Andrea Sankar

What do we know about older adults and HIV? a review of social and behavioral literature

Abstract The fastest growing segment of the United States HIV population is people aged 50 and older. This heterogeneous group includes people with diverse pathways into HIV positive status in later life, including aging with the disease as well as later life-acquired infections. As people with HIV live into older ages, solving problems of successful secondary prevention and ongoing treatment requires more specific knowledge of the particular aging-related contextual sociocultural, psychosocial, and personal factors salient to the situations of persons living with HIV. Greater knowledge of these factors will help solve challenges to reducing psychological burden and promoting health maintenance for people with HIV. Yet, the current literature on aging and HIV remains nascent. To assess the state of knowledge of the sociocultural and behavioral factors associated with aging with HIV, we conducted a systematic critical content review of peer-reviewed social and behavioral research on aging and HIV to answer the question, “How have older age, and social, cultural, and behavioral aspects of the intersection of HIV and age been addressed in the literature?” We searched First Search, Proquest, Psych Info, Pub Med, Wilson Select Plus, and World Cat and identified 1549 articles. We then reviewed these to select peer-reviewed articles reporting results of research on the social and behavioral aspects of living with HIV at age 50 and older. Fifty-eight publications were identified that met study inclusion criteria. While few publications reported clear age-related differences, there were significant ethnic differences in living with HIV in later life and also differences among older people when groups were defined by mode of transmission. Findings are discussed in light of constructs from gerontology which may contribute to clarifying how later life, life course stage, and psychological development intersect with, influence, and are influenced by HIV disease and long-term anti-retroviral therapy use.

A Multicenter Study of Physician Mindfulness and Health Care Quality

PURPOSE Mindfulness (ie, purposeful and nonjudgmental attentiveness to one’s own experience, thoughts, and feelings) is associated with physician well-being. We sought to assess whether clinician self-rated mindfulness is associated with the quality of patient care. METHODS We conducted an observational study of 45 clinicians (34 physicians, 8 nurse practitioners, and 3 physician assistants) caring for patients infected with the human immunodeficiency virus (HIV) who completed the Mindful Attention Awareness Scale and 437 HIV-infected patients at 4 HIV specialty clinic sites across the United States. We measured patient-clinician communication quality with audio-recorded encounters coded using the Roter Interaction Analysis System (RIAS) and patient ratings of care. RESULTS In adjusted analyses comparing clinicians with highest and lowest tertile mindfulness scores, patient visits with high-mindfulness clinicians were more likely to be characterized by a patient-centered pattern of communication (adjusted odds ratio of a patient-centered visit was 4.14; 95% CI, 1.58–10.86), in which both patients and clinicians engaged in more rapport building and discussion of psychosocial issues. Clinicians with high-mindfulness scores also displayed more positive emotional tone with patients (adjusted β = 1.17; 95% CI, 0.46–1.9). Patients were more likely to give high ratings on clinician communication (adjusted prevalence ratio [APR] = 1.48; 95% CI, 1.17–1.86) and to report high overall satisfaction (APR = 1.45; 95 CI, 1.15–1.84) with high-mindfulness clinicians. There was no association between clinician mindfulness and the amount of conversation about biomedical issues. CONCLUSIONS Clinicians rating themselves as more mindful engage in more patient-centered communication and have more satisfied patients. Interventions should determine whether improving clinician mindfulness can also improve patient health outcomes.

How qualitative methods contribute to understanding combination antiretroviral therapy adherence

Summary:Strict adherence to medication regimens is generally required to obtain optimal response to combination antiretroviral therapy (ART). Yet, we have made limited progress in developing strategies to decrease the prevalence of nonadherence. As we work to understand adherence in developed countries, the introduction of ART in resource-poor settings raises novel challenges. Qualitative research is a scientific approach that uses methods such as observation, interviews, and verbal interactions to gather rich in-depth information about how something is experienced. It seeks to understand the beliefs, values, and processes underlying behavioral patterns. Qualitative methods provide powerful tools for understanding adherence. Culture-specific influences, medication beliefs, access, stigma, reasons for nonadherence, patterns of medication taking, and intervention fidelity and measurement development are areas ripe for qualitative inquiry. A disregard for the social and cultural context of adherence or the imposition of adherence models inconsistent with local values and practices is likely to produce irrelevant or ineffective interventions. Qualitative methods remain underused in adherence research. We review appropriate qualitative methods for and provide an overview of the qualitative research on ART nonadherence. We discuss the rationales for using qualitative methods, present 2 case examples illustrating their use, and discuss possible institutional barriers to their acceptance.

Differences in Patient–Provider Communication for Hispanic Compared to Non-Hispanic White Patients in HIV Care

BackgroundHispanic Americans with HIV/AIDS experience lower quality care and worse outcomes than non-Hispanic whites. While deficits in patient–provider communication may contribute to these disparities, no studies to date have used audio recordings to examine the communication patterns of Hispanic vs. non-Hispanic white patients with their health care providers.ObjectiveTo explore differences in patient–provider communication for English-speaking, HIV-infected Hispanic and non-Hispanic white patients.DesignCross-sectional analysis.SettingTwo HIV care sites in the United States (New York and Portland) participating in the Enhancing Communication and HIV Outcomes (ECHO) study.SubjectsNineteen HIV providers and 113 of their patients.MeasurementsPatient interviews, provider questionnaires, and audio-recorded, routine, patient–provider encounters coded with the Roter Interaction Analysis System (RIAS).ResultsProviders were mostly non-Hispanic white (68%) and female (63%). Patients were Hispanic (51%), and non-Hispanic white (49%); 20% were female. Visits with Hispanic patients were less patient-centered (0.75 vs. 0.90, p = 0.009), with less psychosocial talk (80 vs. 118 statements, p < 0.001). This pattern was consistent among Hispanics who spoke English very well and those with less English proficiency. There was no association between patient race/ethnicity and visit length, patients’ or providers’ emotional tone, or the total number of patient or provider statements categorized as socioemotional, question-asking, information-giving, or patient activating. Hispanic patients gave higher ratings than whites (AOR 3.05 Hispanic vs. white highest rating of providers’ interpersonal style, 95% CI 1.20-7.74).ConclusionIn this exploratory study, we found less psychosocial talk in patient–provider encounters with Hispanic compared to white patients. The fact that Hispanic patients rated their visits more positively than whites raises the possibility that these differences in patient–provider interactions may reflect differences in patient preferences and communication style rather than “deficits” in communication. If these findings are replicated in future studies, efforts should be undertaken to understand the reasons underlying them and their impact on the quality and equity of care.

Patient–Provider Communication Differs for Black Compared to White HIV-Infected Patients

Poor patient–provider interactions may play a role in explaining racial disparities in the quality and outcomes of HIV care in the United States. We analyzed 354 patient–provider encounters coded with the Roter Interaction Analysis System across four HIV care sites in the United States to explore possible racial differences in patient–provider communication. Providers were more verbally dominant in conversations with black as compared to white patients. This was largely due to black patients’ talking less than white patients. There was no association between race and other measures of communication. Black and white patients rated their providers’ communication similarly. Efforts to more effectively engage patients in the medical dialogue may lead to improved patient–provider relationships, self-management, and outcomes among black people living with HIV/AIDS.

Sero-positive African Americans’ Beliefs about Alcohol and Their Impact on Anti-retroviral Adherence

Alcohol consumption has been associated with HIV disease progression; yet, the nature of this association is poorly understood. This study sought to determine the influence of patient beliefs about alcohol on ART adherence, and elucidate clinician beliefs about drinking and taking ART. Most patients (85%) believed alcohol and ART do not mix. The three alcohol consumption groups, light, moderate, and heavy, differed in their beliefs about drinking and ART with 64% of light and 55% of moderate drinkers skipping ART when drinking compared to 29% of heavy drinkers. Beliefs were derived from folk models of alcohol–ART interaction. Patients 50 and older were less likely to skip ART when drinking. Alcohol appears to affect adherence through decisions to forgo ART when drinking not through drunken forgetfulness. Furthermore, over one-half of clinicians believed alcohol and ART should not be taken together. These findings have implications for patient care and physician training.

HIV/AIDS and Aging Minority Populations:

This article focuses on emerging issues associated with HIV/AIDS in aging minoritypopulations. Based on a review of the literature as well as available national surveillance data, this article discusses current knowledge about HIV/AIDS in agingminority populations, particularly as they relate to sociodemographic, cultural, andhealth status factors. The authors not only examine the circumstances of older personsinfected by HIV/AIDS but also those affected by HIV/AIDS as a result of additionalof caregiving responsibilities. Recommendations for future research are provided.

Out of the clinic into the home: Control and patient-physician communication

The communication of information between patient and physician is a difficult and often flawed undertaking. Although the patient may be more immediately aware of dissatisfaction with the results, the presence of incomplete or inaccurate information will ultimately affect the physicians ability to function and the quality of care he can deliver. This is an especially important problem in chronic illness where the social, psychological and environmental factors which may impinge on the illness often cannot be identified or verified by laboratory tests. The physicians need to maintain control and hence power over the patient has been suggested as an explanation for these communication difficulties. This paper examines how the home setting influences physician control by including information about the patient and his disease which the clinic context actively excludes. It argues that the loss of control which physicians experience affects communication between patient and physician and thus the quality of information obtained in that communication, and further that the information gathered is important in the care of the long term chronically ill patient.

Comparative Perspectives on Living With HIV/AIDS in Late Life.

The effects of HIV/AIDS on different societies spanning the globe are only beginningto be described. This article describes HIV/AIDSs emerging impact and consequences for families and societies around the globe, with a primary focus onmiddle-aged and older members. It first provides the current data on the evolvinginternational profile of the HIV/AIDS epidemic. Then, using primary sources andpublished data, it explores three contrasting nation/state settings (Uganda, Thailand,and India) to describe the cultural, social structural, and family consequences ofHIV/AIDS. Findings include identification of emerging and potential strains on corecultural practices related to social integration at the community and family levels, aswell as shifts in normative role relationships between multiple generations. Directand indirect challenges to core moral and ethical issues beyond those simply relatedto infectious disease prevention and treatment are also identified. Finally, this articledraws on these explorations to formulate several key priorities for future research andpractice related to HIV/AIDS among older adults.

Gerontological research in China: The role of anthropological inquiry

One fifth of the worlds elderly population lives in China. Until recently political restrictions have hindered the conduct of research particularly ethnography. This piece provides an overview of recent research findings by Western scholars and of ethnographic research in progress in the areas of demography, state policy, age stratification, family planning, residence patterns, inter-generational transfers, patrilineality, health, illness, long term care, social welfare, and mortuary ritual. It analyzes the potential contributions of ethnography in this area.