Adherence to antiretroviral therapy in rural persons living with HIV disease in the United States.

The current study delineated patterns and predictors of adherence to antiretroviral therapy in 329 persons living with HIV disease in rural areas of 12 US states. Participants provided self-report data on patterns of HIV medication adherence, reasons for missing medication doses, psychological symptomatology, life-stressor burden, social support, ways of coping, coping self-efficacy, the quality of their relationship with their main physician, and barriers to health care and social services. Based on adherence data collected via retrospective, self-report assessment instruments, only 50% of participants adhered consistently to antiretroviral therapy regimens in the past week. Consistent adherence was more common in White participants, persons who had progressed to AIDS, and 'native infections' (i.e. persons who were born, raised, and infected in their current place of residence). Logistic regression analyses indicated that consistent adherence was reported by persons who drank less alcohol, had a good relationship with their main physician, and engaged in more active coping in response to HIV-related life stressors. As the number of rural persons living with HIV disease continues to increase, research that identifies correlates of non-adherence and conceptualizes approaches to optimize adherence in this group is urgently needed.

Psychological symptoms among persons 50 years of age and older living with HIV disease.

Although persons 50 years of age and older account for 10% of all US AIDS cases, the mental health needs of this growing group remain largely overlooked. The current study delineated patterns and predictors of psychological symptoms amongst late middle-aged and older adults living with HIV/AIDS in two large US cities. In late 1998, 83 HIV-infected individuals 50-plus years of age (M = 55.2, Range = 50-69) completed self-report surveys eliciting data on psychological symptomatology, HIV-related life-stressor burden, social support, barriers to health care and social services, and sociodemographic characteristics. Based on the Beck Depression Inventory, 25% of participants reported 'moderate' or 'severe' levels of depression. HIV-infected older adults also evidenced an elevated number of symptoms characteristic of somatization. A hierarchical multiple regression analysis revealed that HIV-infected older adults who endorsed more psychological symptoms also reported more HIV-related life-stressor burden, less support from friends, and reduced access to health care and social services due to AIDS-related stigma. As the impact of HIV on older communities continues to increase, geropractitioners must be prepared to provide care to greater numbers of HIV-infected older adults, a substantial minority of whom will present with complex comorbid physical and mental health conditions.

A pilot coping improvement intervention for late middle-aged and older adults living with HIV/AIDS in the USA.

As AIDS becomes more prevalent among late middle-aged and older adults, mental health support services that facilitate the coping and adjustment efforts of this group are increasingly needed. The current article: (1) outlines a coping improvement group intervention for HIV-infected older adults; and (2) examines the efficacy of the intervention utilizing a small sample (N = 16) of older adults living with HIV/AIDS in Milwaukee, Wisconsin and New York City. The intervention focused on enabling HIV-infected older adults to accurately appraise sources of stress, develop adaptive coping responses and access social support resources to facilitate coping efforts. An evaluation of this pilot intervention, conducted using a pretest-posttest, no control group design, revealed that the intervention increased participants' perceptions of social support, produced higher perceptions of social wellbeing and enabled participants to engage in more planful problem solving, confrontive coping and future optimism. Intervention participants also experienced less stressor burden associated with AIDS-related loss and health concerns. While the current intervention showed potential to facilitate the adjustment efforts of HIV-infected older adults, randomized clinical trials of this intervention with larger samples are needed before its appropriateness for this population can be determined.

Transfer of research-based HIV prevention interventions to community service providers: fidelity and adaptation.

HIV prevention research interventions usually follow protocols with specific procedures. If a community-delivered intervention uses the same procedures with the same populations as those in the original research, the behavior change effects should be similar. However, community-based providers may not replicate an intervention exactly as it was conducted in the effectiveness study. Adaptation may be needed to better meet the needs of the clients, community, or organization. We propose that interventions can be defined in terms of core elements likely to be responsible for effectiveness. These core elements cannot be changed without fundamentally changing the intervention, whereas other characteristics may be modified without altering effectiveness. HIV prevention researchers and service providers can collaborate to develop interventions that not only are effective but can also be successfully implemented by service organizations. If researchers actively involve service providers and community members in intervention planning, technology transfer goals can be better achieved.

Late middle-aged and older men living with HIV/AIDS: race differences in coping, social support, and psychological distress.

Although AIDS mental health research has recently devoted more attention to the psychosocial needs of older adults living with human immunodeficiency virus (HIV) disease, studies of this population have typically combined older African-American and white participants into one large sample, thereby neglecting potential race differences. The current study examined race differences in stressor burden, ways of coping, social support, and psychological distress among late middle-aged and older men living with HIV/AIDS. Self-administered surveys were completed by 72 men living with HIV/AIDS in New York City and Milwaukee, WI (mean age = 53.4 years). Older African-American and white men experienced comparable levels of stress associated with AIDS-related discrimination, AIDS-related bereavement, financial dilemmas, lack of information and support, relationship difficulties, and domestic problems. However, in responses to these stressors, older African-American men more frequently engaged in adaptive coping strategies, such as greater positive reappraisal and a stronger resolve that their future would be better. Compared to their African-American counterparts, HIV-infected older white men reported elevated levels of depression, anxiety, interpersonal hostility, and somatization. African-American men also received more support from family members and were less likely to disclose their HIV serostatus to close friends. As AIDS becomes more common among older adults, mental health-interventions will increasingly be needed for this group. The development of intervention programs for this group should pay close attention to race-related differences in sociodemographic, psychosocial, and behavioral characteristics.

Bridging the gap between the science and service of HIV prevention: transferring effective research-based HIV prevention interventions to community AIDS service providers.

OBJECTIVES: AIDS service organizations (ASOs) rarely have access to the information needed to implement research-based HIV prevention interventions for their clients. We compared the effectiveness of 3 dissemination strategies for transferring HIV prevention models from the research arena to community providers of HIV prevention services. METHODS: Interviews were conducted with the directors of 74 ASOs to assess current HIV prevention services. ASOs were randomized to programs that provided (1) technical assistance manuals describing how to implement research-based HIV prevention interventions, (2) manuals plus a staff training workshop on how to conduct the implementation, or (3) manuals, the training workshop, and follow-up telephone consultation calls. Follow-up interviews determined whether the intervention model had been adopted. RESULTS: The dissemination package that provided ASOs with implementation manuals, staff training workshops, and follow-up consultation resulted in more frequent adoption and use of the research-based HIV prevention intervention for gay men, women, and other client populations. CONCLUSIONS: Strategies are needed to quickly transfer research-based HIV prevention methods to community providers of HIV prevention services. Active collaboration between researchers and service agencies results in more successful program adoption than distribution of implementation packages alone.

Outcomes of a randomized community-level HIV prevention intervention for women living in 18 low-income housing developments.

OBJECTIVES: Women in impoverished inner-city neighborhoods are at high risk for contracting HIV. A randomized, multisite community-level HIV prevention trial was undertaken with women living in 18 low-income housing developments in 5 US cities. METHODS: Baseline and 12-month follow-up population risk characteristics were assessed by surveying 690 women at both time points. In the 9 intervention condition housing developments, a community-level intervention was undertaken that included HIV risk reduction workshops and community HIV prevention events implemented by women who were popular opinion leaders among their peers. RESULTS: The proportion of women in the intervention developments who had any unprotected intercourse in the past 2 months declined from 50% to 37.6%, and the percentage of women's acts of intercourse protected by condoms increased from 30.2% to 47.2%. Among women exposed to intervention activities, the mean frequency of unprotected acts of intercourse in the past 2 months tended to be lower at follow-up (mean = 4.0) than at baseline (mean = 6.0). These changes were corroborated by changes in other risk indicators. CONCLUSIONS: Community-level interventions that involve and engage women in neighborhood-based HIV prevention activities can bring about reductions in high-risk sexual behaviors.

Life optimism, substance use, and AIDS-specific attitudes associated with HIV risk behavior among disadvantaged innercity women.

The development of more effective human immunodeficiency virus (HIV) prevention programs for disadvantaged women requires identification of factors associated with risk. In the present study, 158 women - all of whom met criteria indicative of HIV risk - were recruited in innercity primary healthcare clinics and administered measurements that assessed variables in three domains believed pertinent to HIV sexual risk behavior: (1) substance use in the past 3 months, (2) acquired immunodeficiency syndrome (AIDS)-specific cognitive and attitudinal factors, including AIDS risk knowledge, condom attitudes, perceived risk for AIDS, behavior change intentions, and perceived self-efficacy, and (3) life context variables, including self-esteem, fatalism, personal optimism toward the future, and current life satisfaction. When women were categorized into highest and lower groups based on their recent risk behavior, AIDS-specific cognitive and attitudinal factors, as expected, differentiated the groups. However, women at highest risk for HIV also most often used a variety of substances and scored lower in self-esteem, held views more characterized by personal fatalism and low optimism concerning the future, and had greater life dissatisfaction than women at lower risk. HIV prevention programs for disadvantaged women require attention not only to AIDS-specific knowledge, attitudes, and skills development but also to broader issues of life context that, if unaddressed, may limit women's ability and motivation to reduce risk for HIV/AIDS.

Coping strategies and emotional wellbeing among HIV-infected men and women experiencing AIDS-related bereavement.

AIDS influences the psychological coping not only of the person with the disease but also those close to that individual. Following a death from AIDS, family members and friends may experience atypical bereavement. Bereavement coping challenges can be especially difficult and pronounced for persons who are themselves HIV-positive. The prevalence of AIDS-related bereavement and psychosocial predictors of grief severity were examined in an ethnically diverse sample of 199 HIV-infected men and women. Eighty per cent of HIV-positive respondents had experienced the loss of someone close to AIDS, the majority of whom had sustained multiple and repetitive losses. Two-thirds of the participants who had experienced an AIDS-related loss reported grief symptoms in the past month. Hierarchical regression analyses revealed that grief was most closely associated with emotional suppression and avoiding coping strategies, with residual variance related to depression. Interventions for AIDS-related bereavement that reduce distress and maladaptive ways of coping are needed in order to meet the secondary prevention needs of bereaved people living with HIV/AIDS.

Current HIV prevention activities for women and gay men among 77 ASOs.

Community-based AIDS service organizations (ASOs) are important providers of HIV prevention services in cities throughout the United States. This study examined the types of HIV prevention programs that are being undertaken by ASOs and assessed the kinds of new programs that ASOs feel are needed as the HIV epidemic continues to evolve. Factors that will need attention as new HIV prevention programs are developed by ASOs include high turnover of personnel in the organizations, capacity building that will be needed for ASOs to offer more intensive or specialized programs, and strategies to provide technical assistance as ASOs develop new types of programs.

HIV risk differences between African-American and white men who have sex with men.

African-American men who have sex with men remain at disproportionately greater risk for contracting human immunodeficiency virus (HIV) infection. While high HIV seroincidence has been documented among homosexual African-American men, behavioral research has rarely studied the HIV risk issues confronting these men. This study assessed a sample of 253 men who have sex with men to determine if African-American (n = 79) and white (n = 174) men report different rates of HIV risk behaviors and differ in characteristics indicative of risk. African-American men who have sex with men were more likely to be HIV-seropositive, to report past treatment for gonorrhea and syphilis, and to have a recent unprotected sex partner known or believed to be HIV-seropositive. Multivariate analyses of covariance, controlling for group differences in age, education, and income, revealed that African-American men who have sex with men were less open about their sexual orientation, scored lower in HIV risk behavior knowledge, had more female sexual partners, and more frequently used cocaine in association with sex relative to white men who have sex with men. Human immunodeficiency virus prevention programs tailored to the needs and risk issues of African-American men who have sex with men are needed.

Factors influencing attitudes within AIDS service organizations toward the use of research-based HIV prevention interventions.

Although the efficacy of small-group, risk reduction interventions based on cognitive behavioral principles has been widely documented in HIV behavioral research literature, little is known about how AIDS service organizations (ASOs) view these research-based models. From a nationwide sample of 77 ASOs, this study assessed factors influencing attitudes of prevention program directors and frontline staff toward research-based interventions. Characteristics of individual respondents as well as organizational characteristics of the ASO itself were used to predict perceived benefits of adopting this type of intervention, perceived efficacy (confidence) in the ASO's ability to implement it, and perceived barriers to adoption. Findings revealed uniformly positive perceptions of benefits among respondents from ASOs of different sizes and organizational experiences, although directors held more favorable evaluations than frontline staff. Respondents from ASOs that were larger, had previously delivered group or workshop interventions, or had received outside technical assistance in the past expressed more confidence in the ability of their ASO to implement the intervention. On the other hand, older and more highly education individuals had less confidence in their organization's ability to implement the model. Resource constraints (money, staff, and time) were the most common barriers cited by the respondents. Overall, higher organizational role and longer tenure at an ASO were associated with the perception of more barriers to adopting science-based interventions. Respondents from ASOs with a history of receiving technical assistance reported fewer perceived barriers. The successful dissemination of HIV prevention models from the research arena to the service arena will require mechanisms to provide appropriate funding and technical assistance, particularly to smaller organizations. Mindful of the resource constraints faced by ASOs, researchers can facilitate this process by attempting to develop interventions that are less resource- and time-consuming than current models.

Barriers to care among persons living with HIV/AIDS in urban and rural areas.

People living with HIV disease, particularly those in small towns and rural areas, face many barriers that prevent them from receiving important life-care services. We developed the Barriers to Care Scale (BACS) to delineate the problem severity of factors that impede care and service provision among a sample of 226 men and women living with HIV disease in a single midwestern state. Both urban and rural respondents indicated that major barriers to life-care services included the lack of knowledge about HIV among citizens in the community, insufficient personal financial resources, the lack of employment opportunities for people living with HIV, and the lack of supportive and understanding work environments. Rural persons living with HIV disease, compared to their urban counterparts, assigned significantly higher problem severity ratings to the following barriers: the need to travel long distances to medical facilities and personnel; a shortage of adequately trained medical and mental health professionals; a lack of personal or public transportation; and community residents' stigma toward people living with HIV. The large number of barriers to care identified in the present study indicates that innovative programmes designed to remove these barriers and improve the life quality of rural persons living with HIV are urgently needed.

Psychosocial differences between urban and rural people living with HIV/AIDS.

During the past decade, many investigations have examined the life circumstances of people living with HIV disease. Most of these studies, however, have focused on HIV-infected people in large metropolitan areas. This study compares the psychosocial profiles of rural and urban people living with HIV disease. Anonymous, self-administered surveys were completed by 276 people with HIV/AIDS in a Midwestern state. The assessment instrument measured respondents' quality of life, perceptions of loneliness, social support, experiences with AIDS-related discrimination, access to services, and illness-related coping strategies. Compared with their urban counterparts, rural people with HIV reported a significantly lower satisfaction with life, lower perceptions of social support from family members and friends, reduced access to medical and mental health care, elevated levels of loneliness, more community stigma, heightened personal fear that their HIV serostatus would be learned by others, and more maladaptive coping strategies. Programs that are designed to improve the life circumstances of people with HIV disease in rural areas--particularly those that facilitate access to adequate health care, increase perceptions of social support, and improve illness-related coping--are urgently needed.

Patterns, predictors and gender differences in HIV risk among severely mentally ill men and women.

A number of studies have established high human immunodeficiency virus (HIV) seroprevalence among severely mentally ill men and women living in large urban areas. Much less research has characterized the patterns of risk behavior that contribute to elevated vulnerability to HIV/AIDS among the mentally ill, as well as psychological, situational, and gender-related influences on risk in this population. One-hundred thirty-four severely mentally ill men and women who reported sexual activity outside of an exclusive relationship or with high-risk partners completed an extensive measure battery concerning HIV risk. Knowledge about HIV was low and sexual risk behavior levels were high in the sample. On average, condoms were used in only 32% of intercourse occasions in the past three months, and nearly one-half of participants reported multiple sexual partners in the same period. Patterns common in the sample were sex associated with substance use; coerced sex, bartering sex for money, food, clothes, or a place to stay; and sex with injection drug user partners. Factors predictive of greater risk were being female, presently being in a relationship, perceiving oneself to be at risk, high levels of alcohol use, and weak risk reduction behavioral intentions. Mental health programs serving severely mentally ill men and women are reaching a population at elevated risk for contracting HIV infection, and can serve as a venue for targeted HIV prevention interventions.

Developmental stages and spiritual coping responses among economically impoverished women living with HIV disease.

Identifies environmental markers, situational appraisals, perceived ability to mediate situations and outcomes, primary coping strategies, and purposes served by religion and spirituality in 10 HIV-positive women recruited from a regional health care clinic. Findings indicated that the women experienced a disintegration of family during their early developmental years, yielding feelings of hopelessness and isolation; that their sexual development was marked by rape and incest, and their early adulthood was characterized by failed relationships, pregnancies, drugs, and alcohol. Reports that the women's religious influences were predominantly maternal and provided a model for intercessory prayer. Notes that prior to their diagnosis of HIV, participants described their coping as escapist, while after diagnosis they believed there was a divine intercession renewing their spiritual growth and connectedness with others. Reports that the women's personal spirituality was greatly influenced by prayer, television ministries, and reading the Bible. Suggests the interventions that actively recruit women into social support services, health care systems, and faith congregations are needed and that television ministries may serve as access points for connecting women with necessary services.

Psychosocial predictors of life satisfaction among persons living with HIV infection and AIDS.

As AIDS becomes a more chronic but manageable illness, understanding quality of life issues among persons living with this disease has become an important goal of health care researchers. However, most quality of life investigations of persons living with HIV disease have relied heavily on clinical samples (e.g., hospitalized patients, psychiatric outpatients). The present study sought to identify psychosocial predictors of general life satisfaction in a community sample of 275 persons living with HIV/AIDS in a large midwestern state. Principal components and multiple regression analyses revealed that improved physical/functional well-being, increased social support, more frequent use of active coping strategies, and fewer incidents of AIDS-related discrimination and stigma predicted higher levels of general life satisfaction (R2 = 39). Intervention strategies likely to produce higher levels of life satisfaction among persons living with HIV disease are discussed.

The response of religious congregations to the spiritual needs of people living with HIV/AIDS.

Investigates the perceptions and responses of members of five diverse religious congregations to the spiritual needs of people living with AIDS, the impact of AIDS on membership participation, and the beliefs held by different congregations regarding AIDS. Evaluates and compares the AIDS-related perceptions of 204 participants in five congregations (Buddhists, Catholic, Fundamental Christians, Protestants, and Unitarians). Results indicated that congregations differed in how their members responded to the spiritual needs of people living with HIV/AIDS, the level of influence AIDS had on membership participation in formal religions, and whether AIDS was seen as the result of sinful behavior or divine retribution. Concludes that the congregational differences appeared consistent with the core beliefs of the faith communities. Suggests that clergy and congregations need to take specific steps to provide spiritual support to people living with HIV/AIDS consistent with their history of caregiving to all people regardless of the crisis situation.

HIV risk behaviors among inner-city African American women. The Community Housing AIDS Prevention Study Group.

This study examined the prevalence and predictors of HIV risk behaviors among a sample of 875 low-income, African American women residents of inner-city housing developments. The women completed an anonymous questionnaire that revealed that one third of them were at high risk for HIV either because they had multiple partners or because of the high-risk behaviors of their regular partner. HIV risk was highest among women who accurately perceived themselves to be at increased HIV risk, reported weak behavioral intentions to reduce risk, and held stronger beliefs about psychosocial barriers to condom use. Women at high risk were also younger, reported higher rates of substance use, and indicated that their housing development lacked social cohesiveness. These findings suggest that HIV prevention efforts for this population should focus on strengthening women's risk reduction behavioral intentions and self-efficacy through skill development, overcoming psychosocial barriers to condom use, managing the risk related to substance use, and incorporating approaches that take into account the social, psychological, and relationship barriers to change among economically impoverished African American women.

Predictors of condom use and human immunodeficiency virus test seeking among women living in inner-city public housing developments.

BACKGROUND AND OBJECTIVES: To examine prevalence and predictors of condom use and human immunodeficiency virus (HIV) test seeking among women living in inner-city housing developments. STUDY DESIGN: Between April and June 1994, 671 women living in low-income housing developments in five cities in the United States completed an anonymous self-report questionnaire eliciting information on acquired immune deficiency syndrome (AIDS) risk behavior and characteristics indicative of risk. RESULTS: Most participants were women of color who were economically disadvantaged. Fifteen percent reported multiple sex partners, and 30% of women with one sex partner believed he had sex with someone else in the past year. Predictors of condom use included increased rates of safe-sex negotiation, stronger risk reduction intentions, absence of condom barrier beliefs, and multiple sex partners. Women tested for HIV in the past year were younger, perceived themselves to be at risk for HIV infection, reported more conversations with other women about AIDS concerns, and had condoms readily available. CONCLUSIONS: HIV public health prevention interventions are urgently needed for women who live in low-income urban housing developments.