Stress, social support and housing are related to health status among HIV-positive persons in the deep south of the United States

Perspectives on Social Support and Stigma in PrEP-related Care among Gay and Bisexual Men: A Qualitative Investigation

Despite its effectiveness at preventing HIV, uptake of PrEP has been slow. PrEP-related stigma is a potential barrier to uptake. Social support has been found to buffer against some PrEP stigma. Unfortunately, little research has investigated the relationship between social support and PrEP-related care. In 2018, we conducted 20 semistructured interviews with MSM who use PrEP (ages 22-70). Interview questions explored social support and PrEP-related stigma, and how these and other psychosocial factors affected PrEP use and continuation. Data were analyzed using grounded theory. Social support was important in PrEP-related care and promoted adaptive behavioral responses, such as adherence to PrEP-related medical care and enhancing resilience to stress. Participants described psychosocial benefits of PrEP, such as reduced HIV-related anxiety, but some also reported that PrEP-related stigma was an additional stressor. Findings suggest that social support has significant impacts within PrEP-related care and may help buffer against stigma.

The effect of evictions on accidental drug and alcohol mortality

OBJECTIVE

To assess the relationship between county-level eviction rates and drug and alcohol mortality rates.

DATA SOURCES

Eviction rates from 2003 to 2016 provided by the Princeton University Eviction Lab were merged with Multiple Cause-of-Death Mortality Files and aggregated to the county-year level.

STUDY DESIGN

All opioid (prescription and heroin), cocaine, psychostimulant, benzodiazepine, antidepressant, and alcohol poisoning-related deaths per 100 000 people, eviction rates, and socioeconomic indicators were merged at the county-year level from 2003 to 2016. We estimated a series of mortality rate models with county and year fixed effects and used a control function (2SRI) method to adjust for the endogeneity of eviction rates.

DATA COLLECTION/EXTRACTION METHODS

We matched retrospectively collected datasets.

PRINCIPAL FINDINGS

Higher levels of eviction rates were consistently associated with higher rates of mortality across six of nine substance categories studied when all counties were combined. Subanalysis by USDA population density measures indicated this positive association was almost entirely driven by urban counties; few systematic associations between the eviction rate levels and mortality were observed for suburban or rural counties.

CONCLUSIONS

Risk of eviction appears to exacerbate the current "deaths of despair" crisis associated with substance use. Proposed changes to Housing and Urban Development policy that are expected to substantially increase the risk of eviction may worsen an already-acute mortality crisis.

Factors associated with hostility among people living with HIV/AIDS in Northeast China: a cross-sectional study

Background

Hostility can result in negative outcomes in people living with HIV/AIDS (PLWHA); however, previous research on this topic is far from adequate. To contribute to existing knowledge on this aspect of PLWHA, the current study examined the prevalence of hostility and its potential influencing factors among PLWHA.

Methods

A cross-sectional questionnaire survey was undertaken on 218 HIV patients in Heilongjiang Province of China between March and August in 2013. A multiple logistic regression analysis was performed to identify factors associated with hostility.

Results

The prevalence of hostility was 17.0% among the participants. The three most alarming types of hostility included desiring to kill the person who infected them, blaming the infection on the society, and abandoning themselves to despair. A multiple logistic regression model identified that depression (OR = 3.845, 95% CI = 1.309–9.229), perceived stigma (OR = 3.281, 95% CI = 1.109–7.711), and fear of dying (OR = 2.710, 95% CI = 1.068–6.881) were the risk factors for hostility, while higher levels of trust-in-doctor (OR = 0.176, 95% CI = 0.060–0.517) and per capita household income (OR = 0.344, 95% CI = 0.119–0.991) were protective factors.

Conclusions

Our findings highlight the prominent influence of psychological, healthcare, and social factors on hostility among PLWHA. Interventions specifically targeted to reduce hostility should be provided, including incorporating psychological service into HIV management guidelines, enhancing PLWHA’s trust-in-doctor, establishing comprehensive services for PLWHA, reducing the social stigma against PLWHA, and paying more attention to PLWHA with financial problems. These interventions may improve the management and control of HIV/AIDS.

Diversity, stigma, and social integration among older adults with HIV

The population of people with HIV is aging globally as access to anti-retroviral therapy becomes more widely available. The diversity of older population with HIV has an impact on their experiences of stigma. HIV stigma may be enacted or felt. Enacted stigma is the prejudice, discrimination, and mistreatment that individuals and societies use to sanction people with HIV. Felt stigma refers to the internalized feelings of shame, guilt, and fear that arise from enacted stigma. Nondisclosure is rooted in the fear of negative consequences of revealing one's HIV status, such as losing a job, or being rejected by one's social network. Stigma may also affect social integration through self-protective withdrawal to avoid anticipated stigma. In addition to facing HIV stigma, people with HIV may possess multiple discredited identities due to their race, ethnicity, gender identity, etc., which is described as intersectionality. Older age represents an additional intersectional identity that affects people with HIV through the experience of ageism. Stigma and discrimination from HIV or any discredited identity are linked to poorer physical and mental health outcomes. Given the pervasiveness of stigma, it is not surprising that many older adults with HIV are socially isolated and report greater self-perceived stigma compared to those who are more socially integrated. While there is evidence that HIV stigma has declined compared to previous eras, more research is needed on HIV stigma among older adults in low- and middle-income countries to design policies and programs to combat HIV stigma globally.

'Know that You are not Alone.' Influences of Social Support on Youth Newly Diagnosed with HIV in Kibera, Kenya: A Qualitative Study Informing Intervention Development

The role of social support in assisting youth in developed countries cope with their HIV diagnosis has been examined through a vast body of research; yet, there remains a gap in research around the effects of social support among youth living in sub-Saharan African countries including Kenya. This study aimed to examine the role of social support among Kenyan youth living with HIV, specifically with regard to the variations in influences of this social support. We conducted semi-structured focus group discussions with youth (ages 18 to 27) living in the informal urban settlement of Kibera in Nairobi, Kenya (n = 53). Data analysis followed a phenomenological inquiry framework, and seven major categories of perceived social support influences were identified: (1) linkage to services, (2) antiretroviral (ARV) adherence, (3) self-acceptance of HIV status, (4) healthy and positive living, (5) understanding of what it means to be living with HIV, (6) HIV status disclosure, and (7) family and occupational strengthening. The findings from this study suggest that Kenyan youth living with HIV can benefit from social support in a multitude of ways and can occur across several socio-ecological levels. Future research should further examine these influences, specifically regarding intervention development across socio-ecological levels.

Feasibility of a Texting Intervention to Improve Medication Adherence Among Older HIV+ African Americans: A Mixed-Method Pilot Study

Antiretroviral therapy (ART) is the primary treatment for HIV, and adherence to it is crucial to addressing health disparities. Approximately half of individuals in the United States living with HIV are African Americans, and those over 45 years of age are more likely to die early from HIV/AIDS than their White counterparts. This mixed-method pilot study evaluated the feasibility of a text-based mobile phone intervention designed to improve ART adherence among older African Americans with HIV. Feasibility was assessed via implementation, participant adherence, acceptability, and satisfaction, as well as short-term impact on medication adherence, adherence-related self-efficacy, and positive affect. The intervention utilized pill reminder, motivational, and health educational texts. Participants (N = 21) ranged in age from 50 to 68 years. Outcomes were evaluated via quantitative results from self-report measures and qualitative data from four focus groups. Attrition to the study was 100%. After 8 weeks, participants reported statistically significant improvements in medication adherence, but not in self-efficacy or affect scores. Qualitative findings highlight the psychologically supportive potential of the intervention, challenges to adherence, as well as suggestions for improvement. The study demonstrates that a text messaging intervention may be feasible for older African Americans with HIV, and helpful in supporting ART adherence.

Social support, depression, and quality of life among people living with HIV in Guangxi, China

This study collected data from 2987 people living with HIV in China and employed structural equation modeling to examine the relationships among social support, depression, and quality of life (QOL). Depression was the strongest predictor of the psychological, energy, and mobility aspects of QOL with β = -.70 (p < .001), β = -.47 (p < .001), and β = -.44 (p < .001), respectively. Emotional social support was a significant predictor of depression (β = -.12, p < .001), mobility (β = .20, p < .001), energy (β = .15, p < .001), and psychological aspect (β = .06, p < .05). Informational social support was a significant predictor of mobility (β = -.08, p < .01), energy (β = -.06, p < .05), and psychological aspect (β = -.07, p < .001). Functional social support was only negatively associated with mobility (β = -.16, p < .01). Therefore, depression had a negative effect on physical (perceived mobility and energy) and psychological (positive/negative feelings, thinking, learning, memory, and concentration) aspects of QOL. Emotional social support had both direct and indirect effects (through its buffering effect on depression) on better QOL. However, the associations between informational social support and the three aspects of QOL were negative; and informational social support did not have a buffering effect on depression. Functional social support was negatively associated with mobility, which means provision of functional support to PLHIV may not necessarily be associated with better QOL. The findings confirm that HIV/AIDS care in China should consider the conceptual differences between emotional, informational, and functional support.

A Structural Equation Model of HIV-Related Stigma, Racial Discrimination, Housing Insecurity and Wellbeing among African and Caribbean Black Women Living with HIV in Ontario, Canada

African and Caribbean Black women in Canada have new HIV infection rates 7 times higher than their white counterparts. This overrepresentation is situated in structural contexts of inequities that result in social, economic and health disparities among African and Caribbean Black populations. Economic insecurity is a distal driver of HIV vulnerability, reducing access to HIV testing, prevention and care. Less is known about how economic insecurity indicators, such as housing security, continue to influence the lives of women living with HIV following HIV-positive diagnoses. The aim of this study was to test a conceptual model of the pathways linking HIV-related stigma, racial discrimination, housing insecurity, and wellbeing (depression, social support, self-rated health). We implemented a cross-sectional survey with African and Caribbean Black women living with HIV in 5 Ontario cities, and included 157 participants with complete data in the analyses. We conducted structural equation modeling using maximum likelihood estimation to evaluate the hypothesized conceptual model. One-fifth (22.5%; n = 39) of participants reported housing insecurity. As hypothesized, racial discrimination had significant direct effects on: HIV-related stigma, depression and social support, and an indirect effect on self-rated health via HIV-related stigma. HIV-related stigma and housing insecurity had direct effects on depression and social support, and HIV-related stigma had a direct effect on self-rated health. The model fit the data well: χ² (45, n = 154) = 54.28, p = 0.387; CFI = 0.997; TLI = 0.996; RMSEA = 0.016. Findings highlight the need to address housing insecurity and intersecting forms of stigma and discrimination among African and Caribbean Black women living with HIV. Understanding the complex relationships between housing insecurity, HIV-related stigma, racial discrimination, and wellbeing can inform multi-level interventions to reduce stigma and enhance health.

Depressive and Anxiety Symptoms Predict Sustained Quality of Life Deficits in HIV-Positive Ugandan Adults Despite Antiretroviral Therapy: A Prospective Cohort Study

The impact of psychosocial status at onset of antiretroviral therapy on changes in quality of life (QOL) and subjectively rated health (SRH) among adults on highly active antiretroviral therapy (HAART) in resource-limited settings is poorly understood. Therefore, we evaluate the association between stigma, anxiety, depression, and social support and change in QOL and SRH in HIV-infected Ugandan adults during an 18-month period. Psychosocial indicators were assessed at enrollment using structured questionnaires. QOL and SRH measures were assessed at months 0, 6, 12, and 18 using the Medical Outcomes Survey-HIV. Linear mixed models determined risk estimated differences in QOL and SRH in relation to quartiles of each psychosocial status indicator. Repeated measures generalized estimating equations modeling was implemented to assess differences in likelihood of improved versus nonimproved SRH during follow-up.QOL scores and SRH improved significantly for all participants over 18 months (P < 0.0001). The gain in QOL increased dose-dependently as baseline depressive symptoms (time*depression P < 0.001) and anxiety levels (time*anxiety P < 0.001) declined. Lower social support was associated with worse QOL at baseline (P = 0.0005) but QOL improvement during follow-up was not dependent on baseline level of social support (time*social support P = 0.8943) or number of stigmatizing experiences (time*stigma P = 0.8662). Psychosocial determinants did not predict changes in SRH in this study. High levels of depression and anxiety symptoms at HAART initiation predicts lower gains in QOL for HIV-positive patients for as long as 18 months. Long-term QOL improvements in HIV-infected adults may be enhanced by implementation of psychosocial interventions to reduce depression and anxiety in HIV-infected adults.

The relationship between stress and clinical outcomes for persons living with HIV/AIDS: a systematic review of the global literature

For persons living with HIV/AIDS, the relationship between stress and clinical outcomes has received little attention in current research, yet represents an important area for future research and intervention. Chronic illness has been theorized to place additional demands on a person that may exceed their ability to cope with daily life, leading to long-term stress, which then increases the risk for negative health outcomes in persons already at risk. This paper reviews the existing global literature to answer two main questions: (1) how is stress conceptualized in research with persons living with HIV/AIDS? and (2) what are the current findings linking stress to clinical outcomes? Twenty-three articles are included in the final review. Findings reveal that researchers conceptualize stress in multiple ways for persons living with HIV/AIDS, including depressive symptomology, post-traumatic stress, life events, emotions linked to stress, and biological markers (such as cortisol levels and autonomic nervous system activity). Further, findings related to the link between stress and clinical outcomes are mixed; however, stress was shown to be related to lower CD4 cell counts, higher viral load, and disease progression. Several studies also showed a link between stress and poorer treatment adherence. Implications and directions for future research are discussed, including further thought into how we conceptualize stress for persons living with HIV, future research that is necessary to elucidate current mixed findings on the link between stress and clinical outcomes, and preliminary suggestions for intervention to prevent and alleviate stress in this population.

Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review

BACKGROUND

Accumulating evidence suggests responses to HIV that combine individual-level interventions with those that address structural or contextual factors that influence risks and health outcomes of infection. Housing is such a factor. Housing occupies a strategic position as an intermediate structural factor, linking "upstream" economic, social, and cultural determinants to the more immediate physical and social environments in which everyday life is lived. The importance of housing status for HIV prevention and care has been recognized, but much of this attention has focused on homeless individuals as a special risk group. Analyses have less often addressed community housing availability and conditions as factors influencing population health or unstable, inadequate, or unaffordable housing as a situation or temporary state. A focus on individual-level characteristics associated with literal homelessness glosses over social, economic, and policy drivers operating largely outside any specific individual's control that affect housing and residential environments and the health resources or risk exposures such contexts provide.

OBJECTIVES

We examined the available empirical evidence on the association between housing status (broadly defined), medical care, and health outcomes among people with HIV and analyzed results to inform future research, program development, and policy implementation.

SEARCH METHODS

We searched 8 electronic health and social science databases from January 1, 1996, through March 31, 2014, using search terms related to housing, dwelling, and living arrangements and HIV and AIDS. We contacted experts for additional literature.

SELECTION CRITERIA

We selected articles if they were quantitative analyses published in English, French, or Spanish that included at least 1 measure of housing status as an independent variable and at least 1 health status, health care, treatment adherence, or risk behavior outcome among people with HIV in high-income countries. We defined housing status to include consideration of material or social dimensions of housing adequacy, stability, and security of tenure.

DATA COLLECTION AND ANALYSIS

Two independent reviewers performed data extraction and quality appraisal. We used the Cochrane Risk of Bias Tool for randomized controlled trials and a modified version of the Newcastle Ottawa Quality Appraisal Tool for nonintervention studies. In our quality appraisal, we focused on issues of quality for observational studies: appropriate methods for determining exposure and measuring outcomes and methods to control confounding.

RESULTS

Searches yielded 5528 references from which we included 152 studies, representing 139,757 HIV-positive participants. Most studies were conducted in the United States and Canada. Studies examined access and utilization of HIV medical care, adherence to antiretroviral medications, HIV clinical outcomes, other health outcomes, emergency department and inpatient utilization, and sex and drug risk behaviors. With rare exceptions, across studies in all domains, worse housing status was independently associated with worse outcomes, controlling for a range of individual patient and care system characteristics.

CONCLUSIONS

Lack of stable, secure, adequate housing is a significant barrier to consistent and appropriate HIV medical care, access and adherence to antiretroviral medications, sustained viral suppression, and risk of forward transmission. Studies that examined the history of homelessness or problematic housing years before outcome assessment were least likely to find negative outcomes, homelessness being a potentially modifiable contextual factor. Randomized controlled trials and observational studies indicate an independent effect of housing assistance on improved outcomes for formerly homeless or inadequately housed people with HIV. Housing challenges result from complex interactions between individual vulnerabilities and broader economic, political, and legal structural determinants of health. The broad structural processes sustaining social exclusion and inequality seem beyond the immediate reach of HIV interventions, but changing housing and residential environments is both possible and promising.

Differences in housing, health, and well-being among HIV-positive women living in poverty

The social context of living in poverty has a direct and indirect impact on a woman's health and well-being. This cross-sectional study investigates the relationship between housing and adherence to treatment, emotional wellness, environmental safety, physical health status, and risk behaviors among HIV-positive women receiving services from an AIDS service organization in the mid-South. Significant differences were found between stably housed and unstably housed women on the dependent outcome variables. Results suggest that housing services for HIV-positive women may be an effective way to increase their health and well-being as well as prevent transmission to others.

Self-management interventions for people living with human immunodeficiency virus: a scoping review

BACKGROUND

Self-management is an important emerging intervention for people with human immunodeficiency virus (PHAs). The principles of self-management are consistent with the principles of client-centred occupational therapy.

PURPOSE

This scoping review addressed three questions about self-management interventions for PHAs: (a) What knowledge, skills, and attitudes are taught? (b) What outcomes are intended? (c) What are the participation experiences of PHAs?

METHOD

Questions were searched in six databases. Two researchers independently reviewed abstracts and articles before inclusion. Extracted data were iteratively themed.

FINDINGS

Thirty-five articles were included. Interventions taught self-care, interpersonal skills, technical knowledge, cognitive skills, positive attitudes, planning for the future, and role management. Outcomes included well-being, health and illness management, and health services use. Participation experiences reflected social experiences, needs of PHAs, specific needs of women, participation, empowerment, intervention importance, and experiences with service delivery.

IMPLICATIONS

Self-management interventions are a promising approach for occupational therapists to enable PHAs' occupational performance goals.

Macro-level approaches to HIV prevention among ethnic minority youth: state of the science, opportunities, and challenges

The HIV epidemic continues to disproportionately affect ethnic minority youth. These disconcerting health disparities indicate that although existing HIV preventive strategies for ethnic minority youth have been efficacious, they have not significantly reduced the impact of the epidemic in this population. Macro-level interventions, such as structural or policy interventions, have the potential to impact the HIV epidemic at a population level, and thus reduce the HIV health disparities that exist among ethnic minority youth and other segments of the U.S. population. This article calls for a paradigm shift to develop, evaluate, and disseminate interventions that target upstream/macro-level factors or that, at a minimum, integrate both a macro and individual level perspective. The article also discusses the challenges in developing and evaluating such interventions. Psychologists and other behavioral scientists can play a critical role in reducing the impact of HIV on ethnic minority youth by integrating macro-level approaches to future HIV prevention strategies.

Service priorities and unmet service needs among people living with HIV/AIDS: results from a nationwide interview of HIV/AIDS housing organizations

Housing for people living with HIV/AIDS (PLWHA) has been linked to a number of positive physical and mental health outcomes, in addition to decreased sexual and drug-related risk behavior. The current study identified service priorities for PLWHA, services provided by HIV/AIDS housing agencies, and unmet service needs for PLWHA through a nationwide telephone survey of HIV/AIDS housing agencies in the USA. Housing, alcohol/drug treatment, and mental health services were identified as the three highest priorities for PLWHA and assistance finding employment, dental care, vocational assistance, and mental health services were the top needs not being met. Differences by geographical region were also examined. Findings indicate that while housing affords PLWHA access to services, there are still areas (e.g., mental health services) where gaps in linkages to care exist.

A pilot study of delivering peer health messages in an HIV clinic via mobile media

OBJECTIVE

This pilot study tested the feasibility and impact of using mobile media devices to present peer health messages to human immunodeficiency virus (HIV)-positive patients.

SUBJECTS AND METHODS

A convenience sample of 30 adult patients from an outpatient HIV clinic serving a mostly rural catchment area in central Virginia volunteered for the study. Participants viewed short videos of people discussing HIV health topics on an Apple (Cupertino, CA) iPod® touch® mobile device. Pre- and post-intervention surveys assessed attitudes related to engagement in care and disease disclosure.

RESULTS

Participants found delivery of health information by the mobile device acceptable in a clinic setting. They used the technology without difficulty. Participants reported satisfaction with and future interest in viewing such videos after using the mobile devices. The majority of participants used the device to access more videos than requested, and many reported the videos "hit home." There were no significant changes in participant perceptions about engagement in care or HIV disclosure after the intervention.

CONCLUSIONS

This pilot study demonstrates the feasibility and acceptability of using mobile media technology to deliver peer health messages. Future research should explore how to best use mobile media to improve engagement in care and reduce perceptions of stigma.

Sticking to it: the effect of maximally assisted therapy on antiretroviral treatment adherence among individuals living with HIV who are unstably housed

Housing is a known determinant of health behaviors, which includes adherence to Antiretroviral Therapy (ART). Within the Longitudinal Investigations into Supportive and Ancillary Health Services (LISA) study, unstable housing is inversely associated with adherence. Several comprehensive adherence support services have emerged to improve adherence for unstably housed or otherwise vulnerable populations. The Maximally Assisted Therapy (MAT) program in Vancouver, British Columbia uses a multidisciplinary approach to support HIV-positive clients with a history of addictions or mental illness, many of whom also experience episodic homelessness. This study investigated the association between antiretroviral adherence and use of support services, including the MAT program, amongst people living with HIV and AIDS who are unstably housed in the LISA sample. Of the 212 unstably housed participants, those who attended the MAT program were 4.76 times more likely to be ≥95% adherent (95% CI 1.72-13.13; P = 0.003) than those who did not. The findings suggest that in the absence of sustainable housing solutions, programs such as MAT play an important role in supporting treatment adherence in this population.

Barriers and unmet need for supportive services for HIV patients in care in Los Angeles County, California

Abstract HIV-infected patients frequently experience depression, drug use, and unstable housing but are often unable to access supportive services to manage these challenges. Data on barriers to needed supportive services are critical to improving patient access. Data from the Medical Monitoring Project (MMP), a national supplemental surveillance system for HIV-infected persons in care, was used to examine barriers to support service use and factors associated with need and unmet need for services. Interview data for 333 patients in care in 2007 and 2008 in Los Angeles County (LAC) showed that 71% (n=236) reported needing at least one supportive service and of these, 35% (n=83) reported at least one unmet need for services (46% Latino; 25% white; 83% male; 92% 30+; 77% gay/bisexual; 40% response rate). The main reasons that supportive services were not accessed included lack of information (47%; do not know where to go or who to call); an agency barrier (33%; system too confusing, wait list too long); or a financial/practical barrier (18%; too expensive, transportation problems). In a logistic regression that included all participants (n=333), African Americans (OR=3.1, 95% CI: 1.1-8.7) and those with incomes less than $10,000 were more likely to have service needs (odds ratio [OR]=3.5; 95% confidence interval [CI]: 1.3-9.3). Among those with at least one service need (n=236), those who were gay or bisexual were more likely to report at least one unmet service need (OR=2.8; 95% CI: 1.3-6.1). Disparities were found for need and unmet need for supportive services by race/ethnicity; income and sexual orientation. The reported reasons that services were not obtained suggest needed improvements in information dissemination on availability and location of HIV support services and more streamlined delivery of services.

Do social support, stress, disclosure and stigma influence retention in HIV care for Latino and African American men who have sex with men and women?

Limited research has examined the role that social support, stress, stigma and HIV disclosure play in retention in HIV care for African Americans and Latinos. Among 398 Latino and African American men who have sex with men (MSM) and women, the major predictor of retention in HIV care was disclosure of HIV status to more social network members (OR = 1.5; 95% CI: 1.1, 1.9). Among those who had disclosed (n = 334), female gender (OR = 1.8, 95% CI: 1.1, 3.1) and disclosure of HIV status to more network members (OR = 1.5, 95% CI: 1.1, 1.9) was associated with retention in HIV care. General stress was associated with retention in care (OR = 1.2; 95% CI: 1.1, 1.3) for African American MSM who had disclosed. More MSM-stigma was associated with poorer retention (OR = 0.9; 95% CI: 0.8, 0.9) for Latino MSM. Interventions that help patients safely disclose their HIV status to more social network members may improve HIV care retention as would social network counseling for Latino MSM to reduce MSM-stigma.

Mastery and coping moderate the negative effect of acute and chronic stressors on mental health-related quality of life in HIV

Acute and chronic life stressors have a detrimental effect on the health of people living with HIV. Psychosocial resources such as mastery, coping, and social support may play a critical role in moderating the negative effects of stressors on health-related quality of life. A total of 758 participants provided baseline enrolment data on demographics (age, gender, ethnicity, sexual orientation, education, employment, income), clinical variables (CD4 counts, viral load, AIDS-defining condition, time since HIV diagnosis), psychosocial resources (mastery, coping, social support), life stressors (National Population Health Survey [NPHS] Stress Questionnaire), and health-related quality of life (SF-36). We performed hierarchical multivariate regression analyses to evaluate the potential moderating effects of psychosocial resources on the relationship between stressors and health-related quality of life. The top three stressors reported by participants were trying to take on too many things at once (51%), not having enough money to buy the things they needed (51%), and having something happen during childhood that scared them so much that they thought about it years later (42%). Life stressors were significantly and inversely associated with both physical and mental health-related quality of life. Mastery and maladaptive coping had significant moderating effects on mental health but not on physical health. These results suggest that developing interventions that improve mastery and reduce maladaptive coping may minimize the negative impact of life stressors on the mental health of people with HIV. They also highlight that it is important for clinicians to be mindful of the impact of life stressors on the health of patients living with HIV.

The impact of shame on health-related quality of life among HIV-positive adults with a history of childhood sexual abuse

Childhood sexual abuse is prevalent among people living with HIV, and the experience of shame is a common consequence of childhood sexual abuse and HIV infection. This study examined the role of shame in health-related quality of life among HIV-positive adults who have experienced childhood sexual abuse. Data from 247 HIV-infected adults with a history of childhood sexual abuse were analyzed. Hierarchical linear regression was conducted to assess the impact of shame regarding both sexual abuse and HIV infection, while controlling for demographic, clinical, and psychosocial factors. In bivariate analyses, shame regarding sexual abuse and HIV infection were each negatively associated with health-related quality of life and its components (physical well-being, function and global well-being, emotional and social well-being, and cognitive functioning). After controlling for demographic, clinical, and psychosocial factors, HIV-related, but not sexual abuse-related, shame remained a significant predictor of reduced health-related quality of life, explaining up to 10% of the variance in multivariable models for overall health-related quality of life, emotional, function and global, and social well-being and cognitive functioning over and above that of other variables entered into the model. Additionally, HIV symptoms, perceived stress, and perceived availability of social support were associated with health-related quality of life in multivariable models. Shame is an important and modifiable predictor of health-related quality of life in HIV-positive populations, and medical and mental health providers serving HIV-infected populations should be aware of the importance of shame and its impact on the well-being of their patients.

Forms of social support and their relationships to mental health in HIV-positive persons

A baseline assessment for an HIV health services study recruited 626 people living with HIV/AIDS (PLWHA) in New York city who participated in an interview querying social support, health status, substance use, and mental health. Data were modeled using hierarchical classes (HICLAS) analysis. HICLAS discriminated items reflecting general support and assistance vs. support from an important person in one's life who was named in addition to other family members and friends. HICLAS then identified respondents who reported that they had general support and assistance, support from an important person, both types, or neither type of support. Having one or more important persons as part of the respondent's social network was associated with more positive mental (but not physical) health than having only general support and assistance, or no support at all. Results argue for differentiating support obtained through one's relationship with an important person.

Sources and types of social support that influence engagement in HIV care among Latinos and African Americans

The change in HIV from acute to chronic disease due to the introduction of HAART in the mid-1990s increased the importance of its successful management and imposed substantial lifestyle adjustments on HIV-positive people and their support networks. Few studies have examined the sources and types of social support and the areas of care relevant for engagement in HIV treatment among HIV-positive Latinos and African Americans. This paper reports the results of 24 semi-structured in-depth interviews that were conducted with HIV-positive African American and Latino women and men who have sex with men. Formal networks were found to be more critical for engagement in HIV-specific medical care; specifically, study participants relied primarily on health care providers for support in accessing and maintaining illness-specific care. In contrast, informal networks (family and friends) were crucial for other general subsistence care, such as emotional, household-related, and financial support.

Size matters: community size, HIV stigma, & gender differences

Conclusions regarding HIV stigma in rural areas are hampered by lack of agreement about rural classification. This investigation examined perceptions of HIV stigma among males and females with HIV/AIDS in metropolitan, micropolitan, and rural areas. Two-hundred people with HIV/AIDS completed a measure of perceived HIV stigma. Their county or town of residence was used to classify community size. Results indicated that community size was related to one aspect of perceived stigma, disclosure concerns, differently for men and women. Rural women reported more disclosure concerns than did metropolitan and micropolitan women. They also reported more disclosure concerns than rural men. Men in micropolitan communities reported more disclosure concerns than men in rural areas and tended to report more disclosure concerns than men in metropolitan areas. Understanding the relationship of community size to HIV stigmatization requires acknowledging that many communities are neither urban nor rural, and it requires considering gender differences.

Current issues in care and support for HIV-positive gay men in Sydney

We explored current access to care among HIV-positive people in Australia. In 2006, 270 HIV-positive gay men from a community-based Positive Health cohort in Sydney were asked about their health (including medical and social) service needs and, subsequently, about difficulty in accessing services. We report the prevalence of specific needs, barriers and associated factors. Participants most commonly used general practitioners (64%) for HIV management and needed at least one HIV-related medical service (usually several: doctors experienced in HIV management, dentists and hospital pharmacies). Most participants were able to access them. Barriers in accessing services were related to their convenience rather than lack or quality. Cost emerged as a substantial barrier to dental care and psychological counselling (91% and 48% respectively of those in need). Need for an HIV-related social service was reported by 46% of respondents. Difficulties in accessing these related to poor services and staff attitudes. Income was associated with limited access to multiple services. In Australia, HIV-related medical service needs outweigh those for social services. Complex health services remain essential to HIV-positive people, but some services are currently not meeting their needs. To remain adequate, services need to understand and constantly adapt to the changing needs of HIV-positive people.

Adapting effective narrative-based HIV-prevention interventions to increase minorities' engagement in HIV/AIDS services

Disparities related to barriers to caring for HIV-positive and at-risk minorities continue to be a major public health problem. Adaptation of efficacious HIV-prevention interventions for use as health communication innovations is a promising approach for increasing minorities' utilization of HIV health and ancillary services. Role-model stories, a widely-used HIV-prevention strategy, employ culturally tailored narratives to depict experiences of an individual modeling health-risk reduction behaviors. This article describes the careful development of a contextually appropriate role model story focused on increasing minorities' engagement in HIV/AIDS health and related services. Findings from interviews with community members and focus groups with HIV-positive minorities indicated several barriers and facilitators related to engagement in HIV health care and disease management (e.g., patient-provider relationships) and guided the development of role-model story narratives.

Individual characteristics of the literally homeless, marginally housed, and impoverished in a US substance abuse treatment-seeking sample

BACKGROUND

Many researchers and clinicians believe that understanding substance use problems is key to understanding homelessness. This study's purpose was to test, in a national sample of urban substance abuse treatment seekers, whether (1) income was related to amount of money spent on substances and (2) homeless chronic substance users had more severe psychosocial problems or histories than housed chronic substance users.

METHOD

Questions assessing homelessness were inserted into the Drug Evaluation Network System-a computer-assisted intake interview (including the Addiction Severity Index) implemented in addiction treatment programs across the U.S. Based on these data, clients were divided into four residential groups: literally homeless (n = 654), marginally housed (n = 1138), housed poor (n = 3119), and housed not poor (n = 718). Income, human capital (education level and acquisition of a trade/skill), substance use, mental health, and social support were examined.

RESULTS

The literally homeless was not the poorest group, although these clients did spend the most money on substances. All four groups' incomes were positively related to amount of money spent on drugs, but only the marginally housed's income was related to money spent on alcohol. The literally homeless had the most severe alcohol, mental health, and social support problems. The literally homeless and marginally housed had similar incomes and human capital and the most severe cocaine problems. In general the housed poor and housed not poor fared better than the literally homeless and marginally housed groups.

DISCUSSION

Practitioners should continue to intervene with the homeless and consider working with the marginally housed's social support systems. Future research should examine the marginally housed as an at-risk group for homelessness.

Behavioral mediation of the relationship between psychosocial factors and HIV disease progression

The psychological and physical demands of coping with medication side effects and comorbid illnesses can be overwhelming and may influence behaviors, such as medication adherence, substance use, sexual risk behavior, and exercise that, in turn, affect health outcomes. Cross-sectional and prospective studies among diverse populations of persons living with HIV suggest that these behavioral mechanisms may be associated with HIV disease progression. The motivation to change behavior is often highest in the immediate aftermath of a stressor. However, over time the motivation to continue a particular behavior change is often challenged by habits, environmental influences, and psychosocial factors. Furthermore, a number of studies suggest that behavioral mechanisms may mediate the relationship between psychosocial variables (e.g., stress, depression, coping, and social support) and disease progression in HIV. Thus, developing clinical interventions that address these psychosocial factors and enhance protective health behaviors and reduce behaviors that convey risk to health are likely to lessen overall morbidity and mortality among patients living with HIV/AIDS.

Poverty, unstable housing, and HIV infection among women living in the United States

Women who are HIV positive incur a higher risk of mortality than men who are HIV positive, a difference which is primarily based in the social context of poverty. Economic crises that lead to homelessness, unmet subsistence needs, and sex exchange often reorder priorities among women with HIV infection, de-emphasizing consistent medical care or the use of antiretroviral therapy. High rates of mental illness, drug use, and victimization further increase health and safety risks. HIV prevention messages highlighting education and behavior change insufficiently address the predicament of indigent women where constrained survival choices in the context of poverty may take precedence over safe behaviors. In this article, we highlight the risks of poor and unstably housed women to clarify the context in which risks occur. Suggestions for service provision are offered with the understanding that providers may have limited time and expertise to meet the entire array of needs for impoverished women.

The effects of housing status on health-related outcomes in people living with HIV: a systematic review of the literature

INTRODUCTION

HIV infection is increasingly characterized as a chronic condition that can be managed through adherence to a healthy lifestyle, complex drug regimens, and regular treatment and monitoring. The location, quality, and/or affordability of a person's housing can be a significant determinant of his or her ability to meet these requirements. The objective of this systematic review is to inform program and policy development and future research by examining the available empirical evidence on the effects of housing status on health-related outcomes in people living with HIV/AIDS.

METHODS

Electronic databases were searched from dates of inception through November 2005. A total of 29 studies met inclusion criteria for this review. Seventeen studies received a "good" or "fair" quality rating based on defined criteria.

RESULTS

A significant positive association between increased housing stability and better health-related outcomes was noted in all studies examining housing status with outcomes of medication adherence (n = 9), utilization of health and social services (n = 5), and studies examining health status (n = 2) and HIV risk behaviours (n = 1).

CONCLUSIONS

Healthcare, support workers and public health policy should recognize the important impact of affordable and sustainable housing on the health of persons living with HIV.

Housing need, housing assistance, and connection to HIV medical care

HIV infection has become a chronic condition that for most persons can be effectively managed with regular monitoring and appropriate medical care. However, many HIV positive persons remain unconnected to medical care or have less optimal patterns of health care utilization than recommended by good clinical practice standards. This paper investigates housing status as a contextual factor affecting access and maintenance in appropriate HIV medical care. Data provided from 5,881 interviews conducted from 1994 to 2006 with a representative sample of 1,661 persons living with HIV/AIDS in New York City demonstrated a strong and consistent relationship between housing need and remaining outside of or marginal to HIV medical care. In contrast, housing assistance increased access and retention in medical care and appropriate treatment. The relationship between housing and medical care outcomes remain controlling for client demographics, health status, insurance coverage, co-occurring mental illness, and problem drug use and the receipt of supportive services to address co-occurring conditions. Findings provide strong evidence that housing needs are a significant barrier to consistent, appropriate HIV medical care, and that receipt of housing assistance has an independent, direct impact on improved medical care outcomes.

Occupational therapy for advanced HIV patients at a home care facility: a pilot study

Occupational therapy holds promise to increase quality of life and social functioning in patients with HIV infection. Since 2000 through 2005, we experimented a complex structured intervention including directly administered HAART, psychiatric support and occupational therapy for 14 patients with advanced HIV infection and multiple disabilities, cared for at an Italian home care facility. Social and occupational abilities were evaluated using the Axis V of DMS-IV, as assessed by the Global Assessment of Functioning Scale. Patients' abilities in coping with stressful situations were examined using the Social Dysfunction Rating Scale. Both outcomes were evaluated in interviews at study entrance and yearly thereafter. As compared to baseline, social function mean score significantly increased by 42% after one year of follow-up, and social stress mean score was significantly reduced by 11%. Both outcomes continued to improve constantly during the entire follow-up. Acceptance of the intervention was high, and three patients got outdoor job positions. The findings from this pilot study suggest that occupational therapy could be integrated with success in the treatment of severely disabled patients with advanced HIV infection. Confirmation from further research is required.

Stress overload: a new diagnosis

PURPOSE

To describe the phenomenon of stress overload as a nursing diagnosis.

METHODS

A qualitative study using case study method was conducted with nine adults experiencing stress overload to fully describe the experience and identify possible defining characteristics. Current literature sources on stress and its related factors were examined to support stress overload as a nursing diagnosis for inclusion in the NANDA International classification.

FINDINGS

Stress overload, defined as excessive amounts and types of demands that require action, is a human response that is experienced as a problem and contributes to the development of other problems. The proposed defining characteristics are perceives situational stress as excessive, expresses a feeling of tension or pressure, expresses difficulty in functioning as usual, expresses problems with decision-making, demonstrates increased feelings of anger and impatience, and reports negative effects from stress such as physical symptoms or psychological distress.

PRACTICE IMPLICATIONS

Nursing interventions such as active listening and decision-making support are needed to help people reduce stress levels. Studies are needed to further validate the defining characteristics and related factors of this new diagnosis.