Internalized HIV-Related Stigma and Breast Health Beliefs Among African-American Women Receiving Care for HIV in the USA.

OBJECTIVES: African-American women suffer disproportionately from HIV, breast cancer, and other illnesses. Little is known about the relationship between internalized HIV-related stigma and health beliefs related to other illnesses, including breast cancer. Our study examined (1) the relationship between internalized HIV-related stigma and breast health beliefs over time and (2) the moderating effects of participating in a stigma reduction intervention and/or social support. METHODS: Data from 239 African-American women receiving care for HIV in Chicago, IL, or Birmingham, AL, enrolled in the Unity randomized controlled trial, were used in this secondary analysis. Threat of breast cancer was measured in terms of perceived susceptibility, fear, and adverse consequences as well as an overall perceived threat of breast cancer. We used multivariate models with generalized estimating equations to examine the relationship between internalized HIV-related stigma and breast health beliefs across three time points (baseline, immediately post-workshop, and at 12-month follow-up) and to examine if the study arm (HIV stigma reduction vs. breast cancer education) or social support moderated the relationship. RESULTS: Internalized HIV-related stigma was associated with greater overall perceived threat (p < 0.001), susceptibility (p = 0.03), fear (p < 0.001), and perceived adverse consequences (p < 0.001) of breast cancer. These associations remained consistent across study arms and across all levels of social support. CONCLUSIONS: Future studies that examine co-morbid health conditions among African-American women living with HIV should consider the impact of HIV-related stigma on attitudes and beliefs related to co-morbid conditions.

Exploring HIV-Related Stigma as a Determinant of Engagement in HIV Care by African American Women.

Engagement in HIV care reduces HIV-related health disparities that persist across racial/ethnic and gender lines; yet, African American (AA) women face multiple challenges to remaining engaged in care, including HIV-related stigma. We analyzed longitudinal data from 239 participants in the Unity Health Study to estimate associations between HIV-related stigma and engagement in care among AA women linked to HIV care. In adjusted Poisson regression analyses, engagement in care was not associated with HIV-related stigma but was associated with older age (incidence rate ratio [IRR] = 1.01, 95% confidence interval [CI] = [1.00-1.01], p = .01), higher levels of education (IRR = 1.18, 95% CI = [1.02-1.35], p = .03), and higher levels of social support (IRR = 1.05, 95% CI = [1.01-1.09], p = .04). Our findings suggest the need for targeted interventions to enhance engagement in care and to incorporate social support into health promotion programming for AA women living with HIV.

Reducing the African American HIV Disease Burden in the Deep South: Addressing the Role of Faith and Spirituality.

Nearly half of HIV infections in the United States are concentrated among African Americans, and over half of new HIV infections occur in the South. African Americans have poorer outcomes in the entire continua of HIV and PrEP care. Complex social, structural, and behavioral factors contribute to our nation's alarming racial disparities in HIV infection, particularly in the Deep South. Despite the importance of faith, spirituality and religious practice in the lives of many African Americans, there has been little scientific investment exploring how African Americans' religious participation, faith and spirituality may impact our nation's HIV epidemic. This article summarizes the state of the science on this critical issue. We also identify opportunities for new scholarship on how faith, spirituality and religious participation may impact HIV care continuum outcomes in the South and call for greater federal research investment on these issues.

The use of technology in the sexual health education especially among minority adolescent girls in the United States.

PURPOSE OF REVIEW: The purpose of this review is to examine current sexual health education technologies for adolescents and identify gaps in knowledge. Disparities in sexual health education are prominent and mainly affect young women of color. As a result, the use of technology to reach these marginalized populations could potentially invoke change. Thus, it is crucial to determine the viability of technology as a mechanism to bridge the knowledge gap regarding sexual health for adolescents that are most at risk of sexually transmitted infections and unwanted pregnancies. RECENT FINDINGS: With a lack of standardized, evidenced-based sexual health education programs in the United States, the future of comprehensive sexual health education is moving toward smartphone apps. Many sexual health technologies exist that target adolescents, most of which have been proven to demonstrate positive effects. Use of mobile apps, especially for vulnerable populations, can be more effective because of privacy and widespread dissemination. SUMMARY: Ultimately, more research needs to be conducted to determine the most effective content for these sexual health apps. Additionally, more research should be conducted on effective sexual health apps for marginalized populations to determine whether technology is a viable solution.

African American Clergy Perspectives About the HIV Care Continuum: Results From a Qualitative Study in Jackson, Mississippi.

Mississippi has some of the most pronounced racial disparities in HIV infection in the country; African Americans comprised 37% of the Mississippi population but represented 80% of new HIV cases in 2015. Improving outcomes along the HIV care continuum, including linking and retaining more individuals and enhancing adherence to medication, may reduce the disparities faced by African Americans in Mississippi. Little is understood about clergy's views about the HIV care continuum. We assessed knowledge of African American pastors and ministers in Jackson, Mississippi about HIV and the HIV care continuum. We also assessed their willingness to promote HIV screening and biomedical prevention technologies as well as efforts to enhance linkage and retention in care with their congregations. Four focus groups were conducted with 19 African American clergy. Clergy noted pervasive stigma associated with HIV and believed they had a moral imperative to promote HIV awareness and testing; they provided recommendations on how to normalize conversations related to HIV testing and treatment. Overall, clergy were willing to promote and help assist with linking and retaining HIV positive individuals in care but knew little about how HIV treatment can enhance prevention or new biomedical technologies such as pre-exposure prophylaxis (PrEP). Clergy underscored the importance of building coalitions to promote a collective local response to the epidemic. The results of this study highlight important public health opportunities to engage African American clergy in the HIV care continuum in order to reduce racial disparities in HIV infection.

Cessation-related information, motivation, and behavioral skills in smokers living with HIV.

There is a need for new, targeted smoking cessation interventions for smokers living with HIV. The Information-Motivation-Behavioral Skills (IMB) model has been applied effectively to HIV-related health behaviors and was used in this qualitative study to elicit factors that could lead to the development of innovative and successful cessation interventions for this population. Twenty individuals who smoked from two clinics providing care to people living with HIV participated in open-ended interviews, responding to questions covering the domains of the IMB model, as applied to smokers living with HIV. Participants were enrolled from a larger survey cohort to recruit into groups based on the impact of HIV diagnosis on smoking as well as attempting to enroll a mix of demographics characteristics. Interviews were recorded, transcribed, coded and thematically analyzed using a grounded theory qualitative approach. Interviews continued until thematic saturation was reached. Major themes included: Presence of knowledge deficits regarding HIV-specific health risks of smoking; use of smoking for emotional regulation, where many reported close contacts who smoke and concern with the effect of cessation on their social networks; Use of smoking cessation aids or a telephone-based wellness intervention were acceptable to most. Providing HIV-specific information in cessation advice is of the utmost importance for clinicians caring for smokers living with HIV, as this theme was noted consistently as a potential motivator to quit. Innovative and effective interventions must account for the social aspect of smoking and address other methods of emotional regulation in this population.

Exploring the "Obesity Paradox" as a Correlate of Cognitive and Physical Function in Community-dwelling Black and White Older Adults.

Objective: The obesity paradox has been documented in aged populations, yet it remains unclear if this paradox persists for physical and cognitive outcomes in community-dwelling older adult populations. Our study examines associations between body mass index (BMI) classification, cognitive function, and physical function. We also investigate whether these associations are modified by race or age. Design: Cross-sectional study. Setting: Senior residential sites and community centers in Saint Louis, Missouri. Participants: Study participants included 331 adults, aged >55 years. Age was stratified into young-old (aged 55-74 years) and older (aged ≥75 years). Outcome Measures: Physical function was measured using the mini-Physical Performance Test (mini-PPT) and grip strength. Cognitive function was assessed with the Short Blessed Test (SBT) and the Trail Making Tests (TMT-A and TMT-B) performance. Results: Older adults who were obese had significantly better cognitive flexibility (TMT-B) performance than normal weight older adults (P=.02), and this association was not influenced by age or race. Adiposity was not associated with psychomotor speed (TMT-A), general cognition (SBT), or measures of physical function (Ps>.05). Conclusion: In a diverse sample of community-dwelling older adults, we found partial support for the controversial obesity paradox. Our results suggest excess adiposity may be protective for executive function processes. Future research is needed to examine the underlying physiological processes linking adiposity to executive function in older adults.

Examination of the Role of Religious and Psychosocial Factors in HIV Medication Adherence Rates.

Optimal adherence to antiretroviral therapy (ART) is associated with favorable HIV outcomes, including higher CD4 cell counts, HIV virus suppression and a lower risk of HIV transmission. However, only 25% of people living with HIV/AIDS (PLWH) in the USA are virally suppressed. Sub-optimal adherence (<90-95%) contributes to antiretroviral resistance and worse medical outcomes, including more rapid progression to AIDS and death. Psychosocial factors and religion/spirituality (R/S) have a significant impact on ART adherence, but the findings are mixed. The purpose of this study was to examine religious and psychosocial correlates and predictors of ≥90% ART adherence in PLWH. A cross-sectional study was conducted with a sample of 292 outpatient PLWH in the Southeastern USA. Participants completed computerized surveys. The mean ART adherence percentage was 80.9% and only about half reported ≥90% adherence. There were statistically significant differences in ART adherence rates based on age, depressive symptom status and frequency of religious attendance and prayer. Praying at least once a day was significantly associated with ≥90% ART adherence (OR = 2.26, 95% CI [1.06-4.79], p < 0.05). Social support satisfaction was also significantly associated with ART adherence (OR = 1.52, 95% CI [1.11-2.08], p < 0.05) and energy/fatigue/vitality (OR = 1.03, 95% CI [1.00-1.05], p < 0.05).

A Structural Equation Model of HIV-related Symptoms, Depressive Symptoms, and Medication Adherence.

Adherence to combined antiretroviral therapy (cART) remains critical in management of HIV infection. This study evaluated depression as a potential mechanism by which HIV-related symptoms affect medication adherence and explored if particular clusters of HIV symptoms are susceptible to this mechanism. Baseline data from a multi-visit intervention study were analyzed among 124 persons living with HIV (PLWH). A bifactor model showed two clusters of HIV-related symptom distress: general HIV-related symptoms and gastrointestinal (GI) symptoms. Structural equation modeling showed that both general HIV-related symptoms and GI symptoms were related to higher levels of depressive symptoms, and higher levels of depressive symptoms were related to lower levels of medication adherence. Although general HIV-related symptoms and GI symptoms were not directly related to adherence, they were indirectly associated with adherence via depression. The findings highlight the importance of early recognition and evaluation of symptoms of depression, as well as the underlying physical symptoms that might cause depression, to improve medication adherence.

Correlates of Antiretroviral Therapy Adherence among HIV-Infected Older Adults.

BACKGROUND: Despite the success of antiretroviral therapy (ART), HIV-infected older African Americans experience higher mortality rates compared to their white counterparts. This disparity may be partly attributable to the differences in ART adherence by different racial and gender groups. The purpose of this study was to describe demographic, psychosocial, and HIV disease-related factors that influence ART adherence and to determine whether race and gender impact ART adherence among HIV-infected adults aged 50 years and older. METHODS: This descriptive study involved a secondary analysis of baseline data from 426 participants in "PRIME," a telephone-based ART adherence and quality-of-life intervention trial. Logistic regression was used to examine the association between independent variables and ART adherence. RESULTS: Higher annual income and increased self-efficacy were associated with being ≥95% ART adherent. Race and gender were not associated with ART adherence. CONCLUSION: These findings indicated that improvements in self-efficacy for taking ART may be an effective strategy to improve adherence regardless of race or gender.

Age, Stigma, Adherence and Clinical Indicators in HIV-Infected Women.

Stigma has become a gendered phenomenon that affects increasing numbers of HIV-infected women worldwide. This study examined the role of age as a possible moderator of the relationship between stigma and antiretroviral therapy adherence, CD4% and viral load among 120 HIV-infected women. A secondary analysis was conducted using data from the Keeping Healthy and Active with Risk Reduction and Medication Adherence (KHARMA) Project, an National Institutes of Health (NIH) funded randomized controlled trial to improve Antiretroviral treatment (ART) adherence and reduce risky behaviors in HIV-infected women at five clinical sites in a South-eastern city from 2005 to 2008. Stigma was measured using the Perceived Personal Stigma of Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV/AIDS) scale. Among participants <50 years old (n=90), age was significantly associated with viral load (rho=-.24, p=.02) and stigma was negatively associated with CD4% (r =-.26, p=.02). For the 30 participants >50 years old, age was not significantly associated with viral load, stigma or CD4%, and there was no significant association between stigma and CD4% (r=.07, p=.70). These findings indicate the need for further study regarding this potential moderating effect and possible interventions to address the susceptibility of younger women to the harmful effects of stigma.

Alcohol and associated characteristics among older persons living with human immunodeficiency virus on antiretroviral therapy.

BACKGROUND: Alcohol use, and particularly unhealthy alcohol use, is associated with poor human immunodeficiency virus (HIV)-related outcomes among persons living with HIV (PLWH). Despite a rapidly growing proportion of PLWH ≥50 years, alcohol use and its associated characteristics are underdescribed in this population. The authors describe alcohol use, severity, and associated characteristics using data from a sample of PLWH ≥50 years who participated in a trial of a telephone-based intervention to improve adherence to antiretroviral therapy (ART). METHODS: Participants were recruited from acquired immunodeficiency syndrome (AIDS) service organizations in 9 states and included PLWH ≥50 years who were prescribed ART, reported suboptimal adherence at screening (missing >1.5 days of medication or taking medications 2 hours early or late on >3 days in the 30 days prior to screening), and consented to participate. The AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) alcohol screen, sociodemographic characteristics, substance use, and mental health comorbidity were assessed at baseline. AUDIT-C scores were categorized into nondrinking, low-level drinking, and mild-moderate unhealthy, and severe unhealthy drinking (0, 1-3, 4-6, and 7-12, respectively). Analyses described and compared characteristics across drinking status (any/none) and across AUDIT-C categories among drinkers. RESULTS: Among 447 participants, 57% reported drinking in the past year (35%, 15%, and 7% reported low-level drinking, mild-moderate unhealthy drinking, and severe unhealthy drinking, respectively). Any drinking was most common among men and those who were lesbian, gay, bisexual, or transgender (LGBT), married/partnered, had received past-year alcohol treatment, and never used injection drugs (P values all <.05). Differences in race, employment status, past-year alcohol treatment, and positive depression screening (P values all <.05) were observed across AUDIT-C categories, with African American race, less than full-time employment, past-year alcohol treatment, and positive depression screening being most common among those with the most severe unhealthy drinking. CONCLUSIONS: In this sample of older PLWH with suboptimal ART adherence, a majority reported past-year alcohol use and 22% screened positive for unhealthy alcohol use. Any and unhealthy alcohol use were associated with demographics, depression, and substance use history. Further research is needed regarding alcohol use among older PLWH.

Health literacy: impact on the health of HIV-infected individuals.

Health literacy is known to affect vulnerable communities such as persons living with HIV/AIDS. The purpose of this review was to provide a current summary of research on the impact of health literacy on the health of persons living with HIV/AIDS and to address future areas of need. Contemporary studies focused on expanding the reach of health literacy in HIV/AIDS to retention in HIV care, use of technology for assessing and intervening to improve health literacy, and health literacy across the globe, for example. A number of studies did not find health literacy to explain health behaviors whereas other studies supported such a relationship. Future issues relevant to health literacy in HIV/AIDS include the aging of the HIV population and associated comorbidities, studies to understand the role of health literacy in specific populations affected by HIV/AIDS, and the continued need to refine the definition and measurement of health literacy.

Chronic illness burden and quality of life in an aging HIV population.

The population of persons living with HIV (PLWH) is growing older and more prone to developing other chronic health conditions. Disease progression has been shown to be related to quality of life (QoL). However, descriptions of chronic comorbid illnesses and the unique QoL challenges of older adults living with HIV are not well understood and have not been examined in multiple geographic locations. About 452 PLWH aged 50 years or older were recruited from AIDS Service Organizations in nine states. Participants completed a telephone survey that included measures of other chronic health conditions, perceived stress, depression, and health-related quality of life. As much as 94% of the sample reported a chronic health condition in addition to HIV (mode = 2). The highest reported conditions were hypertension, chronic pain, hepatitis, and arthritis. Despite relatively high rates of depression, overall QoL was moderately high for the sample. Physical functioning was most impacted by the addition of other chronic health problems. Social functioning, mental health functioning, stress, and depression were also strongly associated with chronic disease burden. Additional chronic health problems are the norm for PLWH aged 50 years and older. QoL is significantly related to the addition of chronic health problems. As increasing numbers of PLWH reach older age, this raises challenges for providing comprehensive healthcare to older PLWH with multiple chronic conditions.