factor, were significantly associated with adherence/nonadherence. In a multivariate analysis, six factors - age (younger), gender (female), birth outside the United States, level of hopefulness (lower), access to health care (lower), and treatment by clinic staff (poorer) - accounted for 19.3% of the variance in nonadherence. Results of this study indicated that several individual predisposing and enabling factors were potential predictors of treatment nonadherence; however, system enabling factors, e.g., treatment by clinic staff were also associated with treatment nonadherence. Further studies are needed to examine the complex relationships of individual and system related factors in predicting treatment nonadherence.

Physical and mental health in African American mothers with HIV

This article examines the physical and mental health of African American mothers during a 2-year period following the birth of an infant seropositive for human immunodeficiency virus (HIV). Participants were 34 African American mothers enrolled when the infants were approximately 3 months of age and reinterviewed when the infants were 6, 12, 18, and 24 months. Three self-report questionnaires were used to assess physical health (perception of health, activity limitation, and physical symptoms) and mental health (depressive symptoms and stigma). Health symptoms most often reported were infections, problems thinking and remembering, low energy, and gynecologic problems. Moderate levels of perceived stigma were reported. Depressive symptoms were high; a large number of women at each data point had depressive symptom scores above the cutoff, indicating risk for depression. There were significant correlations between depressive symptoms and health, suggesting a link between mental and physical health. These findings have significance for the health of the mother and the parenting of her infant. Attention should be paid to the mental and physical health of mothers with HIV, especially during the first 2 years after the birth of a child.

Association between ancillary services and clinical and behavioral outcomes among HIV-infected women

The purpose of this study was to evaluate the association between ancillary services, including case management, and clinical and behavioral outcomes for human immunodeficiency virus (HIV)-infected women. Data were obtained from databases systematically maintained by Family Advocacy, Care and Education Services (FACES) and the HIV Outpatient Program (HOP) in New Orleans. HIV-infected women receiving primary care from HOP and ancillary services from FACES between January 1, 1997 and December 31, 1998 were eligible. Data were analyzed using generalized estimating equations (GEE) with STATA software. The majority of women included in the study were African American (86.7%), infected heterosexually (78.8%), and had absolute CD4 counts greater than 200 (58.6%). After adjusting for age, time, entry time into HOP, pregnancy, CD4 count, substance abuse status, and social and clinical stressors, receipt of more than four combined case manager contacts or ancillary services per month was significantly associated with being prescribed a protease inhibitor, improved adherence and retention in primary care, and enrolling on a research protocol. Receiving more than one transportation service per month was significantly associated with improved adherence, improved retention, one or more emergency room visits per month, and one or more hospitalizations per month. Receiving more than one contact with case managers per month was associated with improved retention in primary care. Findings suggest that receipt of case management and ancillary services is associated with improvements in multiple outcomes for HIV-infected women. A client-centered approach to providing ancillary services appears to be effective in improving behavioral and utilization characteristics in this population of low-income, high-risk women.

HIV-1 infected women and prenatal care utilization: barriers and facilitators

In an effort to understand issues affecting prenatal care access and utilization from the perspectives of human immunodeficiency virus (HIV)-infected women who receive inadequate prenatal care, we conducted three in-depth qualitative and quantitative interviews. From a thematic analysis of the narrative interviews, four broad areas emerged as pertinent to these women's prenatal care experiences. These were issues related to pregnancy, HIV, psychosocial conditions, and the health care system. For these women, the barriers to prenatal care utilization included the unexpected and unplanned nature of the pregnancy and mental health issues related to HIV infection. Poverty, periodic homelessness, addiction to illicit substances, and lack of social support were also important barriers. Furthermore, perceptions of the health care system as threatening, including fears related to consequences of disclosing illicit activities, discrimination, and breach of confidentiality emerged as salient barriers. Facilitating factors included the pregnancy being experienced as a life-transforming event, concern for their children, especially preventing HIV-1 vertical transmission, availability of treatment, and support from health care professionals. Prominent throughout the interviews were the women's mental health concerns and need for professional support.

A holistic life view of human immunodeficiency virus-infected African American women

Minority women represent the fastest growing segment of the population to acquire HIV/AIDS in the United States. Although African American women are a large proportion of this group, no published study has concentrated solely on a holistic view of the experiences of HIV-infected African American women. The primary purpose of this phenomenological pilot study was to describe the lives of five HIV-infected African American women. Audiotaped interviews were conducted and subsequently were examined, using Giorgi's steps of analysis. Twelve themes emerged from the data: violence, addiction, it couldn't happen to me, shock and denial, education, time, uncertainty, cycles, secretive nature of their lives, someone, survival, and children. It is clear, even from this small pilot study, that these women have complex experiences that must be better understood before effective health care interventions can be designed and implemented.

Poor women living with HIV: self-identified needs

Women with HIV are a growing at-risk population in our communities. They are often poor members of minority groups who have responsibilities for dependent children and other family members. They may experience physiological, psychological, and social symptoms and have needs that are unique to them as women. The purpose of this study was to give women with HIV the opportunity to identify their needs. Using the Objects Content Test, 48 women attending HIV clinics in a midsouth city listed 349 needs: 32% psychosocial, 14% physical, 13% service and maintenance, and 11% financial and legal. It is important for nurses working with these women in the community to know how they perceive their own needs and issues to plan and provide effective health care programs for this growing group of clients.

Use of hospital services by AIDS patients with psychiatric illness

The purpose of this study was to assess the effect of psychiatric illness on length of stay and patterns of admission among AIDS patients hospitalized for medical illnesses. Medical records were abstracted for AIDS patients admitted to hospitals in Washington State from 1990 through 1992. Psychiatric comorbidity was defined by the presence of an International Classification of Disease-9 code reflecting psychiatric illness. Medical morbidity was addressed using CD4 count and AIDS-defining illnesses as markers of disease severity. Of 2834 admissions, 15% included one or more psychiatric diagnoses. Psychiatric illness (F 39.1; df 1,2830; p < 0.001) and discharge disposition (F 81.2; df 2,2830; p < 0.001) contributed significantly to the model, explaining increased length of stay (F 67.2; df 3,2830; p < 0.001). Future research needs to address the possible etiology of psychiatric comorbidity's contribution to length of stay and the effect on quality and cost of care.

HIV-infected women's decisions to take antiretrovirals

Despite the potential benefits of antiretrovirals, HIV-infected women may not be accepting or adhering to recommended drug therapies. To help women make informed decisions surrounding antiretroviral therapy, health care professionals need insight into how HIV-infected women decide to take or not to take antiretroviral drugs. The purpose of this study was to describe the influences affecting decisions made by women in the southern United States to accept and adhere to antiretroviral therapy. Focus group data with subsequent dimensional analysis were used to discover themes surrounding antiretroviral decisions among 22 women in two predominantly rural, southeastern states. The focus groups included some women who were currently taking antiretrovirals, some who had taken them in the past, and some who had never taken them. The analyses revealed four overarching themes that influenced women's decisions regarding antiretrovirals: health professionals, beliefs about antiretrovirals, side effects, and attitudes of peers and family.

Applying a feminist analysis model to selected nursing studies of women with HIV

Women's mental health has been linked to oppression and to oppressive practices in health care. Feminist approaches to health care delivery and research have been suggested as a remedy for the subtle and overt oppression faced by women, and many nurses have used feminist principles to conduct and report their research and to critique existing studies. Though nursing authors have identified useful feminist guides for conducting and reporting research, few examples of the practice of feminist critiques of research are available in the nursing literature. This analysis synthesizes and adapts feminist principles from nursing literature and presents a feminist model to review selected nursing research reports of women with human immunodeficiency virus (HIV). A convenience sample of eight articles from nursing journals was examined for statements or implications that the author(s) (a) perceived the purposes of the study as benefiting women, (b) demonstrated an awareness of the structures and policies that oppress women, (c) were sensitive to issues of diversity, (d) were committed to social change, and (e) recognized the female participants' strengths. The selected articles were found to meet many of the feminist criteria, although these principles were not always explicitly addressed in the articles.

Social support for HIV-infected mothers: relation to HIV care seeking

A cross-sectional survey was conducted to identify sources of social support for 92 HIV-seropositive mothers and to examine the relationship between social support and initiation of health care after a positive test for HIV antibody. Main outcome measures were self-reported source and amount of social support and length of time between the first positive HIV antibody test and the first visit for HIV care. Results indicated that HIV-infected mothers frequently delay seeking medical care and report attenuated social support networks. A limited program of HIV counseling and testing during pregnancy is unlikely to ensure that they will enter the healthcare system.

Quality of life and coping styles of HIV-positive women with children

This descriptive study explored the quality of life and coping methods of HIV positive women (N = 52) with children. The sample consisted of women with HIV/AIDS who answered an adapted Padilla Quality of Life Index and the Jalowiec Coping Scale. Among the psychological, physical, and social quality of life subscales, social quality of life was rated highest and the psychological scale rated the lowest. Among the three styles of coping, confrontive was used most frequently, passive and emotive less frequently. Significant relationships between coping and quality of life were examined. It is essential that nurses working with women with HIV disease be aware of their common concerns and provide effective strategies to improve quality of life such as enhancing decision making and coping skills within the context of the family unit.