Conceptualizing antiretroviral adherence in Beijing, China

Effect of Fertility Desire-Based Service on HIV Seroconversion Among Serodiscordant Partners: A 12-year Retrospective Cohort Study

BACKGROUND

Fertility desire-based service guided by behavioral theory is a potential strategy to mitigate the HIV transmission risk, while related evidence remains scarce. We examined the long-term effect of theory-guided fertility desire-based services on HIV seroconversion between seropositive and seronegative partners in areas with high HIV prevalence and a cultural emphasis on fertility in China.

METHODS

We established a retrospective cohort by recruiting 8653 seropositive partners with seronegative partners between January 1, 2009, and December 31, 2020, in Liangshan, China. The differences in HIV seroconversion between partners who received fertility desire-based services guided by the extended Information-Motivation-Behavioral Skills model and those who did not were estimated, based on multivariable and inverse probability weighting adjusted multivariable Cox regression models. Subgroup analysis was conducted based on participants' demographic and HIV-related characteristics.

RESULTS

Among the 8653 HIV-seropositive partners, 7958 (92.0%) and their seronegative partners received fertility desire-based services. At the end of the 12-year follow-up, 18 seronegative partners who did not receive fertility desire-based services experienced HIV seroconversion (incidence density: 7.4/1000 person-years), while 98 seronegative partners receiving such services exhibited HIV seroconversion (3.4/1000 person-years). Fertility desire-based services significantly reduced the risk of HIV seroconversion according to multivariable (HR = 0.32, 95% CI: 0.19 to 0.53) and inverse probability weighting-adjusted multivariable Cox regression models (HR = 0.48, 95% CI: 0.27 to 0.84). The effect of fertility desire-based services was more pronounced in men and those older than 40 years.

CONCLUSIONS

Fertility desire-based services based on the extended Information-Motivation-Behavioral Skills model may help reduce the HIV transmission risk between seropositive and seronegative partners in areas with high HIV prevalence.

The Situated Information, Motivation, and Behavioral Skills Model of HIV Antiretroviral Therapy Adherence Among Persons Living With HIV in Haiti: A Qualitative Study Incorporating Culture and Context

ABSTRACT

To inform a clinic-based adherence-promotion intervention, this qualitative study applied the Situated Information, Motivation, and Behavioral Skills Model of Care Initiation and Maintenance to elucidate cultural and contextual factors affecting antiretroviral therapy adherence in Haiti. From the 23 focus group discussions with patients (n = 58) and health care workers (n = 57), culturally specific themes emerged relating to Information (e.g., conflicts with allopathic medicine and heuristics about how treatment failure occurs), Motivation (e.g., protecting family members, health and physical appearance, material advantages, and relationships with health workers), and Behavioral Skills (e.g., managing food intake and side effects, navigating health services utilization, accessing medication, and advocating for care needs). Recommendations include: provide therapeutic education on HIV drug resistance; promote the concept of "undetectable = untransmittable"; develop treatment buddy relationships; invest in training and enforcement of patient privacy, transparency, and fairness in access to services and resources; and provide patient-centered behavioral skills counseling.

An Adaptable Framework for Factors Contributing to Medication Adherence: Results from a Systematic Review of 102 Conceptual Frameworks

OBJECTIVE

To summarize the available conceptual models for factors contributing to medication adherence based on the World Health Organization (WHO)'s five dimensions of medication adherence via a systematic review, identify the patient groups described in available conceptual models, and present an adaptable conceptual model that describes the factors contributing to medication adherence in the identified patient groups.

METHODS

We searched PubMed®, Embase®, CINAHL®, and PsycINFO® for English language articles published from inception until 31 March 2020. Full-text original publications in English that presented theoretical or conceptual models for factors contributing to medication adherence were included. Studies that presented statistical models were excluded. Two authors independently extracted the data.

RESULTS

We identified 102 conceptual models, and classified the factors contributing to medication adherence using the WHO's five dimensions of medication adherence, namely patient-related, medication-related, condition-related, healthcare system/healthcare provider-related, and socioeconomic factors. Eight patient groups were identified based on age and disease condition. The most universally addressed factors were patient-related factors. Medication-related, condition-related, healthcare system-related, and socioeconomic factors were represented to various extents depending on the patient group. By systematically examining how the WHO's five dimensions of medication adherence were applied differently across the eight different patient groups, we present a conceptual model that can be adapted to summarize the common factors contributing to medication adherence in different patient groups.

CONCLUSION

Our conceptual models can be utilized as a guide for clinicians and researchers in identifying the facilitators and barriers to medication adherence and developing future interventions to improve medication adherence.

PROTOCOL REGISTRATION

PROSPERO Identifier: CRD42020181316.

Effectiveness of mobile text reminder in improving adherence to medication, physical exercise, and quality of life in patients living with HIV: a systematic review

Background

Mobile text reminder (SMS) system is considered a viable strategy for targeting/facilitating healthy behavioural change including adherence to prescribed physical exercises (PE) and medication (antiretroviral therapy-ART) which should improve the quality of life (Qol) in people living with HIV/AIDS(PLWHA). Thus, the literature was appraised for evidence of SMS effectiveness in improving ART and PE adherence behaviours and QoL in PLWHA.

Methods

Eight databases–AMED, CINAHL, Cochrane Library, EMBASE, EMCARE, Ovid MEDLINE, PsycINFO, and PubMed-were searched up to December 2020, using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocol.This review included only randomised control trials (RCTs) investigating the effectiveness of SMS in improving QoL or PE or ART adherence behaviour or a combination of these variables in PLWHA >18 years. Two independent reviewers determined the eligibility of the studies. Data were extracted and the quality of the study was assessed with the Physiotherapy Evidence Database (PEDro) tool. The primary outcomes were ART and PE adherence behaviours while the secondary outcome was QoL.

Result

A pooled estimate of effect was not calculated due to the heterogeneity of methods and outcome measures. Therefore, a narrative synthesis of ten studies that met the inclusion criteria (n = 1621 participants at study completion) comprising males/females, aged ≥ 18 years, was done. There was a significant improvement in ART adherence behaviour except in three underpowered studies. Only the SMS interventions that were developed using the Starks 3-steps Adherence model was associated with positive outcome. The only study that evaluated QoL was underpowered and reported no significant change while there were no RCTs on PE.

Conclusion

Effects of SMS intervention trends towards a significant improvement in ART adherence behaviour in PLWHA. It is plausible that SMS reminders developed using the broader framework of the interpersonal health behaviour theory(ies) may have positive outcome. Nevertheless, the observed heterogeneity in the methods/outcome measures warrants a cautious interpretation of the findings. There is a lack/paucity of RCTs and therefore no evidence in support of the effectiveness of SMS intervention in improving PE adherence and QoL. Registration number NPLASY202060016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06563-0.

Translation and Validation: Chinese Version of the HIV-Related Social Support Scale

Purpose

Social support is increasingly recognized to be important in care of people living with HIV/AIDS (PLWH), we firstly translate and validate the disease-targeted social support instrument in Chinese and to explore the correlation with WHOQOL-HIV.

Patients and Methods

We established content validity for HIV-related social support scale (HSSS) and administered the resultant questionnaire to 310 PLWH. Descriptive statistics were generated for each of the variables of general characteristics; student t-test was used to compare the different groups.

Results

The HSSS demonstrated a high level of internal consistency, both within each subscale and with the total score; all Cronbach’s α values exceeded a priori threshold of ≥0.70. The HSSS cores were positively correlated with WHOQOL-HIV total scores (Pearson correlation: 0.39, P < 0.001). We also found that higher educational level, personal income, CD4 cell count, and shorter duration of antiretroviral therapy are significantly associated with a higher level of social support (P < 0.05).

Conclusion

Social support may improve quality of life for PLWH, Chinese version of HIV-related social support scale can be used in future clinical practice.

Promoters and inhibitors of treatment adherence among HIV/AIDS patients receiving antiretroviral therapy in Ghana: Narratives from an underserved population

Adherence to antiretroviral therapy (ART) is essential to achieving an improved cluster of differentiation-4 (CD4) count, viral load, and quality of life while preventing drug resistance. Medication adherence among people living with Human Immunodeficiency Virus (HIV) is influenced by different factors. Several studies have identified adherence promoters and inhibitors that emanate from the internal and external environment. We conducted six (6) individual in-depth interviews and three (3) focus group discussions to explore adherence behaviour among patients diagnosed with HIV in a teaching hospital in Accra, Ghana. Participants were drawn from the intervention arm of a mobile phone adherence intervention program. They had been enrolled in the study for at least six (6) months before the interviews are conducted. Results revealed that participants adhered to treatment irrespective of prompts from significant others. Adherence promoters included perception of ART as part of daily routines, benefits of the ART, awareness of regimen, access to food, and transparency. Adherence inhibitors were forgetfulness, secrecy, waiting time, religious beliefs, and sleep. People living with HIV (PLWHIV) have the personal motivation to take medication; however, negative perceptions about HIV must be addressed to ensure optimum adherence behaviour.

What has changed HIV and syphilis infection among men who have sex with men (MSM) in Southwest China: a comparison of prevalence and behavioural characteristics (2013-2017)

Background

Chongqing reportedly has a large MSM population and a high STI prevalence in previous studies. However, most studies are attributed to independent cross-sectional studies, few studies have investigated trends in the prevalence of syphilis and HIV, as well as behavioural characteristics among MSM using serial surveillance surveys.

Methods

Data were collected in Chongqing through face-to-face questionnaire interview and laboratory testing in Chongqing. The respondents were recruited among MSM by snowball sampling from May 2013 to December 2017. The self-report questionnaire primarily included socio-demographics, HIV knowledge, and HIV-related behaviour characteristics over the year. Blood specimens were tested to diagnose HIV and syphilis infection by Chongqing CDC. Cochran-Armitage trend test and multivariate logistic regression were conducted to compare the changes in STI prevalence and independent behavioural factors among MSM.

Results

There were 6568 eligible participants (98.4%). The overall HIV prevalence was 20.5% among MSM in Chongqing, with a decrease from 23.0% in 2013 to 19.2% in 2017. The overall syphilis prevalence was 5.8%, with an increase from 3.2% in 2013 to 6.7% in 2017. The proportion of consistent condom use (CCU) during anal intercourse (46.3 to 57.7%, P<0.001),CCU with regular male partners(47.7 to 59.7%, P<0.001), CCU with casual male partners (51.5 to 62.3%, P<0.001) and drug use during anal intercourse (0.3 to 1.4%, P<0.05) were increasing. By contrast, a significant decrease was reported in the percentage of MSM with more than two regular male partners (66.0 to 21.4%, P<0.001) and more than two casual male partners (38.3 to 20.7%, P<0.001). A significant difference was observed in syphilis infection, testing for HIV antibodies and drug use during anal intercourse in the past years between the HIV-positive and HIV-negative respondents.

Conclusion

A decreasing trend of HIV prevalence was showed during among MSM from 2013 to 2017 in Chongqing. While gradual reduction of high-risk behaviors along with HIV prevalence supported development of STI counselling and testing, increasing syphilis infection and drug use during anal intercourse warrants further understanding.

Levels of option B+ ART drugs adherence and associated factors among pregnant women following ART services at public health facilities of East Shawa Zone, Oromia, Ethiopia

BACKGROUND

Anti-retroviral therapy has led to a significant reduction in morbidity and mortality related to HIV/AIDS. However, this cannot be fully realized without addressing the barriers related to retention in care and medication adherence.

METHODS

A cross-sectional study design was implemented to select 293 pregnant women on option B+ anti-retroviral treatment (ART). The collected data was cleaned and entered into Epidata version 3.1 and exported to SPSS Version 21 for analysis. Multiple logistic regression models were used to indicate the association between variables.

RESULTS

The overall drug adherence of pregnant women on ART medications was 82.6%. The study showed that participants educational status, AOR 4.54(95% CI; 1.72-11.95), participants status disclosure 2.61(95% CI; 1.01-6.71), social and financial support to the participants AOR 2.76(95% CI; 1.17-6.51), counseling on the benefit AOR 2.9(95% CI; 1.27-6.63), were all positive and significantly associated with adherence to option B + treatment, while experience of drug side effect AOR 0.24(95% CI; 0.1-0.6), and fear of stigma and discrimination AOR 15.79(95% CI; 4.64-53.67), were negatively associated with adherence to option B+ treatment.

CONCLUSION

Educational status, counseling on the health benefit of treatment for the fetus and the mothers, social and financial support favors adherence while fear of stigma and discrimination and drug side effects negatively affect adherence to option B+. The study calls for collaborative work among patients, healthcare professionals, and the public to enhance ART adherence.

LGBT Older Adults at a Crossroads in Mainland China: The Intersections of Stigma, Cultural Values, and Structural Changes Within a Shifting Context

In this article, we explore the lives of lesbian, gay, bisexual, and transgender (LGBT) older adults in mainland China, with an emphasis on the shifting nature of the cultural context. Based on a culturally informed perspective, the intersection of LGBT stigma with cultural values (familial responsibility, filial piety, and loss of face) and larger structural changes (the aftermath of the one-child policy, economic reforms and globalization, LGBT human rights, and HIV policies) are creating dramatic shifts in Chinese society and impacting the lives of LGBT older adults. The increasing prevalence of HIV among gay and bisexual older men, although rarely acknowledged, is also contributing to challenges facing LGBT older adults and their families. These changes render LGBT older adults and those living with HIV and their caregivers at risk of economic insecurity. Resilience and resistance of LGBT older adults in China must be considered in both practice and policy to strengthen LGBT human rights globally.

HIV care engagement and ART adherence among Kenyan gay, bisexual, and other men who have sex with men: a multi-level model informed by qualitative research

Gay, bisexual, and other men who have sex with men (GBMSM) are highly stigmatized and male-male sex is often criminalized in sub-Saharan Africa, impeding access to quality care for sexual health, HIV prevention, and treatment. To better understand HIV care engagement and antiretroviral therapy (ART) adherence among GBMSM in this context, a conceptual model incorporating sociocultural factors is needed. We conducted a qualitative study of barriers to and facilitators of HIV care engagement and ART adherence among Kenyan GBMSM, informed by a conceptual model based on an access, information, motivation, and behavioral skills (access-IMB) model, with trust in providers and stigma and discrimination as a priori factors of interest. We conducted 30 semi-structured interviews with HIV-positive Kenyan GBMSM, of whom 20 were taking ART and 10 had not yet initiated treatment. A deductive approach was used to confirm the relevance of basic concepts of the access-IMB model, while an inductive approach was used to identify content that emerged from men's lived experiences. Access-related information, motivation, and behavioral skills appeared relevant to HIV care engagement and ART adherence, with stigma and discrimination appearing consistently across discourse exploring facilitators and barriers. Trusted providers and supportive family and friends helped many men, and resilience-related concepts such as selective disclosure of GBMSM status, connection to lesbian, gay, bisexual, and transgender (LGBT) organizations, self-acceptance, goal-setting, social identity and altruism emerged as important facilitators. Findings suggest a need to increase support from providers and peers for Kenyan GBMSM living with HIV infection. In addition, they point toward the potential value of interventions that provide opportunities to build or enhance one's sense of community belonging in order to improve HIV care engagement and promote ART adherence for this vulnerable population.

Medication adherence to antiretroviral therapy among newly treated people living with HIV

BACKGROUND

Free antiretroviral therapy has been implemented in China since 2004, but adherence to antiretroviral therapy among people living with HIV is suboptimal. The effectiveness of antiretroviral therapy is subject to medication adherence, which decreases with prolonged treatment times. The aim of this study was to investigate medication adherence and related factors among people living with HIV with newly initiated antiretroviral therapy.

METHODS

This observational study was conducted in consecutive samples of people living with HIV who had newly initiated antiretroviral therapy. Participants were recruited between March 1, 2013, and August 31, 2014, from the local Center for Disease Control and Prevention and Infectious Disease hospital in a capital city in central China. A standard set of questionnaires was adopted, including the Community Programs for Clinical Research on AIDS Antiretroviral Medications and Self-Report Questionnaire (CPCRA), the Patient Health Questionnaire-9 (PHQ-9) and the 7-item Generalized Anxiety Disorder Scale (GAD-7). T-test, Chi square test and multivariate logistic regression analysis with backward stepwise were performed to explore factors that might influence medication adherence.

RESULTS

Of the 207 participants, 85.5% of the participants (177/207) were categorized with good adherence, and 14.5% (30/207) with poor adherence. The multivariate logistic regression analyses showed that participants with positive depression (OR = 5.95, 95% CI: 2.34-15.11) and without disclosure of their HIV status to others (OR = 2.62, 95% CI: 1.06-6.50) were more susceptible to poor adherence.

CONCLUSIONS

One-sixth of the participants reported suboptimal medication adherence within the first 6 months. Factors associated with poor adherence included non-disclosure of their HIV status, had positive depression. Tailored interventions, such as effective psychological coping strategies, should be implemented for people living with HIV with newly initiated antiretroviral therapy to improve their medication adherence.

It's Not Just the Pills: A Qualitative Meta-Synthesis of HIV Antiretroviral Adherence Research

Antiretroviral therapy (ART) improves the health and longevity of people living with HIV infection (PLWH) and also prevents transmission of the virus. Yet, lack of adherence to ART regimens has been a persistent problem, even with simpler regimens. Guidelines that deal with ART adherence are based almost solely on quantitative studies; this focus ignores the context and complexity of patients' lives. Guidelines are also focused on the individual. We argue that the solution is to include the broader communities in which patients live, and to deal with systemic disparities that persist worldwide; this can be done in part through demedicalizing HIV care for healthy PLWH. We present findings from a qualitative meta-synthesis of 127 studies conducted around the world on the last two pillars of the HIV treatment cascade: starting and remaining on ART until optimal viral suppression is achieved. We use Maslow's hierarchy of needs to frame our findings.

Health Provider Views on Improving Antiretroviral Therapy Adherence Among Men Who Have Sex with Men in Coastal Kenya

HIV-positive Kenyan men who have sex with men (MSM) are a highly stigmatized group facing barriers to care engagement and antiretroviral therapy (ART) adherence. Because care providers' views are important in improving outcomes, we sought the perspective of those serving MSM patients on how to optimize ART adherence in a setting where same-sex behavior is criminalized. We conducted 4 focus group discussions with a total of 29 healthcare workers (HCWs) experienced in providing HIV care to MSM. The semistructured, open-ended topic guide used was based on an access-information-motivation-proximal cues model of adherence, with added focus on trust in providers, stigma, and discrimination. Detailed facilitator notes and transcripts were translated into English and reviewed for common themes. The HCW identified adherence challenges of MSM patients that are similar to those of the general population, including HIV-related stigma and lack of disclosure. In addition, HCWs noted challenges specific to MSM, such as lack of access to MSM-friendly health services, economic and social challenges due to stigma, difficult relationships with care providers, and discrimination at the clinic and in the community. HCWs recommended clinic staff sensitivity training, use of trained MSM peer navigators, and stigma reduction in the community as interventions that might improve adherence and health outcomes for MSM. Despite noting MSM-specific barriers, HCWs recommended strategies for improving HIV care for MSM in rights-constrained settings that merit future research attention. Most likely, multilevel interventions incorporating both individual and structural factors will be necessary.

Acceptability and efficacy of interactive short message service intervention in improving HIV medication adherence in Chinese antiretroviral treatment-naïve individuals

AIM

The aim of this study was to examine the acceptability and efficacy of interactive short message service (SMS) in improving medication adherence in antiretroviral treatment (ART)-naïve individuals living with HIV/AIDS in Hengyang, Hunan, China.

BACKGROUND

SMS via mobile phone has emerged as a potential tool for improving ART adherence. However, most studies used SMS only as a medication reminder, with few studies exploring the effect of comprehensive, interactive SMS.

PATIENTS AND METHODS

In a randomized controlled trial, 100 HIV-positive patients on ART for <3 months were randomized into control or intervention arm. Participants in the control group received routine standard instruction for ART medication in the HIV clinics, while the intervention group received 6 months of an SMS intervention in addition to the standard care. A total of 124 text messages within 6 modules were edited, preinstalled, and sent to participants according to personalized schedules. Knowledge (of HIV and HIV medications), self-reported antiretroviral adherence (Visual Analog Scale [VAS] and Community Programs for Clinical Research on AIDS [CPCRA] Antiretroviral Medication Self-Report), and CD4 count were assessed at baseline and immediate post-intervention. Intervention participants were interviewed after completion of the study about their satisfaction with and acceptability of the SMS intervention.

RESULTS

Baseline assessments were comparable between arms. Repeated-measures analysis showed that both HIV-related and ART medication knowledge of the intervention group showed better improvement over time than those of the control group after the intervention (P<0.0001). For the adherence measures, compared with the control group, participants in the intervention group had significantly higher VAS mean score (Z=2.735, P=0.006) and lower suboptimal adherence rate (Z=2.208, P=0.027) at the end of the study. The intervention had no effect on CD4 cell count. Almost all (96%) intervention participants reported satisfaction or high satisfaction with the SMS intervention, with 74% desiring to continue to receive the SMS intervention. The preferred frequency of messages was 1-2 messages per week.

CONCLUSION

An interactive SMS intervention with comprehensive content shows promising efficacy in promoting medication adherence in ART-naïve individuals. Future work might further refine its ability to optimally tailor the intervention for individual preferences.

Side effects, adherence self-efficacy, and adherence to antiretroviral treatment: a mediation analysis in a Chinese sample

Antiretroviral therapy (ART) is a lifelong treatment. To date, ART adherence is suboptimal for most patients in resource-poor settings. Previous research indicates that medication side effects are perceived to be a significant barrier of high ART adherence. Data regarding the role of adherence self-efficacy in mediating the relationship between side effects from ART and adherence to ART are limited; thus, this study examines this potential mediational role of self-efficacy. A cross-sectional survey of 2987 people living with HIV aged ≥18 years was conducted in 2012-2013 in Guangxi Autonomous Region (Guangxi) which has one of the fastest-growing HIV rates in China. Of the total sample, 2146 (72.1%) participants had initiated ART. Participants reported the number of days of completing the daily dose of ART in the past month; adherence was defined as completing the daily dose at least 28 days in the last month (≥90%). Side effects were significantly negatively related to adherence to ART. Mediation analyses indicated that adherence self-efficacy significantly mediated the side effects-adherence relationship. Future interventions to increase adherence self-efficacy and effective coping with side effects among HIV patients are needed in order to improve their ART adherence.

Development and pilot testing of an intervention to promote care engagement and adherence among HIV-positive Kenyan MSM

OBJECTIVES

In many African settings, MSM are a stigmatized group whose access to and engagement in HIV care may be challenging. Our aim was to design a targeted, culturally appropriate intervention to promote care engagement and antiretroviral therapy (ART) adherence for MSM in coastal Kenya, and describe intervention safety, feasibility, and acceptability based upon a small pilot study.

DESIGN

Based on qualitative work including in-depth interviews with HIV-positive MSM and focus groups with providers, we developed a tailored intervention and conducted a pilot test to refine intervention materials and procedures.

METHODS

The Shikamana intervention combines modified Next-Step Counseling by trained providers, support from a trained peer navigator, and tailored use of SMS messaging, phone calls, and discrete pill carriers. Providers, including counselors and clinicians, work together with peer navigators as a case management team.

RESULTS

Forty HIV-positive MSM aged 19-51 participated in intervention development and testing. Six counselors, three clinical officers, and four MSM peers were trained in intervention procedures. Of 10 ART-naïve participants who enrolled in the pilot, eight completed follow-up with no adverse events reported. One participant was lost to follow-up after 2 months and another failed to initiate ART despite ongoing counseling. No adverse events were reported. Staff feedback and exit interviews rated the intervention as feasible and acceptable.

CONCLUSION

This adherence support intervention tailored for Kenyan MSM was well tolerated, feasible, and acceptable in the pilot phase. A randomized controlled trial of a scaled-up programme to estimate intervention efficacy is ongoing.

Stigma, HIV and health: a qualitative synthesis

Background

HIV-related stigma continues to negatively impact the health and well-being of people living with HIV, with deleterious effects on their care, treatment and quality of life. A growing body of qualitative research has documented the relationship between HIV-related stigma and health. This review aims to synthesize qualitative evidence that explored the intersections of stigma and health for people with HIV.

Methods

A thematic summary was conducted that was guided by the qualitative metasummary technique developed by Sandelowski and Barraso. Literature searches yielded 8,622 references of which 55 qualitative studies were identified that illustrated HIV-related stigma in the context of health.

Results

The metasummary classified qualitative findings into three overarching categories: conceptualizing stigma which identified key dimensions of HIV-related stigma; experiencing stigma which highlighted experiences of stigma in the health context, and managing stigma which described ways in which stigma is avoided or addressed. To better illustrate these connections, the qualitative literature was summarized into the following themes: stigma within health care settings, the role of stigma in caring for one’s health, and strategies to address HIV-related stigma in the health context. A number of health care practices were identified – some rooted in institutional practices, others shaped by personal perceptions held by practitioners – that could be stigmatizing or discriminatory towards people with HIV. There existed interconnections between enacted stigma and felt stigma that influenced health care utilization, treatment adherence, and overall health and well-being of people with HIV. Intersectional stigma also emerged as instrumental in the stigma experiences of people living with HIV. A number of strategies to address stigma were identified including social support, education, self-efficacy, resilience activities, and advocacy.

Conclusion

This review of the qualitative evidence indicates that HIV-related stigma within health contexts is a broad social phenomenon that manifests within multiple social spheres, including health care environments. Findings from this review indicate that future stigma research should consider the social structures and societal practices – within and outside of health care environments – that perpetuate and reinforce stigma and discrimination towards people with HIV.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2197-0) contains supplementary material, which is available to authorized users.

Revising the American dream: how Asian immigrants adjust after an HIV diagnosis

AIM

We explored how acculturation and self-actualization affect depression in the HIV-positive Asians and Pacific Islanders immigrant population.

BACKGROUND

Asians and Pacific Islanders are among the fastest growing minority groups in the USA. Asians and Pacific Islanders are the only racial/ethnic group to show a significant increase in HIV diagnosis rate.

DESIGN

A mixed-methods study was conducted.

METHODS

Thirty in-depth interviews were conducted with HIV-positive Asians and Pacific Islanders in San Francisco and New York. Additionally, cross-sectional audio computer-assisted self-interviews were conducted with a sample of 50 HIV-positive Asians and Pacific Islanders. Content analysis was used to analyse the in-depth interviews. Also, descriptive, bivariate statistics and multivariable regression analysis was used to estimate the associations among depression, acculturation and self-actualization. The study took place from January-June 2013.

DISCUSSION

Major themes were extracted from the interview data, including self-actualization, acculturation and depression. The participants were then divided into three acculturation levels correlating to their varying levels of self-actualization. For those with low acculturation, there was a large discrepancy in the Center for Epidemiologic Studies Depression Scale scores between those who had totally lost their self-actualization and those who believed they could still achieve their 'American dreams'. Among those who were less acculturated, there was a significant difference in depression scores between those who felt they had totally lost their ability to self-actualize and those who still believed they could 'make their dreams come true.'

CONCLUSION

Acculturation levels influence depression and self-actualization in the HIV-positive Asians and Pacific Islanders population. Lower acculturated Asian Americans achieved a lower degree of self-actualization and suffered from depression. Future interventions should focus on enhancing acculturation and reducing depression to achieve self-actualization.

Addressing predictors of HIV related risk behaviors: demographic and psychosocial profile of Iranian patients

BACKGROUND

For effective implementation of HIV-related behavioral interventions, better understanding the demographic characteristics of infected patients in relation with high-risk behavior profiles, physical and mental health are essential.

METHODS

In a cross-sectional descriptive study, 400 HIV infected patients from December 2011 through January 2013 were evaluated regarding their demographic features, and four selected subscales (high-risk behaviors, self-efficacy, well-being, and social participation). A validated questionnaire of 62 items was used for assessment.

RESULTS

Almost 33% of all participants were women, 28% were younger than 30 years old, and 43% were never married; 50% had no permanent jobs. Women, widowed participants, patients <30 years, and those with higher educational levels had higher mean HIV risk behavior scores. In simple and multiple linear regression models, women >50 years and <30 years had the highest scores (β=2.714, p<0.0001; β=2.00, p<0.001). Furthermore, male and illiterate patients had higher social participation scores while female and divorced participants had higher well-being and self-efficacy scores.

CONCLUSION

We propose that demographic features play a critical role in increasing engagement in HIV-related high-risk behaviors; these characteristics also affect patients' social participation, well-being and self-efficacy. High-risk behaviors and social participation scores among women of different age groups and the youth highlight the need for future age and gender-specific educational and behavioral interventions among them.

Suboptimal antiretroviral therapy adherence among HIV-infected adults in Guangzhou, China

Despite China's free antiretroviral therapy (ART) program, there are high rates of treatment failure, large sociodemographic disparities in care outcomes and emerging medication resistance. Understanding patient medication adherence behaviors and challenges could inform adherence interventions to maximize the individual and prevention benefits of ART. This study assessed recent nonadherence and treatment interruption among 813 HIV-infected adult outpatients in Guangzhou, China. Participants completed a behavioral survey, underwent chart review, and were tested for syphilis, gonorrhea, and chlamydia. Factors associated with suboptimal adherence were identified using univariate and multivariate logistic regression. Among 721 HIV-infected adults receiving ART, 18.9% reported recent nonadherence (any missed ART in the past four weeks) and 6.8% reported treatment interruption (four or more weeks of missed ART in the past year). Lower education, living alone, alcohol use, and being on ART one to three years were associated with recent nonadherence. Male gender, lower education, and being on ART one to three years were associated with treatment interruption. ART medication adherence interventions are needed in China that include individualized, long-term adherence plans sensitive to patients' educational and economic situations. These interventions should also consider possible gender disparities in treatment outcomes and address the use of alcohol during ART. Successful ART medication adherence interventions in China can inform other international settings that face similar adherence challenges and disparities.

Personal health record use and its association with antiretroviral adherence: survey and medical record data from 1871 US veterans infected with HIV

Patient electronic personal health record (PHR) use has been associated with improved patient outcomes in diabetes and depression care. Little is known about the effect of PHR use on HIV care processes and outcomes. We evaluated whether there was an association between patient PHR use and antiretroviral adherence. Data came from the Veterans Aging Cohort Study and included cross-sectional survey and medical record data from 1871 HIV+ veterans. Our adherence measure was an antiretroviral medication possession ratio, dichotomized at 0.90, and based on pharmacy refill data. In our sample 44 % did not use the internet, 14 % used internet but not for health, 27 % used internet for health but not the PHR, and 14 % used the PHR. In multivariable analysis PHR use was associated with ≥90 % adherence after controlling for socio-demographic variables. Findings provide support for longitudinal studies and studies that identify which PHR functions (e.g. online medication refills, viewing lab results, secure messaging with providers) are most closely associated with medication adherence.

The Chinese Life-Steps Program: A Cultural Adaptation of a Cognitive-Behavioral Intervention to Enhance HIV Medication Adherence

China is considered to be the new frontier of the global AIDS pandemic. Although effective treatment for HIV is becoming widely available in China, adherence to treatment remains a challenge. This study aimed to adapt an intervention promoting HIV-medication adherence-favorably evaluated in the West-for Chinese HIV-positive patients. The adaptation process was theory-driven and covered several key issues of cultural adaptation. We considered the importance of interpersonal relationships and family in China and cultural notions of health. Using an evidence-based treatment protocol originally designed for Western HIV-positive patients, we developed an 11-step Chinese Life-Steps program with an additional culture-specific intervention option. We describe in detail how the cultural elements were incorporated into the intervention and put into practice at each stage. Clinical considerations are also outlined and followed by two case examples that are provided to illustrate our application of the intervention. Finally, we discuss practical and research issues and limitations emerging from our field experiments in a HIV clinic in Beijing. The intervention was tailored to address both universal and culturally specific barriers to adherence and is readily applicable to generalized clinical settings. This evidence-based intervention provides a case example of the process of adapting behavioral interventions to culturally diverse communities with limited resources.

Vietnamese women's struggle to access antiretroviral drugs in a context of free treatment

This qualitative study aims to explore how HIV positive women living in a northern province of Vietnam experience seeking antiretroviral (ARV) treatment in the public health system, and how they address obstacles encountered along the way. Despite the fact that antiretroviral drugs were freely provided, they were not always accessible for women in need. A variety of factors at the population and health system level interacted in ways that often made access to ARV drugs a complicated and time-consuming process. We have suggested changes that could be made at the health system level that may help facilitate women's ability to access treatment.

Social support mediates the relationship between HIV stigma and depression/quality of life among people living with HIV in Beijing, China

Stigma towards people living with HIV is pervasive in China and related to poor service utilization, psychosocial distress and diminished quality of life (QOL). In an effort to identify mechanisms to reduce HIV stigma and its negative consequences, we examined whether social support mediates the relation between enacted stigma and both depressive symptoms and QOL among 120 HIV outpatients in Beijing, China. Generally, perceived social support was associated with less stigma, less depressive symptomatology and better QOL. Using multivariable regression models, we found that social support was a full mediator of the impact of stigma on both depressive symptomatology and QOL. The findings suggest social support may be an important target of interventions to reduce the impact of stigma on poor psychosocial health outcomes.

Current strategies for improving access and adherence to antiretroviral therapies in resource-limited settings

The rollout of antiretroviral therapy (ART) significantly reduced human immunodeficiency virus (HIV)-related morbidity and mortality, but good clinical outcomes depend on access and adherence to treatment. In resource-limited settings, where over 90% of the world's HIV-infected population resides, data on barriers to treatment are emerging that contribute to low rates of uptake in HIV testing, linkage to and retention in HIV care systems, and suboptimal adherence rates to therapy. A review of the literature reveals limited evidence to inform strategies to improve access and adherence with the majority of studies from sub-Saharan Africa. Data from observational studies and randomized controlled trials support home-based, mobile and antenatal care HIV testing, task-shifting from doctor-based to nurse-based and lower level provider care, and adherence support through education, counseling and mobile phone messaging services. Strategies with more limited evidence include targeted HIV testing for couples and family members of ART patients, decentralization of HIV care, including through home- and community-based ART programs, and adherence promotion through peer health workers, treatment supporters, and directly observed therapy. There is little evidence for improving access and adherence among vulnerable groups such as women, children and adolescents, and other high-risk populations and for addressing major barriers. Overall, studies are few in number and suffer from methodological issues. Recommendations for further research include health information technology, social-level factors like HIV stigma, and new research directions in cost-effectiveness, operations, and implementation. Findings from this review make a compelling case for more data to guide strategies to improve access and adherence to treatment in resource-limited settings.

Antiretroviral Therapy (ART) Side Effect Impacted on Quality of Life, and Depressive Symptomatology: A Mixed-Method Study

Antiretroviral therapy (ART) is known for its side effects. In this paper, we describe ART side effects as experienced by Chinese HIV+ individuals. This study presents two stages of a research project, combining qualitative in-depth interviews (29 HIV+ participants) with quantitative statistical data analysis (N = 120). All data was collected between July 2005 to March 2008 at Beijing's Ditan Hospital. Consent was obtained from each participant for the qualitative interview and again for the quantitative survey. During in-depth interviews, Chinese HIV+ patients reported experiencing digestive discomfort, skin rashes, numbness, memory loss, nightmares, and dizziness, which not only brought them physical discomfort, but also interrupted different dimensions of their social lives. Furthermore, multiple regression analyses revealed that those who reported more severe side effects also experienced greater depressive mood after controlling for other clinical and psychosocial factors. ART side effects are one of the primary reasons causing HIV+ individuals to delay or stop taking life-saving medication; therefore, clinical interventions are critically needed to assist HIV+ individuals in managing ART side effects. ART side effects reinforced existing negative attitudes toward ART and lead to lower ART adherence. Future research should focus on developing culturally sensitive interventions to enhance HIV+ self-management, to alleviate physical and psychological burden from ART and HIV.

"You must take the medications for you and for me": family caregivers promoting HIV medication adherence in China

China is experiencing a rapid increase in the incidence of HIV infections, which it is addressing proactively with broad implementation of antiretroviral therapy (ART). Within a cultural context extolling familial responsibility, family caregiving may be an important component to promote medication adherence for persons living with HIV in China. Based on 20 qualitative interviews with persons living with HIV and their family caregivers and a cross-sectional survey with 113 adults receiving HIV care at Beijing's Ditan outpatient clinic, this mixed-methods study examines family caregivers' role in promoting adherence to ART. Building upon a conceptual model of adherence, this article explores the role of family members in supporting four key components enhancing adherence (i.e., access, knowledge, motivation, and proximal cue to action). Patients with family caregiving support report superior ART adherence. Also, gender (being female) and less time since ART initiation are significantly related to superior adherence. Since Chinese cultural values emphasize family care, future work on adherence promotion in China will want to consider the systematic incorporation of family members.

Technology-based self-care methods of improving antiretroviral adherence: a systematic review

BACKGROUND

As HIV infection has shifted to a chronic condition, self-care practices have emerged as an important topic for HIV-positive individuals in maintaining an optimal level of health. Self-care refers to activities that patients undertake to maintain and improve health, such as strategies to achieve and maintain high levels of antiretroviral adherence.

METHODOLOGY/PRINCIPAL FINDINGS

Technology-based methods are increasingly used to enhance antiretroviral adherence; therefore, we systematically reviewed the literature to examine technology-based self-care methods that HIV-positive individuals utilize to improve adherence. Seven electronic databases were searched from 1/1/1980 through 12/31/2010. We included quantitative and qualitative studies. Among quantitative studies, the primary outcomes included ARV adherence, viral load, and CD4+ cell count and secondary outcomes consisted of quality of life, adverse effects, and feasibility/acceptability data. For qualitative/descriptive studies, interview themes, reports of use, and perceptions of use were summarized. Thirty-six publications were included (24 quantitative and 12 qualitative/descriptive). Studies with exclusive utilization of medication reminder devices demonstrated less evidence of enhancing adherence in comparison to multi-component methods.

CONCLUSIONS/SIGNIFICANCE

This systematic review offers support for self-care technology-based approaches that may result in improved antiretroviral adherence. There was a clear pattern of results that favored individually-tailored, multi-function technologies, which allowed for periodic communication with health care providers rather than sole reliance on electronic reminder devices.

Factors influencing adherence to antiretroviral treatment in Asian developing countries: a systematic review

OBJECTIVE

To systematically review the literature of factors affecting adherence to Antiretroviral treatment (ART) in Asian developing countries.

METHODS

Database searches in Medline/Ovid, Cochrane library, CINAHL, Scopus and PsychINFO for studies published between 1996 and December 2010. The reference lists of included papers were also checked, with citation searching on key papers.

RESULTS

A total of 437 studies were identified, and 18 articles met the inclusion criteria and were extracted and critically appraised, representing in 12 quantitative, four qualitative and two mixed-method studies. Twenty-two individual themes, including financial difficulties, side effects, access, stigma and discrimination, simply forgetting and being too busy, impeded adherence to ART, and 11 themes, including family support, self-efficacy and desire to live longer, facilitated adherence.

CONCLUSION

Adherence to ART varies between individuals and over time. We need to redress impeding factors while promoting factors that reinforce adherence through financial support, better accessible points for medicine refills, consulting doctors for help with side effects, social support and trusting relationships with care providers.

In sickness and in health: a qualitative study of how Chinese women with HIV navigate stigma and negotiate disclosure within their marriages/partnerships

In China, there are currently an estimated 180,000 women between 16 and 45 years of age living with HIV. However, we know very little about their lived experiences. Given the spread of the AIDS epidemic in China and the burden it exerts on quality of life, there is an urgent need to understand how HIV affects Chinese women, particularly in the context of their marriages. How do they negotiate the extreme stigma of their illness in making decisions about disclosure and social support, especially in the context of their family life? We recruited 26 Chinese women with HIV in Beijing and Shanghai for in-depth interviews employing a phenomenological approach. We examined the process and outcomes of disclosure within the course of the women's search for social support. Women in HIV-discordant relationships often experienced a termination of their marriage after disclosure, yet others exhibited remarkable resilience, finding new strength through the challenge of their illness. Findings underscore the need for accessible and culturally acceptable interventions for Chinese women with HIV who face considerable stigma in their search for support.

A preliminary randomized controlled trial of a nurse-delivered medication adherence intervention among HIV-positive outpatients initiating antiretroviral therapy in Beijing, China

We evaluated a nurse-delivered adherence intervention in a preliminary randomized controlled trial among 70 HIV-positive outpatients initiating antiretroviral therapy (ART) in Beijing, China. In both arms, participants received a 30-min educational session, a pillbox, and a referral to a peer support group. In the enhanced arm, participants could choose an electronic reminder device, three sessions of counseling either alone or with a treatment adherence partner, or both reminder and counseling. Survey assessments and blood draws occurred at baseline, post-intervention (13 weeks), and follow-up (25 weeks). Primary outcomes were 7-day and 30-day adherence assessed by self-report and electronic drug monitoring (EDM), and secondary outcomes were HIV-1 RNA viral load and CD4 count. The intervention was feasible and well received. It led to some improvement in self-reported and EDM-assessed adherence but not the biological outcomes. Providing counseling and facilitating the use of electronic reminders to patients initiating ART merits further investigation as a culturally viable means of promoting adherence in China.

Strategies to improve HIV treatment adherence in developed countries: clinical management at the individual level

REMARKABLE ADVANCES IN THE TREATMENT OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE HAVE BEEN BLUNTED BY WIDESPREAD SUBOPTIMAL ADHERENCE (IE, NONADHERENCE), WHICH HAS EMERGED AS A MAJOR BARRIER TO ACHIEVING THE PRIMARY GOAL OF ANTIRETROVIRAL (ARV) THERAPY: suppression of HIV viral load. Nonsuppressed HIV viral load is associated with drug resistance, increased morbidity and mortality, and a higher risk of person-to-person HIV transmission. For HIV-infected individuals who are failing HIV treatment due to nonadherence, becoming adherent is a life-saving behavior change. However, overcoming nonadherence is one of the most daunting challenges in the successful management of HIV disease. The purpose of this paper is to provide clinicians with a better understanding of nonadherence to ARV treatment and to review the various factors that have been associated with either adherence or nonadherence. Strategies are presented that may help the nonadherent individual become ready to take HIV medications as prescribed.

Optimizing HIV care by expanding the nursing role: patient and provider perspectives

AIM

This paper is a report of a study conducted to explore HIV healthcare services from the perspectives of both healthcare providers and patients in order to understand how to optimize HIV nursing care.

BACKGROUND

In China, healthcare providers usually first diagnose HIV in a general hospital. Then, HIV-positive individuals are transferred to a specialist hospital. Between healthcare providers and healthcare institutions, there are many gaps in the process from diagnosis to treatment.

METHODS

One focus group with six healthcare providers and 29 in-depth interviews with people living with HIV/AIDS were conducted during 2005.

FINDINGS

Patients who were diagnosed with HIV in a general hospital often did not discuss their condition with a healthcare provider before being sent to a specialist hospital. Furthermore, since the patients had already been diagnosed, healthcare providers in the specialist hospital did not deal adequately with the disclosure process and emotional reactions to the diagnosis. They reported feeling overwhelmed in their role in providing healthcare services. Nurses reported that they were responsible for many 'non-nursing' tasks and did not have the opportunity to give the type of care they were trained to offer.

CONCLUSION

Optimizing HIV care in China will involve establishing clear boundaries between general and specialist hospitals and a division of labour among healthcare providers that eases the burden of care and takes advantage of the full scope of practice that nurses are trained to provide.

Using electronic drug monitor feedback to improve adherence to antiretroviral therapy among HIV-positive patients in China

Effective antiretroviral therapy (ART) requires excellent adherence. Little is known about how to improve ART adherence in many HIV/AIDS-affected countries, including China. We therefore assessed an adherence intervention among HIV-positive patients in southwestern China. Eighty subjects were enrolled and monitored for 6 months. Sixty-eight remaining subjects were randomized to intervention/control arms. In months 7–12, intervention subjects were counseled using EDM feedback; controls continued with standard of care. Among randomized subjects, mean adherence and CD4 count were 86.8 vs. 83.8% and 297 vs. 357 cells/μl in intervention vs. control subjects, respectively. At month 12, among 64 subjects who completed the trial, mean adherence had risen significantly among intervention subjects to 96.5% but remained unchanged in controls. Mean CD4 count rose by 90 cells/μl and declined by 9 cells/μl among intervention and control subjects, respectively. EDM feedback as a counseling tool appears promising for management of HIV and other chronic diseases.

The psychological status of HIV-positive people and their psychosocial experiences in eastern China

OBJECTIVES

The aim of the study was to investigate the psychological status and the psychosocial experiences of HIV-positive people using Symptom Check List 90 (SCL-90) in eastern China.

METHODS

Two hundred and fourteen HIV-positive people and 200 controls were recruited to the study. Participants were given an anonymous questionnaire which included questions pertaining to demography, SCL-90 and psychosocial experiences.

RESULTS

The mean subscale scores for SCL-90 in the HIV-positive group were all higher than those of the control group (P<0.001), especially for depression, anxiety, obsessive-compulsive disorder and hostility. Female HIV-positive individuals had significantly higher depression and anxiety scores (P<0.05) and more scores higher than 2.0 than male HIV-positive individuals. The average number of subscales with mean scores higher than 2.0 was 4.1 for female HIV-positive individuals and 3.7 for male HIV-positive individuals. The most common psychosocial experiences related to HIV infection were fear (36.9%) and helplessness (31.8%). 90.2% of HIV-positive people would not tell others about their disease because of fear of discrimination against family members (42.2%), exclusion by community members (26.9%) and abandonment (23.3%). Discrimination from acquaintances (38.8%) was a main stressor in the HIV-positive individuals' daily life. Most members of HIV-positive individuals' communities expressed negative attitudes: alienation, coldness, aversion and fear. 38.3% of the HIV-positive participants reported that their family members had been discriminated against.

CONCLUSIONS

The results demonstrate that HIV-positive people in eastern China live in a negative psychosocial environment and suffer from psychological distress. It is necessary to provide psychological interventions for people living with AIDS and to educate community members in order to improve the psychosocial environment.

Attitudes toward antiretroviral therapy and complementary and alternative medicine in Chinese patients infected with HIV

HIV is an emerging health issue in China, and effective antiretroviral therapy (ART) is now available throughout the country. Complementary and alternative medicine (CAM) includes traditional Chinese medicine (TCM) and has been used in Chinese society for more than 5,000 years. In the West, CAM use is widespread among HIV-infected individuals; however, rates of CAM use among HIV-infected individuals in China are unknown. This qualitative study explores issues related to attitudes toward ART and CAM in HIV-infected individuals in Beijing, China. Semistructured, in-depth interviews were used to explore attitudes, experiences, and perceptions about ART and CAM among people living with HIV (PLWH). Results indicate that Chinese PLWH have both positive and negative attitudes toward ART and CAM, which led many to report taking CAM not only for daily discomforts but to counteract the side effects of ART. This study shows that social, cultural, and governmental factors coalesced to shape Chinese PLWH attitudes toward ART and CAM.