Reproductive health counseling delivered to women living with HIV in the United States

Advances in antiretroviral therapy (ART) and reproductive technologies have made transmission of HIV to partners and infants almost completely preventable. Comprehensive reproductive health counseling (CRHC) is an important component of care for women living with HIV, but few women report discussing reproductive health with an HIV care provider. We surveyed a probability sample of U.S. HIV care providers during 2013–2014. Of 2023 eligible providers, 1234 responded (64% adjusted provider response rate). We estimated the percentage delivering CRHC to their female patients. CRHC was defined as delivering each of five components of reproductive health care to most or all female patients. We assessed associations between provider characteristics and delivering CRHC using chi-squared tests and multivariable logistic regression. Of all providers, 49% (95% confidence interval [CI], 42–55) reported delivering all components of CRHC: 71% assessed reproductive intentions of reproductive-aged women, 78% explained perinatal transmission risk, 87% discussed ART for preventing perinatal transmission, 76% provided contraception as appropriate, and 64% provided referrals for preconception care. Among providers who offered primary care (83% of sample), 52% (CI: 44–60) delivered CRHC compared to 33% (CI: 22–44) of providers who did not offer primary care (P?=?.01). More female providers (46% of sample) compared to male providers delivered CRHC (57% [CI: 48–65] vs. 40% [CI: 31–50], P?相似文献   

Helping clients with HIV disease navigate managed care

The transition of medical care from fee-for-service to managed care is having an impact on health and mental health practitioners who provide care to people with HIV and AIDS. Evidence suggests that the quality of managed care is not adequate for older patients and patients with chronic diseases. Satisfaction with a managed care plan is often linked to perception of the plan's convenience, the relationship with one's primary health care provider, and the limits on out-of-pocket expenses. Dissatisfaction is linked to inefficient service, limits on choice of provider, and substandard care. The experiences of mental health care providers and recipients in the managed care system are discussed. Advocates note enhanced communication among health care providers and opponents voice concerns about regulation. The greatest concern is that treatment decisions will be based on factors other than the client's needs and best interests. Managed care has the potential to constrain psychotherapeutic treatment, however, understanding managed care plans can result in creative treatment approaches and strategies.     

Assessing self-management information needs of persons living with HIV/AIDS

In order to maximize their health status, persons living with HIV/AIDS must use a variety of self-management strategies. They learn these strategies from many sources often based on a specific need or problem. Information needs can be addressed during health care appointments but time is often limited and spent on more acute issues such as symptom control or medication adherence. In order to assess information needs, a 76-item HIV+ Information for Self-Care Quiz was developed and piloted with two samples. Both samples (n = 50, 43) were predominantly people of color and male with a mean age of either 44 or 56 years, respectively. This paper describes the phases of development and offers suggestions for its use in clinical settings, research, and provider education. By using this quiz to determine preexisting knowledge level, interactions with the health care provider can be more focused to address knowledge gaps and less time could be spent teaching information that the client already knows.     

Healthcare providers’ understanding of HIV serodiscordance in South Africa and Uganda: implications for HIV prevention in sub-Saharan Africa

HIV transmission within stable heterosexual HIV serodiscordant couples accounts for almost half the new incident infections in South Africa and Uganda. Advances in HIV prevention provide opportunities to reduce transmission risk within serodiscordant partnerships (e.g., antiretroviral treatment (ART), pre-exposure prophylaxis (PrEP), medical male circumcision, and couples-based HIV counselling and testing). These interventions require a clinical encounter with a provider who recognises prevention opportunities within these partnerships. We explored healthcare provider understanding of HIV serodiscordance in a reproductive counselling study with providers in eThekwini district, South Africa, and Mbarara district, Uganda. In eThekwini, in-depth interviews (29) and focus group discussions (2) were conducted with 42 providers (counsellors, nurses and doctors) from public sector clinics. In Mbarara, in-depth interviews were conducted with 38 providers (medical officers, clinical officers, nurses, peer counsellors and village health workers). Thematic analysis was conducted using NVivo software. In eThekwini, many providers assumed HIV seroconcordance among client partners and had difficulty articulating how serodiscordance occurs. Mbarara providers had a better understanding of HIV serodiscordance. In the two countries, providers who understood HIV serodiscordance were better able to describe useful HIV-prevention strategies. Healthcare providers require training and support to better understand the prevalence and mechanisms of HIV serodiscordance to implement HIV-prevention strategies for HIV serodiscordant couples.     

Healthcare provider characteristics and perceived confidence from HIV/AIDS education

This study reports findings from six training projects designed to keep health providers up-to-date on emerging developments and approaches in HIV/AIDS care. Participants were 3,779 individuals who described themselves, their professional background, and their specific experience in the HIV/AIDS field. These characteristics were compared with their self-reported confidence in managing clients, counseling clients, providing services, and the training topics. A repeated-measures design examining level and change of confidence showed little support for links between provider characteristics and confidence due to HIV/AIDS training experience. Thus, knowing a provider's background does not necessarily provide diagnostic information about who might most benefit in improved confidence from HIV/AIDS educational training. These results suggest that HIV/AIDS training programs may be targeted broadly-to a wide range of healthcare providers of diverse backgrounds-with little or no impact on overall levels and changes in provider confidence.     

Client and provider perspectives of the efficiency and quality of care in the context of rapid scale-up of antiretroviral therapy

Global scale-up of antiretroviral therapy (ART) has focused on clinical outcomes with little attention on its impact on existing health systems. In June-August 2008, we conducted a formative evaluation on ART scale-up and clinic operations at three clinics in Uganda to generate lessons for informing policy and larger public health care systems. Site visits and semistructured interviews with 10 ART clients and 6 providers at each clinic were used to examine efficiency of clinic operations (patient flow, staff allocation to appropriate duties, scheduling of clinic visits, record management) and quality of care (attending to both client and provider needs, and providing support for treatment adherence and retention). Clients reported long waiting times but otherwise general satisfaction with the quality of care. Providers reported good patient adherence and retention, and support mechanisms for clients. Like clients, providers mentioned long waiting times and high workload as major challenges to clinic expansion. Providers called for more human resources and stress-release mechanisms to prevent staff burnout. Both providers and clients perceive these clinics to be delivering good quality care, despite the recognition of congested clinics and long waiting times. These findings highlight the need to address clinic efficiency as well as support for providers in the context of rapid scale-up.     

Positive provider interactions, adherence self-efficacy, and adherence to antiretroviral medications among HIV-infected adults: A mediation model

Adherence to antiretroviral (ARV) therapy for HIV infection is critical for maximum benefit from treatment and for the prevention of HIV-related complications. There is evidence that many factors determine medication adherence, including adherence self-efficacy (confidence in one's ability to adhere) and relations with health care providers. However, there are no studies that examine how these two factors relate to each other and their subsequent influence on HIV medication adherence. The goal of the current analysis was to explore a model of medication adherence in which the relationship between positive provider interactions and adherence is mediated by adherence self-efficacy. Computerized self-administered and interviewer-administered self reported measures of medication adherence, demographic and treatment variables, provider interactions, and adherence self-efficacy were administered to 2765 HIV-infected adults on ARV. Criteria for mediation were met, supporting a model in which adherence self-efficacy is the mechanism for the relationship between positive provider interactions and adherence. The finding was consistent when the sample was stratified by gender, race, injection drug use history, and whether the participant reported receipt of HIV specialty care. Positive provider interactions may foster greater adherence self-efficacy, which is associated with better adherence to medications. Results suggest implications for improving provider interactions in clinical care, and future directions for clarifying interrelationships among provider interactions, adherence self-efficacy, and medication adherence are supported.     

HIV provider perspectives: the impact of stigma on substance abusers living with HIV in a rural area of the United States

Recent literature has documented growing concerns related to access to HIV care services for rural individuals living with both HIV and a dual diagnosis of substance abuse. Previous research has investigated issues from a client perspective, but limited research has investigated provider perspectives of rural issues surrounding HIV and substance abuse. The purpose of this qualitative study was to examine issues that impact the ability of care providers to create sustainable linkages to care for dual diagnosed individuals who live in rural areas. In-depth interviews were conducted in late 2005 with 39 HIV service providers at 11 agencies that provided HIV-related services to individuals in rural areas of a Midwestern state in the United States. Findings suggest multidimensional stigma in the medical referral network as the leading factor that presents challenges to service providers in rural areas. The service providers reported verbal stigma in the form of insults, a loss of role/respect, and a global loss of resources such as poorer quality health care or no health care provided. The stigma is conceptualized in four themes: (1) staff of medical referral sources stigmatizing against rural dual-diagnosis clients, (2) physicians stigmatizing against rural dual-diagnosis clients, (3) medical specialists stigmatizing against rural dual-diagnosis clients, and (4) client-perceived stigma. These themes were expressed equally among all of the providers, regardless of geographic location, type of HIV-related organization, or job title.     

Effects of mental health centre staff turnover on HIV/AIDS service delivery integration

This study examined the effects of mental health service provider turnover rates on system integration. System integration was defined as appropriate referrals and the freeflow exchange of information among three components: mental health care, primary health care, and dedicated HIV care coordination services. From a sample of 17 mental health centres across a midwestern state, higher staff turnover rates did not negatively impact integration, with the exception of within-centre services. Mental health service providers are aware of who other network providers are, but integration breaks down at a level of implementation in terms of contacts, exchange of information and referrals. Integrative efforts focused on care coordination with little to no evidence of bidirectionality.     

Comprehensive care: the healthcare provider's perspective

A paradigm shift, or change in worldview, is currently occurring in which clients are being comprehensively viewed within the environmental context. This shift addresses both mind and body in client care and views healthcare providers as part of the environment. Wound care specialists can refine and extend their practice by: a) using concepts from comprehensive care and holistic nursing, b) focusing on the outcome and process of delivering care, and c) caring for themselves in a comprehensive manner. This article describes the author's development as a comprehensive and holistic healthcare provider and the impact of comprehensive care on her practice.     

Health needs of HIV-infected women in the United States: insights from the women living positive survey

The objective of this study was to describe attitudes, opinions, and perceived health needs of HIV-infected women in the United States. In this cross-sectional study, women were invited to participate in the Women Living Positive survey, a structured interview instrument with 45 questions. Collected data were deidentified and the margin of error was calculated as four percentage points. Incoming toll-free phone interviews were conducted from December 21, 2006, through March 14, 2007 among subjects recruited from a U.S. national network of AIDS counseling centers. Seven hundred HIV-infected women (43% African American, 28.5% Hispanic, 28.5% Caucasian; median age, 42.5 years) receiving combination antiretroviral therapy for 3 years or more replied to recruitment flyers. Overall, 55% of survey participants had never discussed gender-specific HIV treatment issues with their HIV care providers. Of the 45% who did discuss these issues, almost all (96%) were satisfied. On average, one-third of the women had seen three or more providers since beginning HIV treatment; 43% indicated they had switched providers because of communication issues. Among women who had been or were pregnant at the time of the survey (n=159), more than half (57%) had not had pre-pregnancy discussions with their HIV provider about the most appropriate HIV regimens for women attempting to become pregnant. Significant communication gaps exist between HIV-infected women and their providers when discussing gender-specific treatment issues. These data highlight a need for U.S. health care providers to incorporate discussion of gender-specific issues, including preconception and reproductive counseling, into management strategies for HIV-infected women.     

The experience of having a positive HIV antibody test

Little is known about the logistics of taking an HIV antibody test and yet knowledge of people's experiences of having a test result is helpful to evolving a sensitive and client oriented service and can provide some guidelines for organisation issues around testing. This paper reports the experiences of 252 gay men who had an HIV test which proved to be positive. The most frequent reasons for people to take a test were perception of personal risk or were related to perceived health problems. Ten per cent of people did not know they had had a test until they were told they were anti HIV positive--lack of knowledge was related mostly to the place where the test was done. Over one third of people said they knew little about the test or its implications before they contacted anyone, over half said they did not receive information at the time of the test and 41% when they were given the result. There were few changes over time in the experience of having a test.     

Missed opportunities for HIV testing in health care settings among young African American men who have sex with men: implications for the HIV epidemic

Limited health care access and missed opportunities for HIV and other sexually transmitted infection (STI) education and testing in health care settings may contribute to risk of HIV infection. In 2008, we conducted a case-control study of African American men who have sex with men (MSM) in a southeastern city (Jackson, Mississippi) with an increase in numbers of newly reported HIV cases. Our aims were to evaluate associations between health care and HIV infection and to identify missed opportunities for HIV/STI testing. We queried 40 potential HIV-infected cases and 936 potential HIV-uninfected controls for participation in this study. Study enrollees included HIV-infected cases (n=30) and HIV-uninfected controls (n=95) who consented to participate and responded to a self-administered computerized survey about sexual risk behaviors and health care utilization. We used bivariate analysis and logistic regression to test for associations between potential risk factors and HIV infection. Cases were more likely than controls to lack health insurance (odds ratio [OR]=2.5; 95% confidence interval [CI]=1.1-5.7), lack a primary care provider (OR=6.3; CI=2.3-16.8), and to not have received advice about HIV or STI testing or prevention (OR=5.4; CI=1.3-21.5) or disclose their sexual identity (OR=7.0; CI=1.6-29.2) to a health care provider. In multivariate analysis, lacking a primary health care provider (adjusted odds ratio [AOR]=4.5; CI=1.4-14.7) and not disclosing sexual identity to a health care provider (AOR=8.6; CI=1.8-40.0) were independent risk factors for HIV infection among African American MSM. HIV prevention interventions for African American MSM should address access to primary health care providers for HIV/STI prevention and testing services and the need for increased discussions about sexual health, sexual identity, and sexual behaviors between providers and patients in an effort to reduce HIV incidence and HIV-related health disparities.     

Provider perceptions of stigma and discrimination experienced by adolescents and young adults with pHiV while accessing sexual and reproductive health care

Historically, children with perinatally-acquired HIV (PHIV) were viewed as the “innocent victims” as their HIV infection was not acquired through sexual/drug related means. Today, adolescents with PHIV are surviving into young adulthood and are engaging in developmentally expected behaviors such as establishing intimate, sexual relationships. Like other youth, those living with PHIV often need to access sexual and reproductive health (SRH) services. Previous research has documented stigma and discrimination experienced by adult women living with HIV as they try to access SRH care. However, little is known about the experiences of stigma and discrimination encountered by the maturing adolescents and young adults (AYA) with PHIV when accessing services. HIV health care providers (HHCPs) who frequently care for this population are in a unique position to learn about and understand the stigma and discrimination experienced by their patients in formal service settings. HHCPs (n?=?57, 28 medical and 29 social service providers) were recruited using snowball sampling, and completed an online survey based on patient-shared experiences of stigma and discrimination when accessing SRH-related health care and social services. Thirty-eight percent (22/57) of providers reported that their patients with PHIV had shared encounters of stigma or discrimination when accessing SRH services. Coded open-ended provider comments indicated that AYA patients experienced challenges with providers who were unfamiliar with PHIV and expressed surprise that someone with PHIV was still alive. Analyses also revealed prejudicial attitudes towards women with HIV. Patients reported being counseled to terminate their pregnancy and lectured about their “poor choices.” As AYA with PHIV transition out of pediatric and adolescent care, it is important for providers to simultaneously help them navigate care in other health settings, as well as educate adult health care providers about possible misconceptions of caring for individuals with PHIV.     

Patient and provider priorities for self-reported domains of HIV clinical care

We sought to understand how HIV-infected patients, their providers, and HIV care researchers prioritize self-reported domains of clinical care. Participants rank-ordered two lists of domains. A modified Delphi process was used for providers and researchers. Approximately 25% of patients were interviewed to discuss rationale for rank order choices. List 1 included anger, anxiety, depression, fatigue, physical function, pain, and sleep disturbance. List 2 included alcohol abuse, cognitive function, HIV stigma, HIV and treatment symptoms, medication adherence, positive affect, sexual risk behavior, sexual function, social roles, spirituality/meaning of life, and substance abuse. Seventy-four providers, 80 HIV care researchers, and 66 patients participated. Patients ranked context-based domains, such as HIV stigma, more highly than providers, while health behaviors, such as drug or alcohol use, ranked lower. Patients described a need to address wider-context challenges such as HIV stigma in order to positively impact health behaviors. Divergent patient and provider priorities highlight the importance of incorporating views from all stakeholders and suggests the need for a care approach that more effectively addresses contextual barriers to adverse health behaviors.     

Linkages to care for newly diagnosed individuals who test HIV positive in nonprimary care settings

Linkage services are an increasingly important component of the continuum of care for people living with HIV, particularly for individuals diagnosed in nonprimary care settings who are less likely than those identified in primary care settings to have a usual source of care. This study examines successful models used by hospital emergency departments, health department outpatient clinics, and other nonprimary care providers for testing, linking, and engaging newly diagnosed HIV-positive racial and ethnic minorities into medical care. Based on studies of five mature linkage-to-care (LTC) programs implemented in geographically and institutionally diverse settings, we identify five key characteristics that make them viable. Effective linkage programs are low cost, intensive, time limited, unique, and flexible. We also identify four core components of successful LTC protocols: directly employed linkage workers, active referral to medical care, person-centered linkage case management, and cultural and linguistic concordance. Finally, we develop a set of operational strategies to help providers address barriers at all levels of the health care system to help promote the effective linkage of newly diagnosed patients to care. We organize the strategies around four key areas: adherence to LTC protocols, selection of linkage workers, execution of linkage programs, and sustainability of linkage programs. The findings presented in this study provide a practical and operational guide for developing and implementing policies and procedures for linking newly diagnosed individuals who test HIV positive in nonprimary care settings into ongoing care for HIV infection.     

Health-related correlates of perceived discrimination in HIV care

Negative interactions with health care providers can have important implications for the health and health care of HIV-positive individuals. The purpose of this study was to examine perceptions of race-based and socioeconomic status (SES)-based discrimination during interactions with HIV treatment providers. We recruited 110 individuals (17% female, 51% white) living with HIV from an AIDS service organization in a midwestern city. Results indicated that the majority of participants had perceived discrimination in their interactions with providers when getting treatment for HIV. More specifically, 71% reported having experienced discrimination when receiving treatment for HIV based on their race or color, and 66% reported discrimination attributed to their socioeconomic status, position, or social class. However, participants indicated that they experienced discrimination infrequently. No significant racial/ethnic differences in reports of discrimination were observed. In addition, greater race-based and SES-based discrimination were each associated with greater levels of depression and posttraumatic stress symptoms, greater severity of AIDS-related symptoms, lower perceived general health, and less health care satisfaction. Greater SES-based discrimination was also related to lower adherence to antiretroviral medications. Our findings suggest that experiences with discrimination when getting treatment have important implications for the health and health care of HIV-positive individuals. It is important to note, however, that discrimination based on HIV status or sexual orientation was not assessed and may have affected the results. Studies that explore perceptions of discrimination based on other factors among HIV-positive individuals may improve understanding of the nature, extent, and consequences of discrimination in patient-provider interactions.     

Application of an ecological framework to examine barriers to the adoption of safer conception strategies by HIV-affected couples

Safer conception interventions can significantly reduce the risk of horizontal HIV transmission between HIV-serodiscordant partners. However, prior to implementing safer conception interventions, it is essential to understand potential barriers to their adoption so that strategies can be developed to overcome these barriers. This paper examines potential barriers to the adoption of safer conception strategies by HIV-affected couples in Iringa, Tanzania using an ecological framework. We interviewed 30 HIV-positive women, 30 HIV-positive men and 30 health providers engaged in delivering HIV-related services. We also conducted direct observations at five health facilities. Findings suggest that there are multiple barriers to safer conception that operate at the individual, relational, environmental, structural, and super-structural levels. The barriers to safer conception identified are complex and interact across these levels. Barriers at the individual level included antiretroviral adherence, knowledge of HIV status, knowledge and acceptability of safer conception strategies, and poor nutrition. At the relational level, unplanned pregnancies, non-disclosure of status, gendered power dynamics within relationships, and patient–provider interactions posed a threat to safer conception. HIV stigma and distance to health facilities were environmental barriers to safer conception. At the structural level there were multiple barriers to safer conception, including limited safer conception policy guidelines for people living with HIV (PLHIV), lack of health provider training in safer conception strategies and preconception counseling for PLHIV, limited resources, and lack of integration of HIV and sexual and reproductive health services. Poverty and gender norms were super-structural factors that influenced and reinforced barriers to safer conception, which influenced and operated across different levels of the framework. Multi-level interventions are needed to ensure adoption of safer conception strategies and reduce the risk of HIV transmission between partners within HIV-serodiscordant couples.     

Utilizing the Clinical Social Work Model to Foster Collaboration Among HIV Providers in North Carolina

Abstract

This article demonstrates one effort to examine the applicability of client behavioral change models to medical provider and case manager behavioral change. The clinical social work model is used to explain the behavioral change process when providers were asked to utilize a voluntary and complex data management system to manage clients' HIV care. Through intense psychosocial support and training initiatives, providers were able to alter their behaviors so that they could successfully integrate new strategies and technologies into their practice while providing better quality care to their clients.