Factors associated with HIV-infected women's use or intention to use AZT during pregnancy

Values and preferences of women living with HIV who are pregnant, postpartum or considering pregnancy on choice of antiretroviral therapy during pregnancy

OBJECTIVE

To investigate women's values and preferences regarding antiretroviral therapy (ART) during pregnancy to inform a BMJ Rapid Recommendation.

SETTING

Primary studies reporting patient-reported outcomes relevant to decision-making regarding ART in any clinical and geographical setting.

PARTICIPANTS

Women living with HIV who are pregnant, postpartum or considering pregnancy.

OUTCOME MEASURES

Quantitative measurements and qualitative descriptions of values and preferences in relation to ART during pregnancy. We also included studies on women's reported barriers and facilitators to adherence. We excluded studies correlating objective measures (eg, CD4 count) with adherence, or reporting only outcomes which are not expected to differ between ART alternatives (eg, access to services, knowledge about ART).

RESULTS

We included 15 qualitative studies reporting values and preferences about ART in the peripartum period; no study directly studied choice of ART therapy during pregnancy. Six themes emerged: a desire to reduce vertical transmission (nine studies), desire for child to be healthy (five studies), concern about side effects to the child (eight studies), desire for oneself to be healthy (five studies), distress about side effect to oneself (10 studies) and pill burden (two studies). None of the studies weighed the relative importance of these outcomes directly, but pill burden/medication complexity appears to be a lower priority for most women compared with other factors. Overall, the body of evidence was at low risk of bias, with minor limitations.

CONCLUSIONS

Women who are or may become pregnant and who are considering ART appear to place a high value on both their own and their children's health. Evidence on the relative importance between these values when choosing between ART regimens is uncertain. There is variability in individual values and preferences among women. This highlights the importance of an individualised women-centred approach, such as shared decision-making when choosing between ART alternatives.

TRIAL REGISTRATION NUMBER

International Prospective Register of Systematic Reviews:CRD42017057157.

The Role of ARV Associated Adverse Drug Reactions in Influencing Adherence Among HIV-Infected Individuals: A Systematic Review and Qualitative Meta-Synthesis

Poor adherence remains a major barrier to achieving the clinical and public health benefits of antiretroviral drugs (ARVs). A systematic review and qualitative meta-synthesis was conduct to evaluate how ARV adverse drug reactions may influence ARV adherence. Thirty-nine articles were identified, and 33 reported that ARV adverse drug reactions decreased adherence and six studies found no influence. Visually noticeable adverse drug reactions and psychological adverse reactions were reported as more likely to cause non-adherence compared to other adverse drug reactions. Six studies reported a range of adverse reactions associated with EFV-containing regimens contributing to decreased adherence. Informing HIV-infected individuals about ARV adverse drug reactions prior to initiation, counselling about coping mechanisms, and experiencing the effectiveness of ARVs on wellbeing may improve ARV adherence.

Chronic Disease Self-Management by People With HIV

As HIV has transitioned into a chronic disease, reappraisal of clinical management has occurred with chronic disease self-management (CDSM) as one possibility. However, despite extensive work on CDSM across a range of diseases, little attention has focused on psychosocial contexts of the lives of people for whom programs are intended. This article reports semi-structured interviews used to explore health practices and motivations of 33 people with HIV (PWHIV) in Australia. Within participants' accounts, different forms of subjectivity and agency emerged with implications for how they understood and valued health-related behaviors. Four themes arose: health support and disclosure, social support and stigma, employment/structure, and health decisions beyond HIV. The experience of stigma and its intersection with CDSM remains relatively un-chartered. This study found stigma shapes agency and engagement with health. Decisions concerning health behaviors are often driven by perceived social and emotional benefit embedded in concerns of disclosure and stigma.

Bayesian data augmentation methods for the synthesis of qualitative and quantitative research findings

The possible utility of Bayesian methods for the synthesis of qualitative and quantitative research has been repeatedly suggested but insufficiently investigated. In this project, we developed and used a Bayesian method for synthesis, with the goal of identifying factors that influence adherence to HIV medication regimens. We investigated the effect of 10 factors on adherence. Recognizing that not all factors were examined in all studies, we considered standard methods for dealing with missing data and chose a Bayesian data augmentation method. We were able to summarize, rank, and compare the effects of each of the 10 factors on medication adherence. This is a promising methodological development in the synthesis of qualitative and quantitative research.

A systematic review comparing antiretroviral adherence descriptive and intervention studies conducted in the USA

We examined the extent to which studies aimed at testing interventions to improve antiretroviral adherence have targeted the facilitators of and barriers known to affect adherence. Of the 88 reports reviewed, 41 were reports of descriptive studies conducted with US HIV-positive women and 47 were reports of intervention studies conducted with US HIV-positive persons. We extracted from the descriptive studies all findings addressing any factor linked to antiretroviral adherence and from the intervention studies, information on the nature of the intervention, the adherence problem targeted, the persons targeted for the intervention, and the intervention outcomes desired. We discerned congruence between the prominence of substance abuse as a factor identified in the descriptive studies as a barrier to adherence and its prominence as the problem most addressed in those reports of intervention studies that specified the problems targeted for intervention. We also discerned congruence between the prominence of family and provider support as factors identified in the descriptive studies as facilitators of adherence and the presence of social support as an intervention component and outcome variable. Less discernible in the reports of intervention studies was specific attention to other factors prominent in the descriptive studies, which may be due to the complex nature of the problem, individualistic and rationalist slant of interventions, or simply the ways interventions were presented. Our review raises issues about niche standardization and intervention tailoring, targeting, and fidelity.

A Bayesian method for the synthesis of evidence from qualitative and quantitative reports: the example of antiretroviral medication adherence

OBJECTIVES

Bayesian meta-analysis is a frequently cited but very little-used method for synthesizing qualitative and quantitative research findings. The only example published to date used qualitative data to generate an informative prior probability and quantitative data to generate the likelihood. We developed a method to incorporate both qualitative and quantitative evidence in the likelihood in a Bayesian synthesis of evidence about the relationship between regimen complexity and medication adherence.

METHODS

Data were from 11 qualitative and six quantitative studies. We updated two different non-informative prior distributions with qualitative and quantitative findings to find the posterior distribution for the probabilities that a more complex regimen was associated with lower adherence and that a less complex regimen was associated with greater adherence.

RESULTS

The posterior mode for the qualitative findings regarding more complex regimen and lesser adherence (using the uniform prior with Jeffreys' prior yielding highly similar estimates) was 0.588 (95% credible set limits 0.519, 0.663) and for the quantitative findings was 0.224 (0.203, 0.245); due to non-overlapping credible sets, we did not combine them. The posterior mode for the qualitative findings regarding less complex regimen and greater adherence was 0.288 (0.214, 0.441) and for the quantitative findings was 0.272 (0.118, 0.437); the combined estimate was 0.299 (0.267, 0.334).

CONCLUSIONS

The utility of Bayesian methods for synthesizing qualitative and quantitative research findings at the participant level may depend on the nature of the relationship being synthesized and on how well the findings are represented in the individual reports.

Transforming verbal counts in reports of qualitative descriptive studies into numbers

Reports of qualitative studies typically do not offer much information on the numbers of respondents linked to any one finding. This information may be especially useful in reports of basic, or minimally interpretive, qualitative descriptive studies focused on surveying a range of experiences in a target domain, and its lack may limit the ability to synthesize the results of such studies with quantitative results in systematic reviews. Accordingly, the authors illustrate strategies for deriving plausible ranges of respondents expressing a finding in a set of reports of basic qualitative descriptive studies on antiretroviral adherence and suggest how the results might be used. These strategies have limitations and are never appropriate for use with findings from interpretive qualitative studies. Yet they offer a temporary workaround for preserving and maximizing the value of information from basic qualitative descriptive studies for systematic reviews. They show also why quantitizing is never simply quantitative.

HIV and pregnancy intentions: do services adequately respond to women's needs?

Too little is known about how an HIV diagnosis and access to care and treatment affect women's childbearing intentions. As access to antiretroviral therapy improves, greater numbers of HIV-positive women are living longer, healthier lives, and many want to have children. Effectively supporting women's reproductive decisionmaking in the context of HIV requires understanding how pregnancy, reproduction, and HIV intersect and asking questions that bridge the biomedical and social sciences. Considering women to be at the center of decisions on health policy and service delivery can help provide an appropriate constellation of services. A clear research agenda is needed to create a more coordinated approach to policies and programs supporting the pregnancy intentions of women with HIV.

Rights of HIV positive people to sexual and reproductive health: parenthood

In many areas of the globe most HIV infection is transmitted sexually or in association with pregnancy, childbirth and breastfeeding, raising the need for sexual and reproductive health and HIV/AIDS initiatives to be mutually reinforcing. Many people with HIV, who are in good health, will want to have children, and highly active antiretroviral therapy provides women and men living with AIDS the possibility of envisaging new life projects such as parenthood, because of a return to health. However, there are still difficult choices to face concerning sexuality, parenthood desires and family life. Structural, social and cultural issues, as well as the lack of programmatic support, hinder the fulfilment of the right to quality sexual and reproductive health care and support for having a family. This paper addresses the continuum of care involved in parenthood for people living with HIV, from pregnancy to infant and child care, and provides evidence-based examples of policies and programmes that integrate sexual and reproductive health interventions with HIV/AIDS care in order to support parenthood. Focusing on parenthood for people living with and affected by HIV, that is, focusing on the couple rather than the woman as the unit of care, the individual or the set of adults who are responsible for raising children, would be an innovative programmatic advance. Going beyond maternal and child health care to providing care and support for parents and others who are responsible for raising children is especially relevant for those living with HIV infection.

Using qualitative metasummary to synthesize qualitative and quantitative descriptive findings

The new imperative in the health disciplines to be more methodologically inclusive has generated a growing interest in mixed research synthesis, or the integration of qualitative and quantitative research findings. Qualitative metasummary is a quantitatively oriented aggregation of qualitative findings originally developed to accommodate the distinctive features of qualitative surveys. Yet these findings are similar in form and mode of production to the descriptive findings researchers often present in addition to the results of bivariate and multivariable analyses. Qualitative metasummary, which includes the extraction, grouping, and formatting of findings, and the calculation of frequency and intensity effect sizes, can be used to produce mixed research syntheses and to conduct a posteriori analyses of the relationship between reports and findings.

How qualitative methods contribute to understanding combination antiretroviral therapy adherence

Strict adherence to medication regimens is generally required to obtain optimal response to combination antiretroviral therapy (ART). Yet, we have made limited progress in developing strategies to decrease the prevalence of nonadherence. As we work to understand adherence in developed countries, the introduction of ART in resource-poor settings raises novel challenges. Qualitative research is a scientific approach that uses methods such as observation, interviews, and verbal interactions to gather rich in-depth information about how something is experienced. It seeks to understand the beliefs, values, and processes underlying behavioral patterns. Qualitative methods provide powerful tools for understanding adherence. Culture-specific influences, medication beliefs, access, stigma, reasons for nonadherence, patterns of medication taking, and intervention fidelity and measurement development are areas ripe for qualitative inquiry. A disregard for the social and cultural context of adherence or the imposition of adherence models inconsistent with local values and practices is likely to produce irrelevant or ineffective interventions. Qualitative methods remain underused in adherence research. We review appropriate qualitative methods for and provide an overview of the qualitative research on ART nonadherence. We discuss the rationales for using qualitative methods, present 2 case examples illustrating their use, and discuss possible institutional barriers to their acceptance.

Research results have expiration dates: ensuring timely systematic reviews

Time and timeliness are key issues in appraising and ensuring the clinical relevance of systematic reviews. Time considerations entering the systematic review process include the history of the clinical problem, disease, or treatment that is the target of the review, and the history of the research conducted to address it. These considerations guide: (i) formulation of the research problems and questions; (ii) setting of parameters for the search and retrieval of studies; (iii) determination of inclusion and exclusion criteria; (iv) appraisal of the clinical relevance of findings; (v) selection of the findings that will be synthesized; and (vi) interpretation of the results of that synthesis.

Changes in attitudes toward antiviral medication: a comparison of women living with HIV/AIDS in the pre-HAART and HAART Eras

To examine potential changes in attitudes toward antiviral medication since the advent of highly active antiretroviral therapy (HAART), focused interviews were conducted with two samples of women living with HIV/AIDS; one in the pre-HAART era (1994-1996) and a second matched sample in the HAART era (2000-2003). Women in the pre-HAART era held highly negative attitudes toward antiviral medications, perceived them as ineffective with few benefits and viewed side effects as intolerable. In contrast, women in the HAART era were less likely to report negative attitudes, which were balanced by more frequent reports of perceived benefits and more likely to view side effects as temporary and manageable. African American women in both eras were more likely to hold negative attitudes and less likely to perceive benefits than White and Puerto Rican women. These findings suggest that views of antiviral medication have improved since the advent of HAART, but that negative attitudes and side-effect concerns remain which should be addressed in interventions to promote treatment acceptance and adherence.

Neonatal HIV infection

The purpose of this article is to describe the pertinent issues related to mother-to-child transmission of HIV infection. Significant succcss has been achieved in developed countries to reduce the incidence of this devastating disease in neonates through screening of pregnant women, maternal antiretroviral therapy to reduce transmission, and cesarean section for delivery. Prophylaxis continues for the first six weeks of the newborn's life with antiretroviral therapy and careful monitoring of clinical well-being. Antiretroviral therapy offers significant reduction in the rate of mother-to child transmission, and this is presently the cornerstone of therapy for the HIV-infected pregnant woman. Clinical studies of treatment modalities continue to offer new hope to prevent transmission of the virus to the fetus. Care for the HIV infected newborn is highly complex and constantly evolving. All neonatal nurses should be aware of these issues so that they can be partners in the identification of new cases and the ongoing treatment of babies who are infected.

Motherhood in the context of maternal HIV infection

Metasummary and metasynthesis techniques were used to integrate findings pertaining to motherhood in 56 reports of qualitative studies conducted with HIV-positive women. Motherhood in the context of maternal HIV infection entailed work directed toward the illness itself and the social consequences of having HIV infection in the service of two primary goals: the protection of children from HIV infection and HIV-related stigma and the preservation of a positive maternal identity. Motherhood both intensified and mitigated the negative physical and social effects of HIV infection. HIV-positive mothers engaged in a distinctive kind of maternal practice-virtual motherhood-to resist forces that disrupted their relationships with and ability to care for their children, as well as their identities as mothers.

Disparity between pediatricians' knowledge and practices regarding perinatal human immunodeficiency virus counseling and testing

OBJECTIVES

This survey of members of the American Academy of Pediatrics (AAP) was initiated by the AAP Committee on Pediatric AIDS to assess the knowledge, attitudes, and behaviors of pediatricians regarding prenatal and neonatal screening as a means to reduce mother-to-child transmission of human immunodeficiency virus (HIV).

METHODS

The survey consisted of a 4-page, self-administered questionnaire, which was mailed to a random sample of 1647 active US members of the AAP. The original and 5 subsequent mailings to nonresponders were conducted from July to November 2001.

RESULTS

Completed questionnaires were received from 982 pediatricians, for a response rate of 59.6%. Nearly all pediatricians (96.6%) agree on the importance of knowing the HIV status of pregnant women, and more than three-fourths (78.5%) do not think that HIV screening during pregnancy or postpartum should be limited to women with perceived risk for infection. Approximately 6 (58.5%) of 10 pediatricians indicate that they counsel or provide education on HIV screening to pregnant women or mothers of newborns whose HIV status is unknown; 41.5% do not. Pediatricians reported evaluating an average of 56 newborns each during the 3 months before the survey. The HIV infection status of the mother was unknown for 40.6% of these cases. During the same time period, pediatricians said that they discussed a newborn or maternal HIV screening test with only 10.4% of the mothers whose HIV infection status was unknown. Reasons given for not counseling mothers with unknown HIV infection status about maternal and/or newborn screening for HIV included low prevalence of HIV in the pediatrician's practice area (65.4%), assessment by the pediatrician that the parents did not fit the profile of those "at risk" for HIV infection (56.1%), fear of offending the parents (50.2%), parental lack of understanding regarding the importance of screening (50.1%), and lack of sufficient time for counseling (44.4%).

CONCLUSIONS

Pediatricians exhibit a high degree of understanding of the importance of HIV screening as a means to reduce mother-to-child transmission of HIV, but this does not always translate into their clinical practices.

Classifying the findings in qualitative studies

A key task in conducting research integration studies is determining what features to account for in the research reports eligible for inclusion. In the course of a methodological project, the authors found a remarkable uniformity in the way findings were produced and presented, no matter what the stated or implied frame of reference or method. They describe a typology of findings, which they developed to bypass the discrepancy between method claims and the actual use of methods, and efforts to ascertain its utility and reliability. The authors propose that the findings in journal reports of qualitative studies in the health domain can be classified on a continuum of data transformation as no finding, topical survey, thematic survey, conceptual/thematic description, or interpretive explanation.

Toward a metasynthesis of qualitative findings on motherhood in HIV-positive women

A qualitative metasynthesis of qualitative findings ought to be more than a mere summary of those findings. Yet the processes by which the interpretive innovation expected of qualitative metasynthesis projects can be achieved remain opaque. Several analytic devices for the metasynthesis of findings were clarified in the course of an ongoing methodological project involving 45 reports of qualitative studies of HIV-positive women. These devices include the creation of a taxonomy of findings, the explicit use of sustained comparisons, the translation of in vivo concepts, and the use of imported concepts. Any qualitative metasynthesis of findings constitutes an interpretation at least three times removed from the lives represented in them. Clarifying the analytic devices used to create such metasyntheses is essential to demonstrating that despite being far away from participants' lives, these interpretations remain close to them.

The evolving art of caring for pregnant women with HIV infection

Care for the pregnant woman who has human immunodeficiency virus (HIV) is highly complex and constantly evolving. The purpose of this article is to describe the pertinent issues regarding women and HIV during pregnancy, including epidemiology of mother-to-child transmission, the effect of the disease on pregnancy, care issues in the perinatal period, and the issues in women's lives that place them at risk for HIV infection. Antiretroviral therapy offers significant reduction in the rate of mother-to-child transmission, and this is presently the cornerstone of therapy for the pregnant woman with HIV. Careful intrapartum management may also reduce the risk of transmission. Clinical studies of treatment modalities continue to offer new hope to prevent transmission of the virus to the fetus.