A State of the Science on HIV Prevention Over 40 Years Among Black and Hispanic/Latinx Communities.

ABSTRACT: We present a state of the science on HIV behavioral prevention interventions in Black and Hispanic/Latinx communities. The purpose of this article is threefold: (a) highlight the early documented underlying social and political barriers that constrained interventions to prevent new HIV infections; (b) address the structural inequities in HIV prevention and treatment; and (c) describe the need for increasing HIV multilevel prevention interventions that support greater HIV testing and pre-exposure prophylaxis uptake. To address HIV prevention, multilevel interventions that address individual, structural, and social level components have demonstrated more sustainable outcomes. Implications for research and clinical practice include (a) updating antiquated curricula in nursing, medicine, and public health that perpetuate racial, structural-level inequities and (b) increasing the pipeline for Black and Hispanic/Latinx persons to pursue research or clinical-focused doctorate degrees.

A qualitative description of service providers' experiences of ethical issues in HIV care.

BACKGROUND: Managing HIV treatment is a complex multi-dimensional task because of a combination of factors such as stigma and discrimination of some populations who frequently get infected with HIV. In addition, patient-provider encounters have become increasingly multicultural, making effective communication and provision of ethically sound care a challenge. PURPOSE: This article explores ethical issues that health service providers in the United States and Botswana encountered in their interaction with patients in HIV care. RESEARCH DESIGN: A descriptive qualitative design was used to collect data from health service providers and patients using focused group discussions. This article is based on responses from health service providers only. PARTICIPANTS AND CONTEXT: This article is based on 11 focused group discussions with a total sample of 71 service providers in seven US sites and one Botswana site. ETHICAL CONSIDERATIONS: Ethical review boards at all the study sites reviewed the study protocol and approved it. Ethical review boards of the study's coordinating centers, Rutgers University and the University of California at San Francisco, also approved it. The study participants provided a written informed consent to participate. FINDINGS: HIV service providers encountered ethical challenges in all the four Beauchamp and Childress' biomedical ethics of respect for patients' autonomy, beneficence, justice, and nonmaleficence. DISCUSSION: The finding that HIV service providers encounter ethical challenges in their interaction with patients is supported by prior studies. The ethical challenges are particularly prominent in multicultural care and resource-constrained care environments. CONCLUSION: Provision of HIV care is fraught with ethical challenges that tend to pose different issues depending on a given care environment. It is important that strong partnerships are developed among key stakeholders in HIV care. In addition, health service providers need to be provided with resources so they can provide quality and ethically sound care.

Does pre-exposure prophylaxis for HIV prevention in men who have sex with men change risk behaviour? A systematic review.

AIMS AND OBJECTIVES: To review the literature regarding PrEP and sexual behaviour change in MSM. BACKGROUND: Pre-exposure prophylaxis for HIV has been available since 2012. Even so, pre-exposure prophylaxis has not been widely accepted among healthcare providers and men who have sex with men some of whom are convinced that pre-exposure prophylaxis decreases condom use and increases sexually transmitted infections. DESIGN: A systematic review of the state of the evidence regarding the association of pre-exposure prophylaxis with condom use, sexually transmitted infection incidence and change in sexual risk behaviours in men who have sex with men. A structured search of databases resulted in 142 potential citations, but only 10 publications met inclusion criteria and underwent data abstraction and critical appraisal. METHODS: An adapted Cochrane Collaboration domain-based assessment tool was used to critically appraise the methodological components of each quantitative study, and the Mixed Methods Appraisal Tool was used to critically appraise qualitative and mixed-methods studies. RESULTS: Condom use in men who have sex with men using pre-exposure prophylaxis is influenced by multiple factors. Studies indicate rates of sexually transmitted infections in treatment and placebo groups were high. Pre-exposure prophylaxis did not significantly change sexually transmitted infection rates between baseline and follow-up. Reporting of sexual risk improved when questionnaires were completed in private by clients. Our review found that pre-exposure prophylaxis may provide an opportunity for men who have sex with men to access sexual health care, testing, treatment and counselling services. We did not find any conclusive evidence that pre-exposure prophylaxis users increase sexual risk behaviours. CONCLUSION: The perception among healthcare providers that pre-exposure prophylaxis leads to increased sexual risk behaviours has yet to be confirmed. In order to provide effective sexual health services, clinicians need to be knowledgeable about pre-exposure prophylaxis as an HIV prevention tool. RELEVANCE TO CLINICAL PRACTICE: In an era where HIV prevention methods are rapidly improving, strategies for sexually transmitted infection testing, treatment, counselling and prevention remain vital to improve health. All healthcare providers are uniquely positioned to promote sexual health through the dissemination of accurate information.

A multinational qualitative investigation of the perspectives and drivers of exercise and dietary behaviors in people living with HIV.

Globally, people living with HIV (PLWH) are at remarkably high risk for developing chronic comorbidities. While exercise and healthy eating reduce and mitigate chronic comorbidites, PLWH like many others, often fail to engage in recommended levels. We qualitatively examined the perspectives and contextual drivers of diet and exercise reported by PLWH and their health care providers. Two hundred and six participants across eight sites in the United States, Puerto Rico and Botswana described one overarching theme, Arranging Priorities, and four subthemes Defining Health, Perceived Importance of Diet and Exercise, Competing Needs, and Provider Influence. People living with HIV and their health care providers recognize the importance of eating a healthy diet and engaging in regular exercise. Yet there are HIV-specific factors limiting these behaviors that should be addressed. Health care providers have an important, and often underutilized opportunity to support PLWH to make improvements to their exercise and diet behavior.

90-90-90-Plus: Maintaining Adherence to Antiretroviral Therapies.

Medication adherence is the "Plus" in the global challenge to have 90% of HIV-infected individuals tested, 90% of those who are HIV positive treated, and 90% of those treated achieve an undetectable viral load. The latter indicates viral suppression, the goal for clinicians treating people living with HIV (PLWH). The comparative importance of different psychosocial scales in predicting the level of antiretroviral adherence, however, has been little studied. Using data from a cross-sectional study of medication adherence with an international convenience sample of 1811 PLWH, we categorized respondent medication adherence as None (0%), Low (1-60%), Moderate (61-94%), and High (95-100%) adherence based on self-report. The survey contained 13 psychosocial scales/indices, all of which were correlated with one another (p < 0.05 or less) and had differing degrees of association with the levels of adherence. Controlling for the influence of race, gender, education, and ability to pay for care, all scales/indices were associated with adherence, with the exception of Berger's perceived stigma scale. Using forward selection stepwise regression, we found that adherence self-efficacy, depression, stressful life events, and perceived stigma were significant predictors of medication adherence. Among the demographic variables entered into the model, nonwhite race was associated with double the odds of being in the None rather than in the High adherence category, suggesting these individuals may require additional support. In addition, asking about self-efficacy, depression, stigma, and stressful life events also will be beneficial in identifying patients requiring greater adherence support. This support is essential to medication adherence, the Plus to 90-90-90.

Cytokine polymorphisms are associated with daytime napping in adults living with HIV.

OBJECTIVE/BACKGROUND: Daytime napping longer than one hour has been associated with an increased risk for all-cause mortality. Associations between cytokine polymorphisms and daytime napping in chronic illnesses such as HIV, however, have not been well described. The purpose of this study was to examine cytokine polymorphisms associated with long daytime napping in adults living with HIV. METHODS: A cross-sectional analysis was conducted using a convenience sample of 257 adults living with HIV. Daytime napping was assessed with wrist actigraphy data collected over three days. Participants categorized as long nappers (≥60 min) were compared to short nappers and non-nappers (<60 min). Single nucleotide polymorphisms (SNPs) for 15 candidate genes involved in cytokine signaling were analyzed. Genes included: interferon-gamma (IFNG), IFNG receptor 1 (IFNGR1), interleukins (IL1B, IL1R, IL1R2, IL2, IL4, IL6, IL8, IL10, IL13, IL17A), nuclear factors of kappa light polypeptide gene enhancer in B cells (NFKB1 and NFKB2), and tumor necrosis factor alpha (TNFA). RESULTS: After adjusting for relevant demographic and clinical characteristics, long daytime napping was associated with 12 SNPs from seven genes: 1) IFNG rs2069728; 2) IL1B rs1143642, rs1143627, and rs16944; 3) IL2 rs2069763; 4) IL6 rs4719714, rs1554606, and rs2069845; 5) IL17A rs3819024 and rs8193036; 6) NFKB1 rs4648110; and 7) NFKB2 rs1056890. CONCLUSIONS: Cytokine genetic variations may have a role in physiological regulation of daytime napping as well as nocturnal sleep. Cytokine polymorphisms associated with long daytime napping could help identify adults with HIV who may benefit from targeted therapeutic interventions.

Language and Culture in Health Literacy for People Living with HIV: Perspectives of Health Care Providers and Professional Care Team Members.

Low health literacy has been linked to inadequate engagement in care and may serve as a contributor to poor health outcomes among people living with HIV and AIDS. The purpose of this paper was to examine the perspectives of health care providers and professional care team members regarding health literacy in HIV disease. A secondary data analysis was conducted from a qualitative study aimed at understanding factors that help an HIV positive person to manage their HIV disease. Data were collected from sites in Botswana, the US, and Puerto Rico. In the parent study, data were collected through focus group discussions with 135 people living with HIV, 32 HIV health care providers (HCPs), and 39 HIV professional care team members (PCTMs). SPSS was used to analyze quantitative data while ATLAS.ti was used to analyze qualitative data. The findings from analyses of the perspectives of HCPs/PCTMs suggested that linguistic and cultural factors were important themes in the exchange of HIV information between health care providers and PLHIV. These themes included ineffective communication, health seeking behavior, cultural facilitators, and complementary and alternative/traditional healing methods. Thus, this study suggests that language and culture have a major role in health literacy for PLHIV.

Clinicians' Views of Hepatitis C Virus Treatment Candidacy With Direct-Acting Antiviral Regimens for People Who Inject Drugs.

BACKGROUND: Direct-acting antivirals (DAAs) are curative in most persons with chronic hepatitis C virus (HCV) infection. However, high cost and concerns about adherence and reinfection may present continued barriers to treatment, particularly for people who inject drugs (PWID). OBJECTIVE: To understand changes in assessments of treatment candidacy, given advances in treatment. METHODS: Clinicians attending the Liver Meeting® in 2014 who reported prescribing HCV treatment in the past three years were invited to complete a survey regarding HCV treatment decisions. Participants assessed their likelihood to treat HCV in PWID in association with time of abstinence from injection drug use and what impacts their decision to provide treatment using interferon and DAAs. RESULTS: 108 clinicians completed the survey; 10% were willing to treat an active PWID (last injection within 30 days) using interferon-containing regimens, and 15% with all-oral regimens. For each increasing time interval of injection abstinence, there was an increase in the odds of a clinician reporting willingness to treat with DAAs (Odds Ratio (OR) 2.57, 95% CI 2.18, 3.03) and with interferon-based treatment (OR 2.22 (95% CI 1.90, 2.61), Reinfection and medication cost were cited as most important concerns when determining candidacy. CONCLUSIONS: A cure is now the norm in HCV treatment, and there is an increasing need to address the barriers to treating PWID, the population with the highest burden of infection. Understanding treatment candidacy assessments is essential to improving uptake. This study provides insight into how clinicians view treatment candidacy in this era of DAAs and can help identify supportive treatment environments and concurrent programs.

The HIV Primary Care Workforce of Tomorrow: The UCSF Integrated HIV/AIDS Primary Care Capacity Nurse Practitioner Program.

The increasing demand for primary care services and the current health care workforce shortage is predicted to cause drastic reductions in the number of clinicians who are competent to provide HIV care. For the past decade, the University of California, San Francisco (UCSF) School of Nursing has provided HIV specialty education for Advanced Practice Nursing students in the Master's curriculum. In 2013, UCSF was funded by the Health Resources Services Administration to establish a nurse practitioner (NP) HIV primary care education program to expand the number of NPs prepared to provide culturally appropriate comprehensive HIV primary care. To this end, UCSF faculty have developed and validated a set of HIV Primary Care entry-level NP competencies, integrated general HIV knowledge into the NP curriculum, and enhanced our current HIV Specialty curriculum and clinical training. Described herein is UCSF's Integrated HIV/AIDS Primary Care Capacity Nurse Practitioner Program.

Investing in Nurses is a Prerequisite for Ensuring Universal Health Coverage.

Nurses and midwives constitute the majority of the global health workforce and the largest health care expenditure. Efficient production, successful deployment, and ongoing retention based on carefully constructed policies regarding the career opportunities of nurses, midwives, and other providers in health care systems are key to ensuring universal health coverage. Yet nurses are constrained by practice regulations, workplaces, and career ladder barriers from contributing to primary health care delivery. Evidence shows that quality HIV care, comparable to that of physicians, is provided by trained nurses and associate clinicians, but many African countries' health systems remain dependent on limited numbers of physicians and fail to meet the demand for treatment. The World Health Organization endorses task sharing to ensure universal health coverage in HIV and maternal health, which requires an investment in nursing education, retention, and professional growth opportunities. Exemplars from Haiti, Rwanda, Republic of Georgia, and multi-country efforts are described.

Appreciating Reasons for Nonadherence in Women.

Women aged 15-24 years have an HIV infection rate twice that of men the same age. In this study we examined reasons why HIV-infected women taking antiretroviral therapy (ART) report missing HIV medications. Women (N = 206) on ART were 2.2 times more likely to endorse reasons pertaining to forgetfulness versus reasons pertaining to problems taking pills (OR = 2.2, 95% CI = 1.63, 2.94, p <.001). There was a difference between the adherent and nonadherent groups in types of reasons overall (p <.001, 95% CI = -3.82, -2.03). Using a patient-centered approach to understand type of nonadherence (intentional vs. unintentional) may support development of novel interventions.

Engagement with Care, Substance Use, and Adherence to Therapy in HIV/AIDS.

Engagement with care for those living with HIV is aimed at establishing a strong relationship between patients and their health care provider and is often associated with greater adherence to therapy and treatment (Flickinger, Saha, Moore, and Beach, 2013). Substance use behaviors are linked with lower rates of engagement with care and medication adherence (Horvath, Carrico, Simoni, Boyer, Amico, and Petroli, 2013). This study is a secondary data analysis using a cross-sectional design from a larger randomized controlled trial (n = 775) that investigated the efficacy of a self-care symptom management manual for participants living with HIV. Participants were recruited from countries of Africa and the US. This study provides evidence that substance use is linked with lower self-reported engagement with care and adherence to therapy. Data on substance use and engagement are presented. Clinical implications of the study address the importance of utilizing health care system and policy factors to improve engagement with care.

Self-compassion and risk behavior among people living with HIV/AIDS.

Sexual risk behavior and illicit drug use among people living with HIV/AIDS (PLWHA) contribute to poor health and onward transmission of HIV. The aim of this collaborative multi-site nursing research study was to explore the association between self-compassion and risk behaviors in PLWHA. As part of a larger project, nurse researchers in Canada, China, Namibia, Puerto Rico, Thailand and the US enrolled 1211 sexually active PLWHA using convenience sampling. The majority of the sample was male, middle-aged, and from the US. Illicit drug use was strongly associated with sexual risk behavior, but participants with higher self-compassion were less likely to report sexual risk behavior, even in the presence of illicit drug use. Self-compassion may be a novel area for behavioral intervention development for PLWHA.

Telomere length is associated with sleep duration but not sleep quality in adults with human immunodeficiency virus.

BACKGROUND AND STUDY OBJECTIVE: Telomere length provides an estimate of cellular aging and is influenced by oxidative stress and health behaviors such as diet and exercise. This article describes relationships between telomere length and sleep parameters that included total sleep time (TST), wake after sleep onset (WASO), and self-reported sleep quality in a sample of adults with chronic illness. DESIGN AND PARTICIPANTS: Cross-sectional study of 283 adults (74% male, 42% Caucasian) infected with human immunodeficiency virus (HIV) while living in the San Francisco Bay area, CA, USA. Ages ranged from 22-77 y. MEASUREMENTS AND RESULTS: TST and WASO were estimated with wrist actigraphy across 72 h; self-reported sleep quality was assessed with the Pittsburgh Sleep Quality Index. Relative telomere length (RTL) in leukocytes was estimated by quantitative polymerase chain reaction assays. Shorter RTL was associated with older age, and RTL was shorter in males than females. RTL was unrelated to HIV disease characteristics. RTL was not associated with WASO or self-reported sleep quality. Participants with at least 7 h sleep had longer RTL than those with less than 7 h, even after controlling for the effects of age, sex, race, education, body mass index, metabolic hormones (i.e., leptin, ghrelin, adiponectin, and resistin), depression and anxiety, and sleep quality. CONCLUSION: Results suggest that sleep duration is associated with preserving telomere length in a population of human immunodeficiency virus-infected adults. Getting at least 7 hours of sleep at night may either protect telomeres from damage or restore them on a nightly basis.

Weaving dreamcatchers: mothering among American Indian women who were teen mothers.

AIMS: The aim of this study was to explore the mothering experience and practice among reservation-based adult American Indian women who had been adolescent mothers. BACKGROUND: Adolescent American Indian women are at an elevated risk for teen pregnancy and poor maternal/child outcomes. Identifying mothering practices among this population may help guide intervention development that will improve health outcomes. DESIGN: A collaborative orientation to community-based participatory research approach. METHODS: Employing interpretive phenomenology, 30 adult American Indian women who resided on a Northwestern reservation were recruited. In-depth, face-to-face and telephone interviews were conducted between 2007-2008. FINDINGS: Women shared their mothering experience and practice, which encompassed a lifespan perspective grounded in their American Indian cultural tradition. Four themes were identified as follows: mother hen, interrupted mothering and second chances, breaking cycles and mothering a community. Mothering originated in childhood, extended across their lifespan and moved beyond mothering their biological offspring. CONCLUSION: These findings challenge the Western construct of mothering and charge nurses to seek culturally sensitive interventions that reinforce positive mothering practices and identify when additional mothering support is needed across a woman's lifespan.

Associations between the legal context of HIV, perceived social capital, and HIV antiretroviral adherence in North America.

BACKGROUND: Human rights approaches to manage HIV and efforts to decriminalize HIV exposure/transmission globally offer hope to persons living with HIV (PLWH). However, among vulnerable populations of PLWH, substantial human rights and structural challenges (disadvantage and injustice that results from everyday practices of a well-intentioned liberal society) must be addressed. These challenges span all ecosocial context levels and in North America (Canada and the United States) can include prosecution for HIV nondisclosure and HIV exposure/transmission. Our aims were to: 1) Determine if there were associations between the social structural factor of criminalization of HIV exposure/transmission, the individual factor of perceived social capital (resources to support one's life chances and overcome life's challenges), and HIV antiretroviral therapy (ART) adherence among PLWH and 2) describe the nature of associations between the social structural factor of criminalization of HIV exposure/transmission, the individual factor of perceived social capital, and HIV ART adherence among PLWH. METHODS: We used ecosocial theory and social epidemiology to guide our study. HIV related criminal law data were obtained from published literature. Perceived social capital and HIV ART adherence data were collected from adult PLWH. Correlation and logistic regression were used to identify and characterize observed associations. RESULTS: Among a sample of adult PLWH (n = 1873), significant positive associations were observed between perceived social capital, HIV disclosure required by law, and self-reported HIV ART adherence. We observed that PLWH who have higher levels of perceived social capital and who live in areas where HIV disclosure is required by law reported better average adherence. In contrast, PLWH who live in areas where HIV transmission/exposure is a crime reported lower 30-day medication adherence. Among our North American participants, being of older age, of White or Hispanic ancestry, and having higher perceived social capital, were significant predictors of better HIV ART adherence. CONCLUSIONS: Treatment approaches offer clear advantages in controlling HIV and reducing HIV transmission at the population level. These advantages, however, will have limited benefit for adherence to treatments without also addressing the social and structural challenges that allow HIV to continue to spread among society's most vulnerable populations.

Lack of energy: an important and distinct component of HIV-related fatigue and daytime function.

CONTEXT: Fatigue is a prevalent symptom among adults living with HIV. There is increasing evidence that fatigue and energy are related, yet distinct constructs. Although HIV-related fatigue has been well studied, little is known about perceived energy and how it relates to fatigue, individual characteristics, and other symptoms. OBJECTIVES: To describe the experience of perceived energy in adults with HIV and evaluate its relationship to demographic and clinical characteristics as well as symptoms of fatigue, sleep disturbance, anxiety, depression, and daytime function. METHODS: The design was descriptive, comparative, and correlational. The sample of 318 adults with HIV completed a demographic questionnaire; the Memorial Symptom Assessment Scale; and measures of fatigue, sleep disturbance, anxiety, depressive symptoms, and daytime function. Medical records were reviewed for disease and treatment data. Participants who reported a lack of energy were compared with those who did not on demographic, clinical, and symptom variables. Regression models of perceived energy and its interference with daytime function also were evaluated. RESULTS: Perceived lack of energy was highly prevalent (65%) and more strongly related to interference with daytime function than more general measures of fatigue severity, even when controlling for other characteristics and symptoms. Like other aspects of fatigue, lack of energy was associated with sleep disturbance, anxiety, and depressive symptoms. Lack of energy was more strongly related to morning fatigue than to evening fatigue. CONCLUSION: Lack of energy interferes with daytime function and is not just the inverse of fatigue but a distinct perception that differs from fatigue.

Engagement with Health Care Providers Affects Self- Efficacy, Self-Esteem, Medication Adherence and Quality of Life in People Living with HIV.

The engagement of patients with their health care providers (HCP) improves patients' quality of life (QOL), adherence to antiretroviral therapy, and life satisfaction. Engagement with HCP includes access to HCP as needed, information sharing, involvement of client in decision making and self-care activities, respect and support of the HCP for the client's choices, and management of client concerns. This study compares country-level differences in patients' engagement with HCP and assesses statistical associations relative to adherence rates, self-efficacy, self-esteem, QOL, and symptom self-reporting by people living with HIV (PLHIV). A convenience sample of 2,182 PLHIV was enrolled in the United States, Canada, Puerto Rico, Namibia, and China. Cross-sectional data were collected between September 2009 and January 2011. Inclusion criteria were being at least 18 years of age, diagnosed with HIV, able to provide informed consent, and able to communicate in the local language with site researchers. In the HCP scale, a low score indicated greater provider engagement. Country comparisons showed that PLHIV in Namibia had the most HCP engagement (OR 2.80, p < 0.001) and that PLHIV in China had the least engagement (OR -7.03, p < 0.0001) compared to the PLHIV in the Western countries. Individuals having better HCP engagement showed better self-efficacy for adherence (t = -5.22, p < 0.0001), missed fewer medication doses (t = 1.92, p ≤ 0.05), had lower self-esteem ratings (t = 2.67, p < 0.01), fewer self-reported symptoms (t = 3.25, p < 0.0001), and better overall QOL physical condition (t = -3.39, p < 0.001). This study suggests that promoting engagement with the HCP is necessary to facilitate skills that help PLHIV manage their HIV. To improve ART adherence, HCPs should work on strategies to enhance self-efficacy and self-esteem, therefore, exhibiting fewer HIV-related symptoms and missing less medication doses to achieve better QOL.