Supporting adherence to highly active antiretroviral therapy and protected sex among people living with HIV/AIDS: the role of patient-provider communication in Rio de Janeiro, Brazil

"One pastor advised him to stop taking HIV medication": Promoters and barriers to HIV care among gay, bisexual, and men who have sex with men living with HIV in Ghana

Introduction

Few studies examine Ghanaian gay, bisexual, and other men who have sex with men (GBMSM) experience with HIV diagnoses and linkage to care. This article provides qualitative accounts of promoters and barriers to care among GBMSM living with HIV in Ghana.

Methods

We recruited and interviewed 10 GBMSM living with HIV in two Ghanaian cities. We transcribed the interviews, coded the data, and used thematic content analysis.

Results

We found that community and healthcare facility (HCF) level HIV and sexual stigma, confidentiality issues, alternative medicine, and substance use remain the key barriers to care. Other barriers include healthcare system issues such as long wait times and economic problems (e.g., health insurance and financial difficulties). Nonetheless, HCF-level factors such as positive experiences with providers, HIV counseling, and detailed medication information facilitate adherence to care among GBMSM.

Conclusion

This study highlights the need for interventions that address linkage to care issues, especially substance use, disinformation, and misinformation among GBMSM and other Ghanaian communities.

Patient-Provider Communication and Information, Motivation, and Behavioral Skills in HIV-Positive Adults Initiating Antiretroviral Therapy in Haiti

While Haiti has scaled up use of antiretroviral therapy (ART), current studies suggest sub-optimal adherence threatens long-term viral suppression in this understudied setting. Patient-provider communication (PPC) and information, motivation, and behavioral skills (IMB) have been implicated in ART adherence globally. However, no studies have examined their relevance in Haiti. The present mixed-methods study utilized cross-sectional survey data from 128 ART-initiating patients at 2 large HIV treatment sites in Haiti, as well as observational data from 12 clinic visits, to document associations between adherence-related PPC and IMB. Multivariate regression analyses suggested that PPC is associated with IMB constructs. At the bivariate level, more effective PPC was associated with higher levels of adherence-related information and motivation, but not behavioral skills. Observational findings indicate infrequent and non-collaborative adherence support. Taken together, findings lay the groundwork for additional research in the area of PPC, IMB, and ART adherence in Haiti.

"A dream come true": Perspectives on long-acting injectable antiretroviral therapy among female sex workers living with HIV from the Dominican Republic and Tanzania

BACKGROUND

Long-acting injectable antiretroviral therapy (LA ART) was found to be non-inferior to daily oral ART in Phase 3 clinical trials. LA ART may offer an important alternative for people living with HIV with challenges adhering to daily oral ART or preferences for non-pill-based regimens.

METHODS

Using a mixed methods approach integrating survey, in-depth interview and biological data from female sex workers (FSW) living with HIV in Tanzania (N = 208) and the Dominican Republic (DR) (N = 201), we assessed factors associated with the potential likelihood of LA ART use if it were available. We conducted multivariate logistic regression and thematic content analysis.

RESULTS

Likelihood of LA ART use was high with 84.92% of FSW from the DR and 92.27% of FSW from Tanzania reporting they would be "likely" or "very likely" to use LA ART if available (p = 0.02). In Tanzania better HIV-related patient-provider communication (AOR 4.58; 95% CI 1.90-11.05) and quality of HIV clinical care (AOR 3.68; 95% CI 1.05-12.86) were positively associated with the high likelihood of LA ART use. In the DR, easier clinic access was associated with a higher likelihood of LA ART use (AOR 3.04; 95% CI 1.41-6.56), as was greater monthly income from sex work (AOR 2.37; 95% CI 1.27-4.41). In both settings, years on ART was significantly associated with a strong likelihood of LA ART use (TZ: AOR 1.16 per year; 95% CI 1.00-1.34/DR: AOR 1.07 per year; 95% CI 1.00-1.14). Qualitative findings underscored enthusiasm for LA ART and reinforced its potential to address sex work-specific barriers to daily oral ART adherence including work-related schedules and substance use.

CONCLUSIONS

We found a high likelihood of LA ART use if available among FSW in two diverse settings and documented barriers to future uptake. Community-driven approaches which include tailored health education and improved patient-provider communication and quality of care, as well as strategies to facilitate appointment adherence are needed to optimize LA ART use among FSW.

Developing Prepare2Thrive, a community-based intervention targeting treatment engagement among African American individuals living with HIV and serious mental illness

African American individuals living with HIV and serious mental illness (SMI) may report relatively low treatment engagement, despite treatment engagement being critical to managing both health conditions. Here, we have two aims: to describe the methodology we used to collect focus group data on treatment engagement with a sample of African American individuals living with HIV and SMI, and to describe the results of those focus groups in the context of intervention development. We conducted two focus groups (N = 15), integrating a social-ecological model for our theoretical framework, Community-Based Participatory Research for study design and execution, and group concept mapping for data analysis. Three thematic clusters relating to treatment engagement emerged from each group, with overlap across groups: Medication knowledge, Patient-provider relationships, and Barriers to treatment engagement. Items related to the Patient-provider relationship loaded onto all emergent clusters, demonstrating the pervasive impact of this variable. Findings informed the design of Prepare2Thrive, a community-based, culture-specific intervention aiming to increase treatment engagement among African American individuals living with HIV and SMI. Both our design and findings can be used in future collaborations aiming to maximize treatment engagement, and more broadly health, among individuals in this community.

A multi-level examination of the experiences of female sex workers living with HIV along the continuum of care in the Dominican Republic

Female sex workers (FSWs) are disproportionately affected by HIV, but there is limited research on their HIV care experiences. This study explored the experiences of 44 FSWs living with HIV in Santo Domingo, Dominican Republic along the HIV care continuum using in-depth interviews and focus groups. Data were analysed through narrative and thematic analysis. Individual-level factors that facilitated engagement in HIV care were physical and mental health. At the interpersonal level, disclosure of HIV or sex work status and receipt of emotional and economic support were important influences on engagement. Yet, negative reactions to or lack of disclosure of these statuses compromised engagement, further highlighting the role of stigma and discrimination. At the environmental level, FSWs described considerable challenges with the health system including long waits and treatment stock-outs at their clinics, but were generally satisfied with HIV clinic staff. At the structural level, lack of economic resources complicated care and treatment adherence. Findings underscore the need for psychosocial and economic support tailored to the unique needs of FSWs to maximise the individual and public health benefits of HIV care.

HIV care and treatment experiences among female sex workers living with HIV in sub-Saharan Africa: A systematic review

Female sex workers (FSW) living with HIV in sub-Saharan Africa have poor engagement to HIV care and treatment. Understanding the HIV care and treatment engagement experiences of FSW has important implications for interventions to enhance care and treatment outcomes. We conducted a systematic review to examine the HIV care experiences and determinants of linkage and retention in care, antiretroviral therapy (ART) initiation, and ART adherence and viral suppression among FSW living with HIV in sub-Saharan Africa. The databases PubMed, Embase, Web of Science, SCOPUS, CINAHL, Global Health, Psycinfo, Sociological Abstracts, and Popline were searched for variations of search terms related to sex work and HIV care and treatment among sub-Saharan African populations. Ten peer-reviewed articles published between January 2000 and August 2015 met inclusion criteria and were included in this review. Despite expanded ART access, FSW in sub-Saharan Africa have sub-optimal HIV care and treatment engagement outcomes. Stigma, discrimination, poor nutrition, food insecurity, and substance use were commonly reported and associated with poor linkage to care, retention in care, and ART initiation. Included studies suggest that interventions with FSW should focus on multilevel barriers to engagement in HIV care and treatment and explore the involvement of social support from intimate male partners. Our results emphasise several critical points of intervention for FSW living with HIV, which are urgently needed to enhance linkage to HIV care, retention in care, and treatment initiation, particularly where the HIV prevalence among FSW is greatest.

Palliative care needs in Malawi: Care received by people living with HIV

Background

Infection with human immunodeficiency virus (HIV) has changed from an acute to a chronic illness in the past decade, because of highly active antiretroviral therapy (ART). Malawi’s response to the HIV challenge included provision of ART for people living with HIV or AIDS (PLWHA), which significantly reduced HIV- and AIDS-related mortality. In addition, palliative care for PLWHA was introduced as a strategy that improves the success of ART.

Objective

The purpose of the study was to explore the needs of PLWHA concerning care received from primary caregivers and palliative care nurses in Malawi.

Methods

A qualitative, explorative design was used and 18 participants were selected purposefully and interviewed individually using a semi-structured interview guide. Data were analysed using NVivo software package version 10.

Results

Results revealed that PLWHA needed physical care from the primary caregivers due to severity of illness, integration of healthcare services, and continuity of care and proper care from nurses. They also needed knowledge from nurses in several areas which affected decision-making and needed financial and nutritional support.

Conclusion

More could be done in meeting needs of PLWHA to improve their health and survival and assist them to achieve a better quality of life.

Contribuições de uma Intervenção Psicoeducativa para o Enfrentamento do HIV durante a Gestação

RESUMO O estudo investigou as contribuições de uma intervenção psicoeducativa para o enfrentamento da doença entre gestantes vivendo com HIV. Participaram quatro mães com idades entre 29 e 37 anos, sendo que duas souberam da infecção na gestação. Trata-se de estudos de casos longitudinal envolvendo avaliações antes, durante, depois da intervenção e aos três meses de vida do filho/a. Os achados revelaram que a notícia do HIV durante a gestação se associou a grande risco psicológico, pois envolvia imenso esforço de adaptação e sobrecarga emocional potencializadas pelo risco de transmissão do vírus ao filho. A intervenção apresentou contribuições positivas para o enfrentamento da doença e o bem-estar emocional das mães. Discutese a necessidade de ampliar o apoio psicológico dos serviços de saúde a essas mulheres.

HIV+ men need reproductive counseling too: Assessing childbearing goals and provider communication among HIV+ male patients in Rio de Janeiro, Brazil

We assessed reported communication with HIV providers about reproductive plans among HIV+ men in Rio de Janeiro, Brazil, and factors associated with having had such communication. A total of N=311 HIV+ men (18-50 years) receiving HIV care at one of six public primary care clinics in Rio de Janeiro between 2008-2009 were surveyed. We used descriptive statistics, and multivariate logistic regression to identify factors associated with communication about childbearing with an HIV provider. HIV+ male patients (mean age=42.7 years, 57% mixed race; 23% bisexual, 51% married/committed partner, 61% with at least one biological child, 77% on ART) reported accepting attitudes of HIV and childbearing (51%), the desire (39%), and/or intention (19%) to have a future child, and reported communication with the HIV provider (14%) or their primary partner (28%) about having children. There were no significant differences between the responses of HIV+ heterosexual and bisexual men on the above outcomes. Men who discussed childbearing with their HIV provider were more likely to have accepting attitudes about HIV and childbearing [AOR 2.8, 95%CI (1.2-6.4), p=0.014], and intend to have a child [AOR 2.6, 95% CI (1.2-5.6), p=0.018], but less likely to have discussed this topic with their partner [AOR 0.32 (0.15-0.68), p=0.003]. Among men reporting communication, 40% (17/42) reported advice against having a child. An unmet need for collaborative, nonjudgmental, and provider-initiated communication about childbearing goals exists for HIV+ men in clinical care.

Reproductive decisions of couples living with HIV in Malawi: what can we learn for future policy and research studies?

BACKGROUND

The rapid scale-up of free antiretroviral therapy has lead to decline in adult mortality at the population level and reduction of vertical transmission. Consequently, some couples living with HIV are maintaining their reproductive decisions; marrying and having children. This paper analyses policies and guidelines on HIV, AIDS and sexual and reproductive health in Malawi for content on marriage and childbearing for couples living with HIV.

METHODS

A qualitative study using interpretive policy analysis approach was conducted from July to December 2010 in two phases. First, data on access to HIV, AIDS and sexual and reproductive health services were collected using in-depth interviews with twenty couples purposively sampled in matrilineal Chiradzulu and patrilineal Chikhwawa communities. Secondly, data were collected from Malawi policies and guidelines on HIV, AIDS and sexual and reproductive health. The documents were reviewed for content on marriage and childbearing for couples living with HIV. Data were analysed using framework approach for applied policy analysis.

RESULTS

Four categories emerged from each phase. From the study, we extracted health workers attitudes, weak linkage between HIV, AIDS and sexual and reproductive health services, contradictory messages between media and the hospitals and lack of information as factors directly related to guidelines and policies. Analysis of guidelines and policies showed non-prescriptiveness on issues of HIV, AIDS and reproduction: they do not reflect the social cultural experiences of couples living with HIV. In addition, there is; lack of clinical guidelines, external influence on adoption of the policies and guidelines and weak linkages between HIV and AIDS and sexual and reproductive health services.

CONCLUSION

This synthesis along with more detailed findings which are reported in other published articles, provide a strong basis for updating the policies and development of easy-to-follow guidelines in order to effectively provide services to couples living with HIV in Malawi.

Self-Reported Preconception Care of HIV-Positive Women of Reproductive Potential: A Retrospective Study

OBJECTIVES

We determined the proportion and correlates of self-reported pregnancy planning discussions (that is preconception counseling) that HIV-positive women reported to their family physicians (FPs), HIV specialists, and obstetrician/gynecologists (OB/Gyns).

METHODS

In a cross-sectional substudy, HIV-positive women of reproductive potential were asked whether their care providers discussed pregnancy planning. Logistic regression was used to calculate odds ratios for the correlates of preconception counseling.

RESULTS

A total of 431 eligible participants (median age 38, interquartile range = 32-43) reported having discussion with a physician (92% FP, 96% HIV specialists, and 45% OB/Gyns). In all, 34%, 41%, and 38% had their pregnancy planning discussion with FP, HIV specialist, and Ob/Gyns, respectively; 51% overall. In the multivariable model, significant correlates of preconception counseling were age (P = .02), marital status (P < .01), number of years living in Canada (P < .001), and age of youngest child (P < .01).

CONCLUSIONS

Preconception care in our cohort was suboptimal. We recommend that counseling on healthy preconception should be part of routine HIV care.

Barriers to Provider-Delivered Sexual Behavior Counseling for Youth Living with HIV/AIDS in the Democratic Republic of the Congo

AIMS

The study aimed to understand providers' role in delivering HIV transmission prevention counseling to youth living with HIV (YLWH).

METHODS

We conducted 14 in-depth interviews with providers in Kinshasa, DRC.

RESULTS

Providers' lack of knowledge and comfort in talking to youth about sex because of cultural and religious beliefs about sexuality, coupled with confusion about legal issues related to youth and contraception, made it difficult for them to effectively counsel youth.

IMPLICATIONS FOR PRACTICE AND POLICY

In order for providers to deliver effective prevention counseling to YLWH, clinics should follow adolescent-friendly clinic standards, provide counseling in an adolescent-friendly style, and institute an effective referral system for additional prevention services.

CONCLUSION

HIV prevention services can be improved through the creation of an adolescent-friendly environment and by providing "values clarification" and skill-based trainings so that providers are able to assess the role of their own beliefs and learn new skills.

Discussing childbearing with HIV-infected women of reproductive age in clinical care: a comparison of Brazil and the US

Despite long term access to highly active antiretroviral therapy in Brazil and the US, little is known about women's communication with their HIV provider regarding childbearing or the unmet need for reproductive counseling. We utilized identical survey questions to collect data from HIV-infected women of reproductive age in Rio de Janeiro (n = 180) and Baltimore (n = 181). We conducted univariate analyses to compare findings between samples of women and multivariate logistic regression to determine factors associated with childbearing desires, childbearing intentions, and provider communication among the combined sample of women (n = 361). Over one-third of women in Rio de Janeiro and nearly one-half of women in Baltimore reported the desire for future childbearing. Nevertheless, the majority of women in clinical care had not discussed future childbearing with their HIV provider. Even in countries with an advanced approach to HIV care, we found low and inadequate communication between providers and female patients about childbearing.

"Now here come the pills that are going to save your life": pharmacists' discussions of antiretroviral drugs in a context of life and death

HIV/AIDS has associated cultural and social meanings which shape communication. The disease is closely linked to the concepts of life and death. Antiretroviral therapy (ART) has brought hope and life, but its success is heavily dependent on strict adherence. Research has shown that patients and health professionals often find it difficult to talk about these topics. However, there is little research available which focuses on health professionals' and patients' discussion of ART. This paper thus presents some exploratory discussion of extracts from pharmacy interactions in an HIV context which illustrate how pharmacists talk about antiretrovirals (ARVs) with patients with particular reference to the concepts of life and death. Data are taken from 26 video pharmacist-patient interactions recorded in a South African HIV/AIDS pharmacy. A hybrid qualitative analytic approach enabled identification of three types of references to ART, including the need to take ART "for the rest of your life", ART as "saving your life" and ART as "making you better". Explicit references to death were infrequent. These references were often emphatic and there are several potential reasons for this. The pharmacists' communication appears to be influenced by the urgency of the disease, a desire to give patients hope and a need to "normalise" discussions of death and HIV. The importance of ensuring understanding of ARV dosage instructions and discouraging patients from seeking traditional healing also appears to affect communication. The disease, societal and cultural contexts are thus shown to be significant influences which shape discussions of ART. This study has a number of practical implications, which are discussed.

Patient-provider communication and reproductive health among HIV-positive women in Rio de Janeiro, Brazil

OBJECTIVE

To qualitatively assess the influence of patient-provider communication on contraceptive choice among HIV-positive women in the context of universal antiretroviral therapy (ART) access.

METHODS

Focus group discussions (FGD; n=3), in-depth (IDI; n=15) and freelist interviews (FLI; n=36) were conducted with HIV-positive women aged 18-40 years recruited from public health units in Rio de Janeiro/Brazil.

RESULTS

Of 70 participants, 49 used ART and the median time since HIV diagnosis was 6 years (range: 1-18). The majority of participants (71.4%) reported some degree of dissatisfaction with their health providers (usually lack of open dialogue) and a few reported experiences of stigma/prejudice during appointments. Intra, interpersonal and social factors modulated behaviors and reproductive health decisions, and those issues were rarely addressed by providers during HIV clinical care.

CONCLUSION

Despite dramatic increases in survival and life quality after universal ART implementation in Brazil, reproductive health issues are neglected by multiple cadres of HIV health providers. Communication on reproductive health issues remains fragmented and potentially contradictory, compromising care in these settings.

PRACTICE IMPLICATIONS

Adequate provider training to address reproductive health-related issues in a comprehensive, culturally sensitive manner and improved integration of HIV and reproductive health care are urgently needed in this setting.

Barriers to Adherence to Antiretroviral Treatment

Patient advocates were asked for their perspectives on the structural barriers to adherence to antiretroviral treatment among patients living with HIV. Poverty-related barriers were transport difficulties, food insecurity and patients’ receipt of a disability grant. Institutional barriers were long waiting times at clinics, negative experiences with clinic staff, low levels of health literacy and poor access to substance abuse treatment. Social and cultural barriers were the role of traditional healing practices, the influence of charismatic churches and perceived stigmatization. We offer a perspective on assisting patients living with HIV in addressing these key structural barriers to adherence.

Effect of patient-centered communication training on discussion and detection of nonadherence in glaucoma

PURPOSE

To assess communication about adherence and to determine the impact of communication skills training on physicians' approach to nonadherence.

DESIGN

Sociolinguistic analysis of videotaped community ophthalmologists' encounters with patients with glaucoma before and after training. Patients in both phases and physicians in phase I knew communication was being studied but not what the focus of the study was. In phase II, physicians knew the targeted communication behaviors.

PARTICIPANTS

Twenty-three ophthalmologists and 100 regularly scheduled patients with glaucoma (50 per phase).

METHODS

An educational program with videotaped vignettes of simulated patient encounters using audience response and role play to teach patient-centered communication skills, including a 4-step adherence assessment and the use of open-ended questions in ask-tell-ask sequences.

MAIN OUTCOME MEASURES

Physician eliciting an acknowledgment of nonadherence during a clinical encounter compared with acknowledgment of nonadherence during a postvisit research interview (primary outcome), and performance of targeted communication and substantive discussion of adherence.

RESULTS

After intervention, physicians increased the proportion of open-ended questions (15% vs 6%; P = 0.001) and specifically about medication taking (82% compared with 18% of encounters; P<0.001). Compared with the absence of ask-tell-ask communication, 32% of phase II encounters included a complete ask-tell-ask sequence, 78% included an ask-tell sequence, and 32% a tell-ask sequence (P<0.001). Three of 4 steps for assessment of adherence were more common in phase II, and substantial discussions of adherence occurred in 86% versus 30% of encounters (P<0.001). In phase II, physicians elicited acknowledgment of nonadherence in 78% (7/9) of those who acknowledged nonadherence in the postvisit interview compared with 25% in phase I (3/12; P = 0.03).

CONCLUSIONS

This study demonstrates that experienced community physicians significantly improved their communication strategies and ability to detect and address nonadherence after a 3-hour educational program.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Patient-centered communication to assess and enhance patient adherence to glaucoma medication

TOPIC

Using an understanding of a patient's difficulty in revealing nonadherence and patient-centered communication skills to identify and address barriers to adherence to glaucoma medication regimens.

CLINICAL RELEVANCE

In addition to cost and logistical difficulties with obtaining and administering medicine, a patient's adherence to medication is influenced by the balance between the perceived need for medication and concerns about taking medication.

METHODS

This article is based on both the author's clinical experience and peer-reviewed research on effective doctor-patient communication and assessment and management of nonadherence.

RESULTS

Three strategies have been identified that help physicians to detect and address problems with adherence: (1) a 4-step adherence assessment interview designed to detect nonadherence that decreases patient resistance to revealing nonadherence by applying a shared decision-making process and mitigating social undesirability; (2) asking open-ended questions in ask-tell-ask sequences; and (3) tailoring interventions to the patient's stage of readiness for change.

CONCLUSIONS

Patients conceal nonadherence because they want to be thought of by their physicians as good patients. They are driven to nonadherence by an imbalance between their perceived need for medication and their concerns about taking it. Patient-centered communication techniques can engage the patient in shared decision making about medication, thereby redefining the good patient as someone who works with his or her health care provider to address adherence barriers. Those barriers can be explored with open-ended questions designed to elicit the patient's understanding and concerns, to provide information, and to assess change in the patient's understanding and attitudes. Communication will be more effective if it is based on the patient's stage of readiness to adopt adherent self-management practices.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

[Relationship between physicians and HIV patients: influence on adherence and quality of life]

OBJECTIVE

To assess the influence of the relationship between people living with HIV/AIDS and health care providers on treatment adherence and quality of life.

METHODS

Qualitative study conducted in Mexico, in 2003, with informants recruited from HIV/AIDS support groups, non-governmental organizations, and infectious disease clinics in public hospitals. A total of 40 people living with HIV/AIDS and five support group leaders were interviewed. Data were collected using sociodemographic questionnaires and in-depth interviews exploring the experience of living with HIV/AIDS, including treatment, disease perception, quality of life, physical and emotional health, and relationship with physicians. Responses were recorded, transcribed and organized thematically based on codes using an inductive analysis.

RESULTS

Most respondents aged between 26 and 45 years. The main obstacles to care were related to lack of risk awareness and information among people living with HIV/AIDS and physicians. Physicians proved not to be well trained on HIV/AIDS care. During the follow-up care, most problems were related to inadequate treatment adherence mainly caused by poor communication with physicians and discrimination in public services.

CONCLUSIONS

Overall the problems identified were related to information deficiencies, physicians' lack of training and paternalism, and social stigmatization of people living with HIV/AIDS associated with the epidemic.

AIDS mortality, "race or color", and social inequality in a context of universal access to highly active antiretroviral therapy (HAART) in Brazil, 1999-2004

Highly active antiretroviral therapy (HAART) has led to a substantial increase in the survival of people living with AIDS, despite heterogeneities among individuals from different socioeconomic strata. The present paper analyzes AIDS deaths in Brazil during a period in which HAART became a key treatment regimen, exploring the hypothesis that "race or color" defines one dimension of socioeconomic inequality in Brazil. AIDS mortality, stratified by gender and "race or color", was calculated using data from the National Mortality System. The rates were highest among individuals classified as "black" and lower among those classified as "mixed-race", with a continuous increase among the later from 1999 to 2004 for men and women. Among individuals classified as "white", mortality rates remained stable among men, but not women. Median age at death among "mixed-race" individuals was lower for both men and women. Differential trends according to gender and "race or color" were highlighted by the present study, indicating the pressing need to further explore the underlying factors that might explain different mortality rates in a context of universal access.