"Making all the difference in the world": how physicians can help HIV-seropositive patients become more involved in their healthcare

Experiences of HIV-infected adults and healthcare providers with healthcare delivery practices that influence engagement in US primary healthcare settings: a qualitative systematic review

INTRODUCTION

The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is a major public health problem that has claimed the lives of more than 34 million people worldwide. The health of people living with HIV (PLWH) is optimized by ongoing engagement in HIV care, yet many people living with HIV either do not enter or fall out of care. Access to care and ongoing engagement in care for antiretroviral (ARV) medication adherence and psychoeducational support are critical to achieving the desired outcomes of reducing the risk of further HIV transmission and HIV related morbidity and mortality, and managing other commonly co-occurring health, social and behavioral conditions, thereby maximizing wellness.

OBJECTIVE

The objective of the review was to identify, evaluate and synthesize existing qualitative evidence on the experiences of HIV-infected adults with healthcare systems/practices/processes, and the experiences of healthcare providers with healthcare systems/practices/processes that impact engagement in primary healthcare settings in the United States (US).

INCLUSION CRITERIA

The review included studies reporting on the qualitative experiences of HIV-infected adults, aged 18-65 years, with healthcare systems, practices and processes and their healthcare providers (physicians, nurses and others providing care to these patients in the primary care healthcare setting). Qualitative studies including but not limited to designs such as phenomenology, ethnography, grounded theory, action research and qualitative descriptive were included. Studies published in languages other than English and conducted outside of the US were excluded.

METHODS

Using a three-step search strategy, databases of published and unpublished articles were searched from 1997 to 2017. All included studies were assessed by two independent reviewers for methodological quality, and data was extracted and pooled using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Findings were rated according to their level of credibility, categorized based on similarity in meaning and subjected to a meta-synthesis.

RESULTS

A total of 1038 qualitative articles were identified of which 41 were included after critical appraisal. Meta-synthesis generated four synthesized findings: i) What I want from my provider: to be a respectful, empathetic and holistic partner in my care; ii) I cannot do it alone: the critical importance of actively guiding and assisting patients during transitions and securing the needed resources; iii) Help me to understand my illness and care needs; iv) One-stop care that is de-stigmatizing and welcoming to diverse cultures keeps clients in care. These synthesized findings were derived from 243 study findings that were subsequently aggregated into 19 categories. Of the 243 study findings, 240 were rated unequivocal and three were rated credible. The overall ConQual for each of the four synthesized findings was moderate due to common dependability issues across the included studies. A total of 1597 participants were included. Only two studies were included from 1997 to 2000. The majority of included studies were published from 2005 to 2017.

CONCLUSIONS

The synthesized findings illustrate clear quality indicators for primary care practice, emphasizing the patient-provider-care team partnership and shared decision making that is holistic, takes into account a patient's whole life, responsibilities and stressors, and reframes HIV associated misperceptions/myths. The review also highlights the importance of helping patients navigate and interact with the healthcare system by offering one-stop services that assist with multiple medical care needs and "wraparound" services that provide the needed care coordination to assist with critical quality of life needs such as food, housing, transportation, and assistance with applying for health insurance and medication.

Let's talk about sex: A qualitative study exploring the experiences of HIV nurses when discussing sexual risk behaviours with HIV-positive men who have sex with men

BACKGROUND

Despite prevention efforts, the incidence of sexually transmitted infection among HIV-positive men who have sex with men remains high, which is indicative of unchanged sexual risk behaviour. Discussing sexual risk behaviour has been shown to help prevent sexually transmitted infections among HIV-positive men who have sex with men.

OBJECTIVES

The aim of this study was to identify factors that influence whether - and how - specialised HIV nurses discuss sexual risk behaviour with HIV-positive men who have sex with men. Identifying these factors could indicate how best to improve the frequency and quality of discussions about sexual risk behaviour, thereby reducing sexual risk behaviour and sexually transmitted infections.

DESIGN

Qualitative study, focus groups among HIV nurses.

SETTING

Dutch HIV treatment centres.

PARTICIPANTS

A purposive sample was taken of 25 out of 87 HIV nurses working in one of the 26 specialised HIV treatment centres in the Netherlands. Of the 25 HIV nurses we approached, 22 participate in our study.

METHODS

Three semi-structured focus group interviews were held with 22 HIV nurses from 17 hospitals. Interviews were transcribed verbatim, and thematic analysis was performed.

RESULTS

HIV nurses agreed that discussing sexual risk behaviour is important, but barriers were experienced in relation to doing so. In accordance with the theory of planned behaviour, attitudes, perceived norms and perceived behavioural control were all found to be relevant variables. Barriers to discussing sexual risk behaviour were identified as: dealing with embarrassment, the changing professional role of an HIV nurse, time constraints, and the structure of the consultation.

CONCLUSIONS

To improve the frequency and quality of discussions about sexual risk behaviour with HIV-positive men who have sex with men, our data suggests it would be beneficial to support HIV nurses by developing tools and guidelines addressing what to discuss and how. Using a related topic as a conversational 'bridge' may help nurses to broach this subject with their patients. This would allow HIV nurses to discuss possible risk reduction strategies, such as pre-exposure prophylaxis for HIV-negative partners, condom use, strategic positioning, or sero-sorting.

From intention to STI prevention: An online questionnaire on barriers and facilitators for discussing sexual risk behaviour among HIV nurses

AIMS

We aimed to elucidate facilitators and barriers that HIV nurses experience in discussing sexual risk behaviour with HIV-positive men who have sex with men, using variables from a previous qualitative study and the theory of planned behaviour.

BACKGROUND

HIV-positive men who have sex with men are frequently diagnosed with sexually transmitted infections, which can be reduced if HIV nurses discuss sexual risk behaviour.

DESIGN

An online questionnaire was disseminated in April 2015 among all HIV nurses in the Netherlands.

METHODS

We assessed variables, such as attitudes, shame, ability, knowledge and time concerns. A regression analysis was conducted with "intention to discuss sexual risk behaviour" as an outcome variable.

RESULTS

The questionnaire was completed by 60 of 79 HIV nurses. Overall, participants reported high intentions to discuss sexual risk behaviour, and 38% of the variance was explained by attitude, sexual preference, knowing ways to introduce the topic and experiencing enough time or viewing it as a priority. In addition, high intenders significantly differed from low intenders in "experienced shame," "relation with patients," "non-verbal communication," "subjective norm" and "knowledge."

CONCLUSION

Improving sexual health in HIV care translates into improving opportunities and the facilitating factors in initiating the discussion of sexual risk behaviour rather than removing barriers HIV nurses experience. Interventions should mainly focus on improving the HIV nurses' perceived ability to initiate the topic of sexual risk behaviour and to utilize the jargon and terminology that is commonly used among men who have sex with men.

Improving linkage to HIV care at low-threshold STI/HIV testing sites: An evaluation of the Immediate Staging Pilot Project in Vancouver, British Columbia

OBJECTIVES

The objective of the Immediate Staging Pilot Project (ISPP) was to improve linkage to human immunodeficiency virus (HIV) care by increasing the number of referrals made to HIV care, and to decrease the time between diagnosis and linkage to care for newly diagnosed HIV clients. This pilot had the potential to decrease HIV transmission at a population level by engaging clients in treatment earlier.

SETTING

The Bute Street Clinic and Health Initiative for Men Clinic on Davie in Vancouver, British Columbia are low-threshold public health facilities providing HIV/STI testing primarily to men who have sex with men (MSM).

INTERVENTION

To improve engagement of MSM in the cascade of HIV care, the BC Centre for Disease Control implemented a 12-month ISPP in 2012 for clients newly diagnosed with HIV. The pilot offered CD4 and viral load testing at the time of diagnosis, implemented improved referral procedures and enhanced nursing support for clients.

OUTCOMES

Comparing linkage to care outcomes between a group that received the standard of care (SOC) and an intervention group that received immediate staging, the median linkage to care time decreased from 21.5 to 14.0 days respectively (p = 0.053). The referral rates to HIV care were 56.1% in the SOC group and 94.1% in the intervention group (p < 0.001).

CONCLUSION

Creating best practices that include offering CD4 and viral load testing at the time of diagnosis, enhanced nursing support and standardized referral processes has facilitated an improvement in the quality of HIV services provided to MSM clients attending low-threshold clinics.

Results from a secondary data analysis regarding satisfaction with health care among African American women living with HIV/AIDS

OBJECTIVE

To analyze satisfaction with health care among African American women living with HIV/AIDS.

DESIGN

Secondary analysis of baseline data of African American women who participated in Protect and Respect, a sexual risk reduction program for women living with HIV/AIDS SETTING: HIV Care Clinic in an urban city in the northeast United States.

PARTICIPANTS

One hundred fifty-seven (157) African American women living with HIV/AIDS.

METHODS

Regression analyses were used to examine the relationships between demographic variables, self-reported health characteristics, communication with health care providers, and satisfaction with health care provider.

RESULTS

A majority of women reported satisfaction with medical services (88%, n = 140). Communication with health care providers, detectable viral load, education, income, self-reported health status, and sexual orientation were significantly bivariately associated with satisfaction with healthcare (all ps < .05). In the multivariate models, no variables significantly predicted satisfaction with healthcare.

CONCLUSION

Because satisfaction with health care can influence the quality of care received, health outcomes, and adherence to provider recommendations among patients living with HIV/AIDS, health care providers' ability to elicit satisfaction from their patients is just as important as the services they provide. This project is one of the first studies to find high rates of satisfaction with health care among African American women living with HIV/AIDS. Further examination of satisfaction with health care among African American women living HIV/AIDS may help in narrowing health care disparities and negative treatment outcomes.

Toward integrated and sustainable prevention against diabetes in rural China: study rationale and protocol of eCROPS

BACKGROUND

Being an intermediate stage in the development of diabetes, pre-diabetics were estimated as high as 14% to 63% in China and one to three quarters of them will develop into diabetes within 10 years. It is well established that the risk of diabetes progression can be modified substantially and a whole range of proven guidelines, protocols and methodologies are available. Unfortunately, most proven interventions are seldom used in daily practice and this is especially true in resource poor rural China. This project aims at demonstrating that an evolutionary intervention package featuring low cost, integration with routine services, cultural sensitization and self-optimization, is effective and sustainable in preventing diabetes.

METHODS/DESIGN

This project utilizes a quasi cluster randomized controlled trial and a batched implementation strategy in which villages are recruited in 7 blocks within 7 consecutive years respectively. Block 0 involves 3 villages and provides an opportunity for piloting and refining primitive intervention methodologies and protocols. The following 6 blocks consist of 14 villages each and serve as intervention arm; while all the villages not yet started intervention form the control arm. For each block, measurement happens at baseline and every 12 months (for plasma glucose) or monthly (for body weight and blood pressure) after baseline. These arrangements enable documentation of up to 6 years of consecutive measures and detection of lower incidence of progression into diabetes, improved body max index and blood pressure, and increased service use and involvement in healthy dietary and physical activities among pre-diabetics receiving the experimental intervention compared to themselves at baseline or those in the delayed-intervention control condition.

DISCUSSION

China has a long history of separating disease prevention and treatment systems and there is a clear need to leverages key success factors in a synergetic way toward integrated and sustainable diabetes prevention. This project is owned and managed by local health authorities and utilizes available resources. It introduces a package of long-term incentives, establishes ongoing mechanisms for continuous capacity building and quality improvement, and builds up an operational cycle for catalyzing similar efforts in the local prefecture even throughout rural China.

TRIAL REGISTRATION

Current Controlled Trials: ISRCTN66772711.

People living with HIV are receptive to HIV prevention interventions in clinical settings: a qualitative evaluation

In the United States, HIV prevention services are increasingly being offered in the context of healthcare settings. This includes prioritizing prevention services for people living with HIV (PLWH), otherwise known as "prevention with positives." We conducted sixty in-depth interviews to explore patients' perceptions of clinic-based HIV prevention interventions targeting people living with HIV. The majority of patients were receptive to the prevention interventions. Patients described experiencing feeling fulfilled by communicating about issues related to HIV prevention when the conversations were specific to their situation and with an interventionist who was objective, yet empathic and non-judgmental. Provider-delivered interventions opened up new areas of prevention discussions with patients. Specialist-delivered interventions, specifically group-level interventions, provided opportunities to integrate participants into social networks that in turn provided social support and a reduction in social isolation. HIV prevention counseling benefited patients regardless of risk status.

Patient-derived outcome measures for HIV services in the developed world: a systematic review

This review sought to establish the themes and approaches used in the measurement of patient satisfaction regarded by HIV service users as crucial to improving service quality. It also investigated how feedback has been measured previously and whether a gold standard instrument exists that is generalizable across HIV inpatient and clinic settings. Twelve databases and other sources yielded 1474 titles. Using a clinically-focused question and pre-defined inclusion and exclusion criteria, 32 articles were retrieved and reviewed for quality using a quality appraisal checklist. Two reviewers used a data extraction form to identify and verify key patient experiences. Thematic analysis revealed that clinic staffs' current knowledge of HIV was an essential factor in positive feedback. Treating patients with dignity and respecting their autonomy and confidentiality were also important. Developments in treatment, extended life expectancy and quality of life have altered patients' experience and level of satisfaction. Three instruments developed to assess patient satisfaction with HIV care were identified but there was no gold standard method of measuring it. There is a need to develop a specific, valid instrument that is easy to complete and analyse, and the data should be used to inform the redesign of services to promote a dynamic model of care.

Early linkage and retention in care: findings from the outreach, linkage, and retention in care initiative among young men of color who have sex with men

Early linkage and retention in HIV clinical care is essential for optimal disease management, promotion of health, and receipt of secondary prevention messages to decrease onward transmission of HIV. Youth, specifically racial/ethnic minority young men who have sex with men (YMSM), continue to acquire new HIV infections and have been shown to be less likely to engage in regular HIV care and adhere to scheduled medical visits. The goal of the current study was to evaluate the characteristics of participants and program delivery that were associated with early linkage and retention in HIV care among HIV-infected YMSM of color enrolled in an outreach, linkage, and retention study. Of the 334 patients included in the linkage analysis, 72% were linked to care within 30 days of diagnosis, 81% within 60 days, and 87% within 90 days. While no patient-level characteristics were associated with early linkage, having the person who provided the positive HIV test result refer the patient to HIV care (p=0.048), specifically calling to make the appointment (p=0.009), was associated with earlier linkage. Retention of Latino participants (96.2%) was significantly higher than for the African-American (79.9%) youth (p=0.006). Overall, 221 participants had at least 1 year of possible follow-up and 82.8% of these participants were retained at 1 year. While unique challenges exist in the care of adolescents infected with HIV from identification to engagement and retention in clinical care, programs that are responsive and dedicated to the needs of these youth can be successful in retaining them in care.

Health care and social service providers' observations on the intersection of HIV/AIDS and violence among their clients and patients

Associations between HIV/AIDS and several forms of violence have been demonstrated in recent research. We conducted qualitative interviews with 30 providers who offered services related to HIV/AIDS or violence to identify specific manifestations of HIV/AIDS-violence intersections, factors that explain why HIV/AIDS and violence intersect in client/patient populations, and the theoretical salience of providers' narratives. Providers confirmed links between HIV/AIDS and violent victimization, and yielded new insights into crossover risk between HIV/AIDS and suicidality, nonsuicidal self-harm, and witnessing and perpetrating violence. We also isolated 20 explanatory factors, including substance use, poor mental health, sex work/trading sex, and sexual orientation/gender identity. Narratives were consistent with syndemics theory, indicating that HIV/AIDS and violence fueled each other's occurrence and magnified the health-related burden on affected client/patient populations, often under conditions of health and social disparity. Providers contribute a novel perspective on our understanding of HIV/AIDS-violence syndemics that shows promise in informing future interventions and practice.

Decision-making role preferences among patients with HIV: associations with patient and provider characteristics and communication behaviors

BACKGROUND

A preference for shared decision-making among patients with HIV has been associated with better health outcomes. One possible explanation for this association is that patients who prefer a more active role in decision-making are more engaged in the communication process during encounters with their providers. Little is known, however, about patient and provider characteristics or communication behaviors associated with patient decision-making preferences in HIV settings.

OBJECTIVE

We examined patient and provider characteristics and patient-provider communication behaviors associated with the decision-making role preferences of patients with HIV.

DESIGN

Cross-sectional analysis of patient and provider questionnaires and audio recorded clinical encounters from four sites.

PARTICIPANTS

A total of 45 providers and 434 of their patients with HIV.

MEASURES

Patients were asked how they prefer to be involved in the decision-making process (doctor makes all/most decisions, patients and doctors share decisions, or patients make decisions alone). Measures of provider and patient communication behaviors were coded from audio recordings using the Roter Interaction Analysis System.

MAIN RESULTS

Overall, 72% of patients preferred to share decisions with their provider, 23% wanted their provider to make decisions, and 5% wanted to make decisions themselves. Compared to patients who preferred to share decisions with their provider, patients who preferred their provider make decisions were less likely to be above the age of 60 (ARR 0.09, 95% CI 0.01-0.89) and perceive high quality provider communication about decision-making (ARR 0.41, 95% CI 0.23-0.73), and more likely to have depressive symptoms (ARR 1.92, 95% CI 1.07-3.44). There was no significant association between patient preferences and measures of provider or patient communication behavior.

CONCLUSION

Observed measures of patient and provider communication behavior were similar across all patient decision-making role preferences, indicating that it may be difficult for providers to determine these preferences based solely on communication behavior. Engaging patients in open discussion about decision-making preferences may be a more effective approach.

Measuring the Involvement of People with HIV in Treatment Decision Making Using the Control Preferences Scale

Objectives. Since 1983, HIV patients have been advocating for participatory decision making. This study measures the involvement that HIV-positive people perceive in treatment decision making. A secondary objective is to assess the validity of the instrument used to examine decisional roles, the Control Preferences Scale (CPS). Method. The authors interviewed 79 HIV-positive people, a sub-sample of a study on long survival with HIV, diverse with respect to ethnicity, age, gender, and sexual orientation. They compared the self- and researcher-rated decisional roles of participants on the CPS. They also assessed how well the CPS corresponds with Charles's paternalistic, shared- and informed-choice models of decision making about treatment based on decisional roles and information exchange. Results. Most participants (75%) perceived collaborative/active involvement in decision making. Agreement (Kendall's tau-b ) between self- and researcher-rated decisional roles on the CPS was 0.82, whereas agreement between self-ratings on the CPS and researcher ratings on Charles's classification was 0.60. Charles's classification was difficult if participants had chosen not to take their prescribed medication without being adequately informed about the risky consequences of this decision. Conclusions. In this study, HIV-positive people perceived a high level of involvement in decision making. Reliability and convergent validity of the CPS was high. Charles's classification was problematic because decisional roles and information exchange are distinct dimensions. Some people make risky treatment decisions on their own without being adequately informed. The CPS is a useful instrument to measure decisional role perceptions of HIV-positive people but needs to be complemented by an instrument measuring treatment knowledge.

"Getting me back on track": the role of outreach interventions in engaging and retaining people living with HIV/AIDS in medical care

This qualitative study investigated the process of engagement in HIV medical care from the perspective of people living with HIV/AIDS (PLWHA). In-depth interviews were conducted with 76 participants in six cities. All participants were considered underserved because of histories of substance use, mental illness, incarceration, homelessness, or cultural barriers to the traditional health care system. A semistructured interview guide elicited narratives related to health care and the role of program interventions in facilitating access to care. Data analysis revealed that participants cycled in and out of care, a process that was influenced by (1) their level of acceptance of being diagnosed with HIV, (2) their ability to cope with substance use, mental illness, and stigma, (3) their health care provider relationships, (4) the presence of external support systems, and (5) their ability to overcome practical barriers to care. Outreach interventions played a role in connecting participants to care by dispelling myths and improving knowledge about HIV, facilitating access to HIV care and treatment, providing support, and reducing the barriers to care. The findings suggest that outreach programs can interrupt this cyclical process and foster sustained, regular HIV care for underserved PLWHA by conducting client-centered risk assessments to identify and reduce sources of instability and improve the quality of provider relationships; implementing strategies that promote healthy practices; creating a network of support services in the community; and supporting adherence through frequent follow-ups for medication and appointment keeping.

"It's my body'': does patient involvement in decision making reduce decisional conflict?

OBJECTIVE

This study explores how much people with HIV/AIDS wanted and how much they actually perceived being involved in the decision to take or not to take antiretroviral treatment (ART). The congruence between desired and perceived decisional involvement was also related to decisional conflict.

METHOD

Cross-sectional (N = 79), the Control Preferences Scale assessed patients' preferred versus perceived role in treatment decision making. The Decisional Conflict Scale measured patients' perceived difficulties in decision making.

RESULTS

Although a minority of patients (32%) perceived their role as shared decision making, the majority (59%) preferred shared decision making. Some did not desire shared decision making, with 28% preferring to decide on their own versus 13% wanting their physicians to decide for them. Overall, 58% did not feel they had achieved their desired role in decision making (half of whom perceived more control and the other half less control than preferred). Participants declining ART felt more pressure to decide alone compared with those taking ART (P < 0.01). Decisional conflict was expressed by 53% and was highest when physicians unilaterally made decisions about ART for patients who preferred shared decision making (P < 0.001).

CONCLUSIONS

In this study, most physicians do not meet their patients' desired roles in decision making. One-third of people taking ART feel less involved than they desire. More critically, half of those declining ART feel pressured to decide alone, suggesting that physicians should remain involved in the decision to reject treatment, as this requires careful monitoring and periodical revisiting. Because lack of shared decision making is related to decisional conflict, physicians may reduce decisional conflict by meeting patients' desires for shared decision making.

Sex, risk and responsibility: provider attitudes and beliefs predict HIV transmission risk prevention counseling in clinical care settings

We examined factors associated with the frequency of HIV "prevention with positives" (PwP) counseling delivered by providers participating in demonstration projects at 26 clinics. Three hundred and fifteen primary care and support service providers completed a survey assessing the frequency of PwP delivered at initial medical care visits and at regular care visits. Providers reported delivering PwP counseling to more patients at initial visits (67%) than to those returning for regular care (53%; t = 11.8, p < 0.001). During initial and regular care visits, providers reporting a sense of responsibility for conducting PwP and those regularly discussing the risk of reinfection with patients reported significantly more frequent PwP counseling. Providers expressing a belief that no matter how much counseling was delivered, some HIV-infected patients would still infect others (prevention fatalism) reported significantly less frequent counseling at all visits. To improve the quality and quantity of HIV PwP counseling, providers training should address attitudinal barriers and facilitators to counseling and the importance of addressing risk routinely.

An information-motivation-behavioral skills model of adherence to antiretroviral therapy

HIV-positive persons who do not maintain consistently high levels of adherence to often complex and toxic highly active antiretroviral therapy (HAART) regimens may experience therapeutic failure and deterioration of health status and may develop multidrug-resistant HIV that can be transmitted to uninfected others. The current analysis conceptualizes social and psychological determinants of adherence to HAART among HIV-positive individuals. The authors propose an information-motivation-behavioral skills (IMB) model of HAART adherence that assumes that adherence-related information, motivation, and behavioral skills are fundamental determinants of adherence to HAART. According to the model, adherence-related information and motivation work through adherence-related behavioral skills to affect adherence to HAART. Empirical support for the IMB model of adherence is presented, and its application in adherence-promotion intervention efforts is discussed.

Reframing "prevention with positives": incorporating counseling techniques that improve the health of HIV-positive patients

Federal HIV prevention strategy seeks to increase efforts by health care providers to identify and reduce their HIV-positive patients' transmission-related behaviors. Implementation of these recommendations will be hindered if providers perceive these efforts have the potential to harm their relationships with patients. Because transmission-related behaviors (unsafe sex and sharing needles) and the related issues of drug and alcohol use also jeopardize the health of HIV-positive patients, providers can use patient-centered counseling when addressing those behaviors. We suggest efforts to increase provider-delivered transmission-prevention counseling be reframed so that "prevention with positives" includes the goal of protecting HIV-positive patients' health. We review the specific consequences of these risky behaviors on HIV-positive patients' health and review brief counseling strategies appropriate for HIV care providers.

Male Self-Disclosure of HIV-Positive Serostatus to Sex Partners: A Review of the Literature

HIV-positive men face multiple challenges when deciding whether to disclose their serostatus to sex partners. The purpose of this literature review (1996-2004) is to identify valid and reliable research results that identify factors influencing serostatus disclosure to sex partners by men who are HIV-positive. Articles included in the review were identified through an electronic search using pertinent terms related to disclosure to sex partners, followed by a search of references for additional articles. A compilation of research results for 17 articles is presented under the headings of background, contextual, and psychosocial factors influencing disclosure. An analysis of the data suggests that differences in disclosure rates vary based on sex partner factors including serostatus, relationship status, and number of sex partners. Rates of disclosure to primary sex partners ranged from 67% to 88%, suggesting that nearly one third of main sex partners were not disclosed to and were at risk of contracting HIV, whereas a pattern of lower disclosure among casual partners was evident. As the number of sex partners increased, the likelihood of disclosure to all sex partners decreased, ranging from one quarter (25%) to slightly over half (58%). In addition, perceived efficaciousness and positive outcome expectations were the most frequent theoretical constructs embedded in the research associated with disclosure, suggesting that these factors play an important role in the process of disclosure to sex partners. Interpersonal factors that positively influenced self-disclosure included spousal support, emotional investment, and communication about safe sex, including asking about a partner's serostatus. Self-disclosure was not consistently associated with safer sex. Recommendations for future research are presented, based on the results included in this review.

Linking HIV/AIDS clients' self-care with outcomes

The self-care practice of HIV/AIDS patients has become an important topic to help HIV/AIDS patients maintain their maximum level of well-being in chronic illness management. This article presents a self-care outcomes model that is applicable to HIV/AIDS nursing practice and research, and it identifies attributes and outcomes related to HIV/AIDS patients'self-care. The self-care outcomes model was developed based on the Outcomes Model for Health Care Research and literature review. Key variables related to HIV/AIDS self-care were summarized and discussed based on nine dimensions: client inputs, client processes, client outcomes, provider inputs, provider processes, provider outcomes, setting inputs, setting processes, and setting outcomes. This article reveals that self-care in HIV/AIDS is complex and may be influenced by many factors relating to individual, family, and health care system. More research with advanced multivariate statistical models and randomized controlled trial design will help determine the effectiveness of self-care strategies and interventions.

Missed Opportunities: Prevention With HIV-Infected Patients in Clinical Care Settings

OBJECTIVE

To assess current practices related to prevention with HIV-positive patients in Ryan White-funded primary care settings and the barriers to providing such services.

METHOD

Exit surveys about HIV prevention services were conducted with 618 HIV-infected patients at 16 primary HIV care clinics receiving Ryan White CARE Act funding. To place the exit survey findings in context, qualitative in-depth interviews were conducted with 16 clinic administrators, 32 primary care providers, 32 support service providers, and 64 patients.

RESULTS

One quarter of patients reported having had a general discussion of "safer sex and ways to prevent transmission to others" during that day's primary care visit. However, only 6% reported discussing specific sexual activities. HIV prevention counseling was less common than counseling for adherence to antiretroviral therapy, emotional issues, and diet and nutrition (P < 0.001). Patients in clinics with established procedures for HIV prevention counseling were significantly more likely to report receiving such services (odds ratio = 2.17). Qualitative interviews identified barriers to providing prevention services as lack of time, training, funding for staffing, and providers' understanding of their roles and responsibility.

CONCLUSIONS

HIV prevention counseling is not routine in most clinics, and the low frequency of such services represents missed opportunities for HIV prevention.

The social grid of community medication management

Practitioners involved in case management at a community mental health center organized 5 elements of a psychotropic medication experience. Using case records, interview, and observational data, the authors examined an underresearched and especially problematic area of the management process: the interpretation of a medication's effect. They describe the divisions of labor, a grid of social relations, and spaces related to management, and they describe how the limits and potential of medications are realized in the intensity of monitoring and the knowledge produced in the day-to-day practices among all participants.

"Being dealt with as a whole person." Care seeking and adherence: the benefits of culturally competent care

The purpose of this study is to characterize the relationship between identity and health care experiences (including antiretroviral therapy utilization) among HIV-positive sexual minority males. This qualitative study used grounded theory with data collection occurring through focus groups and interviews. A questionnaire was used to complete a demographic profile. The study included 47 HIV positive participants from three minorities: gay men, bisexual men and transgendered persons, gender identifying as female and or living as women. Sessions elicited information on: (1) general experiences with health care, (2) experiences with HIV antiretroviral therapies and issues surrounding access, and (3) adherence to these therapies and identity in relation to health care. These textual data revealed three themes: (1) the importance of sexual identity and its social and cultural context, (2) the differences in the health concerns between the sexual minorities and (3) a wide spectrum of experiences with the health care system that provide information surrounding the access to and adequacy of health care. Successful health care providers are aware of different issues that may play a role in the provision of health care to these sexual minorities. Providers awareness of sexual and social identity and the related different cultural values, beliefs and custom enhance care seeking and therapeutic adherence. For sexual minorities, primary care remains the most important entry point into the health care system. Cultural competence of care providers can foster patient's care seeking and adherence to treatment.

Perceptions of health care professionals and patients about the risk of HIV transmission through oral sex: a qualitative study

We explored health care professionals' beliefs and methods for counseling patients about risks for transmitting human immunodeficiency virus (HIV) through oral sex and HIV-seropositive patients' beliefs and practices regarding oral sex behavior. Health care professionals used divergent counseling strategies, avoided specific recommendations, and expressed ambivalence about recommending barrier protection for oral sex. Patients expressed differing beliefs about oral sex risk; the majority have engaged in unprotected oral sex since diagnosis. Few professionals or patients mentioned oral sex risk for other sexually transmitted diseases (STDs), which can be cofactors for HIV. Although scientific evidence indicates a potential risk for transmitting HIV via oral sex, and patients in our sample want more information about this risk, the health care professionals we interviewed have adopted a largely noncommittal approach to communicating potential risk to patients. Health care professionals should consider discussing more specifically with patients the oral sex risk for transmission of HIV and other sexually transmitted diseases.