Patient and clinician preferences for diabetes management among older adults with co-morbid HIV: A qualitative exploration.

BACKGROUND: Older adults with HIV are at increased risk of developing certain chronic health conditions including type 2 diabetes mellitus (T2DM). As the number and complexity of conditions increases, so do treatment and health care needs. We explored patient and clinician preferences for HIV+T2DM care and perceived solutions to improving care. METHODS: We conducted an exploratory qualitative study comprised of individual in-depth interviews. Participants included English-speaking patients aged 50 and older living with HIV and T2DM and infectious disease (ID) and primary care (PC) clinicians from a large academic health center in Chicago. Thematic analysis drew from the Framework Method. RESULTS: A total of 19 patient and 10 clinician participants were interviewed. Many patients reported seeking HIV and T2DM care from the same clinician; they valued rapport and a 'one-stop-shop'. Others reported having separate clinicians; they valued perceived expertise and specialty care. Nearly all clinicians reported comfort screening for T2DM and initiating first line oral therapy; ID clinicians reported placing referrals for newer, complex therapies. Patients would like educational support for T2DM management; clinicians would like to learn more about newer therapies and easier referral processes. CONCLUSIONS: Patient-centered care includes managing T2DM from a variety of clinical settings for individuals with HIV, yet strategies are needed to better support clinicians. Future research should examine how best to implement these strategies.

Optimizing Telehealth Services: A Mixed-Methods Needs Assessment Conducted Among Community Health Center Patients.

BACKGROUND: The COVID-19 pandemic increased telehealth services in federally funded community health centers (CHCs). Yet little is known about common determinants of use among CHC patients. OBJECTIVE: We examined the use of telehealth among patient participants at 1 large CHC network providing care to underserved populations at urban and suburban sites in the Midwest. METHODS: We conducted a mixed-methods study utilizing a sequential explanatory design. Participants were English and/or Spanish-speaking adults who attended ≥1 visits for themselves or their child over a 12-month period at any practice location. Research staff conducted a structured phone survey of eligible adults. The results subsequently facilitated purposive sampling of telehealth "users" and "nonusers" for qualitative phone interviews. RESULTS: The survey participants included 500 adults. Most had access to the resources needed to utilize telehealth, including a smartphone (90.4%) and home internet (83.0%). About half (50.8%) "rarely or never" had problems with internet speed, reliability, or quality. Most (81.1%) were aware of the patient portal and 59.8% had utilized video visits. Participants who were Spanish-speaking and with limited English proficiency faced some of the greatest barriers. Qualitative interview participants included 12 users and 12 nonusers of telehealth. Users found telehealth convenient and efficient, while nonusers lacked awareness about how telehealth services could be beneficial or needed assistance to sign up, join, or use telehealth. CONCLUSIONS: Most participants had the resources and awareness necessary to use telehealth services. Those who use them appreciate the convenience and efficiency. Nevertheless, additional support may be needed to prevent telehealth from exacerbating health inequities.

Promoting REproductive Planning And REadiness in Diabetes (PREPARED) Study protocol: a clinic-randomised controlled trial testing a technology-based strategy to promote preconception care for women with type 2 diabetes.

INTRODUCTION: Women with type 2 diabetes (T2DM) are more likely to experience adverse reproductive outcomes, yet preconception care can significantly reduce these risks. For women with T2DM, preconception care includes reproductive planning and patient education on: (1) the importance of achieving glycaemic control before pregnancy, (2) using effective contraception until pregnancy is desired, (3) discontinuing teratogenic medications if pregnancy could occur, (4) taking folic acid, and (5) managing cardiovascular and other risks. Despite its importance, few women with T2DM receive recommended preconception care. METHODS AND ANALYSIS: We are conducting a two-arm, clinic-randomised trial at 51 primary care practices in Chicago, Illinois to evaluate a technology-based strategy to 'hardwire' preconception care for women of reproductive age with T2DM (the PREPARED (Promoting REproductive Planning And REadiness in Diabetes) strategy) versus usual care. PREPARED leverages electronic health record (EHR) technology before and during primary care visits to: (1) promote medication safety, (2) prompt preconception counselling and reproductive planning, and (3) deliver patient-friendly educational tools to reinforce counselling. Post-visit, text messaging is used to: (4) encourage healthy lifestyle behaviours. English and Spanish-speaking women, aged 18-44 years, with T2DM will be enrolled (N=840; n=420 per arm) and will receive either PREPARED or usual care based on their clinic's assignment. Data will be collected from patient interviews and the EHR. Outcomes include haemoglobin A1c (primary), reproductive knowledge and self-management behaviours. We will use generalised linear mixed-effects models (GLMMs) to evaluate the impact of PREPARED on these outcomes. GLMMs will include a fixed effect for treatment assignment (PREPARED vs usual care) and random clinic effects. ETHICS AND DISSEMINATION: This study was approved by the Northwestern University Institutional Review Board (STU00214604). Study results will be published in journals with summaries shared online and with participants upon request. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT04976881).

A Qualitative Exploration of Perceived Medication Adherence Determinants Conducted Among Older Adults with HIV and Type 2 Diabetes Mellitus.

Background: People living with HIV (PLWH) are at higher risk of developing type 2 diabetes (T2DM). Both chronic conditions require individuals to adhere to medication regimens, yet few studies have sought to explore medication-taking behaviors among individuals with comorbid HIV and T2DM (HIV+T2DM). Objective: This qualitative study sought to: 1) identify and compare perceived determinants of medication adherence for HIV and, separately, for T2DM, and 2) explore how participants prioritize conditions. Methods: Between October 2022 and January 2023, we conducted in-depth interviews with individuals aged 50 or older, living with comorbid HIV+T2DM. Participants were prescribed oral medications to treat their conditions and had recent clinical measures indicating probable challenges with medication adherence. Interviews with consented participants from a large academic health center in the Midwest were conducted remotely. Questions largely drew from the Theoretical Domains Framework (TDF), a widely used implementation science framework. Additional questions explored the prioritization of conditions. Analysis employed the Framework Method and a side-by-side comparison of key determinants of medication adherence by condition. Results: A total of 19 interviews were audio recorded, transcribed, and analyzed. Participants were an average age of 61, mostly male (89.5%), and Non-Hispanic White (47.4%). Although results revealed many commonalities between perceived determinants of medication adherence for HIV and for T2DM, differences relating to two TDF domains were noted: nature of the behavior (taking medications as prescribed), and motivations and goals. Many participants viewed their conditions as equally important, though they suggested T2DM was more difficult to manage, largely due to lifestyle modifications. Conclusion: As individuals with HIV develop chronic conditions, such as T2DM, they may require additional medication adherence support. Attention should be paid to offering support early. Disease perceptions may differ by condition, and as such, one's motivations to take medication as prescribed may also differ by condition.

Developing, optimizing, and evaluating patient infographics for diagnosing cardiac amyloidosis.

Objective: Advancements in diagnostics and treatment options for cardiac amyloidosis have improved patient outcomes, yet few patient education materials exist to help patients understand the disease and diagnosis process. We sought to develop and evaluate a set of plain language, patient-centered infographics describing the condition and common diagnostic tests. Methods: Using health literacy best practices, we developed 7 infographics which were further revised based on multilevel stakeholder feedback. To evaluate the materials, we recruited 100 patients from healthcare settings in Chicago, IL; participants completed a web-assisted interview during which they were randomized 1:1 to first view either our infographics or a standard material. Participants completed a knowledge assessment on their assigned material and subsequently reported impressions of both materials. Results: No differences were found between study arms in knowledge. The infographics took significantly less time to read and were more highly rated by participants in terms of appearance and understandability. Over two-thirds of participants preferred the infographics to the standard. Conclusions: The infographics created may improve the learning process about a complex condition and diagnosis process unknown to most adults. Innovation: These infographics are the first of their kind for cardiac amyloidosis and were created using health literacy best practices.

The Relationship Between COVID-19 Related Stress and Medication Adherence Among High-Risk Adults During the Acceleration Phase of the US Outbreak.

PURPOSE: To assess the relationship between stress regarding COVID-19 and medication adherence. PATIENTS AND METHODS: Older adults with ≥1 chronic condition(s) were recruited from 4 active, federally funded studies in Chicago to participate in a longitudinal telephone survey. Participants self-reported stress regarding COVID-19 in the last week. Adherence was measured via the ASK-12 survey. RESULTS: Most participants reported feeling stressed "some of the time" (54.0%), while 18.2% felt stressed "most" or "all of the time" and 27.8% "never" felt stressed. In bivariate analyses, participants who reported being stressed "most" or "all of the time" had worse medication adherence than participants who reported being stressed "some of the time" or "never" (p < 0.001). In multivariable analyses, participants who reported feeling stressed "most" or "all of the time" had worse adherence than those who "never" felt stressed (Adjusted Least Square Mean (Standard Error): 21.3 (0.6) vs 19.7 (0.6), p=0.01). CONCLUSION: Stress due to COVID-19 has significantly impacted medication adherence, which has negative implications for the course of both COVID-19 and comorbid conditions. Healthcare providers should be aware of the potential impact of COVID-19 on patients' mental and physical well-being and consider ways to routinely assess patient experiences.

Voluntary Contraceptive Uptake Among Postabortion Care Clients Treated With Misoprostol in Rwanda.

INTRODUCTION: Unsafe abortion remains a problem in Rwanda, where abortion is highly restricted by law. To reduce mortality and morbidity from unsafe abortion, Rwanda implemented a national postabortion care (PAC) program in 2012, which included using misoprostol to treat incomplete abortion. Key components of PAC are offering and providing voluntary contraceptive methods and counseling on their use, but little is known about contraceptive uptake among PAC clients treated with misoprostol. The objectives of the current study were (1) to assess the contraceptive uptake of PAC clients treated with misoprostol, including whether extended bleeding hinders uptake; and (2) to assess providers' knowledge of contraception and their willingness to counsel PAC clients on contraception, provide methods, or refer for contraceptive services. METHODS: We surveyed 68 PAC clients treated with misoprostol and 43 providers (84% nurses) in 17 health facilities across 3 districts in Rwanda where misoprostol for PAC had been introduced recently. PAC clients were recruited into the study prior to facility discharge and surveyed between 10 days and 1 month after discharge. We asked PAC clients and providers about demographic characteristics and attitudes toward contraception. We also asked PAC clients about contraceptive counseling received and postabortion contraceptive uptake or reasons for nonuse, and providers about their knowledge about return to fertility, pregnancy and contraceptive counseling, practices related to contraceptive method provision, and their knowledge and potential biases about PAC clients using contraception. We used descriptive statistics for analysis. RESULTS: PAC clients were 19-46 years old, and most (69%) had at least 1 child. Almost all PAC clients (94%) reported being counseled on contraception, but only 47% reported choosing and receiving a method before being discharged from the facility. Nevertheless, by the time of the survey, 71% reported using a method. PAC clients' main reason for not using contraception was wanting to become pregnant. Only 1 woman reported nonuse because of bleeding. Among providers, more than half (56%) reported there are contraceptive methods PAC clients should never use and about a quarter (26%) reported incorrect information on when PAC clients' fertility could return. CONCLUSION: We found no evidence that bleeding associated with misoprostol for PAC influenced women's contraceptive uptake. However, as PAC programs expand to include misoprostol as a treatment option, accurate and high-quality postabortion contraception counseling and method provision at both treatment and follow-up visits must be strengthened.

Patient and clinician perspectives on optimizing graphical displays of longitudinal medication adherence data.

OBJECTIVE: New pharmacological measures assessing medication adherence, including longitudinal drug levels in hair, are emerging. Little is known, however, about how best to present results from such measures to patients and clinicians in comprehensive, easy-to-understand, acceptable formats. We, therefore, developed three graphical display prototypes of hypothetical daily drug concentrations measured in hair, and assessed their acceptability among participants. METHODS: We interviewed 30 HIV-positive patients and 29 clinicians to examine perceived acceptability for each graphical display prototype. RESULTS: Patients and clinicians generally found the prototypes acceptable for facilitating understanding of patient adherence; however, areas for optimization were identified. For patients with lower health literacy, prototypes did not provide sufficient understanding of the link between medication-taking and drug concentrations in hair. These patients also preferred pictographs over bar or line graphs. Clinicians largely preferred daily drug concentration data in bar graphs with information included about the measure's accuracy. Participants questioned the utility of showing drug concentrations above a therapeutic range, though they found color-coding results acceptable. CONCLUSIONS: Assessing prototype versions of graphical displays of hypothetical longitudinal adherence data indicated ways to optimize their acceptability. PRACTICE IMPLICATIONS: Acceptable prototype-tested graphical displays of longitudinal patient-specific drug concentrations may enhance adherence monitoring in clinical settings.

Stakeholder acceptability of adolescent participation in clinical trials for biomedical HIV prevention products: considerations from Tanzania and India.

Researchers and advocates have increasingly called for adolescent participation in clinical trials for new HIV prevention products, particularly adolescent girls in areas most affected by the epidemic. However, recent trials have highlighted the challenges for young women and adolescents to be able to effectively use new products that require daily dosing. This analysis provides a highly relevant context for this challenging environment by examining community members acceptability of adolescent girls' participation in clinical trials for new HIV prevention products. We conducted 41 in-depth interviews in Dar es Salaam, Tanzania and Pune, India with 22 key informants (KIs). Cultural perspectives on adolescent sexuality varied between countries, with KIs in Tanzania more readily acknowledging adolescent girls' sexual activity than KIs in India. KIs in both countries felt strongly adolescents must be well-informed about research concepts prior to participation, and emphasis should be given to preventative misconception. Despite concern in both countries that the trials might be seen as encouraging sexual behavior, KIs in Tanzania overwhelmingly supported adolescent inclusion, whereas KIs in India were more cautious. Involving adolescent girls in clinical trials for new HIV prevention products is potentially acceptable, although meaningful community engagement will be necessary.

Adaptation and delivery of a motivational interviewing-based counseling program for persons acutely infected with HIV in Malawi: Implementation and lessons learned.

OBJECTIVE: Individuals diagnosed with acute HIV infection (AHI) are highly infectious and require immediate HIV prevention efforts to minimize their likelihood of transmitting HIV to others. We sought to explore the relevance of Motivational Interviewing (MI), an evidence-based counseling method, for Malawians with AHI. METHODS: We designed a MI-based intervention called "Uphungu Wanga" to support risk reduction efforts immediately after AHI diagnosis. It was adapted from Options and SafeTalk interventions, and refined through formative research and input from Malawian team members and training participants. We conducted qualitative interviews with counselors and participants to explore the relevance of MI in this context. RESULTS: Intervention adaptation required careful consideration of Malawian cultural context and the needs of people with AHI. Uphungu Wanga's content was relevant and key MI techniques of topic selection and goal setting were viewed positively by counselors and participants. However, rating levels of importance and confidence did not appear to help participants to explore behavior change as intended. CONCLUSION: Uphungu Wanga may have provided some added benefits beyond "brief education" standard of care counseling for Malawians with AHI. PRACTICE IMPLICATIONS: MI techniques of topic selection and goal setting may enhance prevention education and counseling for Malawians with AHI.

Communicating about microbicides with women in mind: tailoring messages for specific audiences.

INTRODUCTION: Current HIV prevention options are unrealistic for most women; however, HIV prevention research has made important strides, including on-going development of antiretroviral-based vaginal microbicide gels. Nevertheless, social-behavioural research suggests that women's ability to access and use new HIV prevention technologies will be strongly influenced by a range of socio-cultural, gender and structural factors which should be addressed by communications and marketing strategies, so that these products can be positioned in ways that women can use them. METHODS: Based on an extensive literature review and in-country policy consultation, consisting of approximately 43 stakeholders, we describe barriers and facilitators to HIV prevention, including potential microbicide use, for four priority audiences of Kenyan women (female sex workers [FSWs], women in stable and discordant relationships, and sexually active single young women). We then describe how messages that position microbicides might be tailored for each audience of women. RESULTS: We reviewed 103 peer-reviewed articles and reports. In Kenya, structural factors and gender inequality greatly influence HIV prevention for women. HIV risk perception and the ability to consistently use condoms and other prevention products often vary by partner type. Women in stable relationships find condom use challenging because they connote a lack of trust. However, women in other contexts are often able to negotiate condom use, though they may face challenges with consistent use. These women include FSWs who regularly use condoms with their casual clients, young women in the initial stages of a sexual relationship and discordant couples. Thus, we consider two approaches to framing messages aimed at increasing general awareness of microbicides - messages that focus strictly on HIV prevention and ones that focus on other benefits of microbicides such as increased pleasure, intimacy or sexual empowerment, in addition to HIV prevention. CONCLUSIONS: If carefully tailored, microbicide communication materials may facilitate product use by women who do not currently use any HIV prevention method. Conversely, message tailoring for women with high-risk perception will help ensure that microbicides are used as additional protection, together with condoms.

Factors associated with unmet need for modern contraception in post-conflict Liberia.

We examined the association between intimate partner violence and unmet need for modern contraception in post-conflict Liberia. This is a secondary analysis of data collected using the Priorities for Local AIDS Control Efforts (PLACE) method. Data from 499 sexually experienced young women (aged 14-25) in Montserrado County, Liberia were examined. Intimate partner violence (55.7%), unintended pregnancy (83.2%), and abortion (45.3%) were pervasive in the study population. An estimated 35.9% of respondents had an unmet need for modern contraception. However, multivariate logistic regression results did not reveal an association between intimate partner violence and unmet need (OR 1.11; 95% CI 0.70-1.75). Among covariates examined, only contraceptive use at sexual debut (26.1%) was significantly associated with unmet need (OR 0.27; 95% CI 0.14-0.52). Liberian youth need information about and access to modern contraceptive methods besides condoms. Interventions to identify and treat victims of violence are also needed.

Factors associated with unmet need for modern contraception in post-conflict Liberia

We examined the association between intimate partner violence and unmet need for modern contraception in post-conflict Liberia. This is a secondary analysis of data collected using the Priorities for Local AIDS Control Efforts (PLACE) method. Data from 499 sexually experienced young women (aged 14-25) in Montserrado County, Liberia were examined. Intimate partner violence (55.7%), unintended pregnancy (83.2%), and abortion (45.3%) were pervasive in the study population. An estimated 35.9% of respondents had an unmet need for modern contraception. However, multivariate logistic regression results did not reveal an association between intimate partner violence and unmet need (OR 1.11; 95% CI 0.70-1.75). Among covariates examined, only contraceptive use at sexual debut (26.1%) was significantly associated with unmet need (OR 0.27; 95% CI 0.14-0.52). Liberian youth need information about and access to modern contraceptive methods besides condoms. Interventions to identify and treat victims of violence are also needed. Afr J Reprod Health 2014; 18[2]: 58-67)

Intimate partner violence against female sex workers in Mombasa, Kenya.

Female sex workers are known to be at risk of intimate partner violence (IPV) from numerous sources including clients, pimps, boyfriends and husbands. Better understanding the factors associated with IPV in this population will enhance prevention efforts. This work examines baseline survey data collected as part of a randomised controlled trial for an alcohol-harm reduction intervention. The study sample included 619 sex workers. IPV was common in this sample, with 78.7% of women reporting any IPV in the last 30 days. Multivariate logistic regression results indicated that supporting one to two other people, experiencing child abuse, witnessing mother abuse, and greater alcohol consumption were risk factors for IPV in our sample. Women who frequented Population, Health and Integrated Assistance (APHIA) II drop-in centres located along transport corridors were also at greater risk of recent IPV, as compared with those who frequented other drop-in centres. Only one protective effect was identified in this study: condom use at last sex with a non-paying partner was associated with less recent IPV. Health programmes for women sex workers in Mombasa and elsewhere need to expand beyond HIV prevention - they need to incorporate information on violence prevention and treatment referrals, as well as information on alcohol harm reduction.