Forgetting to take HIV antiretroviral therapy: a qualitative exploration of medication adherence in the third decade of the HIV epidemic in the United States.

Optimal adherence to HIV antiretroviral therapy (ART) is challenging, and racial/ethnic disparities in adherence rates are substantial. The most common reason persons living with HIV (PLWH) give for missed ART doses is forgetting. We took a qualitative exploratory approach to describe, from the perspectives of African American/Black and Hispanic/Latino PLWH, what it means to forget to take ART and factors that influence forgetting. Participants (N = 18) were purposively sampled for maximum variability and engaged in semi-structured/in-depth interviews on HIV/ART management. The analysis took a directed content analysis approach. Participants were mostly male (56%) and African American/Black (79%), between 50 and 69 years old, and had lived with HIV for an average of 21 years. Findings were organised into six inter-related themes: (1) forgetting to take ART was a shorthand description of a complex phenomenon, but rarely a simple lapse of memory; (2) 'forgetting' was means of managing negative emotions associated with HIV; (3) life events triggered mental health distress/substance use which disrupted adherence; (4) historical traumatic events (including AZT monotherapy) and recent trauma/loss contributed to forgetting; (5) patient-provider interactions could support or impede adherence; and (6) intrinsic motivation was fundamental. Implications for HIV social service and health care settings are described.

Description of an efficacious behavioral peer-driven intervention to reduce racial/ethnic disparities in AIDS clinical trials.

AIDS clinical trials (ACTs) are critical to the development of new treatments for HIV infection. However, people of color living with HIV/AIDS are involved in ACTs at disproportionally low rates, with African-Americans experiencing the greatest under-representation. In this article, we describe the core elements and key characteristics of a highly efficacious multi-component peer-driven intervention (PDI) designed to increase rates of screening for and enrollment into ACTs among African-American and Latino/Hispanic individuals, by addressing the main complex, multi-level barriers they experience to ACTs. We discuss the process of developing the intervention, the theoretical models guiding its delivery format and content, and provide an overview of the intervention's components. We then use brief case studies to illustrate a number of key issues that may arise during intervention implementation. Finally, we describe lessons learned and provide recommendations for the PDI's uptake in clinical and clinical trials settings.

Gender differences in attitudes toward AIDS clinical trials among urban HIV-infected individuals from racial and ethnic minority backgrounds.

Racial/ethnic minorities and women are under-represented in AIDS clinical trials (ACTs). We examined gender differences in willingness to participate in ACTs among urban HIV-infected individuals (N = 286). Sixty percent of participants were male, and most were from racial/ethnic minority backgrounds (55% African-American, 34% Latino/Hispanic, 11% White/other). Knowledge of ACTs was poor. Males and females did not differ substantially in their distrust of AIDS scientists, or in barriers to ACTs. Almost all (87%) were somewhat or very willing to join ACTs. Females were less willing than males to join, including trials testing new medications or new medication combinations. Males and females differed in correlates of willingness to participate in ACTs. Despite long-standing barriers to medical research among minorities and women, willingness to participate was substantial, particularly for men, although the factors that might motivate them to join differed by gender. Women appeared more averse to trials involving new anti-retroviral regimens than men. Gender-specific outreach, behavioural intervention, and social marketing efforts are needed.

An intervention for parents with AIDS and their adolescent children.

OBJECTIVES: This study evaluated an intervention designed to improve behavioral and mental health outcomes among adolescents and their parents with AIDS. METHODS: Parents with AIDS (n = 307) and their adolescent children (n = 412) were randomly assigned to an intensive intervention or a standard care control condition. Ninety-five percent of subjects were reassessed at least once annually over 2 years. RESULTS: Adolescents in the intensive intervention condition reported significantly lower levels of emotional distress, of multiple problem behaviors, of conduct problems, and of family-related stressors and higher levels of self-esteem than adolescents in the standard care condition. Parents with AIDS in the intervention condition also reported significantly lower levels of emotional distress and multiple problem behaviors. Coping style, levels of disclosure regarding serostatus, and formation of legal custody plans were similar across intervention conditions. CONCLUSIONS: Interventions can reduce the long-term impact of parents' HIV status on themselves and their children.

The coming-out process and its adaptational and health-related associations among gay, lesbian, and bisexual youths: stipulation and exploration of a model.

A model is proposed and explored that links the coming-out process to the psychological functioning (i.e., self-esteem and distress) and sexual behaviors of gay, lesbian, and bisexual youths recruited from gay-focused community-based and college organizations in New York City. The coming-out process is multidimensional, consisting, as defined here, of involvement in gay/lesbian activities, attitudes toward homosexuality, comfort with homosexuality, self-disclosure of sexual identity to others, and sexual identity. The coming-out dimensions were related to self-esteem, distress, and unprotected sexual behaviors. In addition, the relations between the coming-out dimensions and unprotected sexual behaviors were explained by psychological functioning. In particular, limited involvement in gay/lesbian activities was associated with more unprotected sex. Negative attitudes toward homosexuality were related directly to more unprotected sex, and they were related indirectly to more unprotected sex by means of increasing emotional distress. These and other findings have implications for designing preventive interventions to increase the youths' psychological functioning and reduce their unprotected sexual behaviors.

Understanding the unprotected sexual behaviors of gay, lesbian, and bisexual youths: an empirical test of the cognitive-environmental model.

The cognitive-environmental model (CEM; M. Fishbein et al., 1991) was used to understand the unprotected sexual behaviors of 156 gay, lesbian, and bisexual youths. Unprotected anal sex among the males was associated directly with poor protection skills (e.g., incorrect use of barrier methods, such as condoms), poor intentions to use barrier methods, and poor norms by sexual partners concerning barrier methods. Furthermore, the association between low self-efficacy and increasing unprotected anal sex was attributed to poor intentions. Direct associations of unprotected oral sex with poor intentions and poor partner norms also emerged, as did an indirect relation between unprotected oral sex and low self-efficacy via poor intentions. These last 3 findings were replicated when examining unprotected oral or vaginal-digital sex among the females. Relations among the CEM factors supported some CEM-theoretical propositions.

Sexual risk behaviors of Gay, Lesbian, and bisexual youths in New York City: prevalence and correlates.

The lifetime and recent sexual risk behaviors of 156 Gay, Lesbian, and bisexual youths, recruited from Gay-focused organizations in New York City, were examined. The data indicated seven reasons why the youths are at risk for HIV and other STDs: They initiated sex during early adolescence; their first sexual partners were older than they were; HIV barrier methods (e.g., condoms) were initiated subsequent to sexual debut; many lifetime sexual partners and encounters were reported; some youths exchanged sex for goods; many youths reported having had at least one partner at risk for HIV; and the youths engaged in unprotected sexual behaviors during the past 3 months. Significant gender differences emerged (e.g., the male youths reported more lifetime same-sex partners than the female youths; the female youths reported more lifetime other-sex partners than the male youths). Recent sexual risk behaviors (i.e., numbers of same-sex partners, encounters, and unprotected sex during the past 3 months) were related significantly to the youths' average degree of emotional involvement in or average duration of intimate relationships.

PIP: This study examined the lifetime and HIV-related risk behaviors of 156 gay, lesbian, and bisexual youths recruited from gay-focused organizations in New York City. Seven risk behaviors for HIV infection were identified, all of which involved sexual issues. These included 1) sex initiated during adolescence; 2) older sexual partners; 3) HIV barrier methods adopted subsequent to sexual debut; 4) many lifetime sexual partners and encounters; 5) sex for goods; 6) one partner at risk for HIV; and 7) unprotected sex during the past 3 months. The gender differences, which emerged, highlighted the elevated risk associated with having male partners, irrespective of the youth's gender. In addition, recent sexual risk behaviors were related significantly to the average degree of emotional involvement in or average duration of intimate relationships of the youths. These findings indicate that HIV preventive interventions must address relationship characteristics and that there is a need to deliver HIV preventive interventions to gay, lesbian, and bisexual youths as early as the beginning of adolescence.

Timing of HIV interventions on reductions in sexual risk among adolescents.

Examined the effectiveness of an HIV intervention program among 151 adolescents ages 13 to 24 years who were randomly assigned to (a) seven sessions of 1.5 hr each (10.5 hr); (b) three sessions of 3.5 hr each (10.5 hr); or (c) a no-intervention condition. Using cognitive-behavioral intervention strategies, social skills and HIV-related beliefs, perceptions, and norms were targeted in both the three- and seven-session, small-group intervention conditions. Regression analysis indicated that over 3 months, the number of unprotected risk acts and the number of sexual partners were lower in the seven-session condition compared to the other conditions. Factors mediating risk acts changed in a complex manner. For example, perceived vulnerability increased for those with initially lower vulnerability scores among youths in the seven-session condition compared to others. Self-approval of condom use was also higher for those with initially low scores in the seven-session compared to the three-session condition. Self-efficacy for risk avoidance and condom use was significantly higher in the three-session condition for those with initially low scores compared to other groups. On the role-play measure, those with higher baseline scores in the low-pressure situation improved significantly only in the three-session intervention; in the high-pressure situation, the participants reported significantly higher scores in the seven-session intervention, and those with higher scores improved the most. Results suggest the importance of multisession HIV intervention programs to be delivered with fidelity in community settings.

PIP: The effectiveness of a small-group HIV/AIDS prevention intervention was assessed in 151 US adolescents 13-24 years of age who were randomly assigned to seven 1.5-hour sessions, three 3.5-hour sessions, or no intervention. The study participants were recruited from a community-based agency in New York, New York, that serves high-risk Black and Hispanic youth from neighborhoods with high HIV seroprevalence rates. The cognitive-behavioral intervention emphasized role-playing for social skills development and HIV-related beliefs, perceptions, and norms. Regression analysis indicated that over the 3-month study period, the numbers of sexual partners and sex acts unprotected by condoms were significantly lower in the 7-session group than in the other 2 groups. Compared with youths in the 7-session group, those in the control condition reported an average of 7.9 more risk acts and those in the 3-session group had an average of 7.2 more risk acts. The factors mediating risk reduction behavior changed in a complex manner. For example, perceived vulnerability increased more among those with initially lower vulnerability scores among youth in the 7-session group and self-approval of condom use was higher for those with initially low scores in the 7-session compared to the 3-session regimen. Self-efficacy for both risk avoidance and condom use was significantly higher in the 3-session condition for those with initially low scores, however. On the role-play measure, those with higher baseline scores in the low-pressure situation improved significantly only in the 3-session intervention; in the high-pressure situation, adolescents reported significantly higher scores in the 7-session condition and those with higher scores improved the most. These findings support an HIV/AIDS intervention strategy of shorter educational sessions spread over a brief span of time.

HIV testing, behaviors, and knowledge among adolescents at high risk.

PURPOSE: We examined HIV testing behavior and its predictors among adolescents considered at high risk for HIV. METHODS: Self-reports of HIV testing, knowledge, attitudes, and high-risk acts were examined among 272 adolescents aged 13-23 years (M = 18.7; SD = 2.3) attending community-based agencies that serve youth at high risk for HIV in Los Angeles, New York City, and San Francisco. RESULTS: Evidence of adolescents' risk for HIV is reflected in a rate of 4.8% seropositivity, 24% injecting drug use, a mean of 4.3 (SD = 11.6) sexual partners during the previous 3 months, and 71% condom use during vaginal/ anal sex. HIV testing was common (63%) and often repeated (M = 3.6, SD = 4.0). Knowledge of the meaning and consequences of testing was high (84% correct). Contrary to service providers' expectations, youth were likely to return for their test results (90% returned). Youth who were older, labeled themselves gay or bisexual, lived in Los Angeles or San Francisco, and those who injected drugs were significantly more likely, compared to peers, to get tested for HIV. CONCLUSIONS: These results suggest a need for more detailed observational studies of HIV testing behavior that include evaluation of characteristics of the youth, the testing site, and the attitudes and beliefs of providers offering HIV testing.

Molecular and genetic analysis of the toxic effect of RAP1 overexpression in yeast.

Rap1p is a context-dependent regulatory protein in yeast that functions as a transcriptional activator of many essential genes, including those encoding ribosomal proteins and glycolytic enzymes. Rap1p also participates in transcriptional silencing at HM mating-type loci and telomeres. Overexpression of RAP1 strongly inhibits cell growth, perhaps by interfering with essential transcriptional activation functions within the cell. Here we report a molecular and genetic analysis of the toxic effect of RAP1 overexpression. We show that toxicity does not require the previously defined Rap1p activation and silencing domains, but instead is dependent upon the DNA-binding domain and an adjacent region of unknown function. Point mutations were identified in the DNA-binding domain that relieve the toxic effect of overexpression. Two of these mutations can complement a RAP1 deletion yet cause growth defects and altered DNA-binding properties in vitro. However, a small deletion of the adjacent (downstream) region that abolishes overexpression toxicity has, by itself, no apparent effect on growth or DNA binding. SKO1/ACR1, which encodes a CREB-like repressor protein in yeast, was isolated as a high copy suppressor of the toxicity caused by RAP1 overexpression. Models related to the regulation of Rap1p activity are discussed.

Beliefs and behavioral intentions regarding human immunodeficiency virus testing among New York City runaways.

From 1988 to 1991, 139 runaways aged 11-19 years in the New York City area (n = 70 males, 69 females) were recruited from four shelters. Each runaway participated in a semistructured interview assessing beliefs and behavioral intentions regarding human immunodeficiency virus (HIV) testing. When asked how they would respond to being seropositive for HIV, 29% of runaways reported that they would engage in self-destructive acts and/or harm others (e.g., suicide, unprotected sex), 80% anticipated extreme distress, 47% expected difficulty securing housing and food, and 61% believed that friends were likely to avoid them. When presented with specific alternatives, fewer runaways anticipated self-destructive acts. Drug use, rather than sexual behaviors, would lead runaways to get tested for HIV. These results suggest that health-care providers must anticipate emotional distress and potential self-destructive behavior following receipt of documentation of HIV positive serostatus among runaways. Furthermore, prior to testing, youths' access to food, shelter, medical care, and social support must be secured.

Tracking high-risk adolescents longitudinally.

Longitudinal tracking methods rarely have been documented. A discussion is provided here of tracking methods and strategies used in assessing the effectiveness of an AIDS prevention intervention with high-risk adolescents over four years. We demonstrated an ability to follow 92% of a sample of unstable youths in a difficult urban environment. Successful recontacting of youths depended on the structure of the project in the recruitment phases, strategic choice of interviewers, a cost-effective payment schedule and other motivators, knowledge of appropriate social service agencies that could provide information on youths, and methods to elicit cooperation. Confidentiality and other ethical issues are discussed.