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

Including the Household: Individual, Community and Household Factors Affecting Antiretroviral Therapy Adherence After ART Initiation in Cape Town, South Africa

Antiretroviral therapy (ART) adherence is crucial for health outcomes of people living with HIV (PLHIV), influenced by a complex interplay of individual, community, and household factors. This article focuses on the influence of household factors, as well as individual and community factors, on ART adherence among PLHIV in Cape Town who have recently initiated ART. Baseline data for a cluster-randomized controlled trial were collected from 316 PLHIV in 12 districts in Cape Town between 6th May 2021 and 22nd May 2022. Zero-inflated Poisson models, with cluster-adjusted standard errors, were used to analyse the association between individual, household, and community factors and ART adherence measures. At the household-level, household support was associated with both better self-rated adherence (exp(β) = 0.81, z =  - 4.68, p < 0.001) and fewer days when pills were missed (exp(β) = 0.65, z =  - 2.92, p = 0.003). Psychological violence (exp(β) = 1.37, z = 1.97, p = 0.05) and higher household asset scores (exp(β) = 1.29, z =  - 2.83, p = 0.05) were weakly associated with poorer ART adherence. At the individual-level, male gender (exp(β) = 1.37, z = 3.95, p < 0.001) and reinitiating ART (exp(β) = 1.35, z = 3.64, p < 0.001) were associated with worse self-rated ART adherence; higher education levels (exp(β) = 0.30 times, z =  - 3.75, p < 0.001) and better HIV knowledge (exp(β) = 0.28, z =  - 2.83, p = 0.005) were associated with fewer days where pills were missed. At the community-level, community stigma was associated with worse self-rated ART adherence (exp(β) = 1.24, z = 3.01, p = 0.003). When designing interventions to improve ART adherence, household, individual and community factors should all be considered, particularly in addressing gender-based disparities, reducing stigma, tackling violence, and enhancing household support.Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.

Experiences of people living with HIV in low- and middle-income countries and their perspectives in self-management: a meta-synthesis

INTRODUCTION

Availability of anti-retroviral treatment has changed HIV in to a manageable chronic disease, making effective self-management essential. However, only a few studies in low- and middle-income countries (LMICs) reported experiences of people living with HIV (PLWH) on self-management.

METHODS

This meta-synthesis of qualitative studies investigated perspectives of PLWH in LMICs on self-management. Various databases, including PubMed, EMBASE, EBSCO, and CINHAL, were searched through June 2022. Relevant additional articles were also included using cross-referencing of the identified papers. We used a thematic synthesis guided by the "Model of the Individual and Family Self-Management Theory" (IFSMT).

RESULT

PLWH in LIMICs experience a variety of challenges that restrict their options for effective self-management and compromises their quality of life. The main ones include: misconceptions about the disease, poor self-efficacy and self-management skills, negative social perceptions, and a non-patient-centered model of care that reduces the role of patients. The experiences that influenced the ability to practice self-management are summarized in context (the condition itself, physical and environmental factors, individual and family factors) and process factors (knowledge and beliefs, relationship with the health care worker, self-regulation skills and abilities, and social facilitation). Context and process greatly impacted quality of life through the self-management practices of the patients.

CONCLUSION AND RECOMMENDATION

PLWH encounter multiple challenges, are not empowered enough to manage their own chronic condition, and their needs beyond medical care are not addressed by service providers. Self-management practice of these patients is poor, and service providers do not follow service delivery approaches that empower patients to be at the center of their own care and to achieve an effective and sustainable outcome from treatment. These findings call for a comprehensive well thought self-management interventions.

The effect of family support on self-reported adherence to ART among adolescents perinatally infected with HIV in Uganda: A mediation analysis

INTRODUCTION

This study examined the mechanisms through which family support affects self-reported adherence to antiretroviral therapy among adolescents perinatally infected with HIV in Uganda.

METHODS

Longitudinal data from 702 adolescent boys and girls (10-16 years) were analyzed. Structural equation models were conducted to assess the direct, indirect, and total effects of family support on adherence.

RESULTS

Results showed a significant indirect effect of family support on adherence (β = .112, 95% confidence interval [CI]: 0.052-0.173, p < .001). Specific indirect effects of family support through saving attitudes (β = .058, 95% CI: 0.008-0.108, p = .024), and communication with the guardian (β = .056, 95% CI: 0.012-0.100), p = .013), as well as the total effect of family support on adherence (β = .146 (95% CI: 0.032-0.259, p = .012), were statistically significant. Mediation contributed 76.7% of the total effects.

CONCLUSION

Findings support strategies to help promote family support and strengthen open communication between adolescents living with HIV and their caregivers.

The determinants of willingness to care for people living with HIV-AIDS: A cross-sectional study in Indonesia

Acceptance and willingness to care for people living with HIV-AIDS (PLHA) in society is still a concern. The purpose of this study is to analyse the determinants of willingness to care for PLHA in Indonesia. A cross-sectional study was conducted to process the secondary data from the Indonesian Demographic Health Survey (IDHS) conducted in 2017. A total sample of 13,731 individuals was obtained by a two-stage stratified cluster sampling technique. The variables used were socioeconomic characteristics (age, sex, education, wealth quintile, residence, employment status and earnings), knowledge about HIV-AIDS, information about HIV-AIDS and willingness to care for PLHA. Binary logistic regressions were used to analyse the data. According to the data from IDHS 2017, 71.84% of total respondents in Indonesia are willing to care for PLHA. Female respondents, individuals in all wealth quintiles and those who have more information are more likely to care for PLHA. Respondents aged 35-49 years old and currently working are less likely to care for PLHA. However, level of education, level of knowledge, residence and earnings are not related willingness to care for PLHA. The dissemination of correct and accurate information about HIV-AIDS can help the community and society understand this condition. Thus, community members can accept PLHA and become more willing to provide care. The government can determine further policies for the appropriate dissemination of information, maximally and in accordance with recommendations. Collaborations among the government, health workers and the community are needed.

Social and Structural Determinants of Household Support for ART Adherence in Low- and Middle-Income Countries: A Systematic Review

Adherence to HIV antiretroviral therapy (ART) is a crucial factor in health outcomes for people living with HIV (PLWH). Interventions to support ART adherence are increasingly focused on the household as a source of social support. This review aims to examine the social and structural determinants of support for ART adherence within households and families in low- and middle-income countries (LMICs). The review methodology followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Seven databases were searched for peer-reviewed literature. The terms searched thematically covered (1) ART adherence, (2) household and family and (3) support and care. Thirty-three studies conducted in 15 LMICs were selected and a mixed methods synthesis was undertaken. Social and structural determinants affected the type, quality and amount of support for PLWH of all ages, which affected PLWH's ART adherence. Gender norms affected the type of support that household members give to PLWH. Education moderated household support for ART adherence through literacy and language skills. Cultural context, religious beliefs, and social norms reinforced or undermined household support for ART adherence. Stigma affected disclosure, generated secrecy around giving medication and impeded access to support from the community. Supporting PLWH exacerbated economic hardship for household members. Health system dysfunction negatively impacted trust and communication between household members and health professionals. Intersecting social and structural determinants particularly affected the care given by household members who were older, female, with little education and low socioeconomic status. Household members were able to overcome some of these barriers when they received support themselves. Household interventions to support PLWH's ART adherence should take structural factors into account to have maximum impact.

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

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

Medication adherence and barriers among low-income, uninsured patients with multiple chronic conditions

BACKGROUND

Poor adherence to long-term therapies is a public health concern that affects all populations. Little is known about the context of adherence in chronic diseases for the uninsured population in the United States.

OBJECTIVE

To evaluate medication adherence and barriers among low-income, uninsured adults recently initiating new therapy for a chronic disease.

METHODS

A cross-sectional study in two Community Health Centers located in Chatham County, Georgia, was performed between September and December 2015. Patients, randomly selected for inclusion in the study, were eligible if they had been prescribed medication for 2 or more chronic conditions and had recently started a new medication regimen. The Morisky-Green-Levine questionnaire was used to assess adherence. Potential barriers were analyzed using the Multidimensional Model proposed by the World Health Organization-social and economic, healthcare team and system-related, condition-related, therapy-related, and patient-related factors. Multivariate logistic regression models were used to analyze factors associated with non-adherence.

RESULTS

A total of 150 participants were interviewed at 6 months after treatment initiation. Non-adherence was reported by 52% of the participants. Higher adjusted odds of non-adherence were observed in participants who did not receive information about their medications (adjusted odds ratio [AOR] = 2.40, 95% confidence interval [CI] = 1.01-5.74), did not regularly visit a primary health-care provider (AOR = 2.74, 95% CI = 1.09-6.88), and had changes in their treatment (AOR = 3.75, 95% CI = 1.62-8.70). Alternatively, adjusted odds of non-adherence were lower for patients who reported using pillboxes (AOR = 0.31, 95% CI = 0.10-0.95), having help from a caregiver (AOR = 0.15, 95% CI = 0.04-0.60), and integrating medication dosing into daily routines (AOR = 0.18, 95% CI = 0.06-0.59).

CONCLUSIONS

Medication non-adherence was common among low-income, uninsured patients initiating therapy for chronic conditions. Several modifiable barriers highlight opportunities to address medication non-adherence through multidisciplinary interventions.

Facilitators and Barriers Affecting Adherence Among People Living With HIV/AIDS: A Qualitative Perspective

Background:

It is widely accepted that for HIV-positive persons on highly active antiretroviral treatment, high levels of adherence to treatment regimens are essential for promoting viral suppression and preventing drug resistance.

Objectives:

This qualitative study examines factors affecting the adherence to HIV/AIDS treatment among patients with HIV/AIDS at a local hospital in Malaysia.

Methods:

The data from purposefully selected patients were collected by in-depth interviews using a pretested interview guide. Saturation was reached at the 13th interview. All interviews were audio-taped and transcribed verbatim for analysis using thematic content analysis.

Results:

Fear and stigma of perceived negative image of HIV diagnosis, lack of disease understating, poor support from the community, and perceived severity or the treatment side effects were among the reasons of nonadherence. Appropriate education and motivation from the doctors and reduction in pill burden were suggested to improve adherence.

Conclusion:

Educational interventions, self-management, and peer and community supports were among the factors suggested to improve adherence. This necessitates uncovering efficient ways to boost doctor–patient communication and recognizing the role of support group for the social and psychological well-being of the patients.

Caregivers' Support Network Characteristics Associated with Viral Suppression among HIV Care Recipients

Informal care receipt is associated with health outcomes among people living with HIV. Less is known about how caregivers' own social support may affect their care recipient's health. We examined associations between network characteristics of informal caregivers and HIV viral suppression among former or current drug using care recipients. We analyzed data from 258 caregiver-recipient dyads from the Beacon study, of whom 89% of caregivers were African American and 59% were female. In adjusted logistic regression analysis, care recipients had lower odds of being virally suppressed if their caregiver was female, was caring for youth involved in the criminal justice system, and had network members who used illicit drugs. Caregivers' greater numbers of non-kin in their support network was positively associated with viral suppression among care recipients. The findings reveal contextual factors affecting ART outcomes and the need for interventions to support caregivers, especially HIV caregiving women with high-risk youth.

Spousal role and caregiver burden in HIV affected families in Anhui Province, China

This study examined the burden experienced by various roles of family caregivers of people living with HIV (PLH), in particular spouses vs. non-spouses. A total of 475 family members of PLH were recruited from Anhui Province, China. Participants responded to a survey using the Computer Assisted Personal Interview method. The assessment collected data on demographic characteristics and their perceived caregiver burden, which was compared between spouses and non-spouses. Multiple regression models were built to identify factors associated with caregiver burden. About 64.4% of our study participants were female and the mean age was 42.1 years. Among various relationships to PLH, almost half reported being a spouse. Spouses reported significantly higher caregiver burden than non-spouses. In addition, older age and lower family income were significantly associated with higher level of caregiver burden. Among the subsample of spouses, significantly higher level of caregiver burden was identified among wives. Future studies should give special consideration to address the needs of female spouses in order to reduce their caregiver burden.

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

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

Dismantling the Silence: LGBTQ Aging Emerging From the Margins

Historical, environmental, and cultural contexts intersect with aging, sexuality, and gender across communities and generations. My scholarship investigates health and well-being over the life course across marginalized communities, including LGBTQ (lesbian, gay, bisexual, transgender, and queer) midlife and older adults, native communities experiencing cardiovascular risk, and families in China living with HIV, in order to balance the realities of unique lives in contemporary society. By probing the intersection of age, sexuality, and gender, my analysis is informed by both personal and professional experiences. With the death of my partner occurring at a time of profound invisibility and silence before HIV/AIDS, I found my life out of sync, experiencing a loss without a name. My life was thrust into a paradox: My relationship was defined by a world that refused to recognize it. This essay provides an opportunity for me to weave together how such critical turning points in my own life helped shape my approach to gerontology and how gerontology has informed my work and life. Reflecting on this journey, I illustrate the ways in which historical, structural, environmental, psychosocial, and biological factors affect equity, and the health-promoting and adverse pathways to health and well-being across marginalized communities. Although gerontology as a discipline has historically silenced the lives of marginalized older adults, it has much to learn from these communities. The growing and increasingly diverse older adult population provides us with unique opportunities to better understand both cultural variations and shared experiences in aging over the life course.

Enroling and retaining human immunodeficiency virus (HIV) patients in their care: A metasynthesis of qualitative studies

OBJECTIVES

To report the findings of a metasynthesis review of qualitative studies on patient and provider experiences and perspectives on linkage and retention in HIV care.

DESIGN

The review is an extraction, aggregation, interpretation and synthesis of qualitative findings based on the Sandelowski and Barroso method.

DATA SOURCES

A search of the literature was conducted in the databases Cumulative Index to Nursing and Allied Health, PubMed and PsycInfo for articles published from 2008 to 2013. Inclusion criteria were qualitative research articles published in English from across the world and in peer-reviewed journals. Literature reviews, conference abstracts and grey literature were excluded from this metasynthesis.

REVIEW METHODS

The review consisted of a) comprehensive search, b) study classification, c) abstraction of findings, d) synthesis. Of the 4640 citations screened, 69 articles were included for this metasynthesis.

RESULTS

69 unique articles from 44 countries were included. This metasynthesis takes into account the perspectives of at least 2263 HIV-positive participants (740 men, 1008 women, 78 transgender individuals and 437 unspecified sex) and 994 healthcare providers, family members and community members. The most salient barriers and facilitators to HIV linkage and retention in HIV care affirm ecological factors that are mostly beyond individual patients' control. Triadic streams of influence concurrently affect care engagement that include a person's psychological state upon diagnosis and their informational challenges (intrapersonal stream); one-on-one interactions with providers and their immediate community (social stream); and life demands, overall quality of care experiences and other structural barriers (cultural-attitudinal stream). Each stream's influence on HIV care engagement varies at any given point to reflect an individual's evolving and unique experiences with HIV infection throughout the illness trajectory.

CONCLUSION

There is sufficient evidence that detail how to best link and retain patients in HIV care. Themes identified indicate going beyond individual-level factors and towards shifting attention and resources to systems that patients navigate. Forceful structural-level actions are needed to correct these long-identified barriers and enhance care engagement facilitators.

Exploring Coping and Social Support with Gender and Education Among People Living with HIV in China

Social support promotes positive coping strategies among people living with HIV (PLH); however, little is known about the various aspects of social support and their distinct effects on coping. The present study investigates the specific links between coping and perceived social support with respect to gender and education among PLH. A total of 522 PLH in Anhui, China, participated in an assessment that collected data on demographics, perceived tangible and emotional support, and cognitive and behavioral coping. The assessment was conducted using the computer-assisted personal interviewing method. The data were analyzed using linear mixed models. Emotional support was significantly associated with both cognitive and behavioral coping. Tangible support was significantly associated with behavioral coping but not with emotional coping. Women reported significantly lower levels of emotional support, cognitive coping, and behavioral coping than men did. Significant associations between tangible support and coping were found only among illiterate males. Women living with HIV are in greater need of social support and coping strategies. Future interventions should be gender specific, with targeted support for women with lower education levels to enhance their coping strategies.

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

OBJECTIVES

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

Perceived Family Support and Antiretroviral Adherence in HIV-Positive Individuals: Results from a Community-Based Positive Living With HIV Study

The purpose of this study was to examine the association between perceived family support, either positive or negative, and adherence to antiretroviral medication regimens among HIV-positive individuals in the Kathmandu Valley, Nepal. We measured past 3-month antiretroviral adherence among 233 HIV-positive individuals, in relation to perceived family support, both positive (in terms of emotional and instrumental support) and negative (in the form of negative interactions), using the 10-item Nepali Family Support and Difficulty Scale. Medium and high levels of perceived emotional support from family were associated with reduced risk of antiretroviral nonadherence, compared with low levels of perceived emotional support (adjusted odds ratio [AOR]  = 0.37, 95% confidence interval [CI] [0.16, 0.88], and AOR  = 0.23, 95% CI [0.08, 0.64], respectively). Conversely, higher levels of felt emotional distance (AOR  = 1.46, 95% CI [1.00, 2.14]) and experienced physical harm (AOR  = 2.04, 95% CI [1.07, 3.91]) were associated with increased risk of nonadherence. The results support the recommendation that service providers need to be aware of the significant role of family support in shaping antiretroviral adherence and to consider ways to strengthen positive family support while minimizing negative family interactions to increase adherence rates.

Emotional social support and access to care among older people living with HIV in rural China

OBJECTIVES

Globally, the number of older people living with HIV (PLH) is growing. Additionally, older PLH are facing particular challenges related to accessing health care. The objective of this study is to investigate the older PLH's access to care and its relationship to emotional and tangible social support.

METHODS

A cross-sectional study was conducted among 225 PLH who were 50 years of age or older in Anhui, China. A computer-assisted personal interview was used to collect the participants' demographic characteristics, perceived health status, and access to care. The following two dimensions of social support were measured: emotional support and tangible support. The association between emotional/tangible support and access to care was calculated using Pearson's/point-biserial correlations and with multiple linear regression.

RESULTS

Higher tangible support was reported by the participants who were married or living with a partner, those who had higher annual income levels, and those with better perceived health status. Emotional support was correlated with higher education, higher income, and better perceived health status. Multiple regression analyses showed that access to care was significantly associated with emotional support (β = 0.2807, p < 0.0001) but not with tangible support (β = -0.0183, p = 0.7922).

CONCLUSIONS

The study findings point to the importance of providing emotional support for older PLH. It is suggested that emotional support should be provided for older PLH in addition to tangible assistance, in order to engage them in treatment and care.

"Please Don't Make Me Ask for Help": Implicit Social Support and Mental Health in Chinese Individuals Living with HIV

China faces a growing HIV epidemic; psychosocial needs of HIV-positive individuals remain largely unaddressed. Research is needed to consider the gap between need for mental healthcare and lack of sufficiently trained professionals, in a culturally acceptable manner. This study assessed explicit and implicit forms of social support and mental health symptoms in 120 HIV-positive Chinese. Explicit social support refers to interactions involving active disclosure and discussion of problems and request for assistance, whereas implicit social support refers to the emotional comfort one obtains from social networks without disclosing problems. We hypothesized and found using multiple linear regression, that after controlling for demographics, only implicit, but not explicit social support positively predicted mental health. Future research is warranted on the effects of utilizing implicit social support to bolster mental health, which has the potential to circumvent the issues of both high stigma and low professional resources in this population.

Nurse-delivered counselling intervention for parental HIV disclosure: results from a pilot randomized controlled trial in China

OBJECTIVE

The objective of this study was to design and conduct a preliminary evaluation of an intervention to assist parents in decision-making about disclosure of their HIV diagnosis to their children.

DESIGN

This was a pilot randomized controlled trial (RCT) with blinded assessment. Participants were randomized to intervention or treatment-as-usual (TAU) arms.

SETTING

The study occurred at an outpatient HIV primary care centre in Shanghai, China.

PARTICIPANTS

Participants were 20 HIV-positive outpatients with at least one child (13-25 years old) who was unaware of the parent's HIV diagnosis.

INTERVENTION

The nurse-delivered intervention involved three, hour-long, individual sessions over 4 weeks. Intervention content comprised family assessment, discussion of advantages and disadvantages of disclosure, psycho-education about cognitive, social and emotional abilities of children at different developmental stages, and disclosure planning and practicing via role-plays.

MAIN OUTCOME MEASURE(S)

Primary study outcomes for intervention versus TAU arms were self-reported disclosure distress, self-efficacy, and behaviours along a continuum from no disclosure to full disclosure and open communication about HIV.

RESULTS

In all cross-sectional (Wald tests) and longitudinal (general estimating equations) analyses, at both postintervention (4 weeks) and follow-up (13 weeks), effects were in the hypothesized directions. Despite the small sample size, most of these between-arm comparisons were statistically significant, with at least one result for each outcome indicating a 'large' effect size.

CONCLUSION

Our results suggest that nurses are able to deliver a counselling intervention in a clinic setting with the potential to alleviate parental distress around HIV disclosure to their children. Findings warrant future trials powered for efficacy.

Medication adherence is associated with having a caregiver among cardiac patients

BACKGROUND

Medication non-adherence is a significant contributor to suboptimal control of blood pressure and lipids.

PURPOSE

This study determined if having a paid and/or family caregiver was associated with medication adherence in patients hospitalized for cardiovascular disease.

METHODS

Consecutive patients admitted to the cardiovascular service at a university medical center who completed a standardized questionnaire about medication adherence and caregiving (paid/professional or family member/friend) were included in this analysis (N = 1,432; 63 % white; 63%male).

RESULTS

Among cardiac patients, 39 % reported being prescribed ≥ 7 different medications, and one in four reported being non-adherent to their medication(s). Participants who reported having/planning to have a paid caregiver were 40 % less likely to be non-adherent to their medications compared to their counterparts. The association remained significant after adjustment for demographic confounders and comorbid conditions (OR = 0.49; 95 %CI = 0.29-0.82).

CONCLUSION

Cardiac patients with a paid caregiver were half as likely to be non-adherent to medications as those without caregivers.

Efficacy of an evidence-based ARV adherence intervention in China

We designed a randomized controlled trial of a home based intervention to improve antiretroviral adherence and to assess the impact of depressive symptoms among people living with HIV in Hunan, China. At baseline, 110 subjects reported taking 90% or less of prescribed medication. At 6 months, when the intervention ended, 56% of subjects in the control and 87% of subjects in the experimental group were adherent. This difference was maintained at 12 months. In multivariate analyses, controlling for baseline visual analogue adherence scale, stigma, social support, and Center for Epidemiological Studies Depression scale, the experimental group had a significantly higher proportion of people who were adherent (p=0.009). The high prevalence of significant depressive symptoms (67%) at baseline is of concern. It is of particular importance that future studies look at the types of depression likely to be seen in these patients and differentiate early between those likely to benefit from HIV-related support and those who will require additional depression-targeted interventions.

6MP adherence in a multiracial cohort of children with acute lymphoblastic leukemia: a Children's Oncology Group study

Durable remissions in children with acute lymphoblastic leukemia (ALL) require a 2-year maintenance phase that includes daily oral 6-mercaptopurine (6MP). Adherence to oral 6MP among Asian-American and African-American children with ALL is unknown. We enrolled 298 children with ALL (71 Asian Americans, 68 African Americans, and 159 non-Hispanic whites) receiving oral 6MP for the maintenance phase. Adherence was measured electronically for 39 803 person-days. Adherence declined from 95.0% (month 1) to 91.8% (month 5, P < .0001). Adherence rates were significantly (P < .0001) lower in Asian Americans (90.0% ± 4.9%) and African Americans (87.1% ± 4.4%), as compared with non-Hispanic whites (95.2% ± 1.3%). Race-specific sociodemographic characteristics helped explain poor adherence (African Americans: low maternal education [less than a college degree: 78.9%, vs at least college degree: 94.6%; P < .0001]; Asian Americans: low-income households [<$50 000: 84.5%, vs ≥$50 000: 96.7%; P = .04]; households without mothers as full-time caregivers [85.6%] vs households with mothers as full-time caregivers [97.2%; P = .05]). Adherence rate below 90% was associated with increased relapse risk (hazard ratio, 3.9; P = .01). Using an adherence rate <90% to define nonadherence, 20.5% of the participants were nonadherers. We identify race-specific determinants of adherence, and define a clinically relevant level of adherence needed to minimize relapse risk in a multiracial cohort of children with ALL. This trial was registered at www.clinicaltrials.gov as #NCT00268528.

Engagement with Health Care Providers Affects Self- Efficacy, Self-Esteem, Medication Adherence and Quality of Life in People Living with HIV

The engagement of patients with their health care providers (HCP) improves patients' quality of life (QOL), adherence to antiretroviral therapy, and life satisfaction. Engagement with HCP includes access to HCP as needed, information sharing, involvement of client in decision making and self-care activities, respect and support of the HCP for the client's choices, and management of client concerns. This study compares country-level differences in patients' engagement with HCP and assesses statistical associations relative to adherence rates, self-efficacy, self-esteem, QOL, and symptom self-reporting by people living with HIV (PLHIV). A convenience sample of 2,182 PLHIV was enrolled in the United States, Canada, Puerto Rico, Namibia, and China. Cross-sectional data were collected between September 2009 and January 2011. Inclusion criteria were being at least 18 years of age, diagnosed with HIV, able to provide informed consent, and able to communicate in the local language with site researchers. In the HCP scale, a low score indicated greater provider engagement. Country comparisons showed that PLHIV in Namibia had the most HCP engagement (OR 2.80, p < 0.001) and that PLHIV in China had the least engagement (OR -7.03, p < 0.0001) compared to the PLHIV in the Western countries. Individuals having better HCP engagement showed better self-efficacy for adherence (t = -5.22, p < 0.0001), missed fewer medication doses (t = 1.92, p ≤ 0.05), had lower self-esteem ratings (t = 2.67, p < 0.01), fewer self-reported symptoms (t = 3.25, p < 0.0001), and better overall QOL physical condition (t = -3.39, p < 0.001). This study suggests that promoting engagement with the HCP is necessary to facilitate skills that help PLHIV manage their HIV. To improve ART adherence, HCPs should work on strategies to enhance self-efficacy and self-esteem, therefore, exhibiting fewer HIV-related symptoms and missing less medication doses to achieve better QOL.

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

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

The paradox of family support: concerns of tuberculosis-infected HIV patients about involving family and friends in their treatment

Despite the widely documented evidence that family support improves adherence to HIV treatment, some studies have reported no benefit or even a negative association between family support and adherence. This study reexamined the role of family support in treatment adherence to find out the circumstances under which family support for HIV and tuberculosis coinfected patients promotes or hinders treatment adherence in Cross River State, Nigeria. We conducted eight focus group discussions (FGDs) and four case histories with coinfected patients. In addition, 21 in-depth interviews (IDIs) were conducted with: 8 family members, 6 friends, and 7 care providers. Data were analyzed in a thematic format with the aid of NVIVO software. Overall, family support promotes adherence in coinfected patients. Family support may, however, have a negative effect on adherence when the recipient perceives that the support is given with ulterior motives (e.g., gossiping about them and becoming indebted to the support givers) and when the recipient is the primary breadwinner and feels that this role is being undermined. Family support is useful as a tool for scaling up adherence but the usefulness is context-specific and mediated by the patient's subjective interpretation of the support givers' motives.