Aids Interventions

Motivational Enhancement System for Adherence (MESA): Pilot Randomized Trial of a Brief Computer-Delivered Prevention Intervention for Youth Initiating Antiretroviral Treatment

OBJECTIVE To pilot test a two-session computer-delivered motivational intervention to facilitate adherence among youth with HIV newly prescribed antiretroviral treatment (ART). METHODS Youth (N = 76) newly prescribed ART were recruited from 8 sites, and were randomized to the intervention or an active nutrition and physical activity control. Primary outcomes were HIV-1 viral load at baseline, 3 months, and 6 months, and self-reported adherence at 3 and 6 months. RESULTS Satisfaction ratings were high. Effect sizes suggested that the intervention group showed a greater drop than controls in viral load from baseline to 6 months (Cohens d = 0.39 at 3 months; d = 0.19 at 6 months), and had greater percent undetectable by 6 months (d = 0.28). Effects sizes were medium to large for 7-day and weekend adherence. CONCLUSIONS A brief computer-delivered motivational intervention showed promise for youth starting ART and is ready to be tested in a full-scale clinical trial.

Improving comprehension for HIV vaccine trial information among adolescents at risk of HIV.

Abstract A simplified version of the HIVNET prototype HIV vaccine process was developed for adolescents at risk of HIV by: (1) reducing reading level; (2) reorganizing; (3) adding illustrations; and (4) obtaining focus group feedback. Then adolescents (N = 187) in three cities were randomly assigned to the standard or simplified version. Adolescents receiving the simplified version had significantly higher comprehension scores (80% correct vs. 72% correct), with 37% of items significantly more likely to be answered correctly. They were also significantly more likely to recall study benefits and procedures. Overall, adolescents were less willing to participate in a potential HIV vaccine trial after presentation than prior to presentation. The present study indicates that it would be feasible for adolescents to participate in a vaccine trial, as simplification of vaccine information, combined with illustrations to depict key concepts, resulted in improved scores for adolescents on the comprehension and recall test.

Youth living with HIV and problem substance use: Elevated distress is associated with nonadherence and sexual risk

Purpose: To examine health risk behaviors in distressed youth living with HIV (YLH) with problem substance use. Methods: Assessed distress, antiretroviral (ARV) adherence, and unprotected sex in a racially and geographically diverse sample of 122 YLH. Results: A total of 87% of distressed YLH reported significantly more past-month ARV nonadherence (odds ratio [OR] = 7.15) and were more likely to have unprotected sex under the influence (OR = 5.14) than nondistressed youth. Conclusions: Distressed YLH with problem substance use may benefit from interventions to improve adherence and to decrease sexual risk, especially while under the influence of drugs.

Structural determinants of antiretroviral therapy use, HIV care attendance, and viral suppression among adolescents and young adults living with HIV

Background The authors examined associations between structural characteristics and HIV disease management among a geographically diverse sample of behaviorally and perinatally HIV-infected adolescents and young adults in the United States. Methods The sample included 1891 adolescents and young adults living with HIV (27.8% perinatally infected; 72.2% behaviorally infected) who were linked to care through 20 Adolescent Medicine Trials Network for HIV/AIDS Interventions Units. All completed audio computer–assisted self-interview surveys. Chart abstraction or blood draw provided viral load data. Geographic-level variables were extracted from the United States Census Bureau (e.g., socioeconomic disadvantage, percent of Black and Latino households, percent rural) and Esri Crime (e.g., global crime index) databases as Zip Code Tabulation Areas. AIDSVu data (e.g., prevalence of HIV among youth) were extracted at the county-level. Using HLM v.7, the authors conducted means-as-outcomes random effects multi-level models to examine the association between structural-level and individual-level factors and (1) being on antiretroviral therapy (ART) currently; (2) being on ART for at least 6 months; (3) missed HIV care appointments (not having missed any vs. having missed one or more appointments) over the past 12 months; and (4) viral suppression (defined by the corresponding assay cutoff for the lower limit of viral load at each participating site which denoted nondetectability vs. detectability). Results Frequencies for the 4 primary outcomes were as follows: current ART use (n = 1120, 59.23%); ART use for ≥6 months (n = 861, 45.53%); at least one missed HIV care appointment (n = 936, 49.50); and viral suppression (n = 577, 30.51%). After adjusting for individual-level factors, youth living in more disadvantaged areas (defined by a composite score derived from 2010 Census indicators including percent poverty, percent receiving public assistance, percent of female, single-headed households, percent unemployment, and percent of people with less than a high school degree) were less likely to report current ART use (OR: 0.85, 95% CI: 0.72–1.00, p = .05). Among current ART users, living in more disadvantaged areas was associated with greater likelihood of having used ART for ≥6 months. Participants living in counties with greater HIV prevalence among 13–24 year olds were more likely to report current ART use (OR: 1.32, 95% CI: 1.05–1.65, p = .02), ≥6 months ART use (OR: 1.32, 95% CI: 1.05–1.65, p = .02), and to be virally suppressed (OR: 1.50, 95% CI: 1.20–1.87, p = .001); however, youth in these areas were also more likely to report missed medical appointments (OR: 1.32, 95% CI: 1.07–1.63, p = .008). Conclusions The findings underscore the multi-level and structural factors associated with ART use, missed HIV care appointments, and viral suppression for adolescents and young adults in the United States. Consideration of these factors is strongly recommended in future intervention, clinical practice, and policy research that seek to understand the contextual influences on individuals’ health behaviors.

Heavy Marijuana Use Among Gay and Bisexual Male Emerging Adults Living With HIV/AIDS

Marijuana use has been documented to be higher among emerging adults than among other age groups in the United States. Persons living with HIV may use marijuana as a method for alleviating symptoms and side effects associated with treatment as well as a coping or mood adjustment strategy. The authors analyzed data from a two-phase mixed methods study of young HIV-positive gay/bisexual men to explore motivations for heavy marijuana use. Phase I consisted of semistructured qualitative interviews with 54 young gay/bisexual HIV-positive men (mean age 21.0 years) conducted at four geographically and demographically diverse sites. Phase II consisted of a computer-assisted quantitative survey administered to 200 young gay/bisexual HIV-positive men (mean age 21.1 years) across 14 clinical sites within the ATN. Phase I participants described marijuana use chiefly within the contexts of responses to initial HIV diagnosis, stress relief, and relaxation, including active and avoidant coping techniques. Phase II results revealed that almost one-quarter (23%) of the sample reported smoking marijuana every day, and another 16% said they smoked at least weekly but not daily. Logistic regression analysis determined significant predictors of at least weekly marijuana use to be using substances to relieve the stress of living with HIV (β = 1.04, p < .01), using substances alone (β = 2.05, p < .01), and using substances to reduce side effects of medication (β = 2.44, p < .01). Heavy marijuana use in our quantitative sample greatly exceeded rates reported in population-based studies of emerging adults and in previous studies of medicinal marijuana among persons living with HIV. These data have implications for self-care strategies among young persons living with HIV and intervention development for this population.

Perspectives of Community Partners and Researchers About Factors Impacting Coalition Functioning Over Time

This study explored organizational and contextual factors impacting coalition functioning across 15 community–researcher coalitions that were formed to lower rates of HIV among youth. Mixed-methods (qualitative and quantitative) longitudinal data were collected from both community partners and researchers across three time points, and were analyzed to assess factors associated with initial coalition development and functioning. Specific facilitators of coalition functioning over time included developing group trust and cohesion, creating diverse coalition membership, developing a shared vision, and ensuring clarity of coalition purpose and goals. Specific barriers to coalition functioning over time included experiencing a lack of clarity over member roles and responsibilities, balancing power/resource dynamics between researchers and community partners, balancing coalition building and coalition pace, and experiencing HIV/AIDS-related stigma. Recommendations are offered for how to develop and sustain successful community–researcher coalitions over time in order to address relevant social issues.

The Role of Community Resource Assessments in the Development of 15 Adolescent Health Community-Researcher Partnerships

Background: Connect to Protect (C2P): Partnerships for Youth Prevention Interventions is an initiative that alters the communitys structural elements to reduce youth HIV rates.Objectives: This study details a community resource assessment and describes how resources were evaluated in the context of local needs.Methods: Fifteen sites developed a community resource list, conducted a brief survey, created a youth service directory, and mapped where disease prevalence and community resources intersected. Sites also completed a survey to review and verify local site findings.Results: On average, sites identified 267 potential community resources. Sites narrowed their resource list to conduct a brief survey with 1,162 agencies; the site average was 78. Final products of this process included maps comparing resources with risk data.Conclusions: The evaluation of local resources is an important initial step in partnership development and is essential for the success of health promotion and disease prevention interventions that target adolescents.

Creating systems change to support goals for HIV continuum of care: The role of community coalitions to reduce structural barriers for adolescents and young adults

ABSTRACT Routine HIV screening, linkage, and retention in health care are nodes of the HIV continuum of care and goals of the National HIV/AIDS Strategy. However, up to 80% of youth are unaware of their HIV status, 29% are linked to and less than 50% are engaged in HIV health care, and fewer maintain viral suppression. To fill these gaps and to address the national call to establish a seamless system for quality HIV health care, the authors describe the processes by which the SMILE Program, with ATN-affiliated Connect-to-Protect® (C2P) community coalitions, addressed structural barriers that prevented HIV testing, linkage, and engagement in HIV health care among youth.

Differential Challenges in Coalition Building Among HIV Prevention Coalitions Targeting Specific Youth Populations

Coalitions provide the potential for merging the power, influence, and resources of fragmented individuals and institutions into one collective group that can more effectively focus its efforts on a specific community health issue. Connect to Protect® coalitions devote resources to address the HIV epidemic at a structural level. This study examines differential challenges in coalition processes that may hinder coalition building to achieve HIV prevention through structural change. Qualitative interviews conducted with community partners participating across 10 coalitions were analyzed to compare responses of those individuals working on HIV prevention coalitions targeting adolescent and young adult gay and bisexual men versus those targeting adolescent and young adult heterosexual women. Community partner responses revealed differences across several key areas including: (a) acceptability and goals in discussing sexual issues with adolescents, (b) goals of sexual health promotion activities, and (c) competition among collaborating agencies. Themes highlighted in this study can complement existing community intervention literature by helping community mobilizers, interventionists, and researchers understand how cultural norms affect youth-specific coalition work.

Moral conflict and competing duties in the initiation of a biomedical HIV prevention trial with minor adolescents

ABSTRACT Background: Biomedical HIV prevention research with minors is complicated by the requirement of parental consent, which may disclose sensitive information to parents. We examine the experience of principal investigators (PIs) and study personnel who faced this complex ethical issue in the first biomedical HIV prevention study that allowed minors to self-consent for enrollment. Methods: We conducted in-depth interviews with PIs and study personnel from 13 medical trial sites in cities across the United States. Data were analyzed using a conventional content analysis. Results: Participants experienced moral conflict as they struggled to fulfill conflicting duties in this trial involving minor adolescents with multiple vulnerabilities. Our participants experienced conflict between the two types of duties—protective and scientific—previously identified by Merritt. Protective duties were owed to the child, the parents, and the institution, and participants expressed tension between the actions that would protect these subgroups and the actions necessary to fulfill their scientific duties. Conclusions: Moral conflict was resolved in a variety of ways, including reflecting on the protocols alignment with federal regulations, modifying consent language, considering each individual for enrollment carefully, and accepting institutional review board (IRB) decisions. Potential solutions for future studies are discussed, and include flexible protocol consent procedures and centralized IRB reviews.