The three-item patient-reported instrument for retrospective adherence in resource constrained settings: reliability, validity and potential utility

INTRODUCTION

Patient-report instruments remain the most feasible and sustainable approaches for monitoring medication adherence in clinical settings. However, questions of their reliability and validity persist. Studies suggest that the 3-item instrument for retrospective adherence (IRA) developed by Wilson et al. offers a viable option for clinically monitoring medication adherence. Here we report the reliability and validity of the IRA among patients recruited from community-based HIV clinics and antiretroviral therapy (ART) dispensaries in a resource constrained township in Cape Town, South Africa.

METHODS

Women (n = 794) and men (n = 228) receiving ART completed the IRA at three time points: (a) in a face-to-face administration at enrollment (b) in1-week phone interview and (c) 1-month phone interview. Participants also provided contemporaneous blood samples for HIV viral load testing as a clinical outcome and unannounced phone-based pill counts as an objective assessment of ART adherence.

RESULTS

The IRA was internally consistent and showed evidence of time stability. The IRA also demonstrated validity with respect to pill count adherence, correlates of adherence, and HIV viral load. Response operating curve analysis yielded an area under the curve of 0.646, using 75% adherence as the cut-off, with 0.637 sensitivity and 0.567 specificity.

CONCLUSIONS

The IRA demonstrated reliability, construct validity and criterion validity in a resource constrained setting, supporting use of the IRA in research and clinical care.

Unannounced phone-based pill counts for monitoring antiretroviral medication adherence in South Africa

BACKGROUND

Unannounced phone-based pill counts (UPC) are an objective measure of medication adherence that may be used in resource limited settings. The current study reports the feasibility and validity of UPC for monitoring antiretroviral therapy (ART) adherence among people living with HIV in South Africa. People living with HIV (N = 434) in an economically impoverished township and receiving ART for at least 3-months completed: two UPC in a one-month period; measures of clinic and medication experiences; and provided blood samples for HIV viral load and CD4 testing. Analyses compared two methods for managing values of over-dosing (> 100%), specifically censoring values to 100% (> 100% = 100%) vs. subtracting over-dosing from two months of perfect adherence (200% - > 100% value).

RESULTS

Findings showed that two UPC calls were successfully completed with 91% of participants in a one-month period. The average number of call attempts needed to reach participants was 2.4. Results showed that lower UPC adherence was significantly associated with male gender, alcohol use, higher HIV viral loads, lower CD4 cell counts, running out of ART, and intentionally not taking ART. Comparisons of methods for adjusting over-dosing found subtraction yielding a better representation of the data than censoring.

CONCLUSIONS

UPC were demonstrated feasible and valid with patients receiving ART in a resource limited setting and offers a viable method for objectively measuring ART adherence in these settings.

Randomized Clinical Trial of Stigma Counseling and HIV Testing Access Interventions to Increase HIV Testing Among Black Sexual Minority Men and Transwomen

Advances in HIV prevention tools have outpaced our ability to ensure equitable access to these tools. Novel approaches to reducing known barriers to accessing HIV prevention, such as stigma and logistical-related factors, are urgently needed. To evaluate the efficacy of a randomized controlled trial with four intervention arms to address barriers to HIV/STI testing uptake (primary outcome) and PrEP use, depression, and HIV test results (secondary outcomes). We tested a 2 × 2 research design: main effect 1-stigma-focused vs. health information evaluation-focused counseling, main effect 2-offering HIV/STI testing appointments in person vs. at home with a counselor via video chat, and the interaction of the main effects. Participants (N = 474) residing in the southeastern USA were screened and enrolled in a longitudinal trial. Intervention efficacy was established using generalized linear modeling with binomial or Poisson distributions. Intervention efficacy demonstrated an increase in HIV/STI testing uptake when testing was made available at home with a counselor via video chat vs. in person (83% vs. 75% uptake, p < .05), and participants were also more likely to test positive for HIV over the course of the study in the at-home condition (14.5% vs. 9.4%, p < .05). Stigma-focused counseling resulted in lower depression scores and greater uptake of PrEP among participants < 30 years of age when compared with health information counseling (15.4% vs. 9.6%, p < .05). In order to prevent further disparities between HIV prevention advances and access to HIV prevention tools, we must prioritize improvements in linking people to care. Novel interventions, such as those proposed here, offer a practical, evidence-based path to addressing long-standing barriers to HIV prevention strategies. Trial registration: NCT03107910.

Subjective well-being and COVID-19 prevention practices among people living with HIV in Cape Town, South Africa

COVID-19 poses significant threats to the health of people with underlying chronic conditions, including people living with HIV. The association between subjective well-being and practicing COVID-19 preventive behaviours among people living with HIV is yet to be empirically tested. The objective of the current study was to test the hypothesis that subjective well-being would be associated with engaging in greater COVID-19 preventive behaviours. A sample of 200 women and 72 men (mean age 38.1, SD = 10.4) receiving HIV treatment at a clinic in Cape Town, South Africa completed interview administered surveys of health behaviours and three dimensions of subjective well-being: emotional, social and psychological well-being. Hierarchical regression models were performed to test subjective well-being as predictors of COVID-19 preventive behaviours adjusting for age, sex, education, TB history, antiretroviral therapy adherence, and concern about contracting COVID-19. Results showed that psychological well-being, along with concerns over COVID-19, predicted greater COVID-19 preventive behaviours over and above the other variables in the model, accounting for 9.2% of the variance. Results support incorporating interventions to foster psychological well-being into existing clinical services for people living with HIV to improve clusters of health behaviours.

Factors Associated With the Use of the Contraceptive Implant Among Women Attending a Primary Health Clinic in Cape Town, South Africa

Background: Long-acting reversible contraceptives (LARCs), which include the subdermal contraceptive implant and intrauterine contraception, offer women safe, highly effective, long-term pregnancy prevention, and have expanded contraceptive options. The implant greatly expands LARC options for South African women as it is available free of charge at public health facilities, but little is known about factors associated with its uptake. This study describes factors associated with the intention to use the implant, including knowledge and beliefs about the implant and perceived outcome expectancies of implant use among women in Cape Town, South Africa.

Methods: Between 2015 and 2016, the authors conducted a quantitative, cross-sectional survey among adult women attending a public, primary health clinic in Cape Town, South Africa. Using a structured questionnaire, they measured knowledge, awareness, and attitudes, perceived outcome expectancy, and the intention to use the contraceptive implant in future among the women.

Results: The authors surveyed 481 women (mean age 29.1 years). Most of the participants (n = 364, 75.6%) had heard about the implant, 45 (9.4%) were currently using it, and 97 (20.2%) intended to use it in the future. Knowledge about the safety of the implant, beliefs about its effectiveness, and the ease of insertion and removal, and support from intimate partners were positively associated with the current use and intentions to use the implant in the future.

Conclusions: Limited knowledge of the implant, having completed secondary schooling, support from partner for women to use implant and the perceived outcome expectancies of using the implant were factors significantly associated with the intention to use the implant. Ensuring that the contraception information is available in all South African languages, regardless of education levels in women, and that comprehensive contraception education and counseling is provided during all family planning might help improve the uptake of contraceptives, including the use of the implant in the country.

Forgoing antiretroviral therapy to evade stigma among people living with HIV, Cape Town, South Africa

Stigma impedes HIV treatment in multiple ways, including diminished engagement in care, refusing ART, and concealing ART to evade stigma. This study disentangled the degree to which intentionally not taking ART to evade stigma influences overall non-adherence to ART. Patients receiving ART at a community clinic in Cape Town, South Africa (N = 288) completed confidential surveys of demographic and health characteristics, stigma-avoidance non-adherence, and non-stigma-related predictors of non-adherence. Results found nearly half of participants (48%) had forgone taking their ART in social settings. Hierarchically structured regression models showed that alcohol use, medication concerns, and internalized HIV stigma significantly predicted ART non-adherence, accounting for 9.9% of the variance. Stigma-avoidance non-adherence explained an additional 2.6% of the variance in ART non-adherence. The current findings extend previous research to show that stigma-avoidance independently contributes to ART non-adherence, including over and above depression and alcohol use.

Brief Enhanced Partner Notification and Risk Reduction Counseling to Prevent Sexually Transmitted Infections, Cape Town, South Africa

BACKGROUND

Evidence-based interventions are needed to stem sexually transmitted infections (STIs). Clinic-delivered counseling remains an important avenue for effective STI prevention.

METHODS

A 3-arm randomized clinical trial compared (a) STI health education control condition, (b) risk reduction counseling, and (c) enhanced partner notification counseling. Men and women (n = 1050) were recruited from an STI clinic in Cape Town, South Africa. After baseline assessments, participants were randomly allocated to receive 1 of the 3 single-session counseling interventions and were followed up for 9 months of behavioral assessments and 12 months of electronic medical records abstraction for STI clinic services.

RESULTS

Sexual risk reduction counseling reported greater condom use than did the other 2 conditions during the 3 and 6 months follow-ups. In addition, women receiving risk reduction counseling were significantly less likely to have returned for STI clinic services but did not differ in the number of STI clinic visits over the year.

CONCLUSIONS

Brief single-session STI prevention counseling demonstrates significant targeted outcomes. The findings suggest that counseling approaches to both increase condom use and enhance partner notification may offer more robust and sustained outcomes and should be tested in future research.

Factors affecting men's support for the use of the contraceptive implant by their female intimate partners

Background

Family planning services have been available at no cost in the public health settings of South Africa since 1994, and now include the long-acting reversible contraceptives (LARCs) namely, the contraceptive implant and intra-uterine device (IUD). However, the uptake of LARCs has been declining in the recent years and little is known about the cause of the decline. In many relationships, men may influence their female intimate partner’s contraceptive choices. Thus, men’s involvement in reproductive health decisions and family programming may improve their support for contraceptive use, including the LARC use by their female intimate partners. This study investigated factors affecting men’s support for the use of contraceptive implant by their female intimate partners.

Methods

A quantitative, cross-sectional survey was conducted among adult men attending a public, primary health clinic in Cape Town, South Africa. Using a structured questionnaire, we measured men’s knowledge, awareness and support of, and attitudes towards use of the contraceptive implant by their female intimate partners. Data were analyzed using SPSS version 25.

Results

The sample included 65 men with a mean age of 31.2 years. Most (76.6%) believed that both men and women should be responsible for family planning. Support for general contraception use by their female intimate partners was prevalent at 80.0%, but only 33.9% reported that they would like their partners to use the implant in the future, while 35.6% were unsure and 30.5% did not support their partner’s use of the implant. Factors significantly associated with men’s support of their partner’s future use of the contraceptive implant included men’s reports that their partner wished to have another child in future, knowledge that the implant is safe for use by women who have not had children, knowledge that the implant can effectively prevent pregnancy for 3 years, and a positive attitude towards the implant’s long-lasting effectiveness.

Conclusion

Improving men’s knowledge of, and attitudes toward the contraceptive implant might increase their support for their partner’s use of the implant, which in turn might promote uptake of the implant among women. The findings of our study suggest the importance of actively engaging men in reproductive health and family planning programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40834-020-00140-7.

Effects of enhanced STI partner notification counselling and provider-assisted partner services on partner referral and the incidence of STI diagnosis in Cape Town, South Africa: randomised controlled trial

Objectives

We investigated the effects of an enhanced partner notification (PN) counselling intervention with the offer of provider-assisted referral among people diagnosed with STI in a Cape Town public clinic.

Methods

Participants were adults diagnosed with STI at a community clinic. After the standard STI consultation, participants were randomly allocated in a 1:1:1 ratio to (1) ‘HE’: 20 min health education; (2) ‘RR’: 45 min risk reduction skills counselling; or (3) ‘ePN’: 45 min enhanced partner notification communication skills counselling and the offer of provider-assisted referral. The primary outcome was the incidence of repeat STI diagnoses during the 12 months after recruitment, and the secondary outcome was participants’ reports 2 weeks after diagnosis of notifying recent partners. Incidence rate ratios (IRRs) were used to compare the incidence rates between arms using a Poisson regression model.

Results

The sample included 1050 participants, 350 per group, diagnosed with STI between June 2014 and August 2017. We reviewed 1048 (99%) participant records, and identified 136 repeat STI diagnoses in the ePN arm, 138 in the RR arm and 141 in the HE arm. There was no difference in the annual incidence of STI diagnosis between the ePN and HE arms (IRR: 1.0; 95% CI 0.7 to 1.3), or between the RR and HE arms (IRR: 0.9; 95% CI 0.7 to 1.2). There was a greater chance of a partner being notified in the ePN condition compared with the HE condition, 64.3% compared with 53.8%, but no difference between the RR and HE arms.

Conclusions

PN counselling and education with provider-assisted services has the potential to change the behaviour of people diagnosed with STIs, increasing the number of partners they notify by more than 10%. However, these changes in behaviour did not lead to a reduction of repeat STI diagnoses.

Trial registration number

PACTR201606001682364.

Stigmatisation of alcohol use among people receiving antiretroviral therapy for HIV infection, Cape Town, South Africa

Antiretroviral therapy (ART) effectively treats HIV infection, with improved longevity and quality of life among people living with HIV. Alcohol use, however, remains a robust barrier to ART. This study, for the first time, examined the effects of the stigmatisation of alcohol use on ART adherence. Patients receiving ART in Cape Town, South Africa who currently drink alcohol (N = 187) and those who do not drink alcohol (N = 106) completed measures of alcohol use, alcohol-ART adherence, and alcohol-ART stigma. Participants also provided permission to access their most recent HIV viral load from clinic medical records. Results of a mediation model demonstrated significant detrimental effects of alcohol use on ART adherence. In addition, the indirect effects of alcohol use on ART adherence through alcohol-ART stigma was also significant, indicating that alcohol-ART stigma at least in part mediates the association between alcohol use and ART adherence. The same pattern of results was observed in relation to HIV viral load obtained from medical records. Interventions designed to address alcohol use as a barrier to ART adherence should incorporate alcohol-ART stigma as a barrier to adherence as well as a barrier to participating in adherence interventions.

Preliminary Validation of an Unannounced Telephone Pill Count Protocol to Measure Medication Adherence Among Young Adults With Perinatal HIV Infection

Unannounced telephone pill counts are an objective antiretroviral therapy adherence measurement tool, but this method has not been validated in young adults (YA) living with perinatal HIV infection. Perinatally infected YA, recruited from the Child and Adolescent Self-Awareness and Health Study, agreed to unannounced telephone pill counts to measure medication adherence over 4 months and phlebotomy to measure viral load (VL). Differences in pill count adherence scores among YA with a VL of ≤20 versus >20, and demographic differences were assessed. Participants (N = 62) were, on average, 24 years old; 57% were African American, and 40% were Latino. Participants with VL of ≤20 (60%) had significantly higher adherence scores (85% versus 62%; p = .004). Associations were not significant among older YA (range, 25-28 years) or Latinos. Unannounced telephone pill counts are a valid measure of antiretroviral therapy adherence in YA with perinatal HIV infection. Studies with larger samples are needed.

Alcohol-related intentional nonadherence to antiretroviral therapy among people living with HIV, Cape Town, South Africa

Alcohol use may have significant negative impacts on individuals' ability to remain adherent to antiretroviral therapy (ART), and may also yield other negative psychosocial, health-related, and behavioral outcomes. In addition, false beliefs about the consequences of mixing alcohol with ART use may cause individuals to avoid taking ART when drinking (alcohol-related ART avoidance). Although research conducted in the U.S. and Europe has reported on alcohol-ART avoidance, the current study presents among the first quantitative evidence of alcohol-related intentional ART nonadherence in South Africa. Patients receiving ART from a community clinic in Cape Town (N = 441) completed anonymous surveys of alcohol use, ART adherence, and alcohol-ART avoidance. Results showed that 292 (66%) participants reported current alcohol use; 25% who use alcohol believed that people who drink should stop taking ART when they are drinking and 24% stop their own ART when drinking. Alcohol-ART avoidance mediated the association between alcohol use and ART adherence. Results were robust when controlling for participant age, gender, current care status, and first- versus second-line ART. We found alcohol-ART avoidance may threaten successful ART in South Africa. Corrective messages that take a harm reduction approach to maximize ART adherence when drinking should be implemented in existing clinical services.

Exploring motivation to notify and barriers to partner notification of sexually transmitted infections in South Africa: a qualitative study

Background

This article will review qualitative data from intervention-based counselling sessions to explore barriers to partner notification (PN) for South African men and women who have contracted sexually transmitted infections (STIs). This qualitative study took place in a township where there is high STI and HIV prevalence. In addition to reviewing barriers to PN, the study will also identify participants’ perceptions about effective PN strategies that are presented during the intervention. Ultimately, the study will assess the intervention’s impact on participants’ motivation and skills to notify their partners about their STI status.

Methods

Relying on recorded counselling sessions from an intervention run by a parent study, this sub- study reviewed 30 transcripts from counselling sessions with 15 men and 15 women. The intervention was a 60 min interactive session where STI and HIV education, risk mitigation, and effective PN strategies were discussed. Participants were between 19 and 41 years old (mean age = 28.4) and lived within the catchment area of a South African township. Recordings were chosen based on verbal responsiveness of the participant and were manually coded for analysis. In addition, two programme counsellors were interviewed about their perceptions of the intervention and their experiences with participants to enhance rigour and reduce potential bias.

Results

By the conclusion of the intervention session, both male and female participants were motivated to notify their partners face-to-face about their positive STI status. Despite this, misperceptions about the etiology and transmission of STIs, as well as inadequate support from the clinical level and power imbalances amongst men and women emerged as major barriers for the prevention of future STIs.

Conclusions

While the intervention appears to be successful in facilitating partners’ intentions to notify, the data shows significant social and structural barriers that will create difficulties for the prevention of future STIs. Participants’ persistent concerns about acquiring HIV or their current positive status affect decision-making and therefore, could be a window of opportunity for health-care providers or lay counsellors to discuss STIs in high prevalence areas.

Use of Unannounced Telephone Pill Counts to Measure Medication Adherence Among Adolescents and Young Adults Living With Perinatal HIV Infection

Objective

To examine unannounced telephone pill counts as a measure of adherence to antiretroviral therapy among adolescents and young adults living with perinatal HIV infection.

Methods

Participants were recruited from an ongoing longitudinal study to complete four monthly, unannounced telephone pill counts. Detailed notes concerning participants' medication habits surrounding adherence were recorded.

Results

Two-thirds of 102 eligible participants aged 18-27 years participated; 57% were female, 69% were Black. Blacks and participants with viral loads >40 and >1,000 copies/ml were less likely to participate. Average adherence across calls was 77%. Those who completed all calls averaged significantly higher adherence scores than those who did not. Calls revealed adherence barriers at individual (e.g., medication disorganization), social (e.g., limited support), and system (e.g., pharmacy problems) levels.

Conclusions

Despite challenges, this procedure can be implemented with this population and can help identify adherence barriers important for interventions that address medication-taking behaviors.

Perceived barriers to partner notification among sexually transmitted infection clinic patients, Cape Town, South Africa

Background

Public health approaches to sexually transmitted infection (STI) prevention in resource-limited countries rely on patients to self-notify sex partners of their STI. However, a majority of partners go uninformed and remain untreated and infectious.

Methods

Anonymous surveys collected from 776 men and women receiving STI clinic services in Cape Town, South Africa.

Results

Half of patients surveyed intended to inform their partners, while half did not intend to notify partners. Women were more likely than men to intend to notify their partners. Patients who completed formal education were also more likely to indicate intentions to notify partners. There were no associations between numbers of partners patients had or partner types with intentions to notify partners. Among both men and women, concerns about adverse partner reactions were associated with intentions not to notify partners. Multivariable analyses stratified by gender and controlling for confounds showed that intentions to notify partners were significantly related to men's concerns that their partner could react violently against them and women's concerns that their partner may leave them and refuse to see them again.

Conclusions

Interventions that assist patients to develop strategies to safely inform their partners are needed to increase patient-initiated partner notification.

Population Density and AIDS-Related Stigma in Large-Urban, Small-Urban, and Rural Communities of the Southeastern USA

AIDS stigmas delay HIV diagnosis, interfere with health care, and contribute to mental health problems among people living with HIV. While there are few studies of the geographical distribution of AIDS stigma, research suggests that AIDS stigmas are differentially experienced in rural and urban areas. We conducted computerized interviews with 696 men and women living with HIV in 113 different zip code areas that were classified as large-urban, small-urban, and rural areas in a southeast US state with high-HIV prevalence. Analyses conducted at the individual level (N = 696) accounting for clustering at the zip code level showed that internalized AIDS-related stigma (e.g., the sense of being inferior to others because of HIV) was experienced with greater magnitude in less densely populated communities. Multilevel models indicated that after adjusting for potential confounding factors, rural communities reported greater internalized AIDS-related stigma compared to large-urban areas and that small-urban areas indicated greater experiences of enacted stigma (e.g., discrimination) than large-urban areas. The associations between anticipated AIDS-related stigma (e.g., expecting discrimination) and population density at the community-level were not significant. Results suggest that people living in rural and small-urban settings experience greater AIDS-related internalized and enacted stigma than their counterparts living in large-urban centers. Research is needed to determine whether low-density population areas contribute to or are sought out by people who experienced greater AIDS-related stigma. Regardless of causal directions, interventions are needed to address AIDS-related stigma, especially among people in sparsely populated areas with limited resources.

A Randomized Clinical Trial of a Brief Internet-based Group Intervention to Reduce Sexual Transmission Risk Behavior Among HIV-Positive Gay and Bisexual Men

Background

HIV disproportionately affects sexual minority men, and developing strategies to reduce transmission risk is a public health priority.

Purpose

The goal was to empirically test a newly developed, Information, Motivation, Behavioral skills (IMB) theoretically derived, online HIV sexual risk reduction intervention (called HINTS) among a sample of sexual minority men living with HIV.

Methods

Participants were 167 men randomized to either the four-session online HINTS intervention or to a time-matched, online control condition. Participants were assessed at baseline and at 6-month follow-up for demographic, medical and psychosocial factors, and sexual risk behavior. Analyses examined group differences in incidence rates of condomless anal sex (CAS) at follow-up with all male sex partners and by partner serostatus, either seroconcordant or serodiscordant for HIV infection.

Results

Men assigned to the HINTS intervention reported decreased CAS with serodiscordant partners, a behavior that confers high risk of HIV transmission, compared to the control group. Men assigned to the HINTS intervention also reported increased CAS with seroconcordant partners, a behavior indicative of serosorting. Although the IMB model did not appear to mediate these intervention effects, some IMB components were associated with behavioral outcomes at 6-month follow-up.

Conclusions

A new group-based sexual risk reduction intervention conducted exclusively online was successful in reducing HIV transmission risk behavior in a sample of gay and bisexual men living with HIV. Future work should consider utilizing this intervention with other groups living with HIV, perhaps in combination with biomedical HIV prevention strategies.

Male circumcision for HIV prevention: Awareness, risk compensation, and risk perceptions among South African women

Medical male circumcision (MMC) is a proven method of HIV risk reduction for men in southern Africa. MMC promotion campaigns and scale-up programmes are widely implemented throughout the Republic of South Africa. However, the impact of promoting MMC on women's awareness, beliefs, and behaviours has been understudied. We conducted a self-administered anonymous survey of 279 women receiving health services in an impoverished township located in Cape Town, South Africa. Results showed that two in three women were unaware that male circumcision partially protects men from contracting HIV. Women who were aware of MMC for HIV prevention also endorsed beliefs that male circumcision reduces the need for men to worry about HIV and reduces the need for men to use condoms. Male circumcision awareness was also related to reduced perceptions of HIV risk among women. Multivariable models showed that women's MMC awareness, circumcision risk compensation beliefs, and risk perceptions were associated with decreased condom use and higher HIV risk index scores defined as number of condomless vaginal intercourse X number of sex partners. These results suggest a need for MMC education efforts tailored for women living in communities with high-HIV prevalence where men are targeted for MMC.

Dietary intake and overweight and obesity among persons living with HIV in Atlanta Georgia

In the U.S., there has been a rise in overweight and obesity among persons living with HIV (PLWH). The aim of this study was to examine dietary intake and body mass index (BMI) in PLWH in Atlanta Georgia relative to the U.S.

POPULATION

Dietary intake among PLWH was compared with recommended standards as well as estimated dietary intake for adults in the U.S. Over 31% of the study participants were overweight [BMI = 25-29.9 kg/m²], and 33.1% obese [BMI ≥ 30 kg/m²]. Results indicated significant dietary differences between participants in our sample and U.S. daily recommendations for adults as well as estimated intakes of the U.S.

POPULATION

Both males and females consumed more percentage of energy from fat and less fiber as well as fruit and vegetables servings than what is recommended. Results suggest that overweight and obesity are an additional health burden to PLWH in our sample and that their daily dietary practices are not meeting the U.S. government-recommended nutritional standards.

The Achilles' Heel of HIV Treatment for Prevention: History of Sexually Transmitted Coinfections among People Living with HIV/AIDS Receiving Antiretroviral Therapies

BACKGROUND

Antiretroviral therapies (ARTs) offer promising new avenues for HIV prevention. Unfortunately, people infected with HIV who have co-occurring sexually transmitted infections (STIs) are more infectious than suggested by the amount of virus in their peripheral blood. We examined the history of sexually transmitted coinfections in people living with HIV.

METHODS

People living with HIV/AIDS completed confidential computerized interviews that assessed history of STI, sexual behaviors, and STI knowledge.

RESULTS

Among 414 men and 156 women currently receiving ART, 53% had been diagnosed with at least 1 STI since testing HIV positive; 24% women, 19% men, and 11% transgender persons had been diagnosed with an STI in the past year. History of STI was associated with younger age, greater STI knowledge, substance use, and ART nonadherence.

CONCLUSIONS

Aggressive strategies for detecting and treating STI in people receiving ART will be necessary to achieve protective benefits.

Altering key characteristics of a disseminated effective behavioral intervention for HIV positive adults: the "healthy relationships" experience

HIV prevention programs targeted to people living with HIV/AIDS are the US national HIV prevention priority. Healthy Relationships is a nationally disseminated HIV prevention program for HIV positive adults. Key characteristics of the intervention package include gender separated groups facilitated by a mental health professional and a HIV positive peer counselor, both of which cause considerable barriers to implementation. We examined an alteration of the original Healthy Relationships intervention (HR-O) that delivered the intervention to mixed gender groups by non-mental health and non-HIV positive facilitators. Process measures from the altered Healthy Relationships intervention (HR-A) were compared to the same measures taken in the HR-O trial. Intervention completion rates were better in the HR-A model (84%) than HR-O (70%). Results showed that HR-A was comparable to HR-O in social support, group cohesion, and group openness. Facilitators in HR-A were viewed somewhat more positive than in HR-O. We found no empirical basis for conducting separate groups by gender or for constraining the facilitators in terms of their professional and HIV statuses. Research is needed to test the assumptions of other evidence-based HIV prevention programs.

Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP Panel: clinical trial inclusion/exclusion criteria and ethics

The International Campaign for Cures of Spinal Cord Injury Paralysis established a panel tasked with reviewing the methodology for clinical trials for spinal cord injury (SCI), and making recommendations on the conduct of future trials. This is the third of four papers. It examines inclusion and exclusion criteria that can influence the design and analysis of clinical trials in SCI, together with confounding variables and ethical considerations. Inclusion and exclusion criteria for clinical trials should consider several factors. Among these are (1) the enrollment of subjects at appropriate stages after SCI, where there is supporting data from animal models or previous human studies; (2) the severity, level, type, or size of the cord injury, which can influence spontaneous recovery rate and likelihood that an experimental treatment will clinically benefit the subject; and (3) the confounding effects of various independent variables such as pre-existing or concomitant medical conditions, other medications, surgical interventions, and rehabilitation regimens. An issue of substantial importance in the design of clinical trials for SCI is the inclusion of blinded assessments and sham surgery controls: every effort should be made to address these major issues prospectively and carefully, if clear and objective information is to be gained from a clinical trial. The highest ethical standards must be respected in the performance of clinical trials, including the adequacy and clarity of informed consent.

Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: clinical trial design

The International Campaign for Cures of Spinal Cord Injury Paralysis established a panel tasked with reviewing the methodology for clinical trials for spinal cord injury (SCI), and making recommendations on the conduct of future trials. This is the fourth of four papers. Here, we examine the phases of a clinical trial program, the elements, types, and protocols for valid clinical trial design. The most rigorous and valid SCI clinical trial would be a prospective double-blind randomized control trial utilizing appropriate placebo control subjects. However, in specific situations, it is recognized that other trial procedures may have to be considered. We review the strengths and limitations of the various types of clinical trials with specific reference to SCI. It is imperative that the design and conduct of SCI clinical trials should meet appropriate standards of scientific inquiry to insure that meaningful conclusions about efficacy and safety can be achieved and that the interests of trial subjects are protected. We propose these clinical trials guidelines for use by the SCI clinical research community.

Internet-based health information consumer skills intervention for people living with HIV/AIDS

Medical information can improve health, and there is an enormous amount of health information available on the Internet. A randomized clinical trial tested the effectiveness of an intervention based on social- cognitive theory to improve information use among people living with HIV/AIDS. Men and women (N = 448) were placed in either (a) an 8-session intervention that focused on Internet information consumer skills or (b) a time-matched support group and were followed to 9 months postintervention. The Internet skills group demonstrated greater Internet use for health, information coping, and social support compared with the control group. The authors conclude that people with HIV infection may benefit from increased access to health information on the Internet and that vulnerability to misinformation and fraud can be reduced through behavioral interventions.

HIV treatment beliefs and sexual transmission risk behaviors among HIV positive men and women

People are living longer and healthier with HIV infection because of successful combination antiretroviral therapies. HIV treatment beliefs are often associated with sexual practices among people living with HIV/AIDS but these associations may depend on the HIV status of sex partners. In a sample of 158 HIV positive men and women who were receiving HIV treatments, we examined the association between HIV treatment beliefs, HIV transmission risk perceptions, medication adherence, viral load and engaging in unprotected intercourse with any sex partners and specifically with sex partners who were not HIV positive (non-concordant). Results showed having missed medications in the past two days and treatment-related beliefs were significantly associated with engaging in unprotected intercourse with all sex partners as well as non-concordant partners. However, multivariate models showed that only treatment beliefs were significantly associated with engaging in unprotected intercourse with non-concordant partners. These results extend past research by demonstrating that the HIV status of sex partners sets the context for whether prevention-related treatment beliefs are associated with HIV transmission risk behaviors among people living with HIV/AIDS.

Health information on the Internet and people living with HIV/AIDS: Information evaluation and coping styles

Individuals who seek information on the Internet to cope with chronic illness may be vulnerable to misinformation and unfounded claims. This study examined the association between health-related coping and the evaluation of health information. Men (n = 347) and women (n = 72) who were living with HIV/AIDS and reported currently using the Internet completed measures assessing their Internet use. Health Web sites downloaded from the Internet were also rated for quality of information. HIV-positive adults commonly used the Internet to find health information (66%) and to learn about clinical trials (25%); they also talked to their physicians about information found online (24%). In a multivariate analysis, assigning higher credibility to unfounded Internet information was predicted by lower incomes, less education, and avoidant coping styles. People who cope by avoiding health information may be vulnerable to misinformation and unfounded claims that are commonly encountered on the Internet.

Psychosocial and behavioral correlates of seeking sex partners on the internet among hiv-positive men

BACKGROUND

The Internet is revolutionizing how people access and use information; for some people, the Internet is also redefining interpersonal relationships, including sexual relationships.

PURPOSE

The objective of this study was to extend the understanding of HIV-positive men who use the Internet to meet sex partners.

METHODS

This study examined the use of the Internet for meeting sex partners among 141 sexually active HIV-positive men who completed anonymous surveys.

RESULTS

Results showed that 37% of sexually active HIV-positive men who were using the Internet had gone online to seek potential sex partners in the previous 3 months. Seeking sex partners online was associated with greater likelihood of having HIV-negative sex partners and engaging in unprotected intercourse with HIV-negative or unknown HIV status partners. Multivariate analyses showed that seeking sex partners online was associated with greater education, higher CD4 cell counts, using the Internet for sexual entertainment, and higher Sexual Compulsivity scale scores over and above demographic, health, Internet use, sexual behavior, and other psychosocial characteristics including optimism and depression.

CONCLUSIONS

Results suggest a continued need for interventions targeting HIV transmission risk reduction among HIV-positive men who use the Internet to meet potential sex partners.

Pillboxes and antiretroviral adherence: prevalence of use, perceived benefits, and implications for electronic medication monitoring devices

HIV treatment adherence is improved by behavioral interventions, including medication organizers such as pillboxes, which can also interfere with adherence electronic monitoring devices (EMD). This study examined the characteristics of pillbox users and the implications of pillbox use for research using EMD adherence research. Men and women (n = 160) currently taking antiretroviral medications (ARVs) completed anonymous surveys in a community research setting. Sixty-three (39%) of individuals taking ARVs were currently using a pillbox. Pillbox users were significantly more likely to have an undetectable viral load and less likely to have missed their medications within a day of the assessment. Pillbox users indicated feeling that they benefited from using their pillbox and 76% reported they would likely stop using their pillbox if required to participate in a research study that paid them. Adherence EMD pose methodological limitations to research when pillbox users are excluded and ethical implications when pillbox users stop using their pillbox to participate.

Brain injury: functional outcome in children with tracheostomies and gastrostomies

Survival, functional outcome, placement, and need for appliances at six and 24 months after either anoxic metabolic encephalopathies (AME) or traumatic head injuries (TI) were determined in 36 children with both tracheostomies and gastrostomies who were discharged from acute care hospitals. Five deaths occurred in totally dependent children with both tracheostomies and gastrostomies in place. Ten of 22 children with TI (48% of survivors) achieved independence in three functional areas by two years, whereas none of 14 with AME achieved functional independence in any area at two years (p = 0.001). Only one of the 18 who were dependent in all three areas at six months achieved partial independence in any area on reevaluation at two years. Institutionalization at two years was strongly predicted by six-month functional status (p less than 0.01). Four of 18 children dependent at six months returned to home care by two years, whereas all 16 children who achieved partial independence within six months of insult were cared for at home at two years (p less than 0.001), regardless of age or injury type. The need for tracheostomy at two years correlated with functional status at six months (p less than 0.01). Two-year survival was unexpectedly high for this group of children when compared to studies in adults. Functional status at six months is a strong predictor of dependency and institutionalization at two years.