Priorities for HIV and chronic pain research: results from a survey of individuals with lived experience

The Global Task Force on Chronic Pain in HIV published seven research priorities in the field of HIV-associated chronic pain in 2019: (1) causes; (2) management; (3) treatment individualization and integration with addiction treatment; (4) mental and social health factors; (5) prevalence; (6) treatment cost effectiveness; and (7) prevention. The current study used a web-based survey to determine whether the research topics were aligned with the priorities of adults with lived experiences of HIV and chronic pain. We also collected information about respondents' own pain and treatment experiences. We received 311 survey responses from mostly US-based respondents. Most respondents reported longstanding, moderate to severe, multisite pain, commonly accompanied by symptoms of anxiety and/or depression. The median number of pain treatments tried was 10 (IQR = 8, 13), with medications and exercise being the most common modalities, and opioids being viewed as the most helpful. Over 80% of respondents considered all research topics either "extremely important" or "very important". Research topic #2, which focused on optimizing management of pain in people with HIV, was accorded the greatest importance by respondents. These findings suggest good alignment between the priorities of researchers and US-based people with lived experience of HIV-associated chronic pain.

The HIV Empowering Adults' Decisions to Share: UK/Uganda (HEADS-UP) Study-A Randomised Feasibility Trial of an HIV Disclosure Intervention for Young Adults with Perinatally Acquired HIV

Young adults with perinatally acquired HIV (PAH) face numerous challenges, including antiretroviral therapy (ART) adherence, managing onward HIV transmission risks and maintaining wellbeing. Sharing one's HIV status with others (onward HIV disclosure) may assist with these challenges but this is difficult. We developed and tested the feasibility of an intervention to help HIV status sharing decision-making for young adults with PAH. The study used a randomised parallel group feasibility design with 18-25-year-olds in Uganda and 18-29 year-olds in the UK. Participants were randomly assigned to intervention or standard of care (SOC) condition. The intervention consisted of four sessions (3 group, 1 individual) with follow-up support, delivered in person in Uganda and remotely in the UK. Assessments were carried out at: Pre-intervention /baseline; Post-intervention (intervention group only); Six-month follow-up. 142 participants were recruited (94 Uganda, 48 UK; 89 female, 53 male). At six-month follow-up, 92/94 (98%) participants were retained in Uganda, 25/48 (52%) in the UK. Multivariate analysis of combined data from both countries, showed a non-significant effect of intervention condition on HIV disclosure cognitions and affect (p = 0.08) and HIV disclosure intention (p = 0.09). There was a significant intervention effect on well-being (p = 0.005). This study addressed important gaps in understanding acceptable and feasible ways of delivering HIV status sharing support for young people living with PAH across two very different settings. The intervention was acceptable in both countries and feasible in Uganda. In the UK, retention may have been affected by its remote delivery.Trial registration: ISRCTN Registry, ISRCTN31852047, Registered on 21 January 2019.

Cultural Adaption, Translation, Preliminary Reliability and Validity of Key Psychological and Behavioural Measures for 18 to 25 Year-Olds Living with HIV in Uganda: A Multi-Stage Approach

HIV remains a significant public health issue among young adults living in Uganda. There is a need for reliable and valid measures of key psychological and behavioural constructs that are related to important outcomes for this population. We translated, adapted and tested the psychometric properties of questionnaires measuring HIV stigma, HIV disclosure cognitions and affect, antiretroviral therapy (ART) adherence, social support, personal values, and hope, using a multi-step process. This included: translation, back-translation, expert review, cognitive interviewing, readability and assessments of internal consistency with 93 young adults (18-25 years) living with perinatally acquired HIV in Uganda. Preliminary criterion validity was assessed by examining relationships between the adapted measures and wellbeing, HIV disclosure behaviour, HIV disclosure intention and viral load suppression. The measures all showed acceptable reliability and every questionnaire apart from the Agentic and Communal Value Scale was easy to read. Those scales measuring HIV disclosure affect and cognitions, social support, HIV stigma and hope showed relationships with other constructs suggestive of validity. There is preliminary evidence to support the use of these measures in research and clinical contexts for young adults living with perinatally acquired HIV in Uganda.

Psychological and Behavioural Within-participant Predictors of Adherence to Oral HIV Pre-Exposure Prophylaxis (PrEP)

Oral PrEP's effectiveness relies on adequate adherence during periods of substantial HIV risk. Since most PrEP users will miss doses, understanding predictors within participants can help to explain adherence. We used a cross-sectional, within-participant design with 67 gay, bisexual, and other men who have sex with men taking PrEP daily. Using a questionnaire, informed by the Information Motivation Behavioral Skills Model, participants were asked about an adherent and a non-adherent episode. PrEP non-adherence was associated with non-normality of the day (p < .001), being out of the home (p < .001), weekend days (p = .01), having company (p = .02), using substances (p = 0.02), not using reminders (p = .03), lower PrEP information (p = .04), lower behavioural skills (p < .001) and less positive affect (p = .002). PrEP adherence assessment could focus on situational variations, supporting the construction of alternative strategies to facilitate adherence in these situations.

How is Aging Perceived to Affect Well-being in Women Older than 50 Years Living With HIV? A Qualitative Systematic Review

ABSTRACT

Advances in HIV treatment have led to more people with HIV living to 50 years and older. No reviews have qualitatively analyzed and synthesized the literature relevant to theory and practice for well-being specifically in Women living with HIV (WLWH) aged 50 years and older. Sixteen eligible qualitative studies were critically appraised and thematically synthesized to investigate how aging was perceived to affect well-being in WLWH aged 50 years and older. Six themes demonstrated how HIV-related stigmas negatively affected social well-being, and how adjusting to living and aging with HIV negatively affected psychological and physical well-being of older WLWH. Holding caring roles also negatively affected physical well-being of WLWH. Globally, majority women aging with HIV were found to experience additional stigmas. Further research could elucidate how HIV-related stigma affects the well-being of global majority women living and aging with HIV. Recommendations are made for future HIV-related clinical practice and theory development.

The Global Task Force for Chronic Pain in People with HIV (PWH): Developing a research agenda in an emerging field

Chronic pain is a common comorbidity in people with HIV (PWH), with prevalence estimates of 25-85%. Research in this area is growing, but significant gaps remain. A Global Task Force of HIV experts was organized to brainstorm a scientific agenda and identify measurement domains critical to advancing research in this field. Experts were identified through literature searches and snowball sampling. Two online questionnaires were developed by Task Force members. Questionnaire 1 asked participants to identify knowledge gaps in the field of HIV and chronic pain and identify measurement domains in studies of chronic pain in PWH. Responses were ranked in order of importance in Questionnaire 2, which was followed by a group discussion. 29 experts completed Questionnaire 1, 25 completed Questionnaire 2, and 21 participated in the group. Many important clinical and research priorities emerged, including the need to examine etiologies of chronic pain in PWH. Pain-related measurement domains were discussed, with a primary focus on domains that could be assessed in a standardized manner across various cohorts that include PWH in different countries. We collaboratively identified clinical and research priorities, as well as gaps in standardization of measurement domains, that can be used to move the field forward.

Understanding the Relationship Between Sexual Assault and Cervical Screening Uptake

Abstract. Background: Cervical screening helps prevent cervical cancer ( NHS, 2019 ). Women who have experienced sexual assault have lower cervical screening attendance, however, no theory-driven research explores reasons for this. The Health Action Process Approach (HAPA) explains intention and ongoing attendance to health-promoting behaviors. Aims: The HAPA was used to identify and explore how sexual assault impacts cervical screening uptake. Method: An online study of 247 women aged 21–63 explored whether HAPA variables (task, maintenance, and recovery self-efficacy, outcome expectancies, risk perception, action, and coping planning), trauma variables (nature and age of abuse, and level of post-traumatic stress disorder symptoms [PTSD]), and other potentially confounding factors related to cervical screening uptake in women who have experienced sexual assault. Regression and mediation analyses were conducted to explore predictive variables of intention and attendance. Results: Self-efficacy beliefs predicted both intention and attendance of cervical screening. Task self-efficacy predicted intention and mediated relationships between HAPA variables and intention. Maintenance self-efficacy predicted attendance and mediated relationships between HAPA variables and attendance. Trauma variables did not predict more variance in intention or attendance over HAPA variables. Limitations: The cross-sectional nature of the study means causality was not established. Conclusion: Self-efficacy develops an understanding of cervical screening in women with experience of sexual assault, over and above the trauma variables of type of assault and PTSD symptoms. Focusing on self-efficacy to improve cervical screening uptake in women who have experienced sexual assault is considered for clinical implications.

Health-related guilt in chronic primary pain: A systematic review of evidence

PURPOSE

Chronic primary pain conditions are characterized by significant functional disability, emotional distress, and diagnostic uncertainty. Health-related guilt associated with coping and living with chronic pain is poorly understood. There had been no attempts to synthesize findings on health-related guilt across studies. Therefore, the aim of this study was to conduct a systemic review of evidence, to enable an understanding of the role of health-related guilt in chronic primary pain, and to provide directions for future research.

METHOD

A search strategy was developed based on our eligibility criteria. Four databases (PsycINFO, Scopus, PubMed, and Web of Science) were searched for relevant papers from inception to 8 July 2020. Data from 12 qualitative and six quantitative studies were synthesized narratively.

RESULTS

The review of qualitative studies resulted in three themes, relating to the management of pain, diagnostic uncertainty/legitimizing pain, and how participants' actions or inactions affect others. These findings were integrated with evidence from quantitative studies, which showed that higher levels of guilt were associated with more pain and pain interference, functional impairment, and poorer psychological and social functioning.

CONCLUSIONS

The findings demonstrate that health-related guilt is an important psychological factor associated with more pain and poorer function in people with chronic primary pain conditions. Future research should examine health-related guilt as a potential mediating/moderating factor leading to more distress and suffering in this population and as a potential target for interventions.

'We're touching the topic, but we're not opening the book:' A grounded theory study of sibling relationships in young people with perinatally acquired HIV

HIV-related stressors affecting young adults with perinatally acquired HIV (PHIV+) and their siblings include parental and sibling ill-health and death, own ill-health, HIV disclosure, and stigma. Young people with PHIV+ typically share their HIV status with family members. We explored sibling relationships in young people with PHIV+. Ten participants (six females, 17–23 years old) with PHIV+ took part in a semi-structured interview, analysed using Grounded Theory. The data were condensed into three theoretical codes: (1) HIV disclosure in sibling relationship; (2) Patterns of communication about HIV between siblings; and (3) Patterns of coping and support in sibling relationship.

A randomised feasibility trial of an intervention to support sharing of HIV status for 18-25-year olds living with perinatally acquired HIV compared with standard care: HIV Empowering Adults' Decisions to Share-UK/Uganda Project (HEADS-UP)

Abstract

Background

Young adults with perinatally acquired HIV (PAH) face several challenges, including adhering to antiretroviral therapy (ART), managing the risk of onward HIV transmission and maintaining positive well-being. Sharing one’s HIV status with others (onward HIV disclosure) may assist with these challenges by facilitating emotional and practical support. Rates of HIV status sharing are, however, low in this population. There are no existing interventions focused on sharing one’s HIV status for young adults living with PAH. The HEADS-UP study is designed to develop and test the feasibility of an intervention to help the sharing of HIV status for young adults with PAH.

Methods

The study is a 30-month multi-site randomised feasibility study across both a high-income/low-HIV prevalence country (UK) and a low-income/high-HIV prevalence country (Uganda). Phase 1 (12 months) will involve developing the intervention using qualitative interviews with 20 young people living with PAH (ten in the UK—18 to 29 years; ten in Uganda—18 to 25 years), 20 of their social network (friends, family, sexual partners as defined by the young person; ten in the UK, ten in Uganda) and ten professionals with experience working with young adults with PAH (five in the UK, five in Uganda). Phase 2 (18 months) involves conducting a randomised feasibility parallel group trial of the intervention alongside current standard of care condition in each country (main study) with 18- to 25-year olds with PAH. A sample size of 94 participants per condition (intervention or standard of care; 188 participants in total: 47 in each condition in each country) with data at both the baseline and 6-month follow-up time points, across UK and Ugandan sites will be recruited. Participants in the intervention condition will also complete measures immediately post-intervention. Face-to-face interviews will be conducted with ten participants in both countries immediately post-intervention and at 6-month follow-up (sub-study).

Discussion

This study will be the first trial that we are aware of to address important gaps in understanding acceptable and feasible ways of delivering HIV status sharing support for young people living with PAH.

Trial registration

ISRCTN Registry, ISRCTN31852047, Registered on 21 January, 2019. Study sponsor: Royal Holloway University of London. Sponsor contact: alicen.nickson@rhul.ac.uk. Date and version: April 2020. Protocol version 3.5.

"The People That I Think Are Not Going to React Good, I Am Not Going to Tell": Onward Disclosure to Friends by Young Adults With Behaviorally Acquired HIV

Sharing their HIV status with friends may help young people diagnosed with behaviorally acquired HIV access social support. Our qualitative study used constructivist grounded theory to explore onward HIV disclosure decisions within friendships of young adults living with behaviorally acquired HIV. Semistructured interviews were conducted with 10 participants (ages 22-26 years). Three themes were identified: (a) personal factors influencing disclosure decisions; (b) social factors influencing disclosure decisions; and (c) disclosure decision outcomes. The relational context seemed to be particularly important in deciding whether or not to disclose. Participants who had shared their status reported no negative and some positive consequences. Anticipated stigma was influential in situations where participants chose not to disclose; however, friendships were not adversely affected by nondisclosure. Key clinical implications are discussed.

What is the best way to share an HIV diagnosis with an intimate partner? An experimental study of assertive disclosure communication

Living with HIV presents challenges to wellbeing and managing one's own and others' health. Sharing an HIV positive diagnosis can increase social support and antiretroviral adherence and reduce onward HIV transmission. However, HIV disclosure anxiety is common with concerns about partner responses. There is limited research on whether the way HIV is shared affects partners' responses. We assessed whether communication style influences hypothetical partner responses in intimate relationships. Two hundred and four participants (83% female; median age 20, IQR 19-23) were shown four vignettes (high assertion regular partner, low assertion regular partner, high assertion casual partner, low assertion casual partner). Participants responded as the intimate partner to questions addressing affective and cognitive reactions to HIV diagnosis sharing. Assertive compared to non-assertive communication led to intimate partner responses with lower negative affect, warmer feelings toward the character and greater intentions to provide support and to continue a sexual relationship. Participants responded with more global negative affect and shock, and greater intention to provide support and to continue a sexual relationship if the character was a regular compared to a causal partner. Future work could explore whether people with HIV should be assisted to share their diagnosis assertively for greater benefits.

A preliminary analysis of the association between perceived stigma and HIV-related pain in South Africans living with HIV

Background

Stigma related to the human immunodeficiency virus (HIV) remains common and has been associated with severity of HIV-related symptoms. Associations between HIV stigma and HIV-related pain, one of the most common symptoms in HIV, have however not been investigated. Data from low back pain populations suggest that stigma is associated with worse pain intensity and so we hypothesised that the same would be the case in HIV.

Aim

The goal of this study was to assess the association between HIV stigma and pain intensity in people living with HIV (PLWH) with chronic pain whilst controlling for depression, a well-established correlate of pain.

Setting

The study took place at an HIV clinic in Johannesburg, South Africa.

Methods

Mediation analysis was used to assess the effect of depression on the relationship between stigma and pain intensity in a cross-sectional cohort of 50 PLWH and chronic pain (pain most days of the week for > 3 months). All participants were assessed using the HIV/AIDS Stigma Instrument – PLWA, an 11-point numerical pain rating scale and the Beck Depression Inventory II.

Results

In all, 88% (44/50) of participants reported experiencing some form of HIV stigma (HIV stigma scale score ≥ 1). Worst pain intensity and depressive symptoms individually correlated with total stigma score (Spearman’s r = 0.33, p = 0.02 for both). The mediation analysis highlighted that mediation of the relationship by depression was equivocal (b = -0.002, bootstrapped confidence interval -0.02 to 0.00).

Conclusion

Whilst these preliminary data are marginal, they do suggest that associations between HIV stigma and HIV-related pain warrant further investigation. Future study should also include potential mechanisms, which may include mediation through depression.

A longitudinal evaluation of an intensive residential intervention (camp) for 12-16 year olds living with HIV in the UK: evidence of psychological change maintained at six month follow-up

There are large numbers of young people with HIV globally, the majority of whom have perinatally acquired HIV (PAH). Despite evidence of lower levels of wellbeing in young people with PAH compared to HIV unaffected peers, there are few psychosocial interventions for this population. Residential interventions (camps) for young people with HIV have the potential for enhancing well-being and improving HIV-related outcomes. There have not been any quantitative evaluations of camps for young people with HIV. This study evaluated a week-long intensive residential intervention for 12-16 year olds living with HIV in the UK. A quantitative repeated measures design was used. Forty nine participants completed assessments before and immediately after the intervention (post-intervention) and at six month follow-up (73% retention rate; 28 (57%) female; median age 14 years, IQR 13-15 years). Self-report measures suggested improvements in both HIV knowledge and pro HIV disclosure affect and cognitions post-intervention, maintained at six month follow-up. There were improvements in antiretroviral adherence beliefs from baseline to six month follow-up, and in self-perception from baseline to post-intervention. These changes are important in their own right but may also be mediators of other outcomes such as increased ART adherence and reduced onward HIV transmission risk. The study suggests that brief residential interventions have the potential to facilitate sustained change in psychological outcomes. Research and practice implications are outlined.

The Adolescent HIV Communication Belief Scale: Preliminary Reliability and Validity

Globally, there are nearly 2 million HIV positive children, many of whom are adolescents. The majority have perinatally acquired HIV. A key challenge for this population is communicating about HIV to meet emotional and practical needs. Despite evidence of its benefits, HIV communication in adolescents with HIV is rare. To enhance HIV communication, individuals' beliefs may need to be taken into account. There is no measure of beliefs about HIV communication for adolescents living with HIV. A seven-item measure of HIV communication beliefs was developed and administered to 66 adolescents with HIV in the UK (39 female; aged 12-16 years). Data were explored using principal component analysis. Preliminary criterion-related validity was assessed by examining relationships between the measure and communication occurrence, frequency and intention. Preliminary construct validity was assessed by examining relationships between the measure and HIV stigma, HIV disclosure cognition and affect, quality of life and self-perception. Two factors were revealed: communication self-efficacy and normative beliefs; and communication attitudes. The full scale and its subscales were internally consistent. The total score showed statistically significant positive relationships with HIV communication intention, HIV disclosure cognitions and affect, and HIV stigma but not with other variables. Preliminary evidence of the measure's good psychometric properties suggests it may be helpful in outlining relationships between HIV communication beliefs and other constructs. It may also be useful in testing interventions that aim to enhance HIV communication in this population. Further work needs to be done to establish the scale's psychometric properties.

Psychological Factors Associated with Episodic Chelation Adherence in Thalassemia

β-Thalassemia major (β-TM) is a life-long genetic hemoglobin (Hb) disorder requiring intensive treatment regimens, including frequent blood transfusions and daily chelation therapy. Understanding psychosocial correlates of chelation adherence is important for developing interventions to improve adherence. This study investigated within-participant correlates of oral chelation adherence on a daily (episodic) basis. Thirty-seven adult participants with β-TM were recruited from clinics at two hospitals (22 males, 9 females, mean age 34.5 years, range 19-54 years). A structured interview was used to assess behavioral and psychological situational variables related to an adherent and a nonadherent episode for each participant. Positive outcome expectancies and higher self-efficacy were both significantly associated with adherent episodes. Behavioral variables, including difficulty in accessing medication, location, and whether alone or with others, were also associated with nonadherent episodes. Findings suggested that situational psychological factors are important for chelation adherence. Adherence interventions should consider focusing on potentially modifiable situational variables (psychological and behavioral).

Anxiety and depression symptoms in young people with perinatally acquired HIV and HIV affected young people in England

Adolescents with perinatal HIV (PHIV) may be at higher risk of anxiety and depression than HIV negative young people. We investigated prevalence of anxiety and depression symptoms in 283 PHIV and 96 HIV-affected (HIV-negative) young people in England recruited into the Adolescents and Adults Living with Perinatal HIV (AALPHI) cohort. We used Hospital Anxiety and Depression Scale (HADS) scores and linear regression investigated predictors of higher (worse) scores.115 (41%) and 29 (30%) PHIV and HIV-affected young people were male, median age was 16 [interquartile range 15,18] and 16 [14,18] years and 241 (85%) and 71 (74%) were black African, respectively. There were no differences in anxiety and depression scores between PHIV and HIV-affected participants. Predictors of higher anxiety scores were a higher number of carers in childhood, speaking a language other than English at home, lower self-esteem, ever thinking life was not worth living and lower social functioning. Predictors of higher depression scores were male sex, death of one/both parents, school exclusion, lower self-esteem and lower social functioning. In conclusion, HIV status was not associated with anxiety or depression scores, but findings highlight the need to identify and support young people at higher risk of anxiety and depression.

'I don't even know how to start that kind of conversation': HIV communication between mothers and adolescents with perinatally acquired HIV

Young people with perinatally acquired HIV are now surviving into late adolescence and adulthood. We explored HIV communication within mother/adolescent dyads following naming of the adolescents' HIV. Five adolescents with perinatally acquired HIV (14-16 years) and their biological mothers were interviewed separately. HIV communication between mothers and children was rare. Discussion most commonly related to biomedical aspects of HIV. Onward HIV disclosure was discouraged by mothers, which often contrasted with adolescents' beliefs. Discussing emotional and sexual aspects of HIV was mutually avoided. Culturally sensitive support and guidance should be offered to families about discussing HIV, considering potentially differing perspectives.

The Adolescent HIV Disclosure Cognition and Affect Scale: Preliminary Reliability and Validity

Objectives

Globally, there are 2 million HIV-positive 10-19-year-olds. One challenge for this population is sharing their HIV status with others (onward HIV disclosure). There are no multi-item, multidimensional scales of HIV disclosure cognitions and affect for young people living with HIV. An 18-item measure of HIV disclosure cognition and affect was developed, administered to 65 adolescents living with HIV (aged 12-16 years). Data were explored using principal component analysis and preliminary construct and criterion validity assessed. Three factors were revealed: negative disclosure attitudes and feelings, self-efficacy, and positive disclosure attitudes and feelings. The full scale and its subscales were internally consistent. The total score showed statistically significant positive relationships with HIV disclosure in the past 6 months, HIV disclosure intention and self-perception. Preliminary evidence of the measure's good psychometric properties suggests it may be helpful in future clinical and research work.

A systematic review of psychological correlates of HIV testing intention

Undiagnosed HIV infection is associated with onward HIV transmission and delays in accessing HIV care and treatment. As a significant proportion of HIV tests are self-initiated, it is important to assess correlates of the intention to test for HIV. Psychological correlates of HIV testing intention are more likely to be the feasible target of interventions than structural determinants. A systematic review of psychological correlates of HIV testing intention was conducted. Twenty studies were included in the review, covering a range of populations and geographical regions. The most commonly assessed variables were HIV risk perception and HIV knowledge rather than HIV test-specific psychological factors. There was evidence that HIV risk perception and pro-testing attitudes were consistently associated with HIV testing intention across a number of studies. There is a need for longitudinal designs, including experimental studies, allowing for more confident casual inferences to be made. Theoretical, research and practice implications are outlined.

HIV Disclosure Anxiety: A Systematic Review and Theoretical Synthesis

HIV disclosure can help people living with HIV to access social support, enhance antiretroviral adherence, facilitate engagement in care and reduce unprotected sex. Given interpersonal risks associated with HIV disclosure, however, anxiety about sharing one's status is common. To investigate anxiety about HIV disclosure in HIV-positive populations, we conducted a systematic review of qualitative and quantitative studies, with 119 studies included. The review demonstrated that perceived interpersonal risks are associated with HIV disclosure and outlined evidence of associations with anxiety, fear and worry. We present a new cognitive model of HIV disclosure anxiety adapted from clinical theories of health and social anxiety, consistent with evidence from the review. The model attempts to explain the development and maintenance of anxiety in individuals whose functioning is most affected by concerns about sharing their status. Implications for helping people living with HIV struggling with significant levels of anxiety about HIV disclosure are discussed.

Factors associated with pre-ART loss-to-follow up in adults in rural KwaZulu-Natal, South Africa: a prospective cohort study

BACKGROUND

Timely initiation of antiretroviral treatment (ART) requires sustained engagement in HIV care before treatment eligibility. We assessed loss to follow-up (LTFU) correlates in HIV-positive adults accessing HIV treatment and care, not yet ART-eligible (CD4 >500 cells/mm(3)).

METHODS

This was a sub-study of a prospective cohort study (focusing on sexual behaviour) in an area of high HIV prevalence and widespread ART availability in rural KwaZulu-Natal, South Africa. Psychosocial, clinical and demographic data were collected at recruitment from individuals with CD4 >500 cells/mm(3). LTFU was defined as not attending clinic within 13 months of last visit or before death. Individuals starting ART were censored at ART initiation. Data were collected between January 2009 and January 2013. Analysis used Competing Risks regression.

RESULTS

Two hundred forty-seven individuals (212 females) were recruited (median follow-up 2.13 years, total follow-up 520.15 person-years). 86 remained in pre-ART care (34.8 %), 94 were LTFU (38.1 %), 58 initiated ART (23.5 %), 7 died (2.8 %), 2 transferred out (0.8 %). The LTFU rate was 18.07 per 100 person-years (95 % CI 14.76-21.12). LTFU before a competing event was 13.5 % at one and 34.4 % at three years. Lower LTFU rates were significantly associated with age (>37 versus ≤37 years: adjusted sub-Hazard ratio (aSHR) 0.51, 95 % CI 0.30-0.87), openness with family/friends (a little versus not at all, aSHR 0.81, 95 % CI 0.45-1.43; a lot versus not at all, aSHR 1.57, 95 % CI 0.94-2.62), children (0 versus 4+, aSHR 0.68, 95 % CI 0.24-1.87; 1 versus 4+, aSHR 2.05 95 % CI 1.14-3.69, 2 versus 4+; aSHR 1.71, 95 % CI 0.94-3.09; 3 versus 4a, aSHR 1.14, 95 % CI 0.57-2.30), previous CD4 counts (1 versus 0, aSHR 0.81, 95 % CI 0.45-1.43; 2+ versus 0, aSHR 0.43, 95 % CI 0.25-0.73), and most recent partner HIV status (not known versus HIV-positive, aSHR 0.77, 95 % CI 0.50-1.19; HIV-negative versus HIV-positive, aSHR 2.40, 95 % CI 1.18-4.88). The interaction between openness with family/friends and HIV partner disclosure was close to significance (p = 0.06). Those who had neither disclosed to partners nor were open with family/friends had lowest LTFU rates.

CONCLUSIONS

Strategies to retain younger people in pre-ART care are required. How openness with others, partner HIV status and disclosure, and children relate to LTFU needs further exploration.

Which Psychological Factors are Related to HIV Testing? A Quantitative Systematic Review of Global Studies

Deciding to test for HIV is necessary for receiving HIV treatment and care among those who are HIV-positive. This article presents a systematic review of quantitative studies on relationships between psychological (cognitive and affective) variables and HIV testing. Sixty two studies were included (fifty six cross sectional). Most measured lifetime testing. HIV knowledge, risk perception and stigma were the most commonly measured psychological variables. Meta-analysis was carried out on the relationships between HIV knowledge and testing, and HIV risk perception and testing. Both relationships were positive and significant, representing small effects (HIV knowledge, d = 0.22, 95 % CI 0.14–0.31, p < 0.001; HIV risk perception, OR 1.47, 95 % CI 1.26–1.67, p < 0.001). Other variables with a majority of studies showing a relationship with HIV testing included: perceived testing benefits, testing fear, perceived behavioural control/self-efficacy, knowledge of testing sites, prejudiced attitudes towards people living with HIV, and knowing someone with HIV. Research and practice implications are outlined.

Habit reversal training and educational group treatments for children with tourette syndrome: A preliminary randomised controlled trial

Quality of life of children with Tourette Syndrome (TS) is impacted greatly by its symptoms and their social consequences. Habit Reversal Training (HRT) is effective but has not, until now, been empirically evaluated in groups. This randomised controlled trial evaluated feasibility and preliminary efficacy of eight HRT group sessions compared to eight Education group sessions. Thirty-three children aged 9-13 years with TS or Chronic Tic Disorder took part. Outcomes evaluated were tic severity and quality of life (QoL). Tic severity improvements were found in both groups. Motor tic severity (Yale Global Tic Severity Scale) showed greatest improvements in the HRT group. Both groups showed a strong tendency toward improvements in patient reported QoL. In conclusion, group-based treatments for TS are feasible and exposure to other children with tics did not increase tic expression. HRT led to greater reductions in tic severity than Education. Implications, such as cost-effectiveness of treatment delivery, are discussed.

Episodic medication adherence in adolescents and young adults with perinatally acquired HIV: a within-participants approach

Due to the success of antiretroviral (ART) medications, young people living with perinatally acquired HIV (PHIV+) are now surviving into adolescence and young adulthood. Understanding factors influencing ART non-adherence in this group is important in developing effective adherence interventions. Most studies of ART adherence in HIV-positive populations assess differences in adherence levels and adherence predictors between participants, over a period of time (global adherence). Many individuals living with HIV, however, including PHIV+ young people, take medication inconsistently. To investigate this pattern of adherence, a within-participants design, focussing on specific episodes of adherence and non-adherence, is suitable (episodic adherence). A within-participants design was used with 29 PHIV+ young people (17 female, median age 17 years, range 14-22 years), enrolled in the UK Adolescents and Adults Living with Perinatal HIV cohort study. Participants were eligible if they could identify one dose of medication taken and one dose they had missed in the previous two months. For each of the two episodes (one adherent, one non-adherent), behavioural factors (whom they were with, location, routine, day, reminders) and psychological factors at the time of the episode (information about medication, adherence motivation, perceived behavioural skills to adhere to medication - derived from the Information-Motivation-Behavioural Skills (IMB) Model - and affect) were assessed in a questionnaire. Non-adherence was significantly associated with weekend days (Friday to Sunday versus Monday to Thursday, p = .001), lack of routine (p = .004), and being out of the home (p = .003), but not with whom the young person was with or whether they were reminded to take medication. Non-adherence was associated with lower levels of behavioural skills (p < .001), and lower positive affect (p = .005). Non-adherence was not significantly associated with negative affect, information about ART, or ART motivation. The use of situationally specific strategies to enhance adherence in young people who take their medication inconsistently is proposed.

What leads some people to think they are HIV-positive before knowing their diagnosis? A systematic review of psychological and behavioural correlates of HIV-risk perception

Current HIV-risk perception refers to the extent to which individuals think they might be HIV-positive. This belief, distinct from the perceived risk about being infected with HIV in the future, is likely to have a range of important consequences. These consequences may include both psychological effects (e.g., impacts on well-being) and behavioural effects (e.g., HIV testing uptake). Given these possible outcomes, and the suggested importance of risk perception in health behaviour models, understanding the behavioural and psychological antecedents of current HIV-risk perception is crucial. This systematic review investigates the relationship between behavioural and psychological factors and current HIV-risk perception (in individuals who are unaware of their actual HIV status). Eight studies were eligible for inclusion in the review (five quantitative and three qualitative studies). Drug risk behaviour and sexual risk behaviour (both self and partner) were often associated with current HIV-risk perception, although other studies failed to show a relationship between one's own sexual risk behaviour and risk perception. Psychological factors were only rarely assessed in relation to current HIV-risk perception. Where these variables were included, there was evidence that experiencing symptoms perceived to be consistent with HIV and prompts to test were associated with increased current HIV-risk perception. These findings are consistent with the Common-Sense Model (CSM) of illness representation and self-regulation. Methodological quality criteria were rarely met for the included studies. In addition, it was often difficult to ascertain whether potentially includable studies were eligible due to imprecise definitions of HIV-risk perception. Research and practice implications are discussed, with particular emphasis on the role of risk appraisals as a potential mediator of the relationship between HIV-risk behaviour, symptoms and current HIV-risk perception.

Intimate relationships in young adults with perinatally acquired HIV: a qualitative study of strategies used to manage HIV disclosure

An increasing number of children born with perinatally acquired HIV (PAH) are surviving into late adolescence and early adulthood. At this developmental stage, forming and sustaining intimate relationships is important. Young adults with PAH face both normative challenges and additional, HIV-related, relationship stressors. One key issue is the decision about whether and how to share their HIV status with others. Being able to disclose one's HIV status to sexual partners may reduce the risk of onward HIV transmission but is associated with the fear of rejection. There has been little research on how young people with PAH manage such disclosure-related stressors in intimate relationships. This study examined how disclosure challenges are managed by young adults with PAH in the UK within their intimate relationships. Seven participants (five females and two males) currently or previously in an intimate relationship, aged 18-23 years, were recruited from a UK hospital clinic. The majority of participants were of sub-Saharan African origins. They took part in in-depth interviews, with data analysed according to the principles of interpretative phenomenological analysis. Four themes were elicited: (1) decisions about starting, continuing or resuming relationships shaped by disclosure, (2) disclosing early to avoid the pain of future rejection, (3) using condoms to avoid disclosure and (4) testing likely partner reactions to disclosure. The study revealed the significant extent to which HIV disclosure affected the experience of relationships in this population. Interventions to support adolescents and young adults with PAH to disclose to their partners should be developed alongside guidance for professionals. Future research should include older samples of adults with PAH and studies in sub-Saharan African settings.

"I Owe Her So Much; Without Her I Would Be Dead": Developing a Model of Mother-Infant Bonding Following a Maternal Antenatal HIV Diagnosis

Women can face a period of psychological vulnerability following antenatal HIV diagnosis, affecting feelings about both the pregnancy and motherhood. Our study explored the impact of being diagnosed with HIV during pregnancy on mother-infant bonding. Grounded Theory was used to assess perceived challenges and facilitating factors for mother-infant bonding for 10 mothers given an HIV diagnosis during pregnancy. Data analysis led to a model of mother-infant bonding composed of four theoretical codes: (a) facing barriers to bonding, (b) feeling disconnected from the baby, (c) developing a special bond, and (d) strengthening and moving on. Challenges with bonding emerged primarily during early stages after diagnosis and birth, with maternal resilience and positivity about the future developing as the infant HIV testing process progressed. Study recommendations include more timely information regarding vertical transmission and more targeted psychological support along with greater promotion of services to support women diagnosed with HIV antenatally.

A model of caregiver paediatric HIV disclosure decision-making

Many of the over 3 million HIV-positive children will only be told of their status as adolescents. Knowing one's status may increase treatment adherence, reduce onward HIV transmission, increase trust in caregivers and maximise available support. Yet deciding whether, what, how and when to tell HIV-positive children about their condition is challenging for caregivers. We systematically review HIV disclosure theories before presenting a process model of caregiver paediatric HIV disclosure decision-making. The model, consisting of both a pre-intention and a post-intention stage, integrates individual and contextual determinants. It aims to be situationally specific, broadly applicable and consistent with the empirical literature. Research and practice implications are discussed.

Restriction and dependence to autonomy and freedom: transformation in adolescent heart transplant recipients

The process of heart transplantation poses numerous challenges and adaptive tasks for paediatric patients and their families. Few studies have examined how the experience of transplant interacts with developmental transitions such as adolescence, a period of significant change, and adjustment in itself. We explored adolescent heart transplant recipients' and their parents' experience of transplant from the point at which their heart condition was diagnosed to several months after transplantation. We adopted a developmental focus, to consider how participants negotiated the tasks of adolescence in the context of their transplant experiences. A qualitative approach was used to interview five adolescent-parent dyads, who reported few post-transplant complications, and the data were analysed according to the principles of IPA. Our findings revealed transplant to be a transformative experience, with two themes marking a contrast between pre- and post-transplant states: "Restriction and Dependence" and "Autonomy and Freedom." The themes are considered in relation to adolescent development. We propose that clinicians working with paediatric heart transplant recipients and their families need to consider the particular developmental challenges faced by adolescent patients and view the attainment of developmental milestones alongside physical and psychological markers of successful adjustment.

The association between self-reported stigma and loss-to-follow up in treatment eligible HIV positive adults in rural Kwazulu-Natal, South Africa

BACKGROUND

The relationship between loss-to-follow-up (LTFU) in HIV treatment and care programmes and psychosocial factors, including self-reported stigma, is important to understand. This prospective cohort study explored stigma and LTFU in treatment eligible adults who had yet not started antiretroviral therapy (ART).

METHODS

Psychosocial, clinical and demographic data were collected at a baseline interview. Self-reported stigma was measured with a multi-item scale. LTFU was defined as not attending clinic in the 90 days since last appointment or before death. Data was collected between January 2009 and January 2013 and analysed using Cox Regression.

RESULTS

380 individuals were recruited (median time in study 3.35 years, total time at risk 1065.81 person-years). 203 were retained (53.4%), 109 were LTFU (28.7%), 48 had died and were not LTFU at death (12.6%) and 20 had transferred out (5.3%). The LTFU rate was 10.65 per 100 person-years (95% CI: 8.48-12.34). 362 individuals (95.3%) started ART. Stigma total score (categorised in quartiles) was not significantly associated with LTFU in either univariable or multivariable analysis (adjusting for other variables in the final model): second quartile aHR 0.77 (95%CI: 0.41-1.46), third quartile aHR 1.20(95%CI: 0.721-2.04), fourth quartile aHR 0.62 (95%CI: 0.35-1.11). In the final multivariable model, higher LTFU rates were associated with male gender, increased openness with friends/family and believing that community problems would be solved at higher levels. Lower LTFU rates were independently associated with increased year of age, greater reliance on family/friends, and having children.

CONCLUSIONS

Demographic and other psychosocial factors were more closely related to LTFU than self-reported stigma. This may be consistent with high levels of social exposure to HIV and ART and with stigma affecting LTFU less than other stages of care. Research and clinical implications are discussed.

Does message framing predict willingness to participate in a hypothetical HIV vaccine trial: an application of Prospect Theory

It is vital that enough participants are willing to participate in clinical trials to test HIV vaccines adequately. It is, therefore, necessary to explore what affects peoples' willingness to participate (WTP) in such trials. Studies have only examined individual factors associated with WTP and not the effect of messages about trial participation on potential participants (e.g., whether losses or gains are emphasized, or whether the outcome is certain or uncertain). This study explores whether the effects of message framing on WTP in a hypothetical HIV vaccine trial are consistent with Prospect Theory. This theory suggests that people are fundamentally risk averse and that (1) under conditions of low risk and high certainty, gain-framed messages will be influential (2) under conditions of high risk and low certainty, loss-framed messages will be influential. This cross-sectional study recruited 283 HIV-negative students from a South African university who were given a questionnaire that contained matched certain gain-framed, certain loss-framed, uncertain gain-framed, and uncertain loss-framed statements based on common barriers and facilitators of WTP. Participants were asked to rate how likely each statement was to result in their participation in a hypothetical preventative HIV vaccine trial. Consistent with Prospect Theory predictions, for certain outcomes, gain-framed messages were more likely to result in WTP than loss-framed messages. Inconsistent with predictions, loss-framed message were not more likely to be related to WTP for uncertain outcomes than gain-framed messages. Older students were less likely to express their WTP across the different message frames. Recruitment for HIV vaccine trials should pay attention to how messages about the trial are presented to potential participants.

Intimate relationships in young adults with perinatally acquired HIV: partner considerations

Due to developments in anti-retroviral treatment, an increasing number of children with perinatally acquired HIV are now surviving into late adolescence and young adulthood. This cohort is facing normative challenges in terms of their intimate relationships as well as challenges that face all individuals with HIV regardless of the route of transmission (for example, concerns about disclosure). There may be additional issues specific to having grown up with HIV that affect intimate relationships, for example, the awareness of being HIV positive before the onset of intimate relationships and the way that identity is shaped by having lived with HIV from a young age. To date there has been some limited research on the experience of intimate relationships in perinatally infected adolescents but none in young adults. This exploratory study examined, in depth, experiences of intimate relationships in perinatally acquired young adults and how they perceived having grown up with HIV to have affected such relationships. Seven participants (five females, two males) aged 18-23 years, were interviewed, with the data analysed according to the principles of interpretative phenomenological analysis (IPA). Three themes emerged that related to partners' perceptions of HIV: (1) HIV being viewed by partners as being linked to AIDS and sexual transmission, (2) discrepancy between young people and their partners' views of HIV, (3) partner views of risk of HIV transmission. There were strong links between participants' personal experiences of HIV-related challenges, for example, disclosure and HIV-related stigma, and their thinking about the perceptions of partners. These findings have important implications for supporting young people in disclosing their HIV status to intimate partners in appropriate ways. Suggestions for future research are offered.

Trauma-related guilt and posttraumatic stress among journalists

This study explored the psychological impact of exposure to work-related trauma among journalists. It was hypothesised that positive associations would exist between (a) exposure and PTSD symptoms, (b) exposure and guilt cognitions, and (c) guilt cognitions and PTSD symptoms, and that the relationship between exposure and PTSD symptoms would be mediated by guilt cognitions. The sample consisted of 50 journalists (response rate = 15%), who had recently been exposed to work-related trauma. They were predominantly male, aged 40 years or older, well-educated, and most had worked in journalism for at least 15 years. Participants completed an online questionnaire that explored their work-related experiences of trauma, PTSD symptoms, and trauma-related guilt cognitions. The findings showed that higher levels of exposure to work-related trauma were significantly associated with higher levels of PTSD symptoms (r = .36) and trauma-related guilt cognitions (r = .29). Guilt cognitions were significantly and positively independently associated with PTSD symptoms (r = .12) and were consistent with partial mediation of relationship between exposure to work-related trauma and PTSD symptoms. This study provides greater insight into the psychological processing of work-related traumatic events among journalists and emphasizes the importance of posttrauma appraisals of guilt regarding their experiences.

Understanding cannabis use in first-episode psychosis: an application of the Theory of Planned Behaviour

AIM

The study aims to examine whether an extended Theory of Planned Behaviour (TPB) model predicts the frequency of past and intended cannabis use in young adults with psychosis.

METHODS

A cross-sectional correlational design was used with 32 participants (aged 18-36 years old) within 3 years (mean = 7 months) of their first psychotic episode. TPB variables and a measure of social influence (descriptive norms) were measured.

RESULTS

The TPB accounted for a large amount of the variance in both the frequency of past cannabis use (25%) and in the intended frequency of future cannabis use (36%). The addition of descriptive norms (beliefs about the frequency of others' cannabis use) accounted for a significant additional amount of the variance in past use (19%). Adding the 'friends' component of descriptive norms only led to a model that accounted for 52% of the variance in past cannabis use.

CONCLUSIONS

Descriptive social norms should be considered when trying to understand cannabis use in early psychosis. Interventions should take account of the individual's attitude towards cannabis, their perceived control over its use and its social context.

No reductions and some improvements in South African lay HIV/AIDS counsellors' motivational interviewing competence one year after brief training

In South Africa, lay HIV/AIDS counsellors are trained in both client-centred and more directive, health-advising techniques. Both approaches are limited in facilitating health behaviour when clients are ambivalent. Motivational interviewing (MI) is a counselling approach that develops the client's intrinsic motivation to change. Evangeli et al. evaluated a 12-hour course of MI delivered to 17 lay HIV/AIDS counsellors in Western Cape Province, South Africa. There was a marked change from MI non-adherent practice to more MI adherent practice at the end of the training. Few counsellors, however, reached the level of beginning proficiency in MI. The current study was a one-year follow-up of MI competence in the same cohort of lay HIV counsellors. Ten counsellors participated. Results confirmed that changes in lay HIV counsellors' level of MI competence as a result of a brief MI course were maintained over a one-year period and in some cases were enhanced. MI competence was independent of self-report and demographic factors. As in Evangeli et al., the majority of counsellors did not attain beginning proficiency level. Reasons for the findings are explored, including consideration of baseline level of counselling, characteristics of the training and individual motivation. Ideas for future research are outlined.

Coping and psychological adjustment in adolescents with vertically acquired HIV

Children with vertically acquired HIV face the challenges of adolescence in addition to the demands of coping with their illness. The relationship between coping and psychological adjustment has been widely studied in adults and children with chronic diseases but it is poorly understood in adolescents with HIV. This study aimed to identify whether a UK sample of adolescents with vertically acquired HIV had poor psychological adjustment and to clarify the relationship between coping and psychological adjustment in this sample. Thirty adolescents with vertically acquired HIV (aged 11-17) filled in questionnaires of coping and psychological adjustment and a correlational design was used to determine if specific coping styles were related to quality of psychological adjustment. Results showed that younger children had lower levels of psychological adjustment than older adolescents, although as a group the adolescents scored within normal ranges. Psychological adjustment was significantly related to two coping styles, Ventilating feelings and Being humorous. Exploratory analysis examined the extent of HIV disclosure in this sample and the degree of satisfaction felt about the nature of communication about the diagnosis. The results showed that participants had few confidants but were satisfied with the nature of communication about their status. The level of satisfaction was not related to adjustment. On the basis of the results, potential clinical implications for adolescents with vertically acquired HIV who might be struggling not only with the challenging demands of adolescence but also with their illness are discussed. The need to adopt a developmental approach to coping and psychological adjustment is emphasized.

Which psychosocial factors are related to chelation adherence in thalassemia? A systematic review

Good adherence to iron chelation therapy in thalassemia is crucial. Although there is evidence that adherence is related to regimen factors, there has been less emphasis on the relationship between psychosocial (psychological, demographic and social) factors and adherence. We present a systematic review of psychosocial correlates of chelation adherence in thalassemia. Nine studies met the inclusion criteria. Information was extracted regarding the study characteristics and the relationship between psychosocial factors and chelation adherence. Methodological quality was rated. The studies took place in a range of countries, were mostly cross sectional in design, and examined adherence to deferoxamine (DFO) only. Sample sizes ranged from 15 to 1573. A variety of psychosocial variables were examined. Definitions of adherence varied between studies and non adherence rates were also variable (9 to 66%). Older age was consistently associated with lower levels of chelation adherence. There were few other consistent findings. The methodological quality of studies was variable. There is a need for more methodologically sophisticated and theoretically informed studies on psychosocial correlates of chelation adherence. We offer specific suggestions.

An evaluation of a brief motivational interviewing training course for HIV/AIDS counsellors in Western Cape Province, South Africa

HIV/AIDS counselling in South Africa covers a range of areas of prevention and treatment with a commonly used model of lay counsellors trained by non-governmental organisations and working alongside professionals in public health settings. This study presents a single group evaluation of a six-session (12-hour) course of Motivational Interviewing (MI) delivered to 17 HIV/AIDS lay counsellors working in peri-urban settings in Western Cape Province, South Africa. Counsellors reported that they used MI techniques both at the start and at the end of the training. In addition, they reported confidence in their ability to influence their clients' motivation at both time points. The results from the ratings of role play performance showed that there was a marked change in emphasis over the group of counsellors from MI non-adherent practice before training (with advice giving, directiveness, control and confrontation) to more MI adherent practice (asking permission before giving advice, emphasising client autonomy, affirming the client and stressing the client's responsibility to change) at the end of the training. Only a small proportion of the counsellors reached the level of beginning proficiency (according to the Motivational Interviewing Treatment Integrity code) on the measure of the ratio of MI adherent to non-adherent responses. The ratio of reflections to questions and the percentage of open questions also showed improvements in performance across the group but generally to levels below that suggesting beginning proficiency in MI. There was no evidence of any change on global therapist ratings (of empathy and the spirit of MI, i.e. collaboration, evocation and autonomy support) or the percentage of complex reflections across the group of counsellors. Possible explanations for the results and public health implications are discussed.