A Comparison of Adherence Timeframes Using Missed Dose Items and Their Associations with Viral Load in Routine Clinical Care: Is Longer Better?

Questions remain regarding optimal timeframes for asking about adherence in clinical care. We compared 4-, 7-, 14-, 30-, and 60-day timeframe missed dose items with viral load levels among 1099 patients on antiretroviral therapy in routine care. We conducted logistic and linear regression analyses examining associations between different timeframes and viral load using Bayesian model averaging (BMA). We conducted sensitivity analyses with subgroups at increased risk for suboptimal adherence (e.g. patients with depression, substance use). The 14-day timeframe had the largest mean difference in adherence levels among those with detectable and undetectable viral loads. BMA estimates suggested the 14-day timeframe was strongest overall and for most subgroups although findings differed somewhat for hazardous alcohol users and those with current depression. Adherence measured by all missed dose timeframes correlated with viral load. Adherence calculated from intermediate timeframes (e.g. 14-day) appeared best able to capture adherence behavior as measured by viral load.

Association between use of specific drugs and antiretroviral adherence: findings from MACH 14.

To determine the association between individual substances of abuse and antiretroviral adherence, analyses require a large sample assessed using electronic data monitoring (EDM). In this analysis, EDM data from 1,636 participants in 12 US adherence-focused studies were analyzed to determine the associations between recent use of various substances and adherence during the preceding 4 weeks. In bivariate analyses comparing adherence among patients who had used a specific substance to those who had not, adherence was significantly lower among those who had recently used cocaine, other stimulants or heroin but not among those who had used cannabis or alcohol. In multivariate analyses controlling for sociodemographics, amount of alcohol use and recent use of any alcohol, cocaine, other stimulants and heroin each was significantly negatively associated with adherence. The significant associations of cocaine, other stimulants, heroin, and alcohol use with adherence suggest that these are important substances to target with adherence-focused interventions.

Evaluation of the single-item self-rating adherence scale for use in routine clinical care of people living with HIV.

The self-rating scale item (SRSI) is a single-item self-report adherence measure that uses adjectives in a 5-point Likert scale, from "very poor" to "excellent," to describe medication adherence over the past 4 weeks. This study investigated the SRSI in 2,399 HIV-infected patients in routine care at two outpatient primary HIV clinics. Correlations between the SRSI and four commonly used adherence items ranged from 0.37 to 0.64. Correlations of adherence barriers, such as depression and substance use, were comparable across all adherence items. General estimating equations suggested the SRSI is as good as or better than other adherence items (p's <0.001 vs. <0.001-0.99) at predicting adherence-related clinical outcomes, such as HIV viral load and CD4(+) cell count. These results and the SRSI's low patient burden suggest its routine use could be helpful for assessing adherence in clinical care and should be more widespread, particularly where more complex instruments may be impractical.

Social support mediates the relationship between HIV stigma and depression/quality of life among people living with HIV in Beijing, China.

Stigma towards people living with HIV is pervasive in China and related to poor service utilization, psychosocial distress and diminished quality of life (QOL). In an effort to identify mechanisms to reduce HIV stigma and its negative consequences, we examined whether social support mediates the relation between enacted stigma and both depressive symptoms and QOL among 120 HIV outpatients in Beijing, China. Generally, perceived social support was associated with less stigma, less depressive symptomatology and better QOL. Using multivariable regression models, we found that social support was a full mediator of the impact of stigma on both depressive symptomatology and QOL. The findings suggest social support may be an important target of interventions to reduce the impact of stigma on poor psychosocial health outcomes.

Modeling HIV transmission risk among Mozambicans prior to their initiating highly active antiretroviral therapy.

Understanding sexual behavior and assessing transmission risk among people living with HIV-1 is crucial for effective HIV-1 prevention. We describe sexual behavior among HIV-positive persons initiating highly active antiretroviral therapy (HAART) in Beira, Mozambique. We present a Bernoulli process model (tool available online) to estimate the number of sexual partners who would acquire HIV-1 as a consequence of sexual contact with study participants within the prior three months. Baseline data were collected on 350 HAART-naive individuals 18-70 years of age from October 2004 to February 2005. In the three months prior to initiating HAART, 45% (n = 157) of participants had sexual relationships with 191 partners. Unprotected sex occurred in 70% of partnerships, with evidence suggesting unprotected sex was less likely with partners believed to be HIV-negative. Only 26% of the participants disclosed their serostatus to partners with a negative or unknown serostatus. Women were less likely to report concurrent relationships than were men (21 versus 66%; OR 0.13; 95%CI: 0.06, 0.26). Given baseline behaviors, the model estimated 23.2 infections/1,000 HIV-positive persons per year. The model demonstrated HAART along with syphilis and herpes simplex virus type 2 (HSV-2) treatment combined could reduce HIV-1 transmission by 87%; increasing condom use could reduce HIV-1 transmission by 67%.

Sex trading and psychological distress among women on methadone.

This study examined the relationship between sex trading and psychological distress among a nonrandom sample of women recruited from 3 methadone maintenance clinics in New York City. Face-to-face interviews with 280 women (M age = 40.7) revealed that 32% had traded sex for money or drugs in the previous year. Compared to other participants, these women reported less education and higher rates of incarceration in the past year, sexually transmitted diseases, childhood sexual abuse, partner abuse, and current regular crack/cocaine and alcohol use. Hierarchical multiple regression analysis indicated that sex traders scored 0.41 units higher than non-sex traders on the General Severity Index of the Brief Symptom Inventory after controlling for all relevant covariates. The findings emphasize the need to consider the interrelation of psychological distress, abuse, and addiction in designing public health interventions addressing methadone maintained women.

Heterosexual identity and heterosexism: recognizing privilege to reduce prejudice.

We propose that heterosexuals' attitudes toward their own heterosexual identity evolve in a manner similar to the development of racial identity attitudes among Whites-another dominant group with privileged social status. A more developed heterosexual identity, we hypothesized, would be associated with diminished levels of negative attitudes toward non-heterosexuals. To test our hypotheses, we administered to 154 heterosexual students Herek's (1988) Attitudes Toward Gays and Lesbians scale measuring heterosexist (i.e., anti-gay) attitudes and a version of Helms and Carter's (1990) White Racial Identity Attitude Scale (WRIAS) modified to assess heterosexual identity attitudes. Hierarchical regression analyses controlling demographic indicators partially confirmed the hypothesized associations between evolving identity stages and less heterosexist attitudes. The role of recognizing one's social privilege is proposed (though not empirically examined) as a potential mediator between developing a dominant group identity and decreasing prejudicial attitudes towards non-privileged groups. Finally, implications and recommendations for future research and addressing heterosexism are presented.

Mothers with HIV/AIDS and their children: disclosure and guardianship issues.

For many mothers living with HIV/AIDS, whether, when, and how to disclose their HIV diagnosis to their children and arranging for future care are important although agonizing issues. Due to the increasing number of children who lose their mothers to AIDS and the dearth of empirical information about them, these issues are increasingly important to research. This study of 188 HIV-positive mothers and their 267 children of minor age in New York City revealed that only half the mothers had disclosed their HIV diagnosis to at least one of their children and only 57% had made formal plans for the children's care. As expected, older children were more likely to be informed than younger children. Contrary to some previous research, maternal disclosure was not related to ethnicity, advanced illness, improved psychological well-being, or greater or more satisfying social support resources. Implications for future research and provision of services to this group of women are discussed.

Stressors and strengths among women living with HIV/AIDS in New York City.

We conducted face-to-face interviews with a non-probability sample of 373 women living with HIV/AIDS in New York City. Most were indigent African-Americans and Latinas (M age = 39.61 years). Participants reported considerable stressors. For example, 59% (n = 221) had been sexually abused and 69% (n = 258) physically abused at some point in their lives. In the past 30 days, 9% reported having injected drugs. However, participants also reported considerable strengths, including high levels of spirituality, mastery and HIV-related social support. Multivariate analyses indicated these resources were generally associated with less depressive symptomatology. Findings suggest the need for thorough psychosocial evaluations of women living with HIV to facilitate psychological adaptation, including an exploration of their strengths and culturally-based competencies.

Patterns and predictors of HIV risk among urban American Indians.

A preliminary survey of HIV risk and service preferences among American Indians residing in the New York metropolitan area included 68 women and 32 men (M age=35.8 years). Overall, the sample was knowledgeable about the mechanisms of HIV transmission, and 58 percent reported having taken an HIV test. However, of the 63 percent who reported sexual activity in the last six months, 73 percent reported engaging in vaginal or anal sex without a condom with at least 1 partner, and 52 percent used condoms none of the time during vaginal and anal sex. Almost half (43 percent) reported alcohol or other drug (AOD) use for non-ceremonial purposes in the last six months. Alarmingly, 44 percent reported lifetime trauma, including domestic violence (20 percent) and physical (29 percent) or sexual (26 percent) assault by a family member or stranger. Bivariate and multivariate analyses indicated trauma and drug use were factors that may place respondents at risk for sexual transmission of HIV. Trauma variables were better predictors of HIV risk behaviors than social cognitive variables providing preliminary support for the use of a postcolonial framework in American Indian HIV studies.

Trauma, coping, and depression among women with HIV/AIDS in New York City.

Among 230 HIV-positive women in New York City, we examined the association of retrospective self-reports of sexual and physical abuse, current coping strategies and depressive symptomatology (CES-D scores). Results revealed a high prevalence of abuse in childhood (50%) and adulthood (68%); 7% reported physical assault or rape in the last 90 days. As expected, childhood abuse was significantly correlated with both adult and recent trauma, and each type of trauma correlated with CES-D scores. Childhood abuse also positively correlated with the frequency of current adaptive and avoidant coping strategies, although avoidant coping had a stronger (negative) association with CES-D scores. Hierarchical regression analyses revealed the association between childhood abuse and CES-D scores persisted even after controlling for relevant demographic variables, more recent trauma and coping strategies. Implications for improving the psychological functioning of women living with HIV/AIDS are discussed.

Is acculturation associated with sexual risk behaviours? An investigation of HIV-positive Latino men and women.

This cross-sectional study of 226 HIV-positive Latino men and women sampled and assessed at an outpatient HIV clinic in Los Angeles examined the associations among acculturation, use of a substance before sex, and unsafe sexual behaviour. As acculturation increased, men and women were increasingly likely to have engaged in unsafe sex in the most recent sexual encounter since testing seropositive. In men, the association was partially mediated by use of a substance (primarily alcohol) in the three hours before the sexual encounter; in women, the association was not mediated by drug use. The findings underscore the need for culturally sensitive, secondary prevention programmes for HIV-positive persons.

Keeping it up: maintaining adherence to antiviral therapies.

AIDS: Combination antiretroviral therapies show unprecedented success in inhibiting viral load; however, their efficacy depends upon strict adherence to complex dosing schedules. If a patient does not adhere to the treatment, the virus can replicate rapidly and generate drug-resistant strains of HIV. An overview of the research literature on various methods of assessing levels of adherence and strategies for increasing adherence from behavioral and psychological perspectives is presented. Most adherence has been measured through self-reporting, an often inaccurate measure. Other methods to track adherence include pill counts, monitoring prescription refills, and direct measurements with biologic assays. The first step in helping patients follow their drug regimen is finding out why they have quit following the schedule. The most common reasons are that the patient forgot, slept through the dose, was away from home, had a change in routine, was busy, was too sick to take the pills, could not tolerate the side effects, or was depressed.^ieng

Disclosing HIV status and sexual orientation to employers.

Seropositive gay and bisexual men who reveal their sexual orientation or HIV/AIDS status to their employer risk discriminatory reprisals. However, non-disclosure may limit potential social, emotional, and tangible support. Among our sample of 389 seropositive gay and bisexual men employed in the US, 52% were 'out' to their employer and 35% had disclosed their serostatus to him or her. Among gay men, employer awareness of their sexual orientation was related to their being European American (vs Latino or African American), being HIV-seropositive for more than 4 years, and having a gay or bisexual employer. Disclosure of HIV infection in the total sample was related to being European American, HIV-seropositive for more than 4 years, symptomatic (vs asymptomatic), 'out' at work, and having a gay or bisexual employer. Men who had informed their employers of their HIV status reported consequences that were substantially more positive than those anticipated by men who had not disclosed. Policy and research implications for improving the work environment for gay and bisexual men living with HIV are considered.

Psychological distress and treatment adherence among children on dialysis.

Among 23 pediatric renal dialysis patients, we obtained self-reported assessments of psychological adjustment and biochemical and subjective ratings of adherence. Findings indicate elevated levels of depressive symptoms and substantial nonadherence. Depressive symptoms were associated with higher levels of hopelessness, more negative self-perceptions, and more depressogenic attributional style. The psychological adjustment measures did not significantly correlate with adherence. Nonsignificant associations among different measures of adherence underscore its multifaceted nature. Implications for monitoring the adjustment of children on dialysis, assessing adherence, and future research are discussed.

Latinos and mutual support group: a case for considering culture.

The literature on recognized Latino cultural values and their effect on mental health interventions with Latinos is reviewed, and experiences in implementing school-based mutual support groups for Latino parents are examined. Recommendations are made for incorporating cultural values in support group interventions with Latinos to promote increased participation. Implications for research are discussed.

Women's self-disclosure of HIV infection: rates, reasons, and reactions.

A survey of 65 ethnically diverse women at 2 outpatient HIV clinics revealed relatively low rates of disclosure of HIV-positive serostatus to extended family members, somewhat higher rates for immediate family members, and highest rates for lovers and friends. Spanish-speaking Latinas were less likely to disclose their serostatus or to discuss HIV-related worries with others than English-speaking Latinas, African Americans, and Anglo Americans. Reasons for disclosure and nondisclosure varied by target. In general, targets reacted positively to disclosure. Implications for clinicians treating women with HIV infection are discussed.