Advance directives among people living with HIV: room for improvement

While HIV has become a largely chronic disease, age-associated comorbidities are prevalent in people living with HIV (PLWH). Therefore, PLWH are appropriate for advance care planning (ACP) and advance directives (ADs) completion. We sought to characterize AD completion among outpatient PLWH. We conducted a retrospective chart review of PLWH who receive their routine care at the University of Wisconsin HIV clinic. Data were extracted from the electronic health record. Variables were entered into a stepwise multivariate logistic regression model to assess which factors were independently associated with AD completion. Five hundred and eighty eight charts were reviewed. Eighty-one percent of subjects were male and 72% were white; mean age was 46.8 years. ADs were completed by 134 subjects and 6.7% of those were completed at the HIV clinic. In the final multivariate model, those who had completed an AD were more likely to be older than age 45; ever been diagnosed with AIDS; have cardiovascular disease, neurologic disorder, chronic kidney disease, or malignancy. In this study, a small percentage of patients had documented ADs, with only a small proportion completed in the HIV clinic. The HIV clinic is an underutilized resource to offer ACP. Interventions are needed to provide the necessary ACP resources for PLWH.     

Impact of age on care pathways of people living with HIV followed up in hospital

The aging population of people living with human immunodeficiency virus (HIV) (PLWH) is exposed to a widening spectrum of non-AIDS-defining diseases. Thus, our objective was to compare the health care offered to PLWH according to age. We conducted a multicenter cross-sectional study on PLWH who consulted at one of 59 French HIV reference centers from 15th to 19th October 2012. Using our survey questionnaires, PLWH self-reported the medical care they received, whether or not tied to HIV infection monitoring, during the previous year. A total of 650 PLWH participated in the survey (median age 48 years, Interquartile range (IQR) 40–54), of which 95 were aged 60 years or over (14.5%). Compared to younger PLWH, 60-and-over PLWH were more often under complementary health insurance cover and less socially deprived based on the French EPICES (Evaluation of Precarity and Inequalities in Health Examination Centers) score. The elderly PLWH presented more comorbidities and less coinfections with hepatitis viruses. During health care, therapeutic education was less often offered to older PLWH (14% vs. 26%, p?=?.01), but this difference was mainly explained by sociodemographic factors and clinical status. Over the previous 6 months, 74% of PLWH who were followed up in hospital had also consulted another doctor, with a mean of 3.75 consultations (±4.18) without difference between age groups. After adjustment for sociodemographic factors and comorbidities, PLWH over 60 years were more likely to have consulted medical specialists as outpatients in the last 6 months (odds ratio [OR]?=?2.63 [1.11–6.20]). Whatever their age, 13% of PLWH had been refused care on disclosure of their HIV status, and 27% of PLWH still did not disclose their HIV status to some caregivers. Coordinated health care throughout patients’ lives is crucial, as health-care pathways evolve toward outpatient care as the patients get older.     

HIV Serostatus Disclosure and Engagement in Medical Care Among Predominantly Low Income but Insured African American Adults with HIV

More than half of persons living with HIV (PLWH) do not enter into or remain in continuous HIV medical care. Disclosure of HIV serostatus to social contacts may play an important role in successful engagement of PLWH with medical care. The effect of disclosure on medical care engagement was examined in a sample of African American PLWH (n = 262) recruited from community-based organizations as part of a peer community health worker initiative. At baseline assessment, many of the PLWH (46 %) reported they had not disclosed their serostatus to others. Engagement in medical care was assessed 45 and 90 days after enrollment. Participants who disclosed their HIV status were subsequently more likely to engage in HIV medical care (78 %) than persons who did not disclose their status (66 %), an effect that was confirmed in multiple logistic regression. The findings highlight disclosure as an important predictor of engagement in HIV medical care for PLWH.     

Sex Trade and Health Care Utilization Among People Living with HIV/AIDS

People living with HIV/AIDS (PLWH) are more likely to have a history of trading sex, but little research has examined whether trading sex is associated with lower health care utilization amongst PLWH. This study assesses this association with PLWH (N?=?583) recruited and surveyed from seven community sites in six US cities participating in a multi-site community-based HIV test and treat initiative. Participants were 90.6% Black or Latino, 30.4% homeless, and 9.0% (1 in 11) sold sex (past 90 days). Most reported receiving HIV clinical care (63.9%, past 6 months) and HIV case management (68.9%, past year), but 35.7% reported a missed health care appointment (past 3 months). In adjusted regression models, trading sex was associated with a missed health care appointment (OR?=?2.44) and receiving psychological assistance (OR?=?2.31), past 90 days, but not receipt of HIV care or supportive HIV services. Trading sex may compromise consistent health care utilization among PLWH.     

Beyond reminders: a conceptual framework for using short message service to promote prevention and improve healthcare quality and clinical outcomes for people living with HIV

The availability of effective antiretroviral therapy has altered HIV from being an acute disease to being a chronic, manageable condition for many people living with HIV (PLWH). Because of their ubiquity and flexibility, mobile phones with short message service (SMS) offer a unique opportunity to enhance treatment and prevention for people managing HIV. To date, very few US studies using SMS for HIV self-management have been published. In this article, we review the published SMS-based intervention research that aimed to improve healthcare quality and outcomes for PLWH and other chronic health conditions, and propose a conceptual model that integrates the communication functionality of SMS with important psychosocial factors that could mediate the impact of SMS on health outcomes. We posit that an SMS-based intervention that incorporates the elements of interactivity, frequency, timing, and tailoring of messages could be implemented to encourage greater medication adherence as well as impact other mutually reinforcing behaviors and factors (e.g., increasing patient involvement and social support, reducing risk behaviors, and promoting general health and well-being) to support better healthcare quality and clinical outcomes for PLWH. We recommend that future studies explore the potential linkages between variations in SMS characteristics and these mediating factors to determine if and how they influence the larger outcomes.     

Recent Tobacco Smoking is Associated with Poor HIV Medical Outcomes Among HIV-Infected Individuals in New York

Tobacco smoking is associated with adverse health effects among people living with HIV (PLWH), including a higher risk of cancer and cardiovascular problems. Further, there is evidence that PLWH are two to three times more likely to smoke than the general population. The aim of this study was to examine the association between tobacco smoking and biomarkers of HIV disease progression, including unsuppressed viral load (viral load >200 copies/mL) and low CD4 cell count (<200 cells/mm³). Recent tobacco smoking was reported by 40 % (n = 5942) of 14,713 PLWH enrolled in Ryan White Part A programs in the New York City metropolitan area. In multivariate analyses controlling for sociodemographic and clinical characteristics, recent tobacco smoking was independently associated with unsuppressed viral load (AOR = 1.38, CI 1.26–1.50) and low CD4 cell count (AOR = 1.12, CI 1.01–1.24). Findings suggest the importance of routine assessments of tobacco use in clinical care settings for PLWH.     

Successful optimization of antiretroviral regimens in treatment‐experienced people living with HIV undergoing liver transplantation

Modern antiretroviral therapy (ART) extends life expectancy for people living with HIV (PLWH). However, most older PLWH (≥50 years) “aged” with HIV and were exposed to historical HIV care practices and older, more toxic ART. In PLWH with exposure to older and multiple ART regimens, the drug interactions between ART frequently used in treatment‐experienced persons and commonly used immunosuppressants remain a significant challenge. However, the advent of newer ART classes (eg, integrase non‐strand transfer inhibitors) and more advanced HIV genetic resistance testing may allow optimization of ART regimens with minimal drug interactions. Here, we present a case series of three PLWH whose complicated ART interacted (or was at risk for interacting) with their post–liver transplant immunosuppression. After a review of their proviral DNA resistance testing, they successfully transitioned onto safer integrase non‐strand transfer inhibitor‐containing ART regimens without viral blips or evidence of organ rejection.     

HIV primary care by the infectious disease physician in the United States - extending the continuum of care

Models of care for people living with HIV (PLWH) have varied over time due to long term survival, development of HIV-associated non-AIDS conditions, and HIV specific primary care guidelines that differ from those of the general population. The objectives of this study are to assess how often infectious disease (ID) physicians provide primary care for PLWH, assess their practice patterns and barriers in the provision of primary care. We used a 6-item survey electronically distributed to ID physician members of Emerging Infections Network (EIN). Of the 1248 active EIN members, 644 (52%) responded to the survey. Among the 644 respondents, 431 (67%) treated PLWH. Of these 431 responders, 326 (75%) acted as their primary care physicians. Responders who reported always/mostly performing a screening assessment as recommended per guidelines were: (1) Screening specific to HIV (tuberculosis 95%, genital chlamydia/gonorrhoea 77%, hepatitis C 67%, extra genital chlamydia/gonorrhoea 47%, baseline anal PAP smear for women 36% and men 34%); (2) Primary care related screening (fasting lipids 95%, colonoscopy 95%, mammogram 90%, cervical PAP smears 88%, depression 57%, osteoporosis in postmenopausal women 55% and men >50 yrs 33%). Respondents who worked in university hospitals, had <5 years of ID experience, and those who cared for more PLWH were most likely to provide primary care to all or most of their patients. Common barriers reported include: refusal by patient (72%), non-adherence to HIV medications (43%), other health priorities (44%), time constraints during clinic visit (43%) and financial/insurance limitations (40%). Most ID physicians act as primary care providers for their HIV infected patients especially if they are recent ID graduates and work in university hospitals. Current screening rates are suboptimal. Interventions to increase screening practices and to decrease barriers are urgently needed to address the needs of the aging HIV population in the United States.     

Desire to have children: gender and reproductive rights of men and women living with HIV: a challenge to health care in Brazil

Links between HIV/AIDS care and reproductive health, including fertility options for people living with HIV (PLWH), have not been sufficiently addressed by health care providers. Moreover, few studies have addressed men in this regard. To describe attitudes toward parenthood and identify factors associated with desire to have children among men and women living with HIV a cross-sectional study involving a sample of 533 women and 206 men (bisexual and heterosexual) attending two reference sexually transmitted disease (STD)/AIDS centers in S?o Paulo, Brazil. Participants answered a standardized questionnaire. Desire to have children as the study outcome was compared between men and women and associated factors searched for in multivariable regression analysis. In contrast to previous studies conducted in developed countries, desire to have children in this sample was more frequent among men than among women and it was reported by 27.9% of participants (50.1% of men versus 19.2% of women). Women were more likely to anticipate doctors' strong opposition to PLWH getting pregnant and men reported lower information level about HIV/mother-to-child transmission (MTCT). Bisexual men were more likely to desire to have biologic children. Male gender, younger age, having no children, living with 1-2 children, and being in a heterosexual partnership were independently associated with desire to have children. Regardless of gender, the childless as well as the youngest should be regarded as groups to be particularly targeted by counseling, to be provided with objective information about reproductive rights and options. Further research is warranted to address the desire for children among strictly homosexual men.     

Characteristics of psychosocial support seeking during HIV-related treatment in western Kenya

While the characteristics of those who seek psychosocial support following an HIV diagnosis have been well documented in western countries where linkages between HIV-related treatment and psychosocial support programs are well established, little is known about those who become engaged with such services in countries of the world where comprehensive HIV-related care and prevention systems are continuing to develop. Data were collected from 397 individuals who had enrolled in HIV-related psychosocial support groups in western Kenya in November 2005. Demographic and HIV-related characteristics, as well as assessments of psychological distress, were collected from each participant and analyzed by gender in order to document the characteristics of those seeking psychosocial care in conjunction with their participation in an HIV-related treatment and prevention program. Those seeking psychosocial support were primarily female (72%), living with HIV for an average of 2.5 years, and unemployed (70%). Women were younger and more likely to be either widowed or never married; while men were more likely to have advanced HIV disease, including lower CD4 counts and an AIDS diagnosis. Across all participants, HIV serostatus disclosure was rarely reported to sex partners, family members, and friends. Symptoms of psychological distress were more prevalent among women on multiple measures, including depression, anxiety, paranoid ideation, interpersonal sensitivity, and somatization. An increased understanding of the characteristics of those likely to seek psychosocial support groups will help HIV program managers to develop protocols necessary for facilitating linkages to psychosocial support for those enrolled in HIV-related treatment programs. Patient engagement in psychosocial support may facilitate improvements in psychological function and support an individual's maintenance of HIV treatment and prevention behaviors.     

Self-reported comorbidities,perceived needs,and sources for usual care for older and younger homeless adults

BACKGROUND: While older individuals who are homeless tend to be in poorer health, it is less clear how they view their health care needs and whether their self-reported patterns for accessing health services differ from younger homeless counterparts. METHODS: Cross-sectional, community-based survey of homeless adults in Pittsburgh and Philadelphia using face-to-face interviews from population proportionate sampling of sites and random sampling of subjects. Survey questions included physical and mental health comorbidities, self-reported health care, social services and personal needs, means of economic support, and sources for usual health care. For analysis purposes, respondents were grouped by age 18 to 49 years old and 50 years old or older. RESULTS: Overall, 531 adults were interviewed, with 74 respondents 50 years old or older (13.9%). Older homeless persons were 3.6 times more likely to report a chronic medical condition, 2.8 times more likely to have health insurance, and 2.4 times more likely to be dependent on heroin than homeless persons less than 50 years old. However, they also tended to use shelter-based clinics and street outreach teams more commonly as their source of usual care (20.9% vs 10.6%, P=.02) and were significantly less likely to report a need for substance abuse treatment despite high rates of abuse. CONCLUSION: Older homeless adults have a greater disease burden than their younger counterparts. However, it is unclear whether these needs are being appropriately identified and met. There is a need for specific and targeted outreach to connect them to appropriate services.     

Reproductive and sexual health knowledge,experiences, and milestones in young adults with life-long HIV

ABSTRACT

Reproductive and sexual health outcomes of adults with perinatal human immunodeficiency virus (PHIV) have not been well-characterized. This prospective cross-sectional study of 35 adult persons living with HIV (PLWH) from early life and 20 matched HIV-negative controls assessed quality of life, depressive symptoms, HIV transmission knowledge, and sexual/reproductive behaviors through self-report questionnaires. PLWH scored significantly worse than controls on depressive symptoms (p?=?0.04) and two of six quality of life domains (p?=?0.03, p?=?0.0002). In contrast, PLWH scored significantly higher on transmission knowledge in the context of family planning (p?=?0.002). PLWH were more likely to learn about sex from healthcare providers (p?=?0.002) and were more confident in their sexual/reproductive health knowledge (p?<?0.05). Both groups reported inconsistent condom use, but PLWH were more likely to have planned pregnancies (p?=?0.005) and to share pregnancy planning with their partners (p?<?0.05). Despite the challenges of living with a chronic stigmatized condition, adults with PHIV were knowledgeable about HIV transmission and family planning and demonstrated sexual practices and reproductive outcomes similar to age-matched controls. However, sub-optimal rates of viral suppression, inconsistent condom use, and the psychosocial impact of living with HIV continue to require the attention of healthcare provides for young adults with PHIV.     

Chronic conditions and health status in older cancer survivors

BackgroundWith the aging population and improved cancer care, the number of cancer survivors is steadily increasing. Planning for their care requires an understanding of the impact of cancer and chronic conditions on quality of life. We sought to determine chronic conditions and health status in older cancer survivors compared to controls.MethodsIn this retrospective cross-sectional study, we used survey data from 18,133 cancer survivors and 94,407 controls age 65 and older who participated in the Behavioral Risk Factor Surveillance System 2009 telephonic survey. Our main measures were chronic conditions (cardiovascular disease, hypertension, diabetes mellitus, high cholesterol, and arthritis) and poor health status (poor or fair self-rated health).ResultsCancer survivors were older, more likely white, had higher education, and slightly more likely to have a healthcare provider and higher levels of emotional support. More survivors reported having 2 or more chronic conditions compared to controls (67.5% vs. 64.5%, respectively). Health status was lower for survivors, and was significantly different by racial/ethnic group. In a multivariable model for health status, having 2 or more chronic conditions was more strongly associated with poorer health status than cancer survivorship.ConclusionsCancer survivors had slightly higher numbers of chronic conditions and poorer health status than controls. However, chronic conditions were more strongly associated with poor health status than cancer. Monitoring for recurrence and second cancers is important in cancer survivors, but chronic conditions also need to be given priority due to their substantial impact on health status.     

Patient activation among people living with HIV: a cross-sectional comparative analysis with people living with diabetes mellitus

Standardized self-management supports are an integral part of care delivery for many chronic conditions. We used the validated Patient Activation Measure (PAM®) to assess level of engagement for self-management from a sample of 165 people living with HIV (PLWH) and 163 people with diabetes. We conducted multivariable logistic regression to assess associations between demographics and PAM® scores. PLWH had high levels of activation that were no different from those of people with diabetes (mean score?=?67.2, SD?=?14.2 versus 65.0, SD?=?14.9, p?=?0.183). After adjusting for patient characteristics, only being on disability compared to being employed or a student was associated with being less activated (AOR?=?0.276, 95%CI?=?0.103–0.742). Our findings highlight the potential for the implementation of existing standardized chronic disease self-management programs to enhance the care delivery for PLWH, with people on disability as potential target populations.     

Addressing health needs of an aging society through medical-religious partnerships: what do clergy and laity think?

PURPOSE: This article reports on the interest within the religious community in a medical-religious partnership model designed to address some of the health challenges communities face as the population continues to age and become more diverse. DESIGN AND METHODS: A geographically and religiously diverse group of 183 clergy who were attending a continuing education program on theology and preaching were invited to complete a 16-item survey asking about their interest in working with hospitals to offer health-related programs and activities in their congregations. Another sample, this one consisting of 524 individuals from a religiously diverse group of congregations in Florida, was also asked about their interest in having health programs offered in their congregations. RESULTS: Of the 54% of clergy who completed the surveys, 72% said it was "very important" and 28% said it was "somewhat important" to actively address the health needs of their congregations. Support for specific programs was also strong, with at least 80% reporting it was very likely they would support screenings, preventive interventions, and health-related classes in their congregations. Strong support was also found among the laity surveyed, with 85% expressing interest in faith-based health programs and 45% reporting they would be interested in helping organize and promote such programs. IMPLICATIONS: Health care systems and other organizations interested in addressing health needs of older adults can look to religious institutions for assistance in providing the information and support patients and family members need to prevent or minimize the impact of chronic illnesses.     

Living with HIV but without medical care: barriers to engagement

This cross-sectional study examined factors associated with the receipt of HIV medical care among people who know their HIV status and are not newly diagnosed with HIV. Interviews were conducted with 1133 HIV-positive individuals between October 2003 and July 2005 who enrolled in 1 of 10 outreach programs across the country. The sample was predominantly non-white (86%), male (59%), and unstably housed (61%), with a past history of cocaine use (68%). Twelve percent had received no HIV medical care in the 6 months prior to the interview. Those with no care were similar to those who received some HIV care in sociodemographic characteristics, but in multivariate analysis were less likely to have a case manager (p < 0.001) or use mental health services (p < .001), had lower mental health status scores (p < 0.05), were more likely to be active drug users (p < 0.01), had greater unmet support service needs (p < 0.05) and reported that health beliefs were a barrier to care (p < 0.001). Interventions to engage people in HIV medical care need to address barriers to care through linkages with mental health, substance abuse treatment and support services, and address the health beliefs that deter people from seeking care.     

Determinants of HIV Serostatus Disclosure to Sexual Partner Among HIV-Positive Alcohol Users in Haiti

This study examined the relationship between antiretroviral therapy use, participants’ knowledge of partner’s HIV serostatus, number of sex partners, perceived infectivity and HIV disclosure to a main sexual partner among 258 HIV-positive Haitian alcohol users. Only 38.6 % had disclosed their HIV serostatus to sexual partners. Logistic regression analyses revealed that participants who self-reported having an HIV-negative partner (OR = 0.36, 95 % CI 0.13–0.97) or a partner of unknown HIV status (OR = 0.09, 95 % CI 0.04–0.22) were less likely to disclose their HIV serostatus than participants who self-reported having an HIV-positive partner. Participants who had more than one sexual partner in the past 3 months (OR = 0.41, 95 % CI 0.19–0.90) were also less likely to disclose than participants who had one partner. These findings suggest the need for couples-based programs to assist people living with HIV (PLWH) with the disclosure process, especially among PLWH who have more than one sexual partner and/or are in serodiscordant relationships.     

Developing and implementing an HIV/AIDS educational curriculum for older adults

PURPOSE: Recent data (2002) from the Centers for Disease Control and Prevention indicate that almost 11% of all cases of AIDS were diagnosed in people 50 and older. Despite the steady rise and future projections of increase, there is still a paucity of education and prevention programs targeting this population. This article reports on the development and piloting of an HIV/AIDS education prevention program. It describes an educational curriculum that provides older adults with accurate information about the relevance of HIV/AIDS to their lives. DESIGN AND METHODS: A purposive sample (n = 249) of ethnically and economically diverse adults 50 years and older was selected from 14 organizations in rural and urban settings in California. They were surveyed to determine their interest in participating in HIV/AIDS education prevention programs. RESULTS: A majority of participants reported interest in an HIV/AIDS prevention program for older people, with female respondents more likely to attend than male respondents. Participants who were moderately or very religious were also more likely to attend. Participants expressed preference for prevention education through presentations at centers serving older adults, and from physicians and other health care providers. On the basis of these findings, a specialized curriculum targeting older adults was developed, presented, and disseminated. IMPLICATIONS: People 50 years and older are sexually active, lack accurate information about HIV/AIDS, and are in need of HIV/AIDS education.