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Kromash J, Friedman EE, Devlin SA, Schmitt J, Flores JM, Ridgway JP. Exploring the Feasibility of an Electronic Tool for Predicting Retention in HIV Care: Provider Perspectives. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:671. [PMID: 38928919 PMCID: PMC11203889 DOI: 10.3390/ijerph21060671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/21/2024] [Accepted: 05/23/2024] [Indexed: 06/28/2024]
Abstract
Retention in care for people living with HIV (PLWH) is important for individual and population health. Preemptive identification of PLWH at high risk of lapsing in care may improve retention efforts. We surveyed providers at nine institutions throughout Chicago about their perspectives on using an electronic health record (EHR) tool to predict the risk of lapsing in care. Sixty-three percent (20/32) of providers reported currently assessing patients' risk for lapsing in care, and 91% (29/32) reported willingness to implement an EHR tool. When compared to those with other job roles, prescribers agreed (vs. neutral) that the tool would be less biased than personal judgment (OR 13.33, 95% CI 1.05, 169.56). Prescribers were also more likely to identify community health workers as persons who should deliver these interventions (OR 10.50, 95% CI 1.02, 108.58). Transportation, housing, substance use, and employment information were factors that providers wanted to be included in an EHR-based tool. Social workers were significantly more likely to indicate the inclusion of employment information as important (OR 10.50, 95% CI 1.11, 98.87) when compared to other participants. Acceptability of an EHR tool was high; future research should investigate barriers and evaluate the effectiveness of such a tool.
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Affiliation(s)
- Jacqueline Kromash
- Pritzker School of Medicine, University of Chicago, 924 E. 57th Street, Suite 104, Chicago, IL 60637, USA
| | - Eleanor E. Friedman
- Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago, 5841 S. Maryland Avenue, MC 5065, Chicago, IL 60637, USA
| | - Samantha A. Devlin
- Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago, 5841 S. Maryland Avenue, MC 5065, Chicago, IL 60637, USA
| | - Jessica Schmitt
- Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago, 5841 S. Maryland Avenue, MC 5065, Chicago, IL 60637, USA
| | - John M. Flores
- Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago, 5841 S. Maryland Avenue, MC 5065, Chicago, IL 60637, USA
| | - Jessica P. Ridgway
- Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago, 5841 S. Maryland Avenue, MC 5065, Chicago, IL 60637, USA
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2
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Dasgupta S, Tie Y, Beer L, Fagan J, Weiser J. Barriers to HIV Care by Viral Suppression Status Among US Adults With HIV: Findings From the Centers for Disease Control and Prevention Medical Monitoring Project. J Assoc Nurses AIDS Care 2021; 32:561-568. [PMID: 33769329 PMCID: PMC8628483 DOI: 10.1097/jnc.0000000000000249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Failure to maintain viral suppression may be attributed to suboptimal care engagement. Using data collected during 2015-2018, we describe nationally representative estimates of engagement in care among US adults with diagnosed HIV, overall and by viral suppression. Of those who felt they did not receive enough care, we described detailed information on barriers to care by viral suppression. We reported weighted percentages and evaluated differences between groups using Rao-Scott chi-square tests (p < .05). Persons who were not virally suppressed were less likely to be retained in care (57.3 vs. 90.8%). Common barriers to care included life circumstances that impeded receipt of care (50.0%), financial barriers (34.5%), and not feeling sick enough to take medicine (32.0%). Barriers to care varied by viral suppression status, and people who were not virally suppressed were more likely to report more than one barrier to care. These findings demonstrate that barriers can be multifaceted; addressing barriers to care by expanding comprehensive care models in HIV care settings could improve clinical outcomes among people with HIV.
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Affiliation(s)
- Sharoda Dasgupta
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Yunfeng Tie
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Linda Beer
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jennifer Fagan
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - John Weiser
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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3
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Bayisa L, Tadesse A, Mulisa D, Turi E, Tolosa T. Behavioral factors associated with delayed ART initiation among people living with HIV/AIDS (PLWH) in Nekemte referral Hospital, Western Ethiopia. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2021. [DOI: 10.1016/j.ijans.2021.100280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Norberg A, Nelson J, Holly C, Jewell ST, Lieggi M, Salmond S. Experiences of HIV-infected adults and healthcare providers with healthcare delivery practices that influence engagement in US primary healthcare settings: a qualitative systematic review. ACTA ACUST UNITED AC 2020; 17:1154-1228. [PMID: 30994499 DOI: 10.11124/jbisrir-2017-003756] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Andrea Norberg
- School of Nursing, Rutgers, The State University of New Jersey, Newark, USA.,The François Xavier Bagnoud Center, Rutgers, The State University of New Jersey, Newark, USA
| | - John Nelson
- School of Nursing, Rutgers, The State University of New Jersey, Newark, USA.,The François Xavier Bagnoud Center, Rutgers, The State University of New Jersey, Newark, USA
| | - Cheryl Holly
- School of Nursing, Rutgers, The State University of New Jersey, Newark, USA.,The Northeast Institute for Evidence Synthesis and Translation (NEST): a Joanna Briggs Institute Centre of Excellence
| | - Sarah T Jewell
- George F. Smith Library of the Health Sciences, Rutgers, The State University of New Jersey, Newark, USA
| | - Michelle Lieggi
- Fishbon Library, University of California San Francisco Medical Center, San Francisco, USA
| | - Susan Salmond
- School of Nursing, Rutgers, The State University of New Jersey, Newark, USA.,The Northeast Institute for Evidence Synthesis and Translation (NEST): a Joanna Briggs Institute Centre of Excellence
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Abstract
OBJECTIVE To estimate the proportion of US HIV-positive men who report a male HIV-negative/unknown status (HIV-discordant) sexual partner taking preexposure prophylaxis (PrEP), and the use of multiple HIV prevention strategies within partnerships. DESIGN The Medical Monitoring Project is a complex sample survey of US adults with diagnosed HIV. METHODS We used data collected during June 2016 to May 2018 among sexually active HIV-positive men who had at least one HIV-discordant male partner (N = 1871) to estimate the weighted prevalence of reporting at least one partner taking PrEP. Among HIV-discordant partnerships (N = 4029), we estimated PrEP use, viral suppression among HIV-positive partners, and condomless anal sex. We evaluated significant (P < 0.05) differences between groups using prevalence ratios with predicted marginal means. RESULTS Twenty-eight percent of sexually active HIV-positive MSM reported at least one HIV-discordant male partner taking PrEP. Twenty percent of HIV-discordant partners were reported to be taking PrEP; 73% were taking PrEP or the HIV-positive partner was virally suppressed. PrEP use was lower among black and Hispanic partners compared with white partners (12% and 19% vs. 27%). Fewer black than white MSM were in partnerships in which PrEP was used or the HIV-positive partner had sustained viral suppression (69% vs. 77%). Condomless anal intercourse was more prevalent in partnerships involving PrEP use and in partnerships involving either PrEP use or sustained viral suppression among the HIV-positive partner. CONCLUSION PrEP use was reported among one in five partners, with disparities between black and white partners. Increasing PrEP use and decreasing racial/ethnic disparities could reduce disparities in HIV incidence and help end the US HIV epidemic.
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Summers NA, Colasanti JA, Feaster DJ, Armstrong WS, Rodriguez A, Jain MK, Jacobs P, Metsch LR, del Rio C. Predictors for Poor Linkage to Care Among Hospitalized Persons Living with HIV and Co-Occurring Substance Use Disorder. AIDS Res Hum Retroviruses 2020; 36:406-414. [PMID: 31914790 DOI: 10.1089/aid.2019.0153] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Persons living with HIV (PLWH) with substance use disorders (SUD) remain a population difficult to engage in HIV care. Project HOPE (Hospital Visits as an Opportunity for Prevention and Engagement), a randomized controlled trial testing patient navigation with/without contingency management for PLWH with SUD, aimed to address this disparity. PLWH with SUD who were out of care were recruited from 11 hospitals across the United States from 2012 to 2014. Baseline socioeconomic factors, medical mistrust scores, and perceived discrimination surveys were collected at enrollment and evaluated for effects on linkage to care at the 6-month follow-up assessment. Linkage to care (attending an outpatient visit for HIV care), early linkage to care (attending first visit within 30 days of enrollment), and engagement in care (two HIV visits within the 6-month period) were determined by medical record abstraction, supplemented by self-report. Among 801 participants enrolled in the study (mean age 45 years, 33% women, and 73% African American), those who did not complete high school and with severe food insecurity had lower odds of being linked to care at 6 months. Those with high levels of medical mistrust, recent drug use, and who did not complete high school had lower odds of early linkage to care. Early linkage was associated with higher odds of engagement at 6 months and was mitigated by both patient navigator interventions (all p < .05). Addressing social determinants of health is critical to correct the disparity seen in HIV outcomes among PLWH with SUD. Identifying factors that alter the effect of interventions could help identify patients who would benefit most.
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Affiliation(s)
- Nathan A. Summers
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jonathan A. Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Emory Center for AIDS Research, Atlanta, Georgia, USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia, USA
| | - Daniel J. Feaster
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Wendy S. Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Emory Center for AIDS Research, Atlanta, Georgia, USA
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia, USA
| | - Allan Rodriguez
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mamta K. Jain
- Division of Infectious Diseases, Department of Medicine, UT Southwestern, Dallas, Texas, USA
| | - Petra Jacobs
- National Institute on Drug Abuse, Bethesda, Maryland, USA
| | - Lisa R. Metsch
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia, USA
- Department of Sociomedical Sciences, Columbia Millner School of Public Health, New York City, New York, USA
| | - Carlos del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Emory Center for AIDS Research, Atlanta, Georgia, USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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7
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Brincks AM, Shiu-Yee K, Metsch LR, del Rio C, Schwartz RP, Jacobs P, Osorio G, Sorensen JL, Feaster DJ. Physician Mistrust, Medical System Mistrust, and Perceived Discrimination: Associations with HIV Care Engagement and Viral Load. AIDS Behav 2019; 23:2859-2869. [PMID: 30879211 DOI: 10.1007/s10461-019-02464-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Medical mistrust is an important risk factor for many health outcomes. For individuals with HIV and substance use co-morbidities, mistrust may influence engagement with health care, and affect overall health and transmission risk. Medical mistrust can be measured by an individual's mistrust of his/her physician, or mistrust of the medical system. This study examined both types of mistrust among 801 substance-using individuals with uncontrolled HIV infection. The aims were to determine how physician mistrust, medical system mistrust, and discrimination experiences were associated with engagement in HIV primary care. Findings indicated higher levels of physician mistrust, but not medical system mistrust, were associated with a longer time since the last visit to an HIV provider. Longer time since seeing an HIV care provider was associated with higher viral load. This study refines our understanding of the relationship between mistrust and HIV care engagement for a large, diverse sample of substance-using individuals.
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8
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Hollingdrake O, Lui CW, Mutch A, Dean J, Howard C, Fitzgerald L. Factors affecting the decision to initiate antiretroviral therapy in the era of treatment-as-prevention: synthesis of evidence from qualitative research in high-income settings. AIDS Care 2018; 31:397-402. [PMID: 30311499 DOI: 10.1080/09540121.2018.1533235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The emergence of treatment-as-prevention has made early initiation of antiretroviral treatment (ART) a "universal" policy. This review synthesizes qualitative research findings on barriers and facilitators of ART initiation in Organization for Economic Co-operation and Development (OECD) countries published since 2010. Ten articles describing seven research studies were included in the review. Findings confirmed ART initiation as a complicated process involving careful deliberation of the personal risks and benefits of treatment within the broader contexts of everyday life for people living with HIV (PLHIV). They also highlight interpersonal dynamics and concern for the public as increasingly important factors in shaping the decision to initiate treatment. The review provides valuable information for understanding treatment behaviour and maximizing treatment options brought forth by new biomedical advances.
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Affiliation(s)
| | - Chi-Wai Lui
- a School of Public Health , University of Queensland , Brisbane , Australia
| | - Allyson Mutch
- a School of Public Health , University of Queensland , Brisbane , Australia
| | - Judith Dean
- a School of Public Health , University of Queensland , Brisbane , Australia
| | - Chris Howard
- b Department of Life and Program , Queensland Positive People , Brisbane , Australia
| | - Lisa Fitzgerald
- a School of Public Health , University of Queensland , Brisbane , Australia
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9
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Friedman EE, Dean HD, Duffus WA. Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Public Health Rep 2018; 133:392-412. [PMID: 29874147 DOI: 10.1177/0033354918774788] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP. METHODS We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article). RESULTS Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%). CONCLUSIONS This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.
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Affiliation(s)
- Eleanor E Friedman
- 1 Association of Schools and Programs of Public Health/CDC Public Health Fellowship Program, Atlanta, GA, USA.,2 Office of Health Equity, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.,3 Chicago Center for HIV Elimination and University of Chicago Department of Medicine, Chicago, IL, USA
| | - Hazel D Dean
- 4 Office of the Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Wayne A Duffus
- 2 Office of Health Equity, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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10
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Jaiswal J, Singer SN, Griffin Tomas M, Lekas HM. Conspiracy Beliefs Are Not Necessarily a Barrier to Engagement in HIV Care Among Urban, Low-Income People of Color Living with HIV. J Racial Ethn Health Disparities 2018; 5:1192-1201. [PMID: 29488174 DOI: 10.1007/s40615-018-0466-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/17/2018] [Accepted: 01/29/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND HIV-related "conspiracy beliefs" include ideas about the genocidal origin of HIV to target minority people, and the notion that a cure for HIV is being deliberately withheld. Previous literature suggests that these beliefs may negatively affect engagement in HIV care and ART adherence, but little is known about how people who are disengaged from care may think about these ideas. METHODS Twenty-seven semi-structured interviews were conducted with low-income Black and Latinx people living with HIV in NYC who were currently disengaged from, or recently re-engaged in, HIV care. FINDINGS The data suggest that HIV-related "conspiracy beliefs" are not necessarily a barrier to care. Regardless of whether or not people endorsed these ideas, participants were largely dismissive, and prioritized focusing on managing their HIV and overall health and life challenges. RECOMMENDATIONS Interventions aiming to improve ART adherence and retention in HIV care should focus on building trust between clinicians and populations that have experienced historical, as well as ongoing, marginalization. HIV care providers should ask patients open-ended questions specifically about their beliefs about HIV and ART in order to address potential suspicion. Moving away from the phrase "conspiracy beliefs" in favor of more neutral language, such as "HIV-related beliefs," can enable us to better understand these ideas in the context of people's daily lives. CONCLUSIONS Further research is needed to better understand how structural inequality may shape how people experience mistrust, and how mistrust may factor into the constellation of barriers to consistent engagement in HIV care.
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Affiliation(s)
- J Jaiswal
- Center for Health Identity, Behavior and Prevention Studies, New York University, 665 Broadway, Ste 800, New York, NY, 10012, USA. .,Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA.
| | - S N Singer
- Center for Health Identity, Behavior and Prevention Studies, New York University, 665 Broadway, Ste 800, New York, NY, 10012, USA
| | - M Griffin Tomas
- Center for Health Identity, Behavior and Prevention Studies, New York University, 665 Broadway, Ste 800, New York, NY, 10012, USA
| | - H-M Lekas
- Division of Social Solutions and Services Research, Nathan Kline Institute for Psychiatric Research, State of New York Office of Mental Health, Orangeburg, NY, USA
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Freeman R, Gwadz MV, Silverman E, Kutnick A, Leonard NR, Ritchie AS, Reed J, Martinez BY. Critical race theory as a tool for understanding poor engagement along the HIV care continuum among African American/Black and Hispanic persons living with HIV in the United States: a qualitative exploration. Int J Equity Health 2017. [DOI: http:/doi.org.10.1186/s12939-017-0549-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
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12
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Freeman R, Gwadz MV, Silverman E, Kutnick A, Leonard NR, Ritchie AS, Reed J, Martinez BY. Critical race theory as a tool for understanding poor engagement along the HIV care continuum among African American/Black and Hispanic persons living with HIV in the United States: a qualitative exploration. Int J Equity Health 2017. [DOI: http://doi.org.10.1186/s12939-017-0549-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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13
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Gwadz MV, Collins LM, Cleland CM, Leonard NR, Wilton L, Gandhi M, Scott Braithwaite R, Perlman DC, Kutnick A, Ritchie AS. Using the multiphase optimization strategy (MOST) to optimize an HIV care continuum intervention for vulnerable populations: a study protocol. BMC Public Health 2017; 17:383. [PMID: 28472928 PMCID: PMC5418718 DOI: 10.1186/s12889-017-4279-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/21/2017] [Indexed: 12/10/2023] Open
Abstract
BACKGROUND More than half of persons living with HIV (PLWH) in the United States are insufficiently engaged in HIV primary care and not taking antiretroviral therapy (ART), mainly African Americans/Blacks and Hispanics. In the proposed project, a potent and innovative research methodology, the multiphase optimization strategy (MOST), will be employed to develop a highly efficacious, efficient, scalable, and cost-effective intervention to increase engagement along the HIV care continuum. Whereas randomized controlled trials are valuable for evaluating the efficacy of multi-component interventions as a package, they are not designed to evaluate which specific components contribute to efficacy. MOST, a pioneering, engineering-inspired framework, addresses this problem through highly efficient randomized experimentation to assess the performance of individual intervention components and their interactions. We propose to use MOST to engineer an intervention to increase engagement along the HIV care continuum for African American/Black and Hispanic PLWH not well engaged in care and not taking ART. Further, the intervention will be optimized for cost-effectiveness. A similar set of multi-level factors impede both HIV care and ART initiation for African American/Black and Hispanic PLWH, primary among them individual- (e.g., substance use, distrust, fear), social- (e.g., stigma), and structural-level barriers (e.g., difficulties accessing ancillary services). Guided by a multi-level social cognitive theory, and using the motivational interviewing approach, the study will evaluate five distinct culturally based intervention components (i.e., counseling sessions, pre-adherence preparation, support groups, peer mentorship, and patient navigation), each designed to address a specific barrier to HIV care and ART initiation. These components are well-grounded in the empirical literature and were found acceptable, feasible, and promising with respect to efficacy in a preliminary study. METHODS/DESIGN Study aims are: 1) using a highly efficient fractional factorial experimental design, identify which of five intervention components contribute meaningfully to improvement in HIV viral suppression, and secondary outcomes of ART adherence and engagement in HIV primary care; 2) identify mediators and moderators of intervention component efficacy; and 3) using a mathematical modeling approach, build the most cost-effective and efficient intervention package from the efficacious components. A heterogeneous sample of African American/Black and Hispanic PLWH (with respect to age, substance use, and sexual minority status) will be recruited with a proven hybrid sampling method using targeted sampling in community settings and peer recruitment (N = 512). DISCUSSION This is the first study to apply the MOST framework in the field of HIV prevention and treatment. This innovative study will produce a culturally based HIV care continuum intervention for the nation's most vulnerable PLWH, optimized for cost-effectiveness, and with exceptional levels of efficacy, efficiency, and scalability. TRIAL REGISTRATION ClinicalTrials.gov, NCT02801747 , Registered June 8, 2016.
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Affiliation(s)
- Marya Viorst Gwadz
- Center for Drug Use and HIV Research, Rory Meyers College of Nursing, New York University, New York, NY, USA.
| | - Linda M Collins
- The Methodology Center and Department of Human Development and Family Studies, Pennsylvania State University, State College, Pennsylvania, PA, USA
| | - Charles M Cleland
- Center for Drug Use and HIV Research, Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Noelle R Leonard
- Center for Drug Use and HIV Research, Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Leo Wilton
- Department of Human Development, State University of New York at Binghamton, Binghamton, NY, USA
- Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - R Scott Braithwaite
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - David C Perlman
- Department of Infectious Diseases, Mount Sinai Beth Israel, New York, NY, USA
| | - Alexandra Kutnick
- Center for Drug Use and HIV Research, Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Amanda S Ritchie
- Center for Drug Use and HIV Research, Rory Meyers College of Nursing, New York University, New York, NY, USA
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Freeman R, Gwadz MV, Silverman E, Kutnick A, Leonard NR, Ritchie AS, Reed J, Martinez BY. Critical race theory as a tool for understanding poor engagement along the HIV care continuum among African American/Black and Hispanic persons living with HIV in the United States: a qualitative exploration. Int J Equity Health 2017; 16:54. [PMID: 28340589 PMCID: PMC5364619 DOI: 10.1186/s12939-017-0549-3] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 03/13/2017] [Indexed: 11/12/2022] Open
Abstract
Background African American/Black and Hispanic persons living with HIV (AABH-PLWH) in the U.S. evidence insufficient engagement in HIV care and low uptake of HIV antiretroviral therapy, leading to suboptimal clinical outcomes. The present qualitative study used critical race theory, and incorporated intersectionality theory, to understand AABH-PLWH’s perspectives on the mechanisms by which structural racism; that is, the macro-level systems that reinforce inequities among racial/ethnic groups, influence health decisions and behaviors. Methods Participants were adult AABH-PLWH in New York City who were not taking antiretroviral therapy nor well engaged in HIV care (N = 37). Participants were purposively sampled for maximum variation from a larger study, and engaged in semi-structured in-depth interviews that were audio-recorded and professionally transcribed verbatim. Data were analyzed using a systematic content analysis approach. Results We found AABH-PLWH experienced HIV care and medication decisions through a historical and cultural lens incorporating knowledge of past and present structural racism. This contextual knowledge included awareness of past maltreatment of people of color in medical research. Further, these understandings were linked to the history of HIV antiretroviral therapy itself, including awareness of the first HIV antiretroviral regimen; namely, AZT (zidovudine) mono-therapy, which was initially prescribed in unacceptably high doses, causing serious side effects, but with only modest efficacy. In this historical/cultural context, aspects of structural racism negatively influenced health care decisions and behavior in four main ways: 1) via the extent to which healthcare settings were experienced as overly institutionalized and, therefore, dehumanizing; 2) distrust of medical institutions and healthcare providers, which led AABH-PLWH to feel pressured to take HIV antiretroviral therapy when it was offered; 3) perceptions that patients are excluded from the health decision-making process; and 4) an over-emphasis on antiretroviral therapy compared to other non-HIV related priorities. We found that although participants were located at the intersection of multiple social categories (e.g., gender, social class, AABH race/ethnicity), race/ethnicity and social class were described as primary factors. Conclusions Critical race theory proved useful in uncovering how macro-level structural racism affects individual-level health decisions and behaviors. HIV clinical settings can counter-balance the effects of structural racism by building “structural competency,” and interventions fostering core self-determination needs including autonomy may prove culturally appropriate and beneficial for AABH-PLWH.
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Affiliation(s)
| | - Marya Viorst Gwadz
- Center for Drug Use and HIV Research (CDUHR), Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY, 10010, USA.
| | - Elizabeth Silverman
- Center for Drug Use and HIV Research (CDUHR), Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY, 10010, USA
| | - Alexandra Kutnick
- Center for Drug Use and HIV Research (CDUHR), Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY, 10010, USA
| | - Noelle R Leonard
- Center for Drug Use and HIV Research (CDUHR), Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY, 10010, USA
| | - Amanda S Ritchie
- Center for Drug Use and HIV Research (CDUHR), Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY, 10010, USA
| | - Jennifer Reed
- Center for Drug Use and HIV Research (CDUHR), Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY, 10010, USA
| | - Belkis Y Martinez
- Center for Drug Use and HIV Research (CDUHR), Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY, 10010, USA
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15
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Barroso J, Leblanc NM, Flores D. It's Not Just the Pills: A Qualitative Meta-Synthesis of HIV Antiretroviral Adherence Research. J Assoc Nurses AIDS Care 2017; 28:462-478. [PMID: 28286006 DOI: 10.1016/j.jana.2017.02.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 02/14/2017] [Indexed: 11/16/2022]
Abstract
Antiretroviral therapy (ART) improves the health and longevity of people living with HIV infection (PLWH) and also prevents transmission of the virus. Yet, lack of adherence to ART regimens has been a persistent problem, even with simpler regimens. Guidelines that deal with ART adherence are based almost solely on quantitative studies; this focus ignores the context and complexity of patients' lives. Guidelines are also focused on the individual. We argue that the solution is to include the broader communities in which patients live, and to deal with systemic disparities that persist worldwide; this can be done in part through demedicalizing HIV care for healthy PLWH. We present findings from a qualitative meta-synthesis of 127 studies conducted around the world on the last two pillars of the HIV treatment cascade: starting and remaining on ART until optimal viral suppression is achieved. We use Maslow's hierarchy of needs to frame our findings.
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16
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Blake Helms C, Turan JM, Atkins G, Kempf MC, Clay OJ, Raper JL, Mugavero MJ, Turan B. Interpersonal Mechanisms Contributing to the Association Between HIV-Related Internalized Stigma and Medication Adherence. AIDS Behav 2017; 21:238-247. [PMID: 26864692 DOI: 10.1007/s10461-016-1320-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Previous research suggests that people living with HIV (PLWH) sometimes internalize HIV-related stigma existing in the community and experience feelings of inferiority and shame due to their HIV status, which can have negative consequences for treatment adherence. PLWH's interpersonal concerns about how their HIV status may affect the security of their existing relationships may help explain how internalized stigma affects adherence behaviors. In a cross-sectional study conducted between March 2013 and January 2015 in Birmingham, AL, 180 PLWH recruited from an outpatient HIV clinic completed previously validated measures of internalized stigma, attachment styles, and concern about being seen while taking HIV medication. Participants also self-reported their HIV medication adherence. Higher levels of HIV-related internalized stigma, attachment-related anxiety (i.e., fear of abandonment by relationship partners), and concerns about being seen by others while taking HIV medication were all associated with worse medication adherence. The effect of HIV-related internalized stigma on medication adherence was mediated by attachment-related anxiety and by concerns about being seen by others while taking HIV medication. Given that medication adherence is vitally important for PLWH to achieve long-term positive health outcomes, understanding interpersonal factors affecting medication adherence is crucial. Interventions aimed at improving HIV treatment adherence should address interpersonal factors as well as intrapersonal factors.
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Affiliation(s)
- C Blake Helms
- The Department of Psychology, University of Alabama at Birmingham, 415 Campbell Hall, Birmingham, AL, 35294-1170, USA
| | - Janet M Turan
- Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ghislaine Atkins
- The Department of Psychology, University of Alabama at Birmingham, 415 Campbell Hall, Birmingham, AL, 35294-1170, USA
| | - Mirjam-Colette Kempf
- Department of Family, Community and Health Systems and Department of Health Behavior, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Olivio J Clay
- The Department of Psychology, University of Alabama at Birmingham, 415 Campbell Hall, Birmingham, AL, 35294-1170, USA
| | - James L Raper
- The Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael J Mugavero
- The Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bulent Turan
- The Department of Psychology, University of Alabama at Birmingham, 415 Campbell Hall, Birmingham, AL, 35294-1170, USA.
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17
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Gwadz M, de Guzman R, Freeman R, Kutnick A, Silverman E, Leonard NR, Ritchie AS, Muñoz-Plaza C, Salomon N, Wolfe H, Hilliard C, Cleland CM, Honig S. Exploring How Substance Use Impedes Engagement along the HIV Care Continuum: A Qualitative Study. Front Public Health 2016; 4:62. [PMID: 27092300 PMCID: PMC4824754 DOI: 10.3389/fpubh.2016.00062] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 03/21/2016] [Indexed: 11/13/2022] Open
Abstract
Drug use is associated with low uptake of HIV antiretroviral therapy (ART), an under-studied step in the HIV care continuum, and insufficient engagement in HIV primary care. However, the specific underlying mechanisms by which drug use impedes these HIV health outcomes are poorly understood. The present qualitative study addresses this gap in the literature, focusing on African-American/Black and Hispanic persons living with HIV (PLWH) who had delayed, declined, or discontinued ART and who also were generally poorly engaged in health care. Participants (N = 37) were purposively sampled from a larger study for maximum variation on HIV indices. They engaged in 1-2 h audio-recorded in-depth semi-structured interviews on HIV histories guided by a multilevel social-cognitive theory. Transcripts were analyzed using a systematic content analysis approach. Consistent with the existing literature, heavy substance use, but not casual or social use, impeded ART uptake, mainly by undermining confidence in medication management abilities and triggering depression. The confluence of African-American/Black or Hispanic race/ethnicity, poverty, and drug use was associated with high levels of perceived stigma and inferior treatment in health-care settings compared to their peers. Furthermore, providers were described as frequently assuming participants were selling their medications to buy drugs, which strained provider-patient relationships. High levels of medical distrust, common in this population, created fears of ART and of negative interactions between street drugs and ART, but participants could not easily discuss this concern with health-care providers. Barriers to ART initiation and HIV care were embedded in other structural- and social-level challenges, which disproportionately affect low-income African-American/Black and Hispanic PLWH (e.g., homelessness, violence). Yet, HIV management was cyclical. In collaboration with trusted providers and ancillary staff, participants commonly reduced substance use and initiated or reinitiated ART. The present study highlights a number of addressable barriers to ART initiation and engagement in HIV care for this vulnerable population, as well as gaps in current practice and potential junctures for intervention efforts.
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Affiliation(s)
- Marya Gwadz
- New York University College of Nursing, New York, NY, USA; Center for Drug Use and HIV Research, New York, NY, USA
| | | | - Robert Freeman
- New York University College of Nursing , New York, NY , USA
| | | | | | - Noelle R Leonard
- New York University College of Nursing, New York, NY, USA; Center for Drug Use and HIV Research, New York, NY, USA
| | | | | | - Nadim Salomon
- Peter Krueger Center for Immunological Disorders, Mount Sinai Beth Israel , New York, NY , USA
| | - Hannah Wolfe
- Mount Sinai St. Luke's-Roosevelt Hospital Center, Spencer Cox Center for Health , New York, NY , USA
| | - Christopher Hilliard
- New York University College of Nursing, New York, NY, USA; Center for Drug Use and HIV Research, New York, NY, USA
| | - Charles M Cleland
- New York University College of Nursing, New York, NY, USA; Center for Drug Use and HIV Research, New York, NY, USA
| | - Sylvie Honig
- New York University College of Nursing, New York, NY, USA; Center for Drug Use and HIV Research, New York, NY, USA
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18
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Gwadz M, Cleland CM, Applegate E, Belkin M, Gandhi M, Salomon N, Banfield A, Leonard N, Riedel M, Wolfe H, Pickens I, Bolger K, Bowens D, Perlman D, Mildvan D. Behavioral intervention improves treatment outcomes among HIV-infected individuals who have delayed, declined, or discontinued antiretroviral therapy: a randomized controlled trial of a novel intervention. AIDS Behav 2015; 19:1801-17. [PMID: 25835462 PMCID: PMC4567451 DOI: 10.1007/s10461-015-1054-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Nationally up to 60 % of persons living with HIV are neither taking antiretroviral therapy (ART) nor well engaged in HIV care, mainly racial/ethnic minorities. This study examined a new culturally targeted multi-component intervention to address emotional, attitudinal, and social/structural barriers to ART initiation and HIV care. Participants (N = 95) were African American/Black and Latino adults with CD4 < 500 cells/mm(3) not taking ART, randomized 1:1 to intervention or control arms, the latter receiving treatment as usual. Primary endpoints were adherence, evaluated via ART concentrations in hair samples, and HIV viral load suppression. The intervention was feasible and acceptable. Eight months post-baseline, intervention participants tended to be more likely to evidence "good" (that is, 7 days/week) adherence (60 vs. 26.7 %; p = 0.087; OR = 3.95), and had lower viral load levels than controls (t(22) = 2.29, p = 0.032; OR = 5.20), both large effect sizes. This highly promising intervention merits further study.
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Affiliation(s)
- Marya Gwadz
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - Charles M Cleland
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - Elizabeth Applegate
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - Mindy Belkin
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - Monica Gandhi
- Division of HIV/AIDS, Department of Medicine, University of California San Francisco (UCSF), San Francisco, CA, USA.
| | - Nadim Salomon
- Department of Infectious Diseases, Peter Krueger Center for Immunological Disorders, Mount Sinai Beth Israel, New York, NY, USA.
| | - Angela Banfield
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - Noelle Leonard
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - Marion Riedel
- School of Social Work, Columbia University, New York, NY, USA.
| | - Hannah Wolfe
- Mount Sinai St. Luke's-Roosevelt Hospital Center, Spencer Cox Center for Health, New York, NY, USA.
| | - Isaiah Pickens
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - Kelly Bolger
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - DeShannon Bowens
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - David Perlman
- Department of Infectious Diseases, Mount Sinai Beth Israel, New York, NY, USA.
| | - Donna Mildvan
- Department of Infectious Diseases, Mount Sinai Beth Israel, New York, NY, USA.
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19
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Allgood KL, Hunt B, Rucker MG. Black:White Disparities in HIV Mortality in the United States: 1990-2009. J Racial Ethn Health Disparities 2015; 3:168-75. [PMID: 26896117 DOI: 10.1007/s40615-015-0141-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 05/22/2015] [Accepted: 06/11/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The aim of this study was to assess whether racial disparities in human immunodeficiency virus (HIV) mortality in the USA have changed over time. METHODS Using vital records from the National Center for Health Statistics and census data from the US Census Bureau, we calculated the race- and gender-specific HIV mortality rates and corresponding racial rate ratios for non-Hispanic Blacks and non-Hispanic Whites in the USA for four 5-year increments from 1990-2009. Rates were age-adjusted using the 2000 USA standard population. Additionally, we calculated excess Black deaths for 2005-2009. RESULTS For the total, male, and female populations, we observed a statistically significant increase in the Black:White HIV mortality disparity between T1 (1990-1994) and T4 (2005-2009). The increasing disparity was due to the fact that the decrease in mortality rates from T1 to T4 was greater among Whites than Blacks. This disparity led to 5603 excess Black deaths in the USA at T4. CONCLUSIONS Previous research suggests that as HIV becomes more treatable, racial disparities widen, as observed in this study for both men and women. Existing disparities could be ameliorated if access to care were equal among these groups. Equal access would enable more individuals to achieve viral suppression, the final step of the HIV Care Continuum.
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Affiliation(s)
- Kristi L Allgood
- Sinai Urban Health Institute, Sinai Health System, 1500 S. Fairfield Avenue, K449, Chicago, IL, 60608, USA.
| | - Bijou Hunt
- Sinai Urban Health Institute, Sinai Health System, 1500 S. Fairfield Avenue, K449, Chicago, IL, 60608, USA
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20
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Newman CE, Mao L, Persson A, Holt M, Slavin S, Kidd MR, Post JJ, Wright E, de Wit J. 'Not Until I'm Absolutely Half-Dead and Have To:' Accounting for Non-Use of Antiretroviral Therapy in Semi-Structured Interviews with People Living with HIV in Australia. AIDS Patient Care STDS 2015; 29:267-78. [PMID: 25806574 DOI: 10.1089/apc.2014.0301] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Current debates regarding the use of antiretroviral therapy (ART) to promote both individual- and population-level health benefits underscore the importance of understanding why a subpopulation of people with diagnosed HIV and access to treatment choose not to use it. Semi-structured interviews were conducted between 2012 and 2014 with 27 people living with HIV in Australia who were not using ART at the time of interview. Analytic triangulation permitted an appreciation of not only the varied personal reasons for non-use of treatment, but also underlying views on HIV treatment, and the ideal conditions imagined necessary for treatment initiation. Policy goals to increase the number of people with HIV using ART must recognize the diverse explanations for non-use of ART, which include concerns about the various impacts of committing to lifelong pharmaceutical treatment use. Our research identified distinctive subgroups among people who are not using antiretroviral therapy, with a range of individual and social needs that may affect treatment decisions. These findings challenge assumptions about treatment non-use in resource-rich settings, revealing persistent consumer fears about the potent and unknown effects of HIV medications that deserve greater recognition in policy debate on treatment uptake.
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Affiliation(s)
- Christy E. Newman
- Centre for Social Research in Health, UNSW Australia, Sydney, Australia
| | - Limin Mao
- Centre for Social Research in Health, UNSW Australia, Sydney, Australia
| | - Asha Persson
- Centre for Social Research in Health, UNSW Australia, Sydney, Australia
| | - Martin Holt
- Centre for Social Research in Health, UNSW Australia, Sydney, Australia
| | - Sean Slavin
- Australian Federation of AIDS Organisations, Sydney, Australia
| | - Michael R. Kidd
- Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Jeffrey J. Post
- Department of Infectious Diseases, The Prince of Wales Hospital, Sydney, Australia
- Prince of Wales Clinical School, UNSW Australia, Sydney, Australia
| | - Edwina Wright
- Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, Australia
- The Burnet Institute, Melbourne, Australia
| | - John de Wit
- Centre for Social Research in Health, UNSW Australia, Sydney, Australia
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21
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Adedinsewo DA, Wei SC, Robertson M, Rose C, Johnson CH, Dombrowski J, Skarbinski J. Timing of antiretroviral therapy initiation in a nationally representative sample of HIV-infected adults receiving medical care in the United States. AIDS Patient Care STDS 2014; 28:613-21. [PMID: 25329710 PMCID: PMC4250960 DOI: 10.1089/apc.2014.0194] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Early antiretroviral therapy (ART) initiation reduces the risk of disease progression and HIV transmission, but data on time from HIV care entry to ART initiation are lacking. Using data from the Medical Monitoring Project (MMP), a population-based probability sample of HIV-infected adults receiving medical care in the United States, we assessed time from care entry to ART initiation among persons diagnosed May 2004-April 2009 and used multivariable Cox proportional-hazards models to identify factors associated with time to ART initiation. Among 1094 MMP participants, 83.9% reported initiating ART, with median time to ART initiation of 10 months. In multivariable models, blacks compared to whites [hazard ratio (HR) 0.82; 95% confidence interval (CI) 0.70-0.98], persons without continuous health insurance (HR 0.82; CI 0.70-0.97), heterosexual women and men who have sex with men compared to heterosexual men (HR 0.66; CI 0.51-0.85 and HR 0.71; CI 0.60-0.84, respectively), and persons without AIDS at care entry (HR 0.37; CI 0.31-0.43) had significantly longer times to ART initiation. Overall, time to ART initiation was suboptimal by current standards and significant disparities were noted among certain subgroups. Efforts to encourage prompt ART initiation should address delays among those without health insurance and among certain sociodemographic subgroups.
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Affiliation(s)
- Demilade A. Adedinsewo
- Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
- National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stanley C. Wei
- National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
- US Public Health Service, Atlanta, Georgia
| | - McKaylee Robertson
- Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
- National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Charles Rose
- National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christopher H. Johnson
- National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Julie Dombrowski
- Department of Medicine, University of Washington, Seattle, Washington
- Public health—Seattle and King County HIV/STD Program, Seattle, Washington
| | - Jacek Skarbinski
- National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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Beer L, Valverde EE, Raiford JL, Weiser J, White BL, Skarbinski J. Clinician Perspectives on Delaying Initiation of Antiretroviral Therapy for Clinically Eligible HIV-Infected Patients. J Int Assoc Provid AIDS Care 2014; 14:245-54. [PMID: 25394912 PMCID: PMC4426141 DOI: 10.1177/2325957414557267] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objectives: Guidelines for antiretroviral therapy (ART) initiation have evolved, but consistently note that adherence problems should be considered and addressed. Little is known regarding the reasons providers delay ART initiation in clinically eligible patients. Methods: In 2009, we surveyed a probability sample of HIV care providers in 582 outpatient facilities in the United States and Puerto Rico with an open-ended question about nonclinical reasons for delaying ART initiation in otherwise clinically eligible patients. Results: Very few providers (2%) reported never delaying ART. Reasons for delaying ART were concerns about patient adherence (68%), patient acceptance (60%), and structural barriers (33%). Provider and practice characteristics were associated with reasons for delaying ART. Conclusion: Reasons for delaying ART were consistent with clinical guidelines and were both patient level and structural. Providers may benefit from training and access to referrals for ancillary services to enhance their ability to monitor and address these issues with their patients.
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Affiliation(s)
- Linda Beer
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Eduardo E Valverde
- Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jerris L Raiford
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - John Weiser
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Becky L White
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Jacek Skarbinski
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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23
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Gwadz M, Applegate E, Cleland C, Leonard NR, Wolfe H, Salomon N, Belkin M, Riedel M, Banfield A, Sanfilippo L, Wagner A, Mildvan D. HIV-Infected Individuals Who Delay, Decline, or Discontinue Antiretroviral Therapy: Comparing Clinic- and Peer-Recruited Cohorts. Front Public Health 2014; 2:81. [PMID: 25077137 PMCID: PMC4100062 DOI: 10.3389/fpubh.2014.00081] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 06/29/2014] [Indexed: 01/05/2023] Open
Abstract
A substantial proportion of persons living with HIV/AIDS (PLHA) delay, decline, or discontinue antiretroviral therapy (ART) when it is medically indicated (40–45%), largely African-Americans and Latinos/Hispanics. This study explores the feasibility of locating PLHA, who are not on ART (PLHA-NOA) through clinics and peer-referral; compares the two cohorts on multi-level barriers to ART; and examines readiness to initiate/reinitiate ART, a predictor of treatment outcomes. We recruited adult HIV-infected African-American and Latino/Hispanic PLHA-NOA through HIV hospital clinics and peer-referral in 2012–2013. Participants were engaged in structured 1-h assessments with reliable/valid measures on barriers to ART. We found that recruitment through peers (63.2%, 60/95) was more feasible than in clinics (36.8%, 35/90). Participants were 48.0 years old and had lived with HIV for 14.7 years on average, and 56.8% had taken ART previously. Most (61.1%) were male and African-American (76.8%), and 23.2% were Latino/Hispanic. Peer-recruited participants were older, had lived with HIV longer, were less engaged in HIV care, and were more likely to have taken ART previously. The cohorts differed in reasons for discontinuing ART. Levels of ART knowledge were comparable between cohorts (68.5% correct), and there were no differences in attitudes toward ART (e.g., mistrust), which were in the neutral range. In bivariate linear regression, readiness for ART was negatively associated with physician mistrust (B = −10.4) and positively associated with self-efficacy (B = 5.5), positive outcome expectancies (B = 6.3), beliefs about personal necessity of ART (B = 17.5), and positive internal norms (B = 7.9). This study demonstrates the feasibility of engaging this vulnerable population through peer-referral. Peer-recruited PLHA evidence particularly high rates of risk factors compared to those in hospital clinics. Interventions to support ART initiation and continuation are sorely needed for both subgroups.
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Affiliation(s)
- Marya Gwadz
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Elizabeth Applegate
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Charles Cleland
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Noelle Regina Leonard
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Hannah Wolfe
- Spencer Cox Center for Health, Mount Sinai St. Luke's-Roosevelt Hospital Center , New York, NY , USA
| | - Nadim Salomon
- Peter Kruger Clinic, Mount Sinai Beth Israel Medical Center , New York, NY , USA
| | - Mindy Belkin
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Marion Riedel
- School of Social Work, Columbia University , New York, NY , USA
| | - Angela Banfield
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Lisa Sanfilippo
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Andrea Wagner
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Donna Mildvan
- Department of Infectious Diseases, Mount Sinai Beth Israel Medical Center , New York, NY , USA
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Beer L, Oster AM, Mattson CL, Skarbinski J. Disparities in HIV transmission risk among HIV-infected black and white men who have sex with men, United States, 2009. AIDS 2014; 28:105-14. [PMID: 23942058 PMCID: PMC4682567 DOI: 10.1097/qad.0000000000000021] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To better understand why HIV incidence is substantially higher among black than white men who have sex with men (MSM), we present the first nationally representative estimates of factors that contribute to transmission - sexual behavior, antiretroviral therapy (ART) use, and viral suppression - among HIV-infected black and white MSM in the United States. DESIGN The Medical Monitoring Project (MMP) is a complex sample survey of HIV-infected adults receiving medical care in the United States. METHODS We used weighted interview and medical record data collected during June 2009 to May 2010 to estimate the prevalence of sexual behaviors, ART use, and viral suppression among sexually active HIV-infected black and white MSM. We used χ tests to assess significant differences between races and logistic regression models to identify factors that mediated the racial differences. RESULTS Sexual risk behaviors among black and white MSM were similar. Black MSM were significantly less likely than white MSM to take ART (80 vs. 91%) and be durably virally suppressed (48 vs. 69%). Accounting for mediators (e.g. age, insurance, poverty, education, time since diagnosis, and disease stage) reduced, but did not eliminate, disparities in ART use and rendered differences in viral suppression among those on ART insignificant. CONCLUSION Lower levels of ART use and viral suppression among HIV-infected black MSM may increase the likelihood of HIV transmission. Addressing the patient-level factors and structural inequalities that contribute to lower levels of ART use and viral suppression among this group will improve clinical outcomes and might reduce racial disparities in HIV incidence.
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Affiliation(s)
- Linda Beer
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Chen WT, Wantland D, Reid P, Corless IB, Eller LS, Iipinge S, Holzemer WL, Nokes K, Sefcik E, Rivero-Mendez M, Voss J, Nicholas P, Phillips JC, Brion JM, Rose CD, Portillo CJ, Kirksey K, Sullivan KM, Johnson MO, Tyer-Viola L, Webel AR. Engagement with Health Care Providers Affects Self- Efficacy, Self-Esteem, Medication Adherence and Quality of Life in People Living with HIV. JOURNAL OF AIDS & CLINICAL RESEARCH 2013; 4:256. [PMID: 24575329 PMCID: PMC3932545 DOI: 10.4172/2155-6113.1000256] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Wei-Ti Chen
- Assistant Professor,400 West Campus Dr. #22110, Orange, CT 06477, School of Nursing, Yale University, Orange, CT 06477, USA
| | - Dean Wantland
- Assistant Professor, Rutgers College of Nursing Ackerson Hall 180 University Avenue, Room 330 Newark, NJ 07102, USA
| | - Paula Reid
- Assistant Professor, University of North Carolina Wilmington (UNCW) School of Nursing 601 South College Road Wilmington, North Carolina, USA
| | - Inge B Corless
- Professor, Institute of Health Professions CNY 36 1st Avenue Boston, MA 02116, USA
| | - Lucille S. Eller
- Associate Professor, Rutgers College of Nursing 101 Glen Rock Road Cedar Grove, NJ 07009, USA
| | - Scholastika Iipinge
- Senior Lecturer University of Namibia Main Campus, Mandume Ndemufayo Avenue, Windhoek Block F, Room 204, 3rd Level Namibia
| | - William L Holzemer
- Dean and Professor Rutgers College of Nursing Ackerson Hall 180 University Avenue, Room 302C Newark, NJ, USA
| | - Kathleen Nokes
- Professor and Graduate Program Director, Hunter College, CUNY, Hunter Bellevue SON, 425 East 25 Street, Box 874, New York, NY 10010, USA
| | - Elizbeth Sefcik
- Professor Texas A&M University-Corpus Christi 6300 Ocean Dr. Island Hall, Rm 329 Corpus Christi, TX 78404, USA
| | - Marta Rivero-Mendez
- Professor University of Puerto Rico PO Box 365067 San Juan, PR 00936-5067, USA
| | - Joachim Voss
- Associate Professor University of Washington, School of Nursing PO Box 357266 Seattle, WA 98195, USA
| | - Patrice Nicholas
- Professor and Director, Global Health and Academic Partnerships Brigham and Women’s Hospital and MGH Institute of Health Professions 36 1st Avenue Boston, MA 02129, USA
| | - J. Craig Phillips
- École des Sciences Infirmières, School of Nursing Faculté des Sciences de la Santé, Faculty of Health Sciences Université d’Ottawa, University of Ottawa 451 chemin Smyth Road Ottawa, Ontario, CANADA
| | - John M. Brion
- Associate Clinical Professor, The Ohio State University College of Nursing 1585 Neil Ave. #344 Columbus, Ohio 43201, USA
| | - Caro Dawson Rose
- Associate Professor UCSF School of Nursing Dept. of Community Health Systems San Francisco, CA, USA
| | - Carmen J Portillo
- Professor and Chair UCSF, School of Nursing, 2 Koret Way San Francisco, CA 94143, USA
| | - Kenn Kirksey
- Director, Nursing Strategic Initiatives Lyndon B. Johnson Hospital, Harris Health System 5656 Kelley Street Houston, TX, USA
| | - Kathleen M Sullivan
- Associate Professor University of Hawaii School of Nursing McCarthy Mall, Webster 439 Honolulu, HI 96822, USA
| | - Mallory O Johnson
- Associate Professor UCSF 50 Beale Street, Suite 1300 San Francisco, CA 94105, USA
| | - Lynda Tyer-Viola
- Assistant Professor MGH Institute of Health Professions 3047 Bonnebridge Way Houston, TX 77082, USA
| | - Allison R Webel
- Instructor Case Western Reserve University School of Nursing Cleveland, OH 44106, USA
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A qualitative study of barriers to enrollment into free HIV care: perspectives of never-in-care HIV-positive patients and providers in Rakai, Uganda. BIOMED RESEARCH INTERNATIONAL 2013; 2013:470245. [PMID: 24058908 PMCID: PMC3766571 DOI: 10.1155/2013/470245] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 07/23/2013] [Indexed: 11/17/2022]
Abstract
Background. Early entry into HIV care is low in Sub-Saharan Africa. In Rakai, about a third (31.5%) of HIV-positive clients who knew their serostatus did not enroll into free care services. This qualitative study explored barriers to entry into care from HIV-positive clients who had never enrolled in care and HIV care providers. Methods. We conducted 48 in-depth interviews among HIV-infected individuals aged 15–49 years, who had not entered care within six months of result receipt and referral for free care. Key-informant interviews were conducted with 12 providers. Interviews were audio-recorded and transcripts subjected to thematic content analysis based on the health belief model. Results. Barriers to using HIV care included fear of stigma and HIV disclosure, women's lack of support from male partners, demanding work schedules, and high transport costs. Programmatic barriers included fear of antiretroviral drug side effects, long waiting and travel times, and inadequate staff respect for patients. Denial of HIV status, belief in spiritual healing, and absence of AIDS symptoms were also barriers. Conclusion. Targeted interventions to combat stigma, strengthen couple counseling and health education programs, address gender inequalities, and implement patient-friendly and flexible clinic service hours are needed to address barriers to HIV care.
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Huang YT. Challenges and responses in providing palliative care for people living with HIV/AIDS. Int J Palliat Nurs 2013; 19:218, 220-5. [DOI: 10.12968/ijpn.2013.19.5.218] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Yu-Te Huang
- PhD student Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street W, Toronto, Ontario, M5S 1V4, Canada
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Christopoulos KA, Massey AD, Lopez AM, Geng EH, Johnson MO, Pilcher CD, Fielding H, Dawson-Rose C. "Taking a half day at a time:" patient perspectives and the HIV engagement in care continuum. AIDS Patient Care STDS 2013; 27:223-30. [PMID: 23565926 DOI: 10.1089/apc.2012.0418] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The HIV treatment continuum, or "cascade," outlines key benchmarks in the successful treatment of HIV-infected individuals. However, the cascade fails to capture important dimensions of the patient experience in that it has been constructed from a provider point of view. In order to understand meaningful steps in the HIV care cascade for individuals diagnosed with HIV through expanded, more routine testing, we conducted in-depth interviews (n=34) with three groups of individuals: those diagnosed with HIV in the emergency department/urgent care clinic who linked to HIV care and exhibited 100% appointment adherence in the first 6 months of HIV care; those diagnosed in the emergency department/urgent care clinic who linked to HIV care and exhibited sporadic appointment adherence in the first 6 months of HIV care, and; hospitalized patients with no outpatient HIV care for at least 6 months. This last group was chosen to supplement data from in-care patients. The engagement in care process was defined by a changing perspective on HIV, one's HIV identity, and the role of health care. The linkage to care experience laid the groundwork for subsequent retention. Interventions to support engagement in care should acknowledge that patient concerns change over time and focus on promoting shifts in perspective.
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Affiliation(s)
- Katerina A. Christopoulos
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Amina D. Massey
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Andrea M. Lopez
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Elvin H. Geng
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Mallory O. Johnson
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California
| | - Christopher D. Pilcher
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Hegla Fielding
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Carol Dawson-Rose
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California
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