Adherence to antiretroviral medication in older adults living with HIV/AIDS: a comparison of alternative models

An exploratory study of community violence and HIV care engagement among Black gay and bisexual men

This study examined the relationship between exposure to community violence and HIV care engagement among 107 Black gay or bisexual men living with HIV in Chicago. Measures assessed the importance of demographic covariates (age, annual income, health insurance status, and years living with HIV), community violence exposures, mental health, social support, in explaining variations in missed doses of antiretroviral therapy (ART) medication and missed HIV care appointments. Results showed that participants who reported higher rates of exposure to community violence were two times more likely to have missed ART doses and HIV care appointments. Participants who reported depression scores were two times more likely to have greater non-ART adherence. Finally, older participants were more likely to report fewer missed ART doses. More research is needed to clarify the mechanisms between age or depression and ART adherence given community violence exposure. Health care providers should screen for depression when attempting to promote better ART adherence and keeping HIV care appointments for Black gay and bisexual men living with HIV. Younger Black gay and bisexual men living with HIV may be more vulnerable than older men for missed ART doses and may require additional screening and follow-up.

Acceptability, Feasibility, and Preliminary Impact of 4 Remotely-Delivered Interventions for Rural Older Adults Living with HIV

People living with HIV (PLH) who live in rural areas of the United States (US) face more challenges to obtaining medical care and suffer higher mortality rates compared to non-rural PLH. Compared with younger PLH, older PLH (age 50+) also face additional challenges to maintaining their health and wellbeing. Despite the heightened barriers to receiving care and remaining adherent to treatment among older rural PLH, few interventions to increase viral suppression and improve quality of life exist for this population. We pilot-tested four remotely-delivered interventions-group-based social support, group-based stigma-reduction, individual strengths-based case management, and individual technology detailing-aimed to improve care engagement and quality of life in rural older PLH in the southern US. Participants (N = 61, Mage = 58, 75% male) completed surveys and self-collected blood specimens at baseline and 3 months; in between, they were randomized to 0-4 interventions. We assessed feasibility, acceptability, and preliminary impact on medication adherence, viral suppression, quality of life, depressive symptoms, and hypothesized mediating mechanisms. More than 80% participated in assigned intervention(s), and 84% completed the study. Interventions were highly acceptable to participants, with more than 80% reporting they would recommend interventions to peers. More than 80% found the social support and case management interventions to be relevant and enjoyable. We found promising preliminary impact of interventions on quality of life, medication adherence, depressive symptoms, internalized stigma, and loneliness. Remotely-delivered interventions targeting rural older PLH are feasible to conduct and acceptable to participants. Larger scale study of these interventions is warranted.

A Review of Interventions to Enhance HIV Medication Adherence

PURPOSE OF REVIEW

Adherence to antiretroviral treatment (ART) is crucial for the successful treatment of HIV. Unfortunately, it is estimated that 45% of persons living with HIV (PLWH) have poor adherence to ART. To provide health care professionals and PLWH with effective tools for supporting adherence, researchers have investigated the effectiveness of psychosocial interventions to enhance adherence to ART. In this paper, interventional studies, systematic reviews, and meta-analyses that examine ART adherence interventions for PLWH are reviewed.

RECENT FINDINGS

There is great variability among interventions in terms of quality, sample, measures, and outcome characteristics. Despite a diverse and wide-ranging assortment of ART adherence interventions, consistent lessons have been learned. Interventions that focus on individual and interpersonal factors have been effective for improving ART adherence; however, the improvement in adherence tends to be short-lived. Additionally, interventions are most successful when tailored to those at risk for poor adherence. Finally, theory-based interventions are more likely to be effective than non-theory-based interventions. A variety of individual-level psychological interventions have been shown to be effective in improving ART adherence in the short term. Digital and mobile interventions have the potential to improve dissemination and implementation of these evidence-based interventions and could be used to extend intervention effects. Future interventions that address issues of accessibility, inequality, structural and institutional barriers to ART adherence should also be tested and prioritized. Implementation science frameworks can be used to assess and address issues of accessibility and systematic barriers to care.

Childhood Sexual Trauma and Antiretroviral Therapy Adherence: A Mixed-Methods Systematic Review

Childhood sexual abuse (CSA) has been shown to be more prevalent among populations living with HIV. Antiretroviral therapy (ART) adherence is crucial for populations living with HIV as it significantly increases the likelihood of attaining and maintaining viral suppression. Previous findings on the association between CSA and ART adherence have been mixed. The current mixed-methods systematic review aimed to identify quantitative and qualitative studies from CINAHL, PsycInfo, PubMed, and Web of Science examining the relationship between CSA and ART adherence. Authors were also contacted if relevant data were unpublished. Studies had to be published from January 1, 2000 to April 1, 2019, written in English, and examined CSA as an exposure and ART adherence as an outcome. Four domains were combined: 1) childhood sexual abuse; 2) child; 3) antiretroviral; and 4) adherence. Eight quantitative and two qualitative studies were retained. The results showed that four quantitative studies found no association while the other four found factors such as timing of victimization, mental health and gender influenced the association between CSA and ART adherence. Themes emerging from the qualitative studies included use of ART evoking memories of CSA; CSA impacting mental health; and mental health treatment improving ART adherence. Mixed insights included the intricate links between CSA and ART adherence and the role of external factors on the relationship. ART adherence intervention programs may be needed for people who have experienced CSA. However, future studies are needed that will examine the association between CSA and ART adherence and include subgroup analyses.

HIV Care Among Elderly Population: Systematic Review and Meta-Analysis

Elderly people living with HIV are increasing. At present in the United States, nearly half of newly diagnosed HIV-infected people are aged >50 years. Diagnosis and treatment of HIV-infected elderly patients tends to be delayed by several health care factors as several life-threatening diseases are common in elderly people. This study aimed to find the pooled HIV prevalence in elderly population and the present situation of continuum care for the elderly HIV patients through systematic review and meta-analysis. All previously published articles from 2000 to 2018 are retrieved using MEDLINE, PUBMED, Cochrane Library, EMBASE, and Google Scholar. DerSimonian and Laird Random Effects model are used to critically appraise articles. STATA 13.0 is used to perform the meta-analysis and quantum-geographic information system (Q-GIS) is used to prepare desired map. I² statistics has been used to test heterogeneity and publication biases. Results have been presented using forest plots. A total of 28 studies are included in this meta-analysis. Present analysis revealed pooled prevalence of HIV in elderly population as 15.79% with a lower rate of viral suppression as 11.524% (95% confidence interval, CI: 11.199-11.855), where a moderate number 38.643% (95% CI: 38.289-38.997) of elderly patients received antiretroviral therapy (ART) globally. The ART retention rate was 12.769% (95% CI: 12.540-13.001) with 6.15% (95% CI: 6.089-6.212) mortality. Despite successful administration of ART in developing part of the world that have relatively higher retention rates among HIV-infected elderly patients only a small percentage are virally suppressed, largely due to elderly drugs interact with ART and several comorbidities reduce the life span of the elderly people.

Age matters: differences in correlates of self-reported HIV antiretroviral treatment adherence between older and younger Black men who have sex with men living with HIV

Black men who have sex with men (BMSM) show lower levels of adherence to antiretroviral therapy (ART) for HIV medications than other racial/ethnic groups in the U.S. Yet, little is known about age differences in factors that predict ART adherence among BMSM. We combined data from two surveys of HIV-positive BMSM, resulting in 209 participants (130 aged 18-50 years; 79 aged 50 years or older). Multivariate linear regressions examined associations between baseline characteristics and adherence to HIV medications as well as interactions of baseline characteristics with age. The associations between trust in healthcare and doctor satisfaction ratings with higher adherence were stronger for older vs younger men (p < .05); the association between problem drinking and lower adherence was stronger among younger men (p < .05). Future research should examine how interventions may address these age-specific factors to improve ART adherence among BMSM living with HIV.

Comparison of Antiretroviral Therapy Adherence Among HIV-Infected Older Adults with Younger Adults in Africa: Systematic Review and Meta-analysis

As access to antiretroviral treatment in low- and middle-income countries improves, the number of older adults (aged ≥ 50 years) living with HIV is increasing. This study compares the adherence to antiretroviral treatment among older adults to that of younger adults living in Africa. We searched PubMed, Medline, Cochrane CENTRAL, CINAHL, Google Scholar and EMBASE for keywords (HIV, ART, compliance, adherence, age, Africa) on publications from 1st Jan 2000 to 1st March 2016. Eligible studies were pooled for meta-analysis using a random-effects model, with the odds ratio as the primary outcome. Twenty studies were included, among them were five randomised trials and five cohort studies. Overall, we pooled data for 148,819 individuals in two groups (older and younger adults) and found no significant difference in adherence between them [odds ratio (OR) 1.01; 95% CI 0.94–1.09]. Subgroup analyses of studies using medication possession ratio and clinician counts to measure adherence revealed higher proportions of older adults were adherent to medication regimens compared with younger adults (OR 1.06; 95% CI 1.02–1.11). Antiretroviral treatment adherence levels among older and younger adults in Africa are comparable. Further research is required to identify specific barriers to adherence in the aging HIV affected population in Africa which will help in development of interventions to improve their clinical outcomes and quality of life.

Social support for the elderly with HIV/Aids: an integrative review

Abstract Objective: The present integrative literature review aimed to verify the scientific knowledge produced about social support for elderly persons with HIV/Aids. Method: A search was carried out in the Lilacs, Medline, Scopus and Web of Science databases for studies published in the last ten years. The final analysis consisted of seven articles. Results: It was found that social support is extremely important in the life of the elderly with HIV/Aids, and a real need for this support was identified. Such support can both contribute to quality of life in many ways, as well as impair the care of those who live with the disease, as the diagnosis, treatment and the entire stigma surrounding this chronic condition directly influence the type and quality of support provided. Conclusion: It is hoped that the results of this review will contribute to are flection on health practices for the elderly with HIV/Aids.

Improving the Adherence to Antiretroviral Therapy, a Difficult but Essential Task for a Successful HIV Treatment-Clinical Points of View and Practical Considerations

HIV infection is responsible for one the most devastating human pandemics. The advent of antiretroviral therapy has changed the course of the pandemic and saved millions of lives. Complex therapeutic regimens have been introduced since 1996 and have contributed to the transformation of HIV infection into a treatable chronic diseases. New types of potent antiretrovirals and their combinations, including “once daily” treatment, have simplified the regimens and diminished side effects. Nevertheless the adherence to antiretroviral therapy remains unsatisfactory and varies between 27 and 80% across different population in various studies, compared with the required level of 95%. The lack of adherence to antiretroviral therapy is a multi-factorial and dynamic process which raises considerable difficulties for long-term follow-up. Current solutions to this problem are complex. These should be applied by a multidisciplinary team and should take into account key features related to both the individual and social factors as well as to the population to whom it belongs (children, teenagers, elderly, marginalized population like drug users, incarcerated patients, sex workers, etc.). Importantly, adherence should continue to be monitored even in patients known to be compliant. In case of subsequent failure the team should identify the reasons for non-adherence and apply the appropriate methods. Where usual methods have no chance of success, a coordinated package of services also known as “harm reduction” can be offered in order to reduce the risks of transmission. The current article analyses the concept of adherence to antiretroviral therapy, the shortcomings of this medication and the methods that can be applied in practice to increase adherence. Emphasis is placed on the analysis of groups at high risk for HIV infection that currently represent the spearhead with which the HIV pandemic is spreading.

Correlates of Combination Antiretroviral Adherence Among Recently Diagnosed Older HIV-Infected Adults Between 50 and 64 years

Optimal adherence to combination antiretroviral therapy is essential to the health of older people living with HIV (PLWH), however, the literature on adherence and aging is limited. Using Medicaid data from 29 states (N = 5177), we explored correlates of optimal adherence among older PLWH. The prevalence of optimal adherence was low (32 %) in this study. Males were more adherent than females (APR = 1.11, 95 % CI 1.02-1.21, P = 0.0127); persons with three or more co-morbidities (APR = 0.67, 95 % CI 0.60-0.74, P < 0.001), two co-morbidities (APR = 0.86, 95 % CI 0.75-0.98, P = 0.0319) and one co-morbidity (APR = 0.82, 95 % CI 0.73-0.92, P = 0.0008) were less adherent than those without any co-morbidity; and residents of rural areas (APR = 0.90, 95 % CI 0.63-0.98, P = 0.0385) and small metropolitan areas (APR = 0.82, 95 % CI 0.72-0.94, P = 0.0032) were less adherent than residents of large metropolitan areas. There were no racial differences in optimal adherence. Targeted interventions that provide adherence support, case management, and peer navigation services may be of benefit in achieving optimal adherence in this population.

Predicting adherence to medications using health psychology theories: a systematic review of 20 years of empirical research

OBJECTIVES

This review sought to identify the empirical evidence for the application of models from sociocognitive theory, self-regulation theory, and social support theory at predicting patient adherence to medications.

METHODS

A systematic review of the published literature (1990-2010) using MEDLINE, EMBASE, Cochrane Library, CINAHL, and PsychINFO identified studies examining the application of health psychology theory to adherence to medication in adult patients. Two independent reviewers extracted data on medication, indication, study population, adherence measure, theory, model, survey instruments, and results. Heterogeneity in theoretical model specification and empirical investigation precluded a meta-analysis of data.

RESULTS

Of 1756 unique records, 67 articles were included (sociocognitive = 35, self-regulation = 21, social support = 11). Adherence was most commonly measured by self-report (50 of 67). Synthesis of studies highlighted the significance (P ≤ 0.05) of self-efficacy (17 of 19), perceived barriers (11 of 17), perceived susceptibility (3 of 6), necessity beliefs (8 of 9), and medication concerns (7 of 8).

CONCLUSIONS

The results of this review provide a foundation for the development of theory-led adherence-enhancing interventions that could promote sustainable behavior change in clinical practice.

Patterns of substance use among HIV-positive adults over 50: implications for treatment and medication adherence

BACKGROUND

The population of older adults living with HIV is increasing in the United States. Despite an increased focus on the health of HIV-positive older adults, knowledge about their substance use, a primary risk factor for HIV medication non-adherence, and the association between use, problems associated with use, and adherence behavior, is limited.

METHODS

Data were collected from 557 HIV-positive adults aged 50 and older in the New York City area via telephone interview. Participants reported the number of days in the past month on which they missed any doses of HIV medication as well as the number of days they used alcohol, marijuana, cocaine/crack, opiates, amyl nitrite (poppers), and other drugs. The severity of substance use associated problems was assessed using the DAST-10 and AUDIT-C.

RESULTS

The sample included gay/bisexual (40.4%) and heterosexual (28.1%) men as well as lesbian/bisexual (4.9%) and heterosexual (26.7%) women. Latent class analyses identified four distinct patterns of substance use: Exclusive Alcohol Use; Alcohol and Marijuana; Alcohol and Cocaine/Crack; and Multiple-Substance Use. Variability in the number of missed HIV medication days and perceptions of substance use associated problems were observed across classes, with poorest adherence reported in the Alcohol and Marijuana class, the Alcohol and Cocaine/Crack class, and the Multiple-Substance Use class. The latter two classes also reported the greatest perceived impairment from substance use.

CONCLUSIONS

Patterns of recent substance use were associated with varying levels of HIV medication adherence and perceived substance use impairment, indicating that substance type matters when considering the health of older adults living with HIV, and that multiple-substance use needs to be addressed by interventions aimed at improving medication adherence.

Gender moderates the influence of psychosocial factors and drug use on HAART adherence in the context of HIV and childhood sexual abuse

This study aimed to examine gender moderation within a stress and coping model of HIV medication adherence in adults with a history of childhood sexual abuse (CSA). Sequelae of CSA, including negative coping, psychological distress, and drug use, interfere with adherence to highly active antiretroviral treatment (HAART). These obstacles to adherence are likely moderated by gender. Gender may particularly influence the mediational effect of drug use on adherence. Participants included 206 adults living with HIV/AIDS and CSA. Categorical/continuous variable methodology in a structural equation modeling framework was used to test a multigroup model with women and men. Gender significantly moderated several effects in the model. For women, the effect of psychological distress on HAART adherence was mediated by drug use and the effect of drug use on viral load was mediated by HAART adherence. Among men, drug use did not significantly impact adherence. Since gender appears to moderate the effect of drug use on medication adherence, it is particularly important to address drug use within the context of HIV disease management in women with a history of CSA. Further, interventions to increase HAART adherence should take trauma history, gender, and drug abuse into account when assessing efficacy.

Aging, antiretrovirals, and adherence: a meta analysis of adherence among older HIV-infected individuals

INTRODUCTION

Older adults are generally considered to be at greater risk for medication non-adherence due to factors such as medication complexity, side effects, cost, and cognitive decline. However, this generalization may not apply to older adults with human immunodeficiency virus (HIV). Regardless of age, suboptimal adherence to antiretroviral therapy (ART) can lead to increased viral load, immunosuppression, drug-resistant viral strains, co-morbidities, and opportunistic infections. Understanding trends of adherence to ART among older adults is critical, especially as the population of people living with HIV grows older.

OBJECTIVES

The purpose of this systematic review and meta-analysis is to determine if older individuals with HIV are less likely to be non-adherent to antiretroviral therapy than younger individuals with HIV.

DESIGN

A systematic search in PubMed, Embase, and PsycINFO was conducted to identify peer-reviewed articles evaluating adherence to ART in older adults. Two independent reviewers screened abstracts, applied inclusion criteria, and appraised study quality. The bibliographies of qualifying studies were searched. Data were abstracted from studies by two independent authors. Meta-analyses were conducted, and adherence levels were reported as the relative risk of non-adherence in older individuals compared to younger individuals.

RESULTS

The systematic search yielded 1,848 abstracts. Twelve studies met full inclusion criteria. The overall meta-analysis found that older age reduced risk for nonadherence by 27 % (relative risk (RR) 0.72, 95 % confidence interval (CI) 0.64–0.82). Studies assessing both short-term and long-term adherence demonstrated a significant reduction in non-adherence among older patients (RR 0.75, 95 % CI 0.64–0.87 and RR 0.65, 95 % CI 0.50–0.85, respectively).

CONCLUSIONS

Older adults with HIV have a reduced risk for non-adherence to ART than their younger counterparts. Future studies should seek to elucidate contributing factors of adherence among older individuals with HIV.

Social network approaches to recruitment, HIV prevention, medical care, and medication adherence

This article reviews the current issues and advancements in social network approaches to HIV prevention and care. Social network analysis can provide a method to understand health disparities in HIV rates, treatment access, and outcomes. Social network analysis is a valuable tool to link social structural factors to individual behaviors. Social networks provide an avenue for low-cost and sustainable HIV prevention interventions that can be adapted and translated into diverse populations. Social networks can be utilized as a viable approach to recruitment for HIV testing and counseling, HIV prevention interventions, optimizing HIV medical care, and medication adherence. Social network interventions may be face-to-face or through social media. Key issues in designing social network interventions are contamination due to social diffusion, network stability, density, and the choice and training of network members. There are also ethical issues involved in the development and implementation of social network interventions. Social network analyses can also be used to understand HIV transmission dynamics.

Medication adherence feedback intervention predicts improved human immunodeficiency virus clinical markers

Thirty-three participants in a human immunodeficiency virus (HIV) medication adherence feedback (MAF) intervention were compared with 58 HIV-positive non-participants in laboratory-tested CD4 and viral load. The intervention provided adherence feedback and counselling based on a visual display from an electronic pill bottle (MEMS(TM) ). Multiple regression controlling for baseline CD4 and showed that postintervention CD4 was higher for MAF participants than for non-MAF participants. Non-MAF participants' CD4 significantly declined over time. MAF participants were also less likely than non-MAF participants to have a detectable postintervention viral load.

Management of human immunodeficiency virus infection in advanced age

IMPORTANCE

Human immunodeficiency virus (HIV)-positive patients treated with antiretroviral therapy now have increased life expectancy and develop chronic illnesses that are often seen in older HIV-negative patients.

OBJECTIVE

To address emerging issues related to aging with HIV. Screening older adults for HIV, diagnosis of concomitant diseases, management of multiple comorbid medical illnesses, social isolation, polypharmacy, and factors associated with end-of-life care are reviewed.

EVIDENCE ACQUISITION

Published guidelines and consensus statements were reviewed. PubMed and PsycINFO were searched between January 2000 and February 2013. Articles not appearing in the search that were referenced by reviewed articles were also evaluated.

FINDINGS

The population of older HIV-positive patients is rapidly expanding. It is estimated that by 2015 one-half of the individuals in the United States with HIV will be older than age 50. Older HIV-infected patients are prone to having similar chronic diseases as their HIV-negative counterparts, as well as illnesses associated with co-infections. Medical treatments associated with these conditions, when added to an antiretroviral regimen, increase risk for polypharmacy. Care of aging HIV-infected patients involves a need to balance a number of concurrent comorbid medical conditions.

CONCLUSIONS AND RELEVANCE

HIV is no longer a fatal disease. Management of multiple comorbid diseases is a common feature associated with longer life expectancy in HIV-positive patients. There is a need to better understand how to optimize the care of these patients.

Social-cognitive correlates of antiretroviral therapy adherence among HIV-infected individuals receiving infectious disease care in a medium-sized northeastern US city

High levels of antiretroviral therapy (ART) adherence are required to achieve optimal viral suppression. To better understand mechanisms associated with ART adherence, this study characterized demographic and social-cognitive correlates of ART adherence among HIV-infected individuals from a medium-sized northeastern US city (n=116; 42% female; 43% African-American). Participants completed an audio computer-assisted self-interviewing survey assessing demographics, social-cognitive constructs, and ART adherence, and the participants' most recent viral load was obtained from their medical charts. Suboptimal ART adherence (taking less than 95% of prescribed medications during the past month) was reported by 39% of participants and was associated with being female, being a minority, and having a detectable viral load. In a hierarchical logistic regression analysis, greater than 95% ART adherence was associated with higher levels of adherence self-efficacy (AOR =1.1; p=0.015), higher perceived normative beliefs about the importance of ART adherence (AOR=1.3; p=0.03), and lower concern about missing ART doses (AOR=0.63; p=0.002). Adherence did not differ based on ART outcome expectancies, ART attitudes, or the perceived necessity of ART. In fact, most participants endorsed positive attitudes and expectancies regarding the need for and effectiveness of ART. Taken together, results indicate that suboptimal adherence remains high among HIV-infected minority women, a subpopulation that experiences particularly high rates of chronic stress due to both illness-specific stressors and broader environmental stressors. Consistent with social-cognitive theory, adherence problems in our sample were linked with deficits in self-efficacy as well as perceived norms and behavioral intentions that do not support a goal of 100% adherence. We suggest that interventions to improve adherence informed by social-cognitive theory (1) target patients who are at risk for adherence problems, (2) provide a supportive environment that promotes high rates of adherence, and (3) address inaccurate beliefs regarding optimal adherence levels.

Medication-taking self-efficacy and medication adherence among HIV-infected cocaine users

This prospective, observational study tested the ability of self-efficacy for taking antiretroviral medications to predict medication adherence among current and former cocaine and heroin users. Electronic monitors to record bottle openings and self-report measures of medication adherence were used. The sample included 99 men and women who were interviewed at 4-week intervals for 6 months. Mixed effects regression models to test the relationship of substance use and self-efficacy for medication-taking with percent of self-report adherence, dose adherence, number of days adherent, and adherence to medication schedule at each study visit showed that medication-taking self-efficacy was significantly related to all measures of adherence except schedule adherence. Findings also showed that electronically monitored adherence measures declined over the study period whereas self-report adherence did not. Findings suggest that self-efficacy can have a sustained effect on adherence to doses but may not be an influential predictor of adherence to their correct timing.

Social networks of substance users with HIV infection: application of the Norbeck Social Support Scale

The role of social support networks in medication adherence among HIV-infected substance users remains understudied. In this secondary data analysis, the authors sought to determine the relationship between social support networks and antiretroviral adherence among HIV-infected substance abusers receiving methadone. They analyzed data collected in a 24-week study of 76 methadone-maintained, HIV-infected substance abusers randomized to directly observed antiretroviral therapy or treatment as usual. The authors used logistic regression to examine the relationship between social support networks and self-reported antiretroviral adherence. Their results showed that study participants had an average of 1.36 social network members (SD = 1.4); 34% of participants had at least one drug user and 25% had at least one HIV-infected person in their network. The presence of network drug users and HIV-infected network members was associated with less antiretroviral medication adherence (p < .05). The authors conclude that both social network density and characteristics of network members have implications for medication adherence.

The effects of HIV medications on the quality of life of older adults in New York City

A three-equation model is used to estimate the multiple effects of antiretroviral medications (ARVs) on the quality of life (QoL) of the elderly with HIV in New York City. The transmission mechanism involves the ARVs having a direct effect on QoL via the side effects of the medications and two other effects (one indirect and one reverse) both working through feelings of depression. On a scale of 0 to 100, ARVs raise the QoL by 1 percentage point. This was because there was a large positive indirect effect of ARVs on QoL of 28 percentage points via the reduction in depression, which offsets both the 24 percentage-point reduction due to the direct effect and the 3 percentage-point decline from the reverse effect. Now, QoL effects can be applied to the additional life years generated by ARVs to form the quality adjusted life years outcome measure for use in economic evaluations of ARVs.

Predicting adherence to antiretroviral therapy in HIV-infected older adults: the moderating role of gender

This study characterized rates and correlates of ART adherence in 242 HIV-infected persons 50+ years of age. Hierarchical regressions tested a model in which depression mediated the relationships between social support and avoidance coping with ART adherence. Results indicated low rates of consistent and timely adherence in both men (48%) and women (51%). For men and women alike, social support and avoidance coping predicted depression. Although rates of adherence and predictors of depression did not differ by gender, predictors of adherence did. Avoidance coping, social support and depression predicted ART adherence in older men, but not in older women. Contrary to expectations, depression did not mediate the relationships of coping and social support with ART adherence for either gender. These findings suggest that while HIV-infected older men and women share similar paths toward depression, they diverge in predictors of adherence. Adherence interventions may be more efficacious if they are sensitive to gender differences, although more research is first needed to identify factors related to adherence in HIV-infected older women.

What do we know about older adults and HIV? A review of social and behavioral literature

The fastest growing segment of the United States HIV population is people aged 50 and older. This heterogeneous group includes people with diverse pathways into HIV positive status in later life, including aging with the disease as well as later life-acquired infections. As people with HIV live into older ages, solving problems of successful secondary prevention and ongoing treatment requires more specific knowledge of the particular aging-related contextual sociocultural, psychosocial, and personal factors salient to the situations of persons living with HIV. Greater knowledge of these factors will help solve challenges to reducing psychological burden and promoting health maintenance for people with HIV. Yet, the current literature on aging and HIV remains nascent. To assess the state of knowledge of the sociocultural and behavioral factors associated with aging with HIV, we conducted a systematic critical content review of peer-reviewed social and behavioral research on aging and HIV to answer the question, "How have older age, and social, cultural, and behavioral aspects of the intersection of HIV and age been addressed in the literature?" We searched First Search, Proquest, Psych Info, Pub Med, Wilson Select Plus, and World Cat and identified 1549 articles. We then reviewed these to select peer-reviewed articles reporting results of research on the social and behavioral aspects of living with HIV at age 50 and older. Fifty-eight publications were identified that met study inclusion criteria. While few publications reported clear age-related differences, there were significant ethnic differences in living with HIV in later life and also differences among older people when groups were defined by mode of transmission. Findings are discussed in light of constructs from gerontology which may contribute to clarifying how later life, life course stage, and psychological development intersect with, influence, and are influenced by HIV disease and long-term anti-retroviral therapy use.

A mixed-methods approach to synthesizing evidence on mediators of intervention effects

Greater understanding of the mechanisms (mediators) by which behavioral-change interventions work is critical to developing theory and refining interventions. Although systematic reviews have been advocated as a method for exploring mediators, this is rarely done. One challenge is that intervention researchers typically test only two paths of the mediational model: the effect of the intervention on mediators and on outcomes. The authors addressed this challenge by drawing information not only from intervention studies but also from observational studies that provide data on associations between potential mediators and outcomes. They also reviewed qualitative studies of participants' perceptions of why and how interventions worked. Using data from intervention (n = 37) and quantitative observational studies (n = 55), the authors conducted a meta-analysis of the mediation effects of eight variables. Qualitative findings (n = 6) contributed to more in-depth explanations for findings. The methods used have potential to contribute to understanding of core mechanisms of behavioral-change interventions.