The Role of HIV Stigma in ART Adherence and Quality of Life Among Rural Women Living with HIV in India

HIV stigma continues to be a barrier to physical and mental health among people living with HIV globally, especially in vulnerable populations. We examined how stigma is associated with health outcomes and quality of life among rural women living with HIV in South India (N?=?600). Interviewer-administered measures assessed multiple dimensions of stigma, as well as loneliness, social support, ART adherence, time since diagnosis, and quality of life. Internalized stigma and a lack of social support were associated with a lower quality of life, while the association between internalized stigma and adherence was mediated by the use of stigma-avoidant coping strategies, suggesting that keeping one’s diagnosis a secret may make it more difficult to take one’s medications. These findings suggest that these women constitute a vulnerable population who need additional services to optimize their health and who might benefit from peer support interventions and stigma-reduction programs for family and community members.     

Understanding Patterns of Social Support and Their Relationship to an ART Adherence Intervention Among Adults in Rural Southwestern Uganda

SMS is a widely used technology globally and may also improve ART adherence, yet SMS notifications to social supporters following real-time detection of missed doses showed no clear benefit in a recent pilot trial. We examine the demographic and social-cultural dynamics that may explain this finding. In the trial, 63 HIV-positive individuals initiating ART received a real-time adherence monitor and were randomized to two types of SMS reminder interventions versus a control (no SMS). SMS notifications were also sent to 45 patient-identified social supporters for sustained adherence lapses. Like participants, social supporters were interviewed at enrollment, following their matched participant’s adherence lapse and at exit. Social supporters with regular income (RR = 0.27, P = 0.001) were significantly associated with fewer adherence lapses. Instrumental support was associated with fewer adherence lapses only among social supporters who were food secure (RR = 0.58, P = 0.003). Qualitative interview data revealed diverse and complex economic and relationship dynamics, affecting social support. Resource availability in emotionally positive relationships seemingly facilitated helpful support, while limited resources prevented active provision of support for many. Effective social support appeared subject to social supporters’ food security, economic stability and a well-functioning social network dependent on trust and supportive disclosure.     

Relationships Among Adherence and Physical and Mental Health Among Women Living with HIV in Rural India

We conducted a cross-sectional examination of the physical and psychological factors related to ART adherence among a sample of 400 women living with HIV/AIDS in rural India. Interviewer-administered measures assessed adherence, internalized stigma, depressive symptoms, quality of life, food insecurity, health history and sociodemographic information. CD4 counts were measured using blood collected at screening. Findings revealed that adherence to ART was generally low, with 94% of women taking 50% or less of prescribed medication in past month. Multivariate analyses showed a non-linear association between numbers of self-reported opportunistic infections (OIs) in past 6 months (p = 0.016) and adherence, with adherence decreasing with each additional OI for 0–5 OIs. For those reporting more than 5 OIs, the association reversed direction, with increasing OIs beyond 5 associated with greater adherence.     

Early Appointment Adherence Among Persons Living with HIV

Medical care for HIV disease may be most effective when medical surveillance and services are initiated early and consistently maintained over time. To benefit from continually improving HIV care regimens, persons living with HIV/AIDS must first adhere to their outpatient medical appointments. The purpose of this study was to examine psychosocial, illness, and demographic factors associated with appointment adherence problems early in HIV treatment. Results indicated that nonadherence to outpatient medical appointments was a significant problem. One hundred forty-four patients were followed for 6 months after their initial appointment at a public HIV clinic. One in five dropped out of treatment before completing their intake assessment (separate nurse and physician appointments). Men and individuals with lower levels of social support were most likely to drop out before seeing a physician. Emotional distress was not associated with early dropout, but elevated levels of anxiety and depression were found across the sample. Those still attending the clinic (n = 114) were then followed for 12 months after clinic enrollment. Overall, 35% of scheduled medical appointments were missed during this period. Higher baseline CD4 counts and injection drug use history were predictive of poor appointment adherence, but other demographic and psychosocial indices were not. These findings suggest increased research and early intervention efforts are needed to improve appointment adherence among persons living with HIV/AIDS.     

Tobacco Use Among Adults Initiating Treatment for HIV Infection in Rural Uganda

We conducted a longitudinal study of tobacco use among adults initiating antiretroviral therapy (ART) in Mbarara, Uganda where 11 % of men and 3 % of women use tobacco according to the 2011 Demographic and Health Survey. In a prospective cohort, self-reported tobacco use was assessed before starting ART and reassessed every 3–4 months. Plasma cotinine, a nicotine metabolite, was measured in a subset of adults pre-ART to verify self-report. Among 496 subjects, 50 (10 %) reported current tobacco use (20 % of men, 6 % of women). Most (53 %) adults with elevated cotinine levels (>15 ng/mL) reported no tobacco use. By 6 months after ART initiation, 33 % of tobacco users had quit (95 % CI 20–46 %). By 5 years, 64 % quit (95 % CI 47–77 %). Self-reported tobacco use among rural Ugandans starting ART was twice as common as among the local background population and use may be underreported. ART initiation could be an opportunity for tobacco cessation interventions.     

Medication and Behavioral Adherence Among HIV+ Older Adults

The purpose of this investigation was to explore HIV medication adherence among older adults. In Study 1, 44 HIV+ adults were recruited from the University of Pennsylvania Center for AIDS Research and interviewed about their health behaviors, including medication adherence. In Study 2, 40 HIV+ adults were surveyed about their communication with their physician and HIV medication and behavioral recommendations. Both studies found that a considerable percentage of participants were not completely adherent to their HIV medications. Furthermore, the majority of participants reported good communication with their physician. The findings of these studies have implications for intervention efforts aimed at increasing adherence to both medications and recommended behaviors among HIV+ older adults.     

Perceived HIV Treatment Norms Modify the Association Between HIV-Related Stigma and Adherence to Antiretroviral Therapy Among Persons Living with HIV in Baltimore,Maryland

AIDS and Behavior - Adherence to antiretroviral therapy (ART) is associated with reduced HIV-related morbidity/mortality and ongoing transmission; however, the extent to which this association is...     

Adherence to Antiretroviral Therapy Among Children Living with HIV in South India

Adherence to ART, fundamental to treatment success, has been poorly studied in India. Caregivers of children attending HIV clinics in southern India were interviewed using structured questionnaires. Adherence was assessed using a visual analogue scale representing past-month adherence and treatment interruptions >48 h during the past 3 months. Clinical features, correlates of adherence and HIV-1 viral-load were documented. Based on caregiver reports, 90.9 % of the children were optimally adherent. In multivariable analysis, experiencing ART-related adverse effects was significantly associated with suboptimal adherence (p = 0.01). The proportion of children who experienced virological failure was 16.5 %. Virological failure was not linked to suboptimal adherence. Factors influencing virological failure included running out of medications (p = 0.002) and the child refusing to take medications (p = 0.01). Inclusion of drugs with better safety profiles and improved access to care could further enhance outcomes.     

Daily Predictors of ART Adherence Among Young Men Living with HIV Who Have Sex with Men: A Longitudinal Daily Diary Study

AIDS and Behavior - Improving adherence to antiretroviral therapy (ART) is essential for limiting HIV disease progression among young sexual minority men living with HIV. Daily diaries allow for a...     

HIV, Sexual Health, and Psychosocial Issues Among Older Adults Living with HIV in North America

It is estimated that by the year 2015, at least half of those living with HIV disease in the United States will be 50?years of age or older. Older adults with HIV disease are living longer than ever before and are living healthier and more normal lives. They continue to be involved in intimate and sexual relationships. This paper provides an overview of some epidemiological trends among older adults living with and at risk for HIV in North America and discusses the current and emerging needs and behaviours related to their sexual health. Included are issues of sexual orientation, sexual behaviour, sexual dysfunction, and sexual risk. In addition, a number of the important psychosocial needs of older adults who are living with HIV are discussed, along with recommendations for future practice, policy, and research. Given that increasingly more people living with HIV are aging, the issues of aging and HIV disease can no longer be seen as unrelated. Gerontological providers, researchers, and policy makers must begin to address the needs of this increasingly common, yet vulnerable population of older people.     

Disclosure of HIV Status and Adherence to Daily Drug Regimens Among HIV-infected Children in Uganda

Pediatric adherence to daily drug regimens has not been widely assessed in Africa where majority of HIV infected children live. Using in-depth interviews of 42 HIV-infected children taking ART and/or cotrimoxazole prophylaxis, and 42 primary caregivers, at a comprehensive HIV/AIDS clinic in Uganda, we evaluated their adherence experiences for purposes of program improvement. Daily drug regimens provided by the pediatric clinic included cotrimoxazole prophylaxis as well as ART and cotrimoxazole combined. Complete disclosure of HIV status by caregivers to children and strong parental relationships were related to good adherence. Structural factors including poverty and stigma were barriers to adherence even for children who had had complete disclosure and a supportive relationship with a parent. To ensure adherence to life-extending medications, our findings underscore the need for providers to support caregivers to disclose, provide on-going support and maintain open communication with HIV-infected children taking cotrimoxazole prophylaxis and ART.     

Loneliness in Older Adults Living with HIV

We conducted a cross-sectional study among HIV-positive adults age ≥ 50 in San Francisco to evaluate the frequency of loneliness, characteristics of those who reported loneliness, and the association of loneliness with functional impairment and health-related quality of life (HRQoL). Participants (N = 356) were predominately male (85%); 57% were white; median age was 56. 58% reported any loneliness symptoms with 24% reporting mild, 22% moderate and 12% severe loneliness. Lonely participants were more likely to report depression, alcohol and tobacco use, and have fewer relationships. In unadjusted models, loneliness was associated with functional impairment and poor HRQoL. In adjusted models, low income and depression remained associated with poor HRQoL, while low income, higher VACS index and depression were associated with functional impairment. A comprehensive care approach, incorporating mental health and psychosocial assessments with more traditional clinical assessments, will be needed to improve health outcomes for the aging HIV-positive population.     

Stigmatizing Attitudes Toward People Living with HIV Among Adults and Adolescents in the United States

Stigmatizing attitudes toward people living with HIV (PLWH) cause psychological distress for PLWH and hinder HIV prevention efforts. We estimated the prevalence of stigmatizing attitudes among 6809 adults and 885 adolescents who responded to online surveys in 2015. Fear of casual contact with PLWH was reported by 17.5% [95% confidence interval (CI) 16.3–18.6%] of adults and 31.6% (CI 27.8–35.4%) of adolescents. Among adults, 12.5% (CI 11.6–13.5%) endorsed a measure of moral judgment toward PLWH. Stigmatizing attitudes toward PLWH persist in the United States. Continued monitoring of these attitudes and efforts to reduce associated stigma are warranted.     

Grit and Ambition are Associated with Better Neurocognitive and Everyday Functioning Among Adults Living with HIV

Grit and ambition are psychological factors that may protect neurocognitive function among persons living with HIV (PLWH). We examined associations between grit, ambition, premorbid verbal intellectual function, and current neurocognitive and everyday functioning among PLWH and persons without HIV (HIV?). 120 PLWH and 94 HIV? adults completed the Grit Scale (includes total score and consistency of interests and perseverance of effort subscales), ambition scale, and a comprehensive neurobehavioral battery. PLWH had lower grit scores than HIV? adults. The two groups did not differ on ambition. No relationship was observed between grit and cognition among HIV? adults. Among PLWH, however, higher perseverance of effort and more ambition was related to better global neurocognitive functioning, and higher grit, but not ambition, was related to independence in daily functioning. Longitudinal studies are needed to elucidate these relationships over time and examine whether grit or ambition have protective effects on cognitive outcomes among PLWH.     

Strategies for Coping in a Complex World: Adherence Behavior Among Older Adults with Chronic Illness

Background Increasing numbers of medicines increase nonadherence. Little is known about how older adults manage multiple medicines for multiple illnesses. Objectives To explore how older adults with multiple illnesses make choices about medicines. Design Semistructured interviews with older adults taking several medications. Accounts of respondents’ medicine-taking behavior were collected. Participants Twenty community-dwelling seniors with health insurance, in Eastern Massachusetts, aged 67–90, (4–12 medicines, 3–9 comorbidities). Approach Qualitative analysis using constant comparison to explain real choices made about medicines in the past (“historical”) and hypothetical (“future”) choices. Results Respondents reported both past (“historical”) choices and hypothetical (“future”) choices between medicines. Although people discussed effectiveness and future risk of the disease when prompted to prioritize their medicines (future choices), key factors leading to nonadherence (historical choices) were costs and side effects. Specific choices were generally dominated by 1 factor, and respondents rarely reported making explicit trade-offs between different factors. Factors affecting 1 choice were not necessarily the same as those affecting another choice in the same person. There was no evidence of “adherent” personalities. Conclusion Prescribing a new medicine, a change in provider or copayment can provoke new choices about both new and existing medications in older adults with multiple morbidities. This paper was presented as: (1) Towards an understanding of non-adherence in the elderly with multiple illnesses, at the RW Johnson Seminar Series, School of Medicine, University of Michigan, Ann Arbor, MI, USA, May 2005; (2) Barriers to medicines taking in vulnerable populations, at the Second Annual Symposium of the HMS Fellowship in Pharmaceutical Policy Research, Harvard Medical School, Boston, MA, USA, June 2005; (3) Barriers to medicines taking in vulnerable populations, at the Harkness Fellows in Health Policy Reporting Seminar, Boston, MA, USA, June 2005; (4) Elliott RA, Ross-Degnan D, Adams AS, Safran DG, Soumerai SB. Towards an understanding of medication non-adherence in the elderly with multiple illnesses. Society of Medical Decision Making, Birmingham June 2006. [oral]     

Antiretroviral Adherence Among Rural Compared to Urban Veterans with HIV Infection in the United States

Rural-dwelling persons with HIV infection face barriers to maintaining high levels of antiretroviral adherence. We compared adherence among 1,782 rural and 18,519 urban veterans initiating antiretroviral therapy in the Veterans Affairs (VA) healthcare system in the United States between 1998 and 2007. Residence was determined using rural urban commuting area codes and adherence using pharmacy-based refill measures. The median proportion of days covered (PDC) by combination antiretroviral therapy in the first year of treatment ranged from 0.72 among urban residents to 0.79 among rural-small town/remote residents (p < 0.0001). In multivariable logistic regression, predictors of high adherence (PDC greater than 0.90) were residence in a rural-small town/remote setting (odds ratio 1.24, 95 % CI 1.09–1.56, relative to urban), increasing age, white race, absence of an alcohol or substance use disorder, and absence of hepatitis C infection. Results may differ outside VA healthcare, where there may be fewer resources to support adherence among rural-dwelling persons with HIV.     

Post-traumatic Stress Disorder Symptoms Among People Living with HIV/AIDS in Rural China

Among people living with HIV/AIDS (PLHA), the occurrence of post-traumatic stress disorder (PTSD) symptoms associated with HIV diagnosis is a common problem. This study examined HIV diagnosis-related PTSD symptoms and its associated factors among PLHA in rural China. We used baseline data from a randomized controlled trial conducted in Anhui Province, China. Surveys of 522 PLHA were conducted via computer-assisted personal interview method. PTSD symptoms were measured based on re-experiencing, avoidance and arousal of the day of HIV diagnosis. Association between PTSD symptoms and demographic characteristics, physical and social functioning were assessed by multiple regression analysis and structural equation modeling. Social functioning exhibited a direct association with HIV diagnosis-related PTSD symptoms, and also mediated the association between PTSD symptoms and age, family income, and physical functioning. The study findings underscore the importance of developing interventions that alleviate PTSD symptoms and improve social functioning among PLHA in rural China.