Effects of behavioral intervention on substance use among people living with HIV: the Healthy Living Project randomized controlled study

AIM: Reductions in substance use were examined in response to an intensive intervention with people living with human immunodeficiency virus (HIV) (PLH). DESIGN, SETTING AND PARTICIPANTS: A randomized controlled trial was conducted with 936 PLH who had recently engaged in unprotected sexual risk acts recruited from four US cities: Milwaukee, San Francisco, New York and Los Angeles. Substance use was assessed as the number of days of use of 19 substances recently (over the last 90 days), evaluated at 5-month intervals over 25 months. INTERVENTION: A 15-session case management intervention was delivered to PLH in the intervention condition; the control condition received usual care. MEASUREMENTS: An intention-to-treat analysis was conducted examining reductions on multiple indices of recent substance use calculated as the number of days of use. FINDINGS: Reductions in recent substance use were significantly greater for intervention PLH compared to control PLH: alcohol and/or marijuana use, any substance use, hard drug use and a weighted index adjusting for seriousness of the drug. While the intervention-related reductions in substance use were larger among women than men, men also reduced their use. Compared to controls, gay and heterosexual men in the intervention reduced significantly their use of alcohol and marijuana, any substance, stimulants and the drug severity-weighted frequency of use index. Gay men also reduced their hard drug use significantly in the intervention compared to the control condition. CONCLUSIONS: A case management intervention model, delivered individually, is likely to result in significant and sustained reductions in substance use among PLH.     

Reduced Sexual Risk Behaviors Among People Living with HIV: Results from the Healthy Relationships Outcome Monitoring Project

In 2006, the Centers for Disease Control and Prevention funded seven community-based organizations (CBOs) to conduct outcome monitoring of Healthy Relationships. Healthy Relationships is an evidence-based behavioral intervention for people living with HIV. Demographic and sexual risk behaviors recalled by participants with a time referent of the past 90 days were collected over a 17-month project period using a repeated measures design. Data were collected at baseline, and at 3 and 6 months after the intervention. Generalized estimating equations were used to assess the changes in sexual risk behaviors after participation in Healthy Relationships. Our findings show that participants (n = 474) in the outcome monitoring project reported decreased sexual risk behaviors over time, such as fewer number of partners (RR = 0.55; 95% CI 0.41–0.73, P < 0.001) and any unprotected sex events (OR = 0.44; 95% CI 0.36–0.54, P < 0.001) at 6 months after the intervention. Additionally, this project demonstrates that CBOs can successfully collect and report longitudinal outcome monitoring data.     

Using HIV surveillance data: recent experiences and avenues for the future

HIV surveillance systems provide information that is crucial to our understanding of epidemic dynamics among different populations in different settings. Surveillance data are also used for advocacy, to inform policies and programming, and for monitoring. Multiple data sources may be used and will expand in the future as service statistics from prevention and treatment programmes become available. Important and new priorities in HIV surveillance data use at the national and local levels can build on past experience with surveillance reports, national estimates, advocacy materials, and communications to the media. A new framework, integrated analysis of data from expanded surveillance systems and other sources, is proposed to inform improved programming. The approach allows making effective programme choices, based on the analysis of biological and behavioral data and the coverage of interventions in an integrated fashion. The comparison of surveillance data with financial data provides added insights in the adequacy of the response. These findings and experiences set a new agenda for technical and structural directions to improve data use in countries.     

Supporting Healthy Alternatives through Patient Education: A Theoretically Driven HIV Prevention Intervention for Persons Living with HIV/AIDS

In the third decade of the HIV/AIDS epidemic, empirically based HIV transmission risk reduction interventions for HIV infected persons are still needed. As part of a Health Resources Services Administration/Special Projects of National Significance initiative to increase prevention services among HIV infected persons, we implemented SHAPE (Supporting Healthy Alternatives through Patient Education). SHAPE is a behavioral HIV prevention intervention delivered to HIV infected persons receiving primary medical care at El Rio Health Center in Tucson, Arizona. The SHAPE intervention is based on Kalichman’s “Healthy Relationships for Men and Women Living with HIV–AIDS.” The intervention is interactive and uses a video discussion intervention format where educational activities, movie clips, and discussions are used to provide participants with information and skills to increase their comfort in disclosing their HIV status and in reducing HIV transmission. This paper describes the intervention in sufficient detail to replicate it in other settings.     

Housing Characteristics and their Influence on Health-Related Quality of Life in Persons Living with HIV in Ontario, Canada: Results from the Positive Spaces, Healthy Places Study

Although lack of housing is linked with adverse health outcomes, little is known about the impacts of the qualitative aspects of housing on health. This study examined the association between structural elements of housing, housing affordability, housing satisfaction and health-related quality of life over a 1-year period. Participants were 509 individuals living with HIV in Ontario, Canada. Regression analyses were conducted to examine relationships between housing variables and physical and mental health-related quality of life. We found significant cross-sectional associations between housing and neighborhood variables—including place of residence, housing affordability, housing stability, and satisfaction with material, meaningful and spatial dimensions of housing—and both physical and mental health-related quality of life. Our analyses also revealed longitudinal associations between housing and neighborhood variables and health-related quality of life. Interventions that enhance housing affordability and housing satisfaction may help improve health-related quality of life of people living with HIV.     

A new approach to prevent HIV transmission: Project Protect intervention for recently infected individuals

Past research suggests that as many as 50% of onward human immunodeficiency virus (HIV) transmissions occur during acute and recent HIV infection. It is clearly important to develop interventions which focus on this highly infectious stage of HIV infection to prevent further transmission in the risk networks of acutely and recently infected individuals. Project Protect tries to find recently and acutely infected individuals and prevents HIV transmission in their risk networks. Participants are recruited by community health outreach workers at community-based HIV testing sites and drug users' community venues, by coupon referrals and through referrals from AIDS clinics. When a network with acute/recent infection is identified, network members are interviewed about their risky behaviors, network information is collected, and blood is drawn for HIV testing. Participants are also educated and given prevention materials (condoms, syringes, educational materials); HIV-infected participants are referred to AIDS clinics and are assisted with access to care. Community alerts about elevated risk of HIV transmission are distributed within the risk networks of recently infected. Overall, 342 people were recruited to the project and screened for acute/recent HIV infection. Only six index cases of recent infection (2.3% of all people screened) were found through primary screening at voluntary counseling and testing (VCT) sites, but six cases of recent infection were found through contact tracing of these recently infected participants (7% of network members who came to the interview). Combining screening at VCT sites and contact tracing the number of recently infected people we located as compared to VCT screening alone. No adverse events were encountered. These first results provide evidence for the theory behind the intervention, i.e., in the risk networks of recently infected people there are other people with recent HIV infection and they can be successfully located without increasing stigma for project participants.     

Moving for care: findings from the US HIV Cost and Services Utilization Study

This paper examines sociodemographic and HIV-related factors associated with moving post-HIV diagnosis for non-care- and care-related reasons (versus never moving post-HIV diagnosis). Distinctions are made between those who move for informal care only, formal care only, or informal and formal care. Data come from the nationally representative US HIV Cost and Services Utilization Study (N=2,864). Overall, 31.8% moved at least once post-HIV diagnosis and 16.3% moved most recently for care. Among those who moved for care, 32.6% moved for informal care only, 26.8% for formal care only, and 40.6% moved for both. Post-HIV diagnosis moves for reasons unrelated to care were less likely among African Americans and older persons, and more likely among those with longer durations positive. Moves for care were less likely among African Americans, older persons, and persons with higher educational attainments, while they were more likely among those with an AIDS diagnosis and longer durations HIV-positive. Among those who moved for care, women and persons with higher incomes were less likely to move for formal or mixed care than informal care only. Given that moving for care may reflect disparities in access to care and unmet needs, additional analyses with more detailed data are warranted.     

Non-enrollment for free community HIV care: findings from a population-based study in Rakai, Uganda

Improved understanding of HIV-related health-seeking behavior at a population level is important in informing the design of more effective HIV prevention and care strategies. We assessed the frequency and determinants of failure to seek free HIV care in Rakai, Uganda. HIV-positive participants in a community cohort who accepted VCT were referred for free HIV care (cotrimoxazole prophylaxis, CD4 monitoring, treatment of opportunistic infections, and, when indicated, antiretroviral therapy). We estimated proportion and adjusted Prevalence Risk Ratios (adj. PRR) of non-enrollment into care six months after receipt of VCT using log-binomial regression. About 1145 HIV-positive participants in the Rakai Community Cohort Study accepted VCT and were referred for care. However, 31.5% (361/1145) did not enroll into HIV care six months after referral. Non-enrollment was significantly higher among men (38%) compared to women (29%, p=0.005). Other factors associated with non-enrollment included: younger age (15-24 years, adj. PRR = 2.22; 95% CI: 1.64, 3.00), living alone (adj. PRR = 2.22; 95% CI: 1.57, 3.15); or in households with 1-2 co-residents (adj. PRR = 1.63; 95% CI: 1.31, 2.03) compared to three or more co-residents, or a CD4 count >250 cells/ul (adj. PRR = 1.81; 95% CI: 1.38, 2.46). Median (IQR) CD4 count was lower among enrolled 388 cells/ul (IQR: 211,589) compared to those not enrolled 509 cells/ul (IQR: 321,754). About one-third of HIV-positive persons failed to utilize community-based free services. Non-use of services was greatest among men, the young, persons with higher CD4 counts and the more socially isolated, suggesting a need for targeted strategies to enhance service uptake.     

HIV/AIDS risks among Native American drug users: key findings from focus group interviews and implications for intervention strategies.

A multisite study funded through the National Institute on Drug Abuse and the Office of Research on Minority Health was conducted in 1996 to determine the HIV/AIDS prevention needs of Native American out-of-treatment drug users. In an effort to recommend directions for HIV/AIDS prevention programming, one component of this study entailed conducting a series of focus groups at each of four sites: Anchorage, Alaska; Denver, Colorado; Flagstaff, Arizona; and Tucson, Arizona. While some site differences were noted, several consistent thematic findings were revealed across all locations. Specifically, focus group members strongly recommended directly involving key members of the Native American community in conducting outreach and intervention activities, involving Native people as the sources of information, and utilizing local and tribally relevant forms of delivering the message. Other consistent themes included getting messages to smaller communities to prevent the potential "annihilation" of tribes, educating youth, and linking alcohol prevention education to HIV/AIDS education. Findings from this study support the idea that future HIV/AIDS prevention programs must take into account subgroup and individual level differences among Native American drug users.     

Precision Medicine,Healthy Living and the Complex Patient: Managing the Patient With Multimorbidity

Multimorbidity is the most common chronic health condition in adults and is associated with poor health outcomes. Optimal care for people with multimorbidity requires a person-centred approach that considers goals and preferences, improves quality of life and coordinates care across services. Because care is focused on patient outcomes, rather than disease outcomes, this provides an ideal setting for delivery of the Healthy Living Polypill (HLPP). Precision in delivery of the HLPP for people with multimorbidity involves active participation of patients in goal setting, strategies to address functional limitations and frailty, and support to develop the self-management skills necessary to adopt and sustain healthy behaviours. The multidisciplinary team is a key feature of integrated care for people with multimorbidity and all members should have the necessary skills to deliver the HLPP. Integration and continuity across health and social care sectors enhances outcomes and increases opportunities for personalised delivery of the HLPP.     

HIV/AIDS stigma at the workplace: Exploratory findings from Pakistan

People living with HIV/AIDS (PLHA) are stigmatised socially. They are devalued and considered like outcasts by having lesser opportunities for education, treatment and housing, and in an organisational context they get reduced opportunities of selection, promotion and income. The phenomena have been extensively researched in developed countries but limited literature addresses the situation in underdeveloped countries like Pakistan, which is also facing spread of the HIV/AIDS epidemic. There are a number of groups who are carrying the disease but the problems being faced by PLHA employed in different organisations have rarely been analysed. Stigma at the workplace can generate a number of negative outcomes. The present study considers two such outcomes among stigmatised PLHA. These outcomes are organisational cynicism and breach of psychological contract. A questionnaire was used to collect data from a sample of 174 PLHA, having a work experience after identification of the epidemic, working in different organisations across Pakistan. These PLHA were identified and recruited through a scattered record available with some government/non-government organisations operating in Pakistan to control HIV/AIDS. Findings of the study extend the knowledge about HIV/AIDS stigma indicating that PLHA are subjected to stigma, which is significantly associated with a breach of psychological contract and organisational cynicism. There is a need at governmental and organisational level as well to increase awareness about the disease and formulate policies to reduce stigma against PLHA working in different organisations.     

Improving psychological outcomes for orphans living with HIV in Tanzania through a novel intervention to improve resilience: findings from a pilot RCT

Parental death and HIV are associated with poor mental health for orphans in sub-Saharan Africa. This study aimed to evaluate a theory-based intervention for orphaned children on treatment in Tanzania, in terms of feasibility, acceptability and preliminary outcomes. A pilot RCT with nested focus group (FGD) allocated 48 children to usual care or residential “Memory Work Therapy”. Children completed outcome measures at T0 (baseline), T1 (2 weeks following intervention) and T2 (9 weeks from T0). Forty percent of eligible children assented. T1 intervention effects were found on all total measures: Brief Symptom Inventory d?=?0.99, p?<?.001; Rosenberg Self Esteem Scale d?=?0.65, p?=?.001; Strengths and Difficulties Questionnaire d?=?0.64, p?=?.002; Self-efficacy questionnaire for children both “social” and “emotional” subscales, d?=?0.54, p?=?.008 and d?=?0.63, p?=?.002, respectively. At T2, significant effects remained for all measures and SES effect increased from medium to large (T1?=?0.65, T2?=?1.33). FGD data found children valued a calm environment that met their basic needs, enabling them to reflect, highlight support resources, and strengthen ability to recognize personal skills. The intervention has strong feasibility and acceptability, with no attrition or missing data. Memory Work Therapy has high potential effect size and should be tested in a fully powered trial. Clinical trials.gov NCT02180750.     

New insights into HIV epidemic in South Africa: key findings from the National HIV Prevalence,Incidence and Behaviour Survey, 2012

This article presents key findings from the 2012 HIV prevalence, incidence and behaviour survey conducted in South Africa and explores trends in the HIV epidemic. A representative household based survey collected behavioural and biomedical data among people of all ages. Chi-squared test for association and formal trend tests (2002, 2005, 2008 and 2012) were used to test for associations and trends in the HIV epidemic across the four surveys. In 2012 a total of 38 431 respondents were interviewed from 11 079 households; 28 997 (67.5%) of 42 950 eligible individuals provided blood specimens. HIV prevalence was 12.2% [95% CI: 11.4–13.1] in 2012 with prevalence higher among females 14.4% than males 9.9%. Adults aged 25–49 years were most affected, 25.2% [95% CI: 23.2–27.3]. HIV prevalence increased from 10.6% [95%CI: 9.8–11.6] in 2008 to 12.2% [95% CI: 11.4–13.1] in 2012 (p < 0.001). Antiretroviral treatment (ART) exposure doubled from 16.6% in 2008 to 31.2% in 2012 (p < 0.001). HIV incidence in 2012 among persons 2 years and older was 1.07% [95% CI: 0.87–1.27], with the highest incidence among Black African females aged 20–34 years at 4.5%. Sexual debut before 15 years was reported by 10.7% of respondents aged 15–24 years, and was significantly higher among male youth than female (16.7% vs. 5.0% respectively, p < 0.001). Reporting of multiple sexual partners in the previous 12 months increased from 11.5% in 2002 to 18.3% in 2012 (p < 0.001). Condom use at last sex dropped from 45.1% in 2008 to 36.2% in 2012 (p < 0.001). Levels of accurate HIV knowledge about transmission and prevention were low and had decreased between 2008 and 2012 from 31.5% to 26.8%. South Africa is on the right track with scaling up ART. However, there have been worrying increases in most HIV-related risk behaviours. These findings suggest that there is a need to scale up prevention methods that integrate biomedical, behavioural, social and structural prevention interventions to reverse the tide in the fight against HIV.     

Who Benefited from an Efficacious Intervention for Youth Living with HIV: A Moderator Analysis

An efficacious intervention that results in young people living with HIV (YPLH) reducing their transmission risk has been identified. The present study identifies who is most likely to benefit from the intervention. Regression models were used to examine whether background contextual factors moderated the intervention’s success. Percentage of protected sex was moderated by ethnicity, use of antiretroviral medications (ARV), healthcare utilization and mental health. Number of partners was moderated by anxiety and depression. When deciding if an intervention is appropriate and beneficial for an individual young person, consideration must be given to type of services the youth currently accesses and the youth’s mental health.     

Employers’ views of the “Healthy Hub Roadshow”: a workplace HIV testing intervention in England*

We explored employer uptake and perceptions of workplace human immunodeficiency virus (HIV) testing delivered to employees as part of Healthy Hub Roadshow, a multi-component general health check. Intervention included health checks with tailored advice delivered to 776 employees at 20 events hosted by 11 different workplaces (29 approached, 38% employer uptake). Delivery partners were third sector organisations with significant expertise in HIV testing and support. Health checks included optional HIV test (using 4th generation Insti finger prick rapid tests), Body Mass Index (BMI), blood glucose, blood pressure, and cholesterol. Mixed-methods evaluation included post-event online survey and qualitative interviews with participating employers. Declining employers were invited to complete an online feedback survey.

Workplace HIV testing was positively received by all participating organisations, although 78% (14/18) of declining organisations did not provide their reasons for non-participation. Factors of importance to employers included the perceived trustworthiness of delivery partners, being able to provide engaging opportunities for employee health, offering HIV testing as part of a wider health check, and having visible top-level managerial support. Concerns about hosting the events were rare and related to having limited budgets for future events, and the potential loss of productivity related to attendance during work time. Employers indicated that they would not actively seek out workplace HIV testing as part of health promotion efforts, but they were highly receptive to its inclusion in workplace health and wellbeing provision by credible external delivery partners.

In conclusion, workplaces are an untapped arena for HIV awareness raising and testing in the UK. Employers should be encouraged and supported to offer opt-in HIV testing as part of a wider workplace health and wellbeing provision for employees.     

The impact of neurobehavioral features on medication adherence in HIV: Evidence from longitudinal models

Effective antiretroviral therapy has led to substantial improvements in health-related outcomes among individuals with HIV. Despite advances in HIV pharmacotherapy, suboptimal medication adherence remains a significant barrier to successful treatment. Although several factors have been associated with medication adherence in the extant literature, study assessing the effects of some of the neurobehavioral features specific to HIV has been limited. Moreover, although there is a growing body of literature measuring medication adherence in HIV prospectively, few employ advanced statistical methodologies suited to handle advanced models with multiple predictors that would strengthen our understanding of medication adherence trajectories in HIV. This study sought to integrate traditionally assessed predictors of medication adherence with neurobehavioral features of HIV in a longitudinal study of medication adherence to combined antiretroviral therapy (cART). The current study used multilevel modeling to examine a wide arrangement of categories of factors – demographic, medication related, psychosocial, and neurobehavioral – on medication adherence. The sample consisted of 235 HIV+ individuals whose medication adherence was monitored over the course of six months using electronic monitoring devices. After controlling for the effects of demographic, medication, and psychosocial factors, neurobehavioral features added predictive validity to the model. In the final model, simultaneously controlling for the effects of each of the predictors within all the categories, age, self-efficacy, executive functioning, apathy, and frequency of stimulant use emerged as unique individual predictors of average medication adherence across the 6-month study. Self-efficacy and irritability predicted changes in medication adherence over time. Adherence behavior is multidetermined. Adequate assessment of these factors, combined with timely intervention, appears to be warranted in order to boost adherence rates.     

Professionally Moderated,Psychoeducational, Web-Based Support for Women Living with HIV: An Exploratory Study

Women living with HIV (WLWH) face stress and stigma due to their HIV status, and web-based support groups may provide a beneficial means for connection and education. This paper presents an exploratory study examining the feasibility and potential benefits of a professionally moderated, psychoeducational, web-based support group for WLWH. Ten women participated and the average number of weekly posts was 13.38. Active participants were more likely to be White and have a history of suicidality/self-harm. Findings suggest that future implementations may lead to improvements in depression, anxiety, and post-traumatic growth. Results substantiate prior research and provide a foundation for future interventions.     

A randomized controlled psycho-education intervention trial: Improving psychological readiness for successful HIV medication adherence and reducing depression before initiating HAART

The purpose of this study was to evaluate a novel psycho-educational intervention intended to increase patients' medication preparedness and treatment adherence skills before initiating highly active antiretroviral therapy (HAART). Sixty-three HIV-positive patients not currently on antiretroviral therapy participated in a randomized controlled trial of a standardized, four-session psycho-educational intervention (Supportive Therapy for Adherence to Antiretroviral Treatment; STAART). Session topics included learning techniques to increase medication adherence and learning effective strategies to cope with stress and depression. Patients completed psychological questionnaires assessing psychological readiness to initiate HAART and depressed mood. They completed both measures at study baseline and at four-weeks post-baseline. After controlling for baseline medication readiness scores, intervention patients (n = 30) reported significantly higher mean medication readiness following the STAART intervention (four-weeks post-baseline) (27.3+/-6.9) compared to controls (n = 33; 24.6+/-9.9; p < 0.05). Among depressed patients (n = 27), those receiving the intervention (n = 15) reported significantly lower mean depression scores at four-weeks post-baseline (22.5+/-12.9) compared to controls (n = 12; 27+/-9.9; p < 0.05). The STAART intervention enhanced HIV treatment readiness by better preparing patients prior to initiating HAART. It was also beneficial for reducing depressive symptoms in depressed, HIV-positive patients.     

HIV Screening Practices for Living Organ Donors, New York State, 2010: Need for Standard Policies

Our survey of kidney and liver transplant centers in New York State found a wide variation among transplant centers in evaluation and screening for HIV risk and infection among prospective living donors. Survey results underscore the need to standardize practices. A recent transmission of human immunodeficiency virus (HIV) from a living donor to a kidney recipient revealed a possible limitation in existing screening protocols for HIV infection in living donors. We surveyed kidney and liver transplant centers (N?=?18) in New York State to assess HIV screening protocols for living donors. Although most transplant centers evaluated HIV risk behaviors in living donors, evaluation practices varied widely, as did the extent of HIV testing and prevention counseling. All centers screened living donors for serologic evidence of HIV infection, either during initial evaluation or ≥1 month before surgery; however, only 50% of transplant centers repeated HIV testing within 14 days before surgery for all donors or donors with specific risk behaviors. Forty-four percent of transplant centers used HIV nucleic acid testing (NAT) to screen either all donors or donors with recognized risk behaviors, and 55% never performed HIV NAT. Results suggest the need to standardize evaluation of HIV risk behaviors and prevention counseling in New York State to prevent acquisition of HIV by prospective living organ donors, and to conduct HIV antibody testing and NAT as close to the time of donation as possible to prevent HIV transmission to recipients.