Supporting adherence to highly active antiretroviral therapy and protected sex among people living with HIV/AIDS: the role of patient-provider communication in Rio de Janeiro, Brazil

This exploratory study examined patient-provider communication dynamics regarding adherence to highly active antiretroviral therapy (HAART) and protective sexual behavior among people living with HIV/AIDS (PLWHA). We conducted 20 direct observations of routine consultations between PLWHA and care providers in two large public health clinics providing free HIV medications and clinical care to PLWHA in the greater Rio de Janeiro area of Brazil. Immediately after these observations, 20 semistructured in-depth interviews were conducted with observation participants regarding their communication with providers, overall clinic experience, and questions and concerns about adherence to HAART and safe sex. Findings from observations showed that patient-provider communication focused almost exclusively on biomedical aspects of HIV-related treatment such as symptom management. In most observations, adherence to HAART was addressed. However, questions posed by providers regarding adherence were generally close-ended and leading, discouraging an open exchange regarding potential difficulties related to adherence. HIV/sexually transmitted infection (STI)- related protective behaviors were seldom addressed except when the patient displayed STI symptoms or was thought to be pregnant. In qualitative interviews, patients generally reported satisfaction with their providers, but also reported a variety of concerns and challenges related to adherence to HAART and protective sexual behavior that were not expressed in patient-provider interactions. We conclude that one way in which adherence to HAART and protective sexual behavior among PLWHA could be facilitated is by improving patient- provider communication on these topics, including increasing the frequency of openended, nonjudgmental dialogue initiated by care providers.     

The Relationship Between Type and Quality of Social Support and HIV Medication Adherence

Abstract

In the last 10 years HIV has become a disease that can be effectively managed using antiretroviral medications. However, many factors affect adherence, including demographics, income, housing, mental health issues, and access to health care, as well as types and quality of social support. This paper summarizes results regarding specific sources of social support that are part of a larger, randomized study of medication adherence among people with HIV/AIDS. Results summarize findings from 98 program participants and include information regarding support from partners, family and health care providers, as well as the impact of support from these sources on medication adherence. Among participants in this study, those with higher levels of social support from partners demonstrated higher rates of medication adherence. Those who received more social support from their families, however, reported significantly lower adherence rates. These results suggest that efforts to improve medication adherence need to address the diverse types of social support networks of people diagnosed with HIV/AIDS.     

Perspectives of middle-aged African-American women in the Deep South on antiretroviral therapy adherence

Despite evidence of stabilization in some areas of the USA, HIV infection in black women is not declining in the Deep South. Using a phenomenological approach to qualitative inquiry, we investigated women's experiences influencing their adherence to highly active antiretroviral therapy (HAART) in an urban setting. Inclusion criteria specified black women who had been aware of their HIV status for at least two years and were engaged in HIV outpatient care. Twelve single face-to-face confidential in-depth semi-structured interviews were conducted from a sample of predominantly middle-aged women retained in care at an HIV clinic in Atlanta, Georgia. Data were analyzed by two independent reviewers and three themes emerged from the group of women's accounts of their experiences. First, sentinel events led to changes in perspective and motivated women to adhere to HAART. Second, recognition that one had the personal strength necessary to cope with HIV fostered adherence. Finally, relationships with healthcare providers especially trust issues surrounding this relationship, impacted adherence both positively and negatively. These findings suggest that HAART adherence is a complex issue among middle-aged urban black women with HIV in the Deep South. Providers caring for this patient population should recognize that sentinel events, personal strength, and positive healthcare relationships are opportunities to improve adherence.     

Medication adherence practices of HIV/AIDS case managers: a statewide survey in North Carolina

The primary objective of this study was to examine the adherence-related practices and attitudes of HIV/AIDS case managers in North Carolina. All North Carolina HIV/AIDS case managers (n = 111) employed by agencies that were state certified to provide HIV case management were sent an adherence counseling survey. Negative binomial regression was used to examine the relationship of case managers' characteristics and attitudes with their medication adherence counseling practices. Of the 94 HIV/AIDS case managers who responded to the survey, the majority (65%) reported discussing medications with almost every client. The adherence-related behaviors that case managers most frequently provided were related to monitoring medication usage rather than providing medication instruction. Most case managers believed that medication adherence counseling is part of their role (77%); however, a substantial minority, (36%) did not believe that their adherence counseling skills were adequate. Multivariate analysis revealed that case managers who provided more adherence counseling services reported greater confidence in their adherence counseling skills, believed that adherence counseling is a HIV/AIDS case management role, and had a higher proportion of substance-abusing clients in their caseload. The adherence counseling activities of HIV/AIDS case managers can potentially supplement the counseling provided by other health professionals and promote greater adherence to medications. However, variability in perceived skills and adherence-related activities suggests that the role of case managers in medication adherence counseling needs to be better defined and appropriate training provided to meet the expectations of this role.     

HIV/AIDS patients’ perspectives on adhering to regimens containing protease inhibitors

OBJECTIVE: To gather qualitative data regarding HIV/AIDS patients’ perspectives about HIV-1 protease inhibitors (PIs), and about their experiences taking and adhering to regimens containing PIs. DESIGN: Six focus groups of persons under care for HIV were conducted between September and November 1996 regarding participants’ knowledge, awareness, experiences when taking, and adherence to antiretroviral regimens containing PIs. An identical discussion guide was used to facilitate all six groups. Focus group proceedings were audiotaped, transcribed, coded for themes, and analyzed qualitatively. SETTING: HIV/AIDS practices of three teaching hospitals and two community health centers. PATIENTS/PARTICIPANTS: Fifty-six patients with HIV disease: 28 men and 28 women. MEASUREMENTS AND MAIN RESULTS: Knowledge and positive impressions of PIs were prevalent among this diverse group of persons with HIV, and did not differ by race/ethnicity or gender. Most knew that these were new, potent medications for treating HIV/AIDS. Networks of persons with HIV and medical providers were the most important information sources. Those taking PIs were aware that adherence to the regimen is important, and most were using special strategies to maximize their own adherence, but expressed considerable frustration about the central role these medication regimens had assumed in their life. A subset who did not believe they would adhere to these regimens had declined treatment with them. Motivating factors for taking and adhering to these complex regimens were improving CD4 counts and viral loads and the patient-provider relationship. CONCLUSIONS: Among those with HIV/AIDS, awareness of PIs and their effectiveness is substantial, owing to the impact of informal networks and medical providers. This early positive “reputation” of PIs may enhance motivation for adherence. Those who are taking PIs invest substantial effort adhering to these complex regimens, but resent the need to make medications the focus of their lives. Preliminary findings of this study were presented at the Society of General Internal Medicine annual meeting on May 3, 1997, and the National Conference on Women and HIV on May 6, 1997. This research was supported by a Generalist Physician Faculty Scholar Award from the Robert Wood Johnson Foundation and a grant from Merck and Co., Inc.     

An examination of HIV/AIDS patients who have excellent adherence to HAART

This paper examines the attitudes and beliefs of HIV/AIDS patients with excellent adherence to highly active antiretroviral therapy (HAART) and how they differ from those with suboptimal adherence. Forty-four persons with HIV/AIDS, 28 men and 16 women, participated in a qualitative semi-structured interview which was based on the Health Belief Model. The main outcomes were themes consistent with several dimensions of this model, reflecting differences in the health-related attitudes and beliefs of the excellent adherers compared to the suboptimal adherers. Patients with excellent adherence voiced the following themes when compared to less adherent patients: (1) believed adherence rates needed to be 90-100% for medication efficacy; (2) trusted their primary providers greatly; (3) took medications even when actively using substances of abuse; (4) were open about their HIV status and received substantial social support; (5) cited staying healthy as their key motivator; (6) were not actively depressed; all had normal CESD scores. Our study suggests that patients with excellent adherence to HAART differ from their less adherent counterparts in terms of key health-related attitudes and beliefs. Identifying and studying excellent adherers provides new insights and strategies for enhancing adherence to HAART.     

HAART adherence in culturally diverse patients with HIV/AIDS: a study of male patients from a Veteran's Administration Hospital in northern California

The objective of this study was to identify the factors that influence adherence to antiretroviral medication regimens in culturally diverse populations with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) related to age, ethnicity, and intravenous drug use. The critical incident technique was used to identify factors determining adherence. Through a series of brief, focused interviews, patients were asked to recall specific incidents that affected their adherence to HIV medications. Patients' responses were grouped into categories using Ethnograph software. Two nurse experts, with 94% agreement, determined the reliability of the category listings. A chi(2) analysis compared the proportion of patients reporting each factor across age, ethnicity, and intravenous drug use categories. The total sample of 52 participants included 46 male outpatients with HIV/AIDS receiving care through a Veteran's Administration Hospital in northern California and 6 health care providers. The interviews yielded a total of 294 incidents. Six major categories were identified, and a taxonomy of critical factors determining highly active antiretroviral therapies (HAART) adherence was developed. The categories included reminders and cues (30%), planning (18%), response to HIV/AIDS (17%), HIV medication characteristics (14%), interactions with others (12%), and patient characteristics (10%). The two largest categories representing patient-related factors accounted for nearly half of the incidents. Patients most influenced by positive support from others included non-Caucasians, those under the age of 50 years, and those with fewer years of education. The taxonomy of adherence behaviors provides important information for developing culturally relevant patient adherence education programs and an essential foundation for developing future studies.     

Improving HIV/AIDS care through treatment advocacy: going beyond client education to empowerment by facilitating client-provider relationships

Treatment advocacy (TA) programs have been implemented by AIDS service organizations (ASOs) and primary care clinics across the USA to help engage clients with HIV into care and support their adherence to antiretroviral therapy (ART). TA aims to empower people with HIV through education and client-centered counseling regarding HIV, ART, and other health issues; advocate on behalf of patients with providers; and make referrals to healthcare services and clinical trials. However, relatively little is known about the impact TA has on clients' healthcare experiences. The present study's objectives included exploring how TA services help clients engage in HIV care, initiate ART, and adhere to HIV medications. We conducted 25 semi-structured qualitative open-ended interviews with clients living with HIV/AIDS recruited from AIDS Project Los Angeles (APLA); four HIV medical providers; and two TA staff at APLA. Of the 25 clients interviewed, 92% were male and 8% were female. The average age was 43 years (SD=9). About 60% were African-American, 20% were White, 12% were other or multiracial, 4% were Latino, and 4% were Asian/Pacific Islander. Five interconnected themes consistently emerged across clients, TAs, and providers. TAs helped clients understand treatments and supported adherence within a holistic context. Further, TAs acted as a bridge to providers and helped clients build self-advocacy skills. Our data show that TA services go beyond traditional areas of education and treatment adherence. TA services within an ASO also provide a safe place to discuss initial HIV diagnoses and other health issues in a more comprehensive manner. TA services complemented medical and other social services by preparing clients with HIV to be better consumers of healthcare services. Future quantitative research examining the effectiveness of TA on improving clients' engagement in care and adherence is a critical next step.     

Self-reported adherence to antiretroviral therapy in HIV+ population from Bata,Equatorial Guinea

The human immunodeficiency virus (HIV) and the acquired immune deficiency syndrome (AIDS) represent a serious public health problem in Equatorial Guinea, with a prevalence of 6.2% among adults. the high-activity antiretroviral treatment (HAART) coverage data is 10 points below the overall estimate for Sub-Saharan Africa, and only 61% patients continue with HAART 12 months after it started. This study aims to assess HAART adherence and related factors in Litoral Province of Equatorial Guinea. In this cross-sectional study, socio-demographic and clinical data were collected at Regional Hospital of Bata, during June–July 2014. Adherence to treatment was assessed by using the Spanish version of CEAT-VIH. Bivariate and linear regression analyses were employed to assess HAART adherence-related factors. We interviewed 50 men (35.5%) and 91 women (64.5%), with a mean age of 47.7?±?8.9 and 36.2?±?11.2, respectively (p?p?=?.005). There was a positive correlation between CEAT-VIH score and current CD4 T-cells count (p?=?.013). The Cronbach's α value was 0.52. To our knowledge, this is the first study to assess HAART adherence in Equatorial Guinea. Internal reliability for CEAT-VIH was low, nonetheless the positive correlation between the CEAT-VIH score and the immunological status of patients add value to our findings. Our results serve as baseline for future research and will also assist stakeholders in planning and undertaking contextual and evidence-based policy initiatives.     

Smoking Among HIV Positive New Yorkers: Prevalence,Frequency, and Opportunities for Cessation

Tobacco use presents unique health risks for persons living with HIV/AIDS (PLWHA). There is an urgent need to characterize tobacco use among PLWHA, and to assess the capacity of HIV/AIDS service providers to deliver smoking cessation interventions. Questionnaires were administered to PLWHA in care in New York State (n = 1,094) and to State-funded HIV/AIDS service providers (n = 173) from 2005 to 2007. Current PLWHA smoking prevalence was 59%, three times the general population rate. Over 50% of current smokers were moderately or highly dependent on nicotine. Three-quarters of smokers indicated an interest in quitting, and 64% reported a least one quit attempt during the past year. Less than half of HIV/AIDS service providers reported always assessing tobacco use status, history, dependence, or interest in quitting at intake. Medical care providers were more likely to conduct assessments and provide services. Although 94% of providers indicated a willingness to incorporate tobacco cessation services, 65% perceived client resistance as a barrier to services. HIV/AIDS service providers are inadequately addressing the high smoking rate among PLWHA, despite being uniquely suited to do so. Efforts are needed to educate providers about the need for, and interest in, tobacco cessation.     

Strategies for optimizing adherence to highly active antiretroviral therapy: lessons from research and clinical practice.

Successful treatment of human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) with highly active antiretroviral therapy (HAART) requires that patients maintain nearly perfect adherence to the prescribed regimen. Suboptimal adherence to antiretroviral therapy is clearly the most common cause of virologic failure of HAART regimens. Given the critical role of adherence in successful antiretroviral therapy, it is essential that providers of care for patients with HIV infection have a strategy that proactively assists and supports their patients' efforts to adhere to medication regimens. This review endeavors to provide a clinically focused approach to optimizing adherence of patients to HAART.     

Role of the HIV/AIDS case manager: analysis of a case management adherence training and coordination program in North Carolina

Highly active antiretroviral therapy (HAART) adherence rates of 90%-95% or more are required to be effective at treating the virus and preventing drug resistance. From both a medical and public health perspective, it is essential that HIV-positive clients strictly adhere to antiretroviral treatment regimens. One promising approach to promoting optimal adherence rates among HIV-positive individuals is training and reimbursing case managers to provide adherence coordination services to HIV-positive clients. In this study, a sample of 16 HIV/ AIDS case managers from agencies across North Carolina participated in a Case Management Adherence Training and Coordination Program for a 3-month period. After case manager training, case managers enrolled 1-4 of their existing clients, who met eligibility criteria, to receive the adherence coordination program. Data were analyzed from focus group interviews and individual interviews conducted with case manager participants; their respective client care plans were also analyzed to identify primary barriers and strategies reported by case managers. Although case managers perceived themselves to be well positioned to provide adherence coordination services for their HIV-positive clients, they also identified barriers that they face in providing these services, including lack of reimbursement for their time, inadequate training, and insufficient knowledge of HIV/AIDS and medications. The findings of this study suggest that, with appropriate training and reimbursement, HIV/AIDS case managers can play a pivotal role in promoting and improving client adherence to antiretroviral medications.     

Psychosocial Predictors of Adherence to Highly Active Antiretroviral Therapy

Abstract

This article reviews studies of psychosocial predictors of Highly Active Antiretroviral Therapy (HAART) among HIV positive clients. Unstable housing and lack of HIV-specific social support predicted low HAART adherence in the studies where they were tested. The most consistent predictor of adherence problems across all populations and measures was active substance use, particularly cocaine use. Younger age and less than high school education were not consistently predictive. Depression predicted adherence problems measured by self-report but not by electronic monitoring. Supplementing the adherence support efforts by physicians, nurses, and pharmacists, clinicians in a range of disciplines and settings can assess and intervene on psychosocial risk factors and thereby reduce adherence problems regardless of their level of knowledge about HIV medications.     

Social and structural determinants of HIV treatment and care among black women living with HIV infection: a systematic review: 2005–2016

Black/African American (black) women comprised 59% of women living with HIV at the end of 2014 and 61% of HIV diagnoses among women in 2015. Black women living with HIV infection (BWLH) have poorer health outcomes compared with women of other races/ethnicities; social and structural determinants are often cited as barriers and facilitators of care. The objective of this qualitative review was to identify social and structural barriers and facilitators of HIV treatment and care among BWLH. The systematic review was conducted in six-stages using databases such as PubMed, PsycINFO, and Google Scholar: 1) searched for studies that enrolled BWLH published between January 2005 and December 2016, 2) excluded unpublished reports and commentaries, 3) limited the search to our primary keywords, 4) limited our search to studies that included participants living with HIV infection that were >60% black and 100% female, 5) extracted and summarized the data, and 6) conducted a contextual review to identify common themes. Of 534 studies retrieved, 16 were included in the final review. Studies focused on: ART medication adherence (n?=?5), engagement/retention in care (n?=?4), HIV care and treatment services (n?=?3), viral suppression (n?=?1), and addressing multiple HIV care outcomes (n?=?3). Main barrier themes included lack of family and/or social support, poor quality HIV services, and HIV-related stigma, particularly from healthcare providers; facilitator themes included resilience, positive relationships between case management and support services, high racial consciousness, and addressing mental health. Interventions that decrease these noted barriers and strengthen facilitators may help improve care outcomes for BWLH. Also, more HIV stigma-reduction training for healthcare providers may be warranted.