Patient-provider relationship predicts mental and physical health indicators for HIV-positive men who have sex with men

Health literacy mediates the association between cognition and healthcare provider interactions among gay and bisexual men with HIV disease

Introduction: Gay and bisexual men (GBM) account for the highest rates of incident infection with HIV in the U.S., and experience social, systemic barriers to accessing and engaging in healthcare services. Interacting with healthcare providers can be a complex process for some GBM with HIV disease. The current study examined the contributions of cognition and health literacy to perceived interactions with healthcare providers among GBM with HIV disease. Methods: The sample included 100 adults with HIV disease (ages 24-75) who identified as GBM. All participants completed the Dealing with Health Professionals subscale of the Beliefs Related to Medication Adherence survey, as well as the Cogstate neuropsychological battery, self-report measures of cognitive symptoms, and well-validated measures of health literacy. Results: Worse performance-based cognition and subjective cognitive symptoms were both associated with perceived difficulties dealing with healthcare providers, but these associations were fully mediated by lower health literacy. Conclusion: Health literacy may play a role in the association between poorer cognitive functioning and difficulties navigating healthcare interactions among GBM with HIV disease. Further studies are needed to determine whether cognitive approaches to enhancing the access, understanding, and use of health information in GBM with HIV disease improves healthcare interactions and outcomes.

Factors associated with quality of life, depressive symptoms, and perceived stress among rural older adults living with HIV in the United States

PURPOSE

Rural older people living with HIV (PLH) in the United States are a population of growing size and significance. A better understanding of factors associated with quality of life (QOL), depressive symptoms, and stress in this population-especially modifiable factors-could inform future interventions.

METHODS

Online or on paper, we surveyed 446 PLH aged 50+ residing in rural counties across the United States (Mage = 56, 67% male, 67% White, and 23% Black). Associations between social support, HIV stigma, satisfaction with medical care, discrimination in health care settings, and structural barriers and health-related QOL, depressive symptoms, and perceived stress were assessed using multiple linear regressions.

FINDINGS

Controlling for demographics, greater social support was associated with better QOL, fewer depressive symptoms, and less stress. Greater HIV stigma was associated with more depressive symptoms and stress. Satisfaction with care was associated with better QOL and less stress. Discrimination in medical settings was associated with lower QOL and more depressive symptoms and stress. Finally, experiencing more structural barriers was associated with lower QOL and more depressive symptoms and stress.

CONCLUSIONS

In addition to engagement in care and viral suppression, QOL and mental health are also critical considerations for rural older PLH. Increasing social support, reducing or providing skills to cope with HIV stigma, improving quality of care, reducing discrimination and stigma in medical settings, and reducing or mitigating the impact of structural barriers present potential targets for interventions aiming to improve the well-being of older rural PLH.

Care engagement with healthcare providers and symptom management self-efficacy in women living with HIV in China: secondary analysis of an intervention study

Background

Symptom management self-efficacy is a prerequisite for individuals to fully manage their symptoms. The literature reports associations between engagement with healthcare providers (HCPs), internalized stigma, and types of self-efficacy other than symptom management. However, the factors of symptom management self-efficacy are not well understood. This study aimed to investigate the relationship among engagement with HCPs, internalized stigma, and HIV symptom management self-efficacy in Chinese women living with HIV (WLWH).

Methods

This current analysis was part of the original randomized control trial, we used data collected from 41 women living with HIV (WLWH) assigned to an intervention arm or a control arm from Shanghai and Beijing, China, at baseline, Week 4 and Week 12. The CONSORT checklist was used. The study was registered in the Clinical Trial Registry (#NCT03049332) on 10/02/2017.

Results

The results demonstrate that HCPs should increase engagement with WLWH when providing care, thereby improving their symptom management self-efficacy. The results suggested that participants’ engagement with HCPs was significantly positively correlated with their HIV symptom management self-efficacy in the latter two time points. Internalized stigma was significantly negatively correlated with HIV symptom management self-efficacy only at the 4-week follow-up.

Conclusions

This study demonstrated the positive effect of engagement with HCPs on WLWHs’ symptom management self-efficacy as well as the negative effect of internalized stigma on symptom management self-efficacy. Future research can further test the relationship between the three key concepts, as well as explore interventions to decrease internalized stigma.

Discrimination and alcohol problems among heavy drinking HIV-positive men who have sex with men: The buffering effect of a brief Motivational Intervention to reduce alcohol use

INTRODUCTION

Heavy alcohol use negatively impacts health outcomes among people with HIV and is especially prevalent among men who have sex with men (MSM). Alcohol problems among MSM with HIV may occur, in part, due to increased stress caused by experiences of identity-based discrimination, such as heterosexism, HIV stigma, and racism. The current study examined (a) whether MSM with HIV who experience greater identity-based discrimination reported higher levels of alcohol problems over time in the absence of alcohol intervention, and (b) whether motivational interviewing (MI) to reduce alcohol use would attenuate the effects of discrimination on alcohol problems.

METHODS

Data came from a clinical trial in which MSM with HIV were randomized into brief MI for alcohol harm reduction [n = 89] or an HIV treatment as usual assessment only control [TAU; n = 91]. Alcohol use and problems were assessed at baseline, 3, 6, and 12 months.

RESULTS

Generalized Estimating Equations found a significant interaction between MI and baseline identity-based discrimination, such that in those not receiving MI, discrimination prospectively predicted alcohol problems over time (B = 0.065, SE = 0.018, p < .001, 95% Wald CI [.030- 0.100]). In those receiving MI, discrimination did not have an effect (B = - 0.002, SE = 0.131, p = .987, 95% Wald CI [- 0.258 to 0.254]).

CONCLUSIONS

Even without explicitly targeting experiences of identity-based discrimination, a person-centered intervention, like MI, appears to mitigate the negative impact of identity-based discrimination on alcohol-related problems.

A more practical guide to incorporating health equity domains in implementation determinant frameworks

BACKGROUND

Due to striking disparities in the implementation of healthcare innovations, it is imperative that researchers and practitioners can meaningfully use implementation determinant frameworks to understand why disparities exist in access, receipt, use, quality, or outcomes of healthcare. Our prior work documented and piloted the first published adaptation of an existing implementation determinant framework with health equity domains to create the Health Equity Implementation Framework. We recommended integrating these three health equity domains to existing implementation determinant frameworks: (1) culturally relevant factors of recipients, (2) clinical encounter or patient-provider interaction, and (3) societal context (including but not limited to social determinants of health). This framework was developed for healthcare and clinical practice settings. Some implementation teams have begun using the Health Equity Implementation Framework in their evaluations and asked for more guidance.

METHODS

We completed a consensus process with our authorship team to clarify steps to incorporate a health equity lens into an implementation determinant framework.

RESULTS

We describe steps to integrate health equity domains into implementation determinant frameworks for implementation research and practice. For each step, we compiled examples or practical tools to assist implementation researchers and practitioners in applying those steps. For each domain, we compiled definitions with supporting literature, showcased an illustrative example, and suggested sample quantitative and qualitative measures.

CONCLUSION

Incorporating health equity domains within implementation determinant frameworks may optimize the scientific yield and equity of implementation efforts by assessing and ideally addressing implementation and equity barriers simultaneously. These practical guidance and tools provided can assist implementation researchers and practitioners to concretely capture and understand barriers and facilitators to implementation disparities.

Factors Related to Biological Sex Differences in Engagement with Healthcare Providers in Persons Living with HIV

Little is known about how engagement with healthcare providers mediates the relationship between psychosocial factors (anxiety, depression, stigma) and medication adherence among persons living with HIV (PLWH). Moreover, little research has investigated potential biological sex differences in this relationship. We conducted a secondary analysis of data collected from four projects (N = 281) focused on improving health outcomes in PLWH. Males displayed (a) negative association between depression and engagement with healthcare providers (β = - 0.02, z = - 3.20, p = 0.001) and (b) positive association between engagement with healthcare providers and medication adherence (β = 0.55, OR = 1.73, z = 2.62, p = 0.009). Females showed no association between any of these factors. Anxiety and stigma were not significantly associated with medication adherence. Path analysis modeling for males had a very good fit (CFI = 1, TLI = 1, RMSEA = 0); none of the regression coefficients was significant for females. The significant relationship between depression and medication adherence among males was fully mediated by engagement with healthcare providers. Findings suggest that adherence interventions for PLWH should be tailored by biological sex.

Relationship Between Depressive Symptoms and Engagement With the Health Care Provider in People Living With HIV: A Two-Wave Cross-Lag Model

Depressive symptoms in persons living with HIV (PLWH) negatively affect retention in care, antiretroviral therapy adherence, and health outcomes. Patient-provider relationships and depressive symptoms are associated, but less is known regarding their bidirectional relationship. We assessed whether depressive symptoms in PLWH are a risk factor or a consequence of the patient-provider relationship or both. We used a two-wave cross-lag model to test the prospective and reciprocal relationship between depressive symptoms and the patient-provider relationship, from baseline to 28-week follow-up. The findings from our study found no causal association between depressive symptoms and the patient-provider relationship. Specifically, findings revealed that available social support and HIV stigma weaken the effect of the baseline patient-provider relationship on later depressive symptoms. Findings from our study suggest that although the patient-provider relationship is beneficial for mental health outcomes in PLWH, addressing sociodemographic factors may be of greater importance.

Sexual minority men want provider behavior consistent with attitudes and norms during patient-provider interactions regarding HIV prevention

HIV is a health problem for sexual minority men in the United States. One factor among many that contributes to this HIV disparity is poor patient-provider interactions. We focused on specific provider behavior preferred by sexual minority men during patient-provider interactions about HIV prevention. We interviewed 20 HIV-negative sexual minority men who endorsed 1+ psychosocial HIV risk factor. We used follow up interviews and conventional content analysis. Among our sample, 55% identified as White; 50% as bisexual, (M_age = 28.45). Findings suggested even some providers knowledgeable about sexual minority health provided unhelpful care to sexual minority men (knowledge-behavior discrepancy). Some knowledgeable providers engaged in affirmative, tailored treatment (knowledge-behavior consistency). Specific behaviors of preferred patient-provider interactions regarding HIV prevention are reported. Our recommendations are based on patient perceptions, which is a limit and strength. We identified an important type of unhelpful patient-provider interaction for HIV-negative sexual minority men beyond discriminatory experiences. Patient-provider interaction efforts need to go beyond education to help providers practice skills. With increased focus on cultural competency for sexual minority patients, more providers may advertise their practice as affirmative, yet interactions will likely vary, may require lifelong practice of cultural humility, and impact HIV prevention.

Barriers and Facilitators for Antiretroviral Treatment Adherence Among HIV-Positive African American and Latino Men Who Have Sex With Men

Some Black/African American and Hispanic/Latino men who have sex with men (MSM) living with HIV do not take antiretroviral therapy (ART). We conducted semistructured interviews with 84 adult, Black/African American and Hispanic/Latino MSM with HIV to understand ART barriers and facilitators. We used chi-square statistics to identify factors associated with ART use (p ≤ .05), and selected illustrative quotes. Over half (51.2%) said they followed their doctor's instructions; however, only 27.4% reported consistently taking ART. Some men delayed ART until overcoming diagnosis denial or becoming very sick. ART use was facilitated by encouragement from others, treatment plans, side effect management, lab test improvements, pill-taking reminders, and convenient care facilities that provide "one-stop shop" services. Men were more likely to take ART when having providers who communicated effectively and were perceived to treat them with respect. Healthcare personnel can use our findings to strengthen services for MSM of color.

The health equity implementation framework: proposal and preliminary study of hepatitis C virus treatment

BACKGROUND

Researchers could benefit from methodological advancements to advance uptake of new treatments while also reducing healthcare disparities. A comprehensive determinants framework for healthcare disparity implementation challenges is essential to accurately understand an implementation problem and select implementation strategies.

METHODS

We integrated and modified two conceptual frameworks-one from implementation science and one from healthcare disparities research to develop the Health Equity Implementation Framework. We applied the Health Equity Implementation Framework to a historical healthcare disparity challenge-hepatitis C virus (HCV) and its treatment among Black patients seeking care in the US Department of Veterans Affairs (VA). A specific implementation assessment at the patient level was needed to understand any barriers to increasing uptake of HCV treatment, independent of cost. We conducted a preliminary study to assess how feasible it was for researchers to use the Health Equity Implementation Framework. We applied the framework to design the qualitative interview guide and interpret results. Using quantitative data to screen potential participants, this preliminary study consisted of semi-structured interviews with a purposively selected sample of Black, rural-dwelling, older adult VA patients (N = 12), living with HCV, from VA medical clinics in the Southern part of the USA.

RESULTS

The Health Equity Implementation Framework was feasible for implementation researchers. Barriers and facilitators were identified at all levels including the patient, provider (recipients), patient-provider interaction (clinical encounter), characteristics of treatment (innovation), and healthcare system (inner and outer context). Some barriers reflected general implementation issues (e.g., poor care coordination after testing positive for HCV). Other barriers were related to healthcare disparities and likely unique to racial minority patients (e.g., testimonials from Black peers about racial discrimination at VA). We identified several facilitators, including patient enthusiasm to obtain treatment because of its high cure rates, and VA clinics that offset HCV stigma by protecting patient confidentiality.

CONCLUSION

The Health Equity Implementation Framework showcases one way to modify an implementation framework to better assess health equity determinants as well. Researchers may be able to optimize the scientific yield of research inquiries by identifying and addressing factors that promote or impede implementation of novel treatments in addition to eliminating healthcare disparities.

Health Care Provider Utilization and Cost of an mHealth Intervention in Vulnerable People Living With HIV in Vancouver, Canada: Prospective Study

Background

Improving adherence to combined antiretroviral therapy (cART) can be challenging, especially among vulnerable populations living with HIV. Even where cART is available free of charge, social determinants of health act as barriers to optimal adherence rates. Patient-centered approaches exploiting mobile phone communications (mHealth) have been shown to improve adherence to cART and promote achievement of suppressed HIV plasma viral loads. However, data are scarce on the health care provider (HCP) time commitments and health care costs associated with such interventions. This knowledge is needed to inform policy and programmatic implementation.

Objective

The purpose of this study was to approximate the resources required and to provide an estimate of the costs associated with running an mHealth intervention program to improve medication adherence in people living with HIV (PLWH).

Methods

This prospective study of HCP utilization and costs was embedded within a repeated measures effectiveness study of the WelTel short-message service (SMS) mHealth program. The study included 85 vulnerable, nonadherent PLWH in Vancouver, Canada, and resulted in improved medication adherence and HIV plasma viral load among participants. Study participants were provided mobile phones with unlimited texting (where required) and received weekly bidirectional text messages to inquire on their status for one year. A clinic nurse triaged and managed participants' responses, immediately logging all patient interactions by topic, HCP involvement, and time dedicated to addressing issues raised by participants. Interaction costs were determined in Canadian dollars based on HCP type, median salary within our health authority, and their time utilized as part of the intervention.

Results

Participant-identified problems within text responses included health-related, social, and logistical issues. Taken together, management of problems required a median of 43 minutes (interquartile range, IQR 17-99) of HCP time per participant per year, for a median yearly cost of Can $36.72 (IQR 15.50-81.60) per participant who responded with at least one problem. The clinic nurse who monitored the texts solved or managed 65% of these issues, and the remaining were referred to a variety of other HCPs. The total intervention costs, including mobile phones, plans, and staffing were a median Can $347.74/highly vulnerable participant per year for all participants or Can $383.18/highly vulnerable participant per year for those who responded with at least one problem.

Conclusions

Bidirectional mHealth programs improve HIV care and treatment outcomes for PLWH. Knowledge about the HCP cost associated, here less than Can $50/year, provides stakeholders and decision makers with information relevant to determining the feasibility and sustainability of mHealth programs in a real-world setting.

Trial Registration

ClinicalTrials.gov NCT02603536; https://clinicaltrials.gov/ct2/show/NCT02603536 (Archived by WebCite at http://www.webcitation.org/70IYqKUjV).

A structural equation model of patient-healthcare provider relationships and HIV-infected patient outcomes in Chinese populations

Obtaining maximum antiretroviral therapy (ART) adherence is critical for maintaining a high CD4 count and strong immune function in PLWHA. Key factors for achieving optimum adherence include good medication self-efficacy, decreased medication-taking difficulties, and positive patient-healthcare provider (HCP) relationships. Limited studies have analyzed the correlation of these factors and ART adherence in Chinese population. In this paper, structural equation modeling was performed to assess the proposed model of relations between patient-HCP relationships and adherence. Audio Computer-Assisted Self-Interview (ACASI) software was used to collect data on ART adherence and patient variables among 227 PLWHA in Shanghai and Taipei. Participants completed a one-time 60-minute ACASI survey that consisted of standardized measures to assess demographics, recent CD4 counts, self-efficacy, patient-HCP relationship, adherence, and medication-taking difficulties. The data shown the relationship between patient-HCP relationships and adherence was significantly consistent with mediation by medication self-efficacy. However, patient-HCP interaction did not directly influence medication-taking difficulties, and medication-taking difficulties did not significantly affect CD4 counts. Furthermore, patient-HCP interactions did not directly impact CD4 counts; rather, the relation was consistent with mediation (by either better medication self-efficacy or better adherence) or by improved adherence alone. Future interventions should be designed to enhance self-management and provide better patient-HCP communication. This improved communication will enhance medication self-efficacy and decrease medication-taking difficulties. This in turn will improve medication adherence and immune function among PLWHA.

Health-related quality-of-life and receipt of women-centered HIV care among women living with HIV in Canada

We measured health-related quality of life (HRQOL) using the SF-12 among women living with HIV (WLWH) in Canada between August 2013 and May 2015. We investigated differences by perceived receipt of women-centered HIV care (WCHC), assessed using an evidence-based definition with a 5-point Likert item: "Overall, I think that the care I have received from my HIV clinic in the last year has been women-centered" (dichotomized into agree vs. disagree/neutral). Of 1308 participants, 26.3 percent were from British Columbia, 48.2 percent from Ontario, and 25.5 percent from Québec. The median age was 43 years (interquartile range = 36-51). Most (42.2 percent) were White, 29.4 percent African/Caribbean/Black, and 21.0 percent Indigenous. Overall, 53.4 percent perceived having received WCHC. Mean physical and mental HRQOL scores were 43.8 (standard deviation [SD] = 14.4) and 41.7 (SD = 14.2), respectively. Women perceiving having received WCHC had higher mean physical (44.7; SD = 14.0) and mental (43.7; SD = 14.1) HRQOL scores than those not perceiving having received WCHC (42.9; SD = 14.8 and 39.5; SD = 14.0, respectively; p < .001). In multivariable linear regression, perceived WCHC was associated with higher mental (β = 3.48; 95 percent confidence interval: 1.90, 5.06) but not physical HRQOL. Improving HRQOL among Canadian WLWH, which was lower than general population estimates, is needed, including examining the potential of WCHC as an effective model of clinical care.

Health care providers' perspectives on a weekly text-messaging intervention to engage HIV-positive persons in care (WelTel BC1)

Though evidence shows that Mobile health (mHealth) interventions can improve adherence and viral load in HIV-positive persons, few have studied the health care providers' (HCP) perspective. We conducted a prospective mixed methods pilot study using the WelTel intervention wherein HIV-positive participants (n = 25) received weekly interactive text messages for 6 months. Text message response rate and topic data were collected to illustrate the HCP experience. The aim of this study is to explore intervention acceptability and feasibility from the HCP perspective through a baseline focus group and end of study interviews with HCP impacted by the intervention. Interview data were thematically coded using the Technology Acceptance Model. HCPs identified that the WelTel intervention engaged patients in building relationships, while organizing and streamlining existing mHealth efforts and dealing with privacy issues. HCPs recognized that although workload would augment initially, intervention benefits were many, and went beyond simply improving HIV viral load.

Perceptions of a patient-staff-caregiver group among inpatients in a radiotherapy unit

Objective:

Coping with cancer and its treatments has significant psychological implications for patients, and hospitalization can lead to emotional distress. Based on a community meeting (CM), a common therapeutic intervention in psychiatric wards, a unique patient–staff–caregiver group is held weekly on the radiotherapy unit of our hospital. The goals are to strengthen patient coping abilities and prompt open communications. The present study aimed at quantitatively estimating the effect of the community meeting by gauging the perceptions with respect to several therapeutic aspects.

Method:

A questionnaire was developed for patients who participated in CMs during their hospitalization based on four theoretical factors: illness perception, relations with the main caregiver, relations with other participants, and relations with unit staff.

Results:

Participants' general satisfaction with the meetings was found to be positive. The most significant aspect of the meetings, as perceived by participants, was relationships with the staff. Patients born in Israel perceived relationships with other participants more positively.

Significance of results:

Attentive interaction with medical staff and open communications are highly important for patients and contribute to their general satisfaction with the meetings.

Patient-provider interaction, patient satisfaction, and health outcomes: testing explanatory models for people living with HIV/AIDS

In the era of highly active antiretroviral therapy era, medication adherence and health-related quality of life (HRQOL) have become critical issues for people living with HIV/AIDS (PLWH). The purpose of this study was to test explanatory models of how patient-provider interaction and patient satisfaction are related to medication adherence and HRQOL for PLWH. A total of 344 PLWH receiving health-care services from a federally funded clinic in the southwest USA completed a survey questionnaire about their perception of interactions with providers, their satisfaction with services, their medication adherence, and their HRQOL. Comparing four latent variable structural equation models of direct and mediated effects of patient-provider interaction and patient satisfaction, the findings illustrate that the best model is one in which patient-provider interaction has a direct and positive effect on patient satisfaction, medication adherence, and HRQOL. These findings suggest that quality patient-provider interaction is a critical element of health-care services for PLWH, while patient satisfaction is an outcome measure and not a mediating factor for medication adherence and HRQOL.

Positive choices: outcomes of a brief risk reduction intervention for newly HIV-diagnosed men who have sex with men

Positive choices (PC), a brief sexual risk reduction intervention conducted with newly HIV-diagnosed men who have sex with men (MSM), was evaluated for preliminary efficacy. Participants were enrolled if they reported unprotected anal intercourse (UAI) in the three months prior to HIV diagnosis (n = 102). Three months after diagnosis, participants completed baseline assessments and were randomly assigned to receive the 3-session PC intervention or the comprehensive standard of care (C-SoC) at a community health center. Participants completed assessments at 3- (post intervention), 6-, and 9- months after baseline. Compared to C-SoC participants, PC participants significantly reduced the frequency of UAI with HIV serodiscordant (HIV negative or status unknown) partners over the 9-month follow-up period. No differences by condition were found in the frequency of UAI with all partners. The findings from this trial suggest that brief risk reduction approaches for newly-diagnosed MSM integrated into HIV care can benefit secondary HIV prevention efforts.

Engagement with Care, Substance Use, and Adherence to Therapy in HIV/AIDS

Engagement with care for those living with HIV is aimed at establishing a strong relationship between patients and their health care provider and is often associated with greater adherence to therapy and treatment (Flickinger, Saha, Moore, and Beach, 2013). Substance use behaviors are linked with lower rates of engagement with care and medication adherence (Horvath, Carrico, Simoni, Boyer, Amico, and Petroli, 2013). This study is a secondary data analysis using a cross-sectional design from a larger randomized controlled trial (n = 775) that investigated the efficacy of a self-care symptom management manual for participants living with HIV. Participants were recruited from countries of Africa and the US. This study provides evidence that substance use is linked with lower self-reported engagement with care and adherence to therapy. Data on substance use and engagement are presented. Clinical implications of the study address the importance of utilizing health care system and policy factors to improve engagement with care.

Self-esteem and quality of life of people living with HIV/AIDS

In India in 2009, it was estimated that 2.4 million people were living with HIV, which equates to a prevalence of 0.3 percent. While this seems low, because India’s population is so large, this rate is third in the world in terms of the absolute number of people living with HIV/AIDS. This study evaluated the self-esteem and quality of life of people living with HIV/AIDS in the Indian population using a correlational design. A significant positive correlation between self esteem and the different dimensions of quality of life was established. Interventions designed for people with HIV/AIDS could well include self esteem as a moderator of quality of life.