Correlates of HIV stigma in HIV-positive women

We examined the variables associated with HIV stigma in HIV-positive women currently living in Ontario, Canada. Based on previous literature, we predicted that variables of social marginalization (e.g., ethnicity, income, education), medical variables (e.g., higher CD4 count, lower viral load), and increased psychological distress would be associated with higher perceived HIV stigma among HIV-positive women. One hundred fifty-nine HIV-positive women between the ages of 18 and 52 in Ontario completed self-report measures of the aforementioned variables. Women were recruited through 28 AIDS service organizations, eight HIV clinics, and two community health centers. In multiple regression analyses, for women born in Canada, lower educational level and higher anxiety were associated with higher HIV stigma. For women born outside of Canada, having been judged by a physician in Canada for trying to become pregnant was associated with higher HIV stigma. For HIV-positive women born outside of Canada, negative judgment by a physician regarding intentions to become pregnant should be addressed to reduce perceived HIV stigma and vice versa. Health care providers should be trained in the provision of sensitive and effective health care for women living with HIV, especially when providing reproductive health care.     

Healthy Aging in Older Women Living with HIV Infection: a Systematic Review of Psychosocial Factors

Due to life-enhancing effects of antiretroviral therapy, HIV-positive persons have the potential for long life comparable to their uninfected peers. Older women (age 50+) living with HIV (OWLH) are often an under-recognized aging group. We conducted a systematic review to examine psychosocial factors that impact how OWLH live, cope, and age with HIV. Initial key word search yielded 1527 records, and 21 studies met our inclusion criteria of original quantitative or qualitative research published between 2013 and 2016 with results specific to OWLH. These focused on health care and self-management, sexual health and risk, stigma, loneliness, mental health (depression, substance use), and protective factors (coping, social support, well-being). Due to the scarcity of studies on each topic and inconclusive findings, no clear patterns of results emerged. As the number of OWLH continues to grow, more research, including longitudinal studies, is needed to fully characterize the psychosocial factors that impact aging with HIV.     

Burden of depression among impoverished HIV-positive women in Peru

OBJECTIVES: In resource-poor settings, the mental health burden among HIV-positive women is exacerbated by poverty. We sought to describe the extent, risk factors, and experience of depression among impoverished HIV-positive women living in Lima, Peru. METHODS: This is a case series of 78 HIV-positive women in Lima, Peru. We measured depression, stigma, and social support and performed a multivariable analysis to identify factors associated with depression. RESULTS: Among 78 HIV-positive patients, 68% were depressed. Depression and suicidal ideation were rarely diagnosed by providers. In multivariable analysis, HIV-related stigma and food scarcity were associated with depression. CONCLUSIONS: In our cohort of HIV-positive women in Lima, Peru, poverty and socioeconomic vulnerability contributed to depression. Findings highlight the heavy burden of depression in this cohort of poor women and the need to incorporate mental health services as an integral component of HIV care.     

African-American men's perceptions of health: a focus group study

African-American men are disproportionately affected by preventable medical conditions, yet they underutilize primary care health services. Because healthcare utilization is strongly dependent on health beliefs, the purpose of this qualitative study was to identify and explore African-American men's perceptions of health and health influences. We conducted eight focus group interviews with select subgroups of African-American men, including adolescents, trauma survivors, HIV-positive men, homeless men, men who have sex with men, substance abusers, church-affiliated men and a mixed sample (N=71). Definitions of health, beliefs about health maintenance and influences on health were elicited. Participants' definitions of health went beyond the traditional "absence of disease" definition and included physical, mental, emotional, economic and spiritual well-being. Being healthy also included fulfilling social roles, such as having a job and providing for one's family. Health maintenance strategies included spirituality and self-empowerment. Stress was cited as a dominant negative influence on health, attributed to lack of income, racism, "unhealthy" neighborhoods and conflict in relationships. Positive influences included a supportive social network and feeling valued by loved ones. This study provides insight into African-American men's general health perceptions and may have implications for future efforts to improve healthcare utilization in this population.     

Adolescents and HIV: Prevention and clinical care

The incidence of HIV infection has increased to alarming proportions among minority youth, in particular among young men who have sex with men and among teenage girls. The unique socioeconomic, behavioral, and emotional vulnerability of adolescents for sexually transmitted diseases, including HIV, requires early identification of HIV infection for linkage to care. Differences in the clinical and psychosocial presentations of youth with perinatally versus behavioral acquired HIV infection are important and influence the acceptance of illness, self-efficacy, and antiretroviral treatment adherence. The ideal multidisciplinary team approach of culturally sensitive services for youth integrates clinical care, psychosocial and peer support interventions, transition planning, primary and secondary prevention, as well as comprehensive reproductive adolescent health services.     

Case Management Interventions for HIV-Infected Individuals

Engagement of HIV-positive persons into care and achieving optimal antiretroviral treatment outcomes is a fundamental HIV prevention strategy. Case management model was recommended as a beneficial model of care for patients with a new HIV diagnosis, focusing on individuals with unmet needs, and linking them with the coordinated health and social services to achieve desired outcomes. HIV case management is population-driven and programs are designed to respond to the unique needs of the client population they serve, such as substance users, homeless, youth, and prison inmates. This view found 28 studies addressing effectiveness and impacts of case management intervention for people living with or at risk of HIV/AIDS. Effectiveness of case management intervention was categorized as follows: decreased mortality and improve health outcomes, linkage to and retention in care, decreased unmet needs, and reducing risky behaviors.     

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.     

Adolescents and HIV infection

HIV studies reveal that adolescents, especially females, are becoming HIV infected at increasingly higher rates, and in some regions, at higher rates than adults. Delays in treatment and delivery of needed health care and services reduces the survival of adolescents living with HIV/AIDS. Following statistics on the epidemiology and seroprevalence surrounding adolescent HIV/AIDS, a subpopulation profile is presented of youth recognized within the cohort of identified HIV-infected adolescents and young adult population in the US. These subsets include minorities, immigrants/non-citizens, gender, gays and bisexuals, and homeless and runaway youths. In addition, infections with STDs increases these groups' risk of contracting HIV. Suggestions are made on managing adolescent adherence and antiviral medications based on the experiences of the Chicago HIV Risk Reduction Partnership for Youth Project protocol.     

African-American sexuality and HIV/AIDS: recommendations for future research

HIV/AIDS continues to create a significant health crisis in African-American communities and health disparities within the United States. Understanding African-American sexuality within a culturally congruent and ethnocentric approach is critical to decreasing the HIV infection and transmission rates for African Americans. This brief discusses two major factors: 1) confusion about race-based stereotypes; and 2) historical health disparities and mistrust, which have influenced our understanding of African-American sexuality despite that fact that very little research has been conducted in this area. This paper discusses the limitations of what is known and makes recommendations for research surrounding sexuality and HIV/AIDS. Research trainings for new and established investigators and collaborations among health, community, religious, political organizations, and historically black colleges and universities are needed to disseminate relevant HIV prevention messages. Conducting research to better understand African-American sexuality will facilitate the development of behavioral interventions that address health, HIV and mental health risk reduction within the context of African-American life.     

Economic evaluation of HIV risk reduction intervention in African-American male adolescents

PURPOSE: To evaluate the cost-effectiveness of a cognitive-behavioral HIV risk reduction intervention for African-American male adolescents that has previously been shown to be effective at reducing sexual risk taking. METHODS: Standard techniques of cost-utility analysis were employed. A societal perspective and a 3% discount rate were used in the main analysis. Program costs were ascertained retrospectively. A mathematical model of HIV transmission was used to translate observed changes in sexual behavior into an estimate of the number of HIV infections the intervention averted. Intervention effects were assumed to last for 1 year. For each infection averted, the corresponding savings in future HIV-related medical care costs and quality-adjusted life years (QALYs) were estimated. The overall net cost per QALY saved (cost-utility ratio) was then calculated. Sensitivity analyses were performed to assess the robustness of the main results. RESULTS: The cost-utility ratio was approximately $57,000 U.S. per QALY saved when training costs were included, and $41,000 U.S. per QALY saved when they were excluded. The intervention appeared substantially more cost-effective when the analysis was restricted to the subgroup of participants who reported being sexually active at baseline. Assumptions about the prevalence of HIV infection and the duration of intervention effectiveness also greatly affected the cost-utility ratio. CONCLUSIONS: The HIV prevention intervention was moderately cost-effective in comparison with other health care programs. Selectively implementing the intervention in high-HIV prevalence communities and with sexually active youth can enhance cost-effectiveness.     

Knowledge, attitudes, and behavior of homeless African-American adolescents: implications for HIV/AIDS prevention

The purpose of this pilot study was to describe the knowledge of HIV/AIDS, attitudes about condom use, and the sexual behavior of African-American adolescents who reside in a children's emergency homeless shelter. The Attitudes Toward Condom Usage Questionnaire, the AIDS Knowledge and Attitude Survey, and a Perceived Risk of HIV/AIDS Scale were modified and administered to 37 African-American male and female adolescents who reside in an emergency shelter. HIV/AIDS knowledge and attitudes about condoms among these respondents were comparable to those of other adolescents described in the literature in that there was a strong knowledge of HIV/AIDS, although sexual behavior and attitudes toward condoms were not consistent with this knowledge. Significant differences between male and female respondents were only found on three items of the Attitudes Toward Condom Usage Questionnaire and on the Perceived Risk of HIV/AIDS Scale at the 0.05 level. The knowledge, attitudes, and sexual behavior of homeless, African-American adolescents should be examined to develop and implement appropriate programs to address the specific needs of this population. Further research should focus on this population and expand on this preliminary data.     

Youth counseled for HIV testing at school- and hospital-based clinics.

The prevalence of human immunodeficiency virus (HIV) in adolescents is difficult to assess as few adolescents consent to testing. This prospective study characterized urban youth requesting HIV testing at two types of health settings, inner-city school-based and hospital-based clinics. Data were obtained on 1652 inner-city youths aged 13 to 19 years who consented to individualized HIV counseling and testing from January 1993 to January 1994. Identified risks for HIV included sexual activity, sexually transmitted disease (STD) history, and substance use by self-report during a confidential structured interview. Data were analyzed using chi-squared analysis. Of the 1652 youth who were counseled, 1602 were from hospital-based clinics. A total of 827 (50%) requested HIV testing. Females accounted for the majority of youth who underwent counseling (79%) and requested HIV testing (75%). However, once counseled, males were more likely to be tested. Risk factors differed by gender; females were more likely to report STDs and marijuana use, and males more likely to report alcohol and cocaine use. These results indicate a need to identify developmentally appropriate methods to educate and counsel youth about HIV that will lead to more youth willing to be tested. School-based clinics may provide easier access than traditional health models for confidential HIV services.     

Estimating HIV prevalence and the impact of HIV/AIDS on a Ugandan hospital by combining serosurvey data and hospital discharge records

OBJECTIVE: To estimate the disease-specific HIV prevalence in a northern Ugandan hospital and to evaluate the impact of HIV/AIDS on hospital services. DESIGN: HIV serosurvey and analysis of routinely compiled hospital records. METHODS: The serosurvey was conducted among all 352 patients admitted to the medical ward of the Lacor Hospital in March 1999 (this ward consists of 3 units: general medicine, tuberculosis, and cancer). The impact on hospital services was estimated using the hospital discharge records for all 3447 patients admitted in 1999, in combination with serosurvey data, and was expressed as the percentage of bed-days attributable to HIV-positive patients. RESULTS: The overall HIV prevalence was 42.0% (52.6, 44.6, and 13.2% in the general medicine, tuberculosis, and cancer units, respectively). The disease-specific prevalence ranged from 45-65% for patients with tuberculosis, pneumonia, malaria, and enteritis. HIV-positive patients, compared with HIV-negative patients, had a higher in-hospital mortality (14.6 vs. 3.0%) and a lower average length of stay (41.4 vs. 48.9 days). AIDS cases accounted for 5.0% of hospital admissions, 4.1% of bed-days, and 11.5% of deaths. When considering all HIV-positive patients, these accounted for 37.2% of the bed-days. CONCLUSIONS: Knowledge of disease-specific HIV prevalence and of the patterns of HIV-related diseases is crucial for early case management. The impact of HIV-positive patients on hospital services is quite high, accounting for >1/3 of the bed-days in 1999. Providing a continuum of care through inpatient, outpatient, and outreach home care services probably represents the only means of relieving the pressure on overloaded hospitals.     

Integrating HIV and maternal health services: will organizational culture clash sow the seeds of a new and improved implementation practice?

Drawing on an analysis by Pritchett et al of the "techniques of persistent implementation failure" common across many development sectors, this commentary suggests that health systems attempting to integrate maternal health and HIV services may need to contend with a profound clash of organizational cultures. For decades, countries have been pressed to implement global "best practices" in maternal health without attention to the systemic capacity building needed to support complex interventions. The result is often form without function, a kind of "isomorphic mimicry" in which policy documents and program plans that meet global standards ultimately camouflage deep dysfunction in the actual delivery of lifesaving services. As a result, the organizational culture that surrounds maternal health services often stands in stark contrast to the can-do style that has characterized the rapid, well-resourced deployment of HIV services over the last few years. As integration proceeds, the resolution of this clash may hold the seeds of a much-needed transformation of implementation support practices in both fields.     

Contribution of substance abuse and HIV infection to psychiatric distress in an inner-city African-American population

We used Symptom Checklist 90-Revised (SCL90-R) to investigate psychiatric symptom severity in African-American drug-abusing individuals. Three hundred and seventeen African-American volunteers (52 control subjects; 265 drug users) were recruited, 19.2% of whom were HIV-positive. The impact of drug of choice or HIV status on mental distress was assessed. Symptomatic HIV-positive participants were excluded. The intake SCL90-R, Addiction Severity Index, and demographic data were subjected to regression analyses. Drug-abusing African Americans reported increased global distress, a finding that remained robust after we adjusted for HIV status, gender, age, and education. Drug of choice had no influence on the severity of global mental distress in our sample. Asymptomatic HIV-positive African Americans who abused drugs reported more distress than the HIV-negative drug users. Levels of global distress were similar in the HIV-negative and the HIV-positive controls. Subscales of the SCL90-R showed more symptom severity among drug-using, compared with nonusing, African Americans. Except for paranoia, anxiety, and obsessive-compulsive subscales, other symptom dimensions were significantly elevated in HIV-positive, compared with HIV-negative, drug abusers. When taken together, these findings suggest that drug abuse can exacerbate the severity of mental distress in HIV-positive patients. Treatment of these patients may be more successful if both sets of needs are addressed with matched interventions.     

Differences in HIV-related hospitalization trends between Haitian-born blacks and US-born blacks

OBJECTIVES: To examine the HIV care needs and hospital admission patterns of HIV-positive Haitian-born blacks (Haitians) and compare them with those of US-born blacks (Blacks). METHODS: We abstracted the medical records of 635 Blacks and Haitians consecutively admitted to the adult HIV Service at Jackson Memorial Hospital during 2004 for information on demographics, use of antiretroviral therapy, CD4 cell counts, primary and secondary diagnoses at admission, and substance use. The probability of being prescribed highly active antiretroviral therapy (HAART) was examined by country of origin. RESULTS: There was no statistically significant difference between the groups in likelihood to be prescribed HAART. In controlled analyses, however, Haitians were 76% more likely than Blacks to have a CD4 count <51 cells/mm3 and tended to be more recently diagnosed with HIV Moreover, tuberculosis was the most prevalent opportunistic infection for Haitians compared with candidiasis for Blacks. CONCLUSIONS: Findings suggest that barriers to medical care may exist for Haitians at an early stage of the access continuum and that prevention efforts among the Haitian HIV-positive population should be directed at promoting the need for timely use of health services.     

Mindfulness-based stress reduction for people living with HIV/AIDS: preliminary review of intervention trial methodologies and findings

In the context of successful antiretroviral therapy (ART) for the management of HIV infection, the harmful effects of stress remain a significant threat. Stress may increase viral replication, suppress immune response, and impede adherence to ART. Stressful living conditions of poverty, facing a chronic life-threatening illness and stigma all exacerbate chronic stress in HIV-affected populations. Stress-reduction interventions are urgently needed for the comprehensive care of people living with HIV. Mindfulness-based stress reduction (MBSR) is one approach that has shown promise as an intervention for patients facing other medical conditions for reducing disease progression, psychological distress and maladaptive behaviours. In this systematic review, we identified 11 studies that have examined MBSR as an intervention for HIV-positive populations. Of the studies, six were randomised designs, one was a quasi-experimental design, and the remaining four were pre- and post-test designs. The preliminary outcomes support MBSR to decrease emotional distress with mixed evidence for impact on disease progression. Effect sizes were generally small to moderate in magnitude. The early findings from this emerging literature must be considered preliminary and support moving forward with more rigorous controlled trials, evaluated with objective assessments in longer-term follow-ups to determine the efficacy of MBSR for people living with HIV.     

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.     

Leveraging HIV programs to deliver an integrated package of health services: some words of caution

Over the past decade, HIV programs have been successfully scaled up in many developing countries, leading some to wonder how the investments made into HIV infrastructure could be leveraged to deliver additional health services. Although the concept is appealing from many perspectives, integrating additional health services into existing vertical HIV infrastructure may not mitigate some of the challenges these programs have introduced in implementing countries. In addition, this approach to integration may countervail parallel efforts of the global health community to strengthen health systems and improve aid effectiveness. It might also undermine the HIV programs themselves. International donors and health system planners should carefully consider whether the benefits outweigh the potential costs of these well-intentioned integration efforts.