Deborah J. Konkle-Parker

Visual analog scale of ART adherence: association with 3-day self-report and adherence barriers.

Background: Brief self-reports of antiretroviral therapy adherence that place minimal burden on patients and clinic staff are promising alternatives to more elaborate adherence assessments currently in use. This research assessed the association between self-reported adherence on visual analog scale (VASs) and an existing, more complex self-reported measure of adherence, the AACTG, and the degree to which each method distinguished optimally and suboptimally adherent patients in terms of reported barriers to adherence. Methods: HIV-infected patients (N = 147) at a southeastern US clinic completed a computerized assessment including an antiretroviral therapy adherence VAS, a modified version of the AACTG, and a measure of adherence. Results: Adherence rates were comparable across the AACTG (81%) and VAS (87%); they significantly correlated (r = 0.585) and produced identical classification of optimal (>90%) or suboptimal (<90%) adherence for 66% of patients. In general, VAS scores tended to be higher than AACTG scores. Suboptimally adherent patients reported more adherence barriers than those classified as optimally adherent, and those so classified by the VAS reported considerably more barriers to adherence than those so classified by the AACTG. Conclusions: Results generally support the construct validity of the VAS and its use as an easily administered assessment tool that can identify patients with barriers to adherence who might benefit from adherence support interventions.

Barriers and facilitators to medication adherence in a southern minority population with HIV disease.

Adherence to HIV medications has been an important focus over the past decade, but little is known about adherence barriers and facilitators specifically in that part of the United States known as the Deep South. Characteristics of the region may affect factors associated with adherence related to the patient, the patient-provider relationship, and the environment. A total of 20 HIV-infected clients of a large public infectious diseases clinic in the Deep South participated in one of three focus groups; themes were identified by content analysis. Barriers included the perceived burden of extra planning, denial, life stress, difficult characteristics of the medicines, social stigma, and shame. Facilitators included acceptance of the diagnosis, thinking about the consequences of not taking the medicines, prayer and spirituality, improvements in the medicines, and support from family and friends. In the South, faith and prayer may be strong facilitators that need to be considered when adapting existing adherence interventions.

The information-motivation-behavioral skills model of ART adherence in a deep south HIV+ clinic sample

High levels of adherence to antiretroviral therapy (ART) are critical to the management of HIV, yet many people living with HIV do not achieve these levels. There is a substantial body of literature regarding correlates of adherence to ART, and theory-based multivariate models of ART adherence are emerging. The current study assessed the determinants of adherence behavior postulated by the Information–Motivation–Behavioral Skills model of ART adherence in a sample of 149 HIV-positive patients in Mississippi. Structural equation modeling indicated that ART-related information correlated with personal and social motivation, and the two sub-areas of motivation were not intercorrelated. In this Deep South sample, being better informed, socially supported, and perceiving fewer negative consequences of adherence were independently related to stronger behavioral skills for taking medications, which in turn associated with self-reported adherence. The IMB model of ART adherence appeared to well characterize the complexities of adherence for this sample.

Reasons for ART non-adherence in the Deep South: Adherence needs of a sample of HIV-positive patients in Mississippi

Abstract HIV prevalence in the American Deep South has reached crisis proportions and greater numbers of patients are enrolling in clinical care and beginning antiretroviral therapy (ART). In order to gain maximum benefit from ART, patients must sustain high levels of adherence to demanding regimens over extended periods of time. Many patients are unable to maintain high rates of adherence and may need assistance to do so, which may be based upon an understanding of barriers to adherence for a given population. The current study sought to gain understanding of barriers to adherence for a mixed urban/rural HIV-positive patient population in Mississippi and to determine whether barriers to adherence may be specific to gender, employment, depressive symptoms or educational attainment status. Seventy-two patients who missed a dose of ART medication over the last three days endorsed the top five reasons for missing a dose as: (1) not having the medication with them, (2) sleeping through the dose time, (3) running out of the medication, (4) being busy with other things and (5) other. Reported barriers were fairly consistent across different groups, although women and those classified as having moderate to severe depressive symptoms reported different patterns of adherence barriers. Results suggest that adherence interventions implemented in the Deep South must take into account specific barriers faced by individuals within this region, where stigma, gender disparities and limited resources are prevalent.

Pilot testing of an HIV medication adherence intervention in a public clinic in the Deep South

Purpose: Strict adherence to HIV medications is critical to ensure long‐term disease control, and adherence interventions that are possible in a clinic setting with limited resources are needed. Data sources: This randomized controlled pilot study tested an adherence intervention guided by the Information‐Motivation‐Behavioral Skills (IMB) model. The intervention included HIV education, a peer video, motivational interviewing, and attention to behavioral skills including communication with providers and adherence‐enhancing devices. Dependent variables included 3‐4 week adherence recall, medication refill rate, changes in IMB subscale scores, appointment attendance, and HIV‐associated laboratory findings. Seventy‐three individuals starting or restarting antiretroviral therapy were enrolled and 56 were randomized. Conclusions: Improvements were seen in most outcomes, with small to moderate effect sizes, but the study was not powered to show statistical significance. Threats to power included a 51% attrition rate, resulting mostly from loss to clinical care or prolonged gaps in care. Implications for practice: A telephone‐based intervention to improve HIV medication adherence shows promise. Further study is needed with greater attention to retention in care.

Lessons learned from an HIV adherence pilot study in the Deep South

OBJECTIVE Adherence to treatment for chronic illnesses, including HIV disease, is a complex process, and needs practical interventions in poorly resourced clinic settings. METHODS This study tested the feasibility of an adherence intervention in 73 HIV-infected individuals in a Deep South public clinic based on Fisher & Fishers Information-Motivation-Behavioral Skills Model. RESULTS There was high baseline adherence and unexpectedly high clinic attrition, and 27% of the intervention group received less than one-quarter of the planned intervention contacts. Refill rate was the adherence measure that correlated best with HIV viral load and CD4 count, and there was poor use of electronic adherence monitoring (MEMS). Interviewed individuals expressed positive feelings about audio-supported computer-assisted survey instruments (ACASI) and the intervention support. CONCLUSIONS This process evaluation showed feasible study components in this population and setting. Lessons learned included: (1) clinic retention is an important part of adherence; (2) telephone interventions may need to add additional technology and flexibility to maximize dose; (3) ongoing fidelity monitoring is important with motivational interviewing; (4) refill rate was the most accurate adherence assessment; (5) MEMS was not well-accepted; (6) ACASI was easily used in this population; and (7) individuals appreciated adherence support from a consistent caring individual.

Effects of an Intervention Addressing Information, Motivation, and Behavioral Skills on HIV Care Adherence in a Southern Clinic Cohort

Multiple studies have shown that subtherapeutic appointment adherence and medication adherence are associated with worse clinical outcomes for people living with HIV disease. Thus, poor appointment and medication adherence diminish individual and community HIV control and transmission. Yet not enough is known about interventions that can improve retention in HIV care. The purpose of this study was to test an intervention to improve retention and/or medication adherence in a public clinic in the Deep South. One hundred participants with retention or medication adherence difficulties were randomized to either a six-month intervention or usual care, and followed longitudinally for one year. The intervention was multidimensional, based on the Information-Motivation-Behavioral Skills (IMB) model. The intervention addressed information about HIV and the importance of retention/adherence, motivation to be retained and/or adhere to medications, and the behavioral skills needed to manage and maintain these healthy behaviors in a combination of face-to-face and telephone sessions. The proportion of those with at least one visit in each four-month block (third) of the year increased in those with minimal exposure to the intervention (three out of eight intervention contacts) as compared to those with less intervention exposure (p = 0.098). Those with at least this minimal exposure averaged a significantly higher number of thirds that included a clinic visit as compared to those with less intervention exposure (p = 0.013). The intervention did not demonstrate a significant effect on medication adherence, though this is contradictory to a previous study testing a version of this intervention designed to address only medication adherence. Further study to increase uptake of the intervention is needed to increase its efficacy.

Physical activity levels and perceived benefits and barriers to physical activity in HIV-infected women living in the deep south of the United States†

ABSTRACT Engaging in regular physical activity (PA) is important in maintaining health and increasing the overall quality of life of people living with HIV (PLWH). The deep south of the USA is known for its high rate of sedentary behavior although data on the activity levels and perceptions of the benefits and barriers to exercise in women living with HIV in the deep south are lacking. Understanding the perceived benefits and barriers to exercise can guide the development of PA interventions. We conducted a cross-sectional study to determine the PA levels and perceived benefits and barriers to exercise associated with both age and depression level in a group of HIV+ women living in the deep south. We recruited a total of 50 participants from a cohort site for the Women’s Interagency HIV Study. Depression was assessed using the Center for Epidemiological Studies Depression Scale (CES-D) and benefits/barriers to exercise were measured using the Exercise Benefits and Barriers Scale (EBBS). We measured PA both subjectively and objectively using the International Physical Activity Questionnaire (IPAQ) and a Fitbit PA monitor, respectively. Our sample was predominantly African-American (96%) and the mean ±SD age, body mass index, and CES-D score were 42 ± 8.8 years, 36.6 ± 11.5 kg/m2, and 15.6 ± 11.4, respectively. Both subjective and objective measures of PA indicated that our participants were sedentary. The greatest perceived benefit to exercise was physical performance and the greatest barrier to exercise was physical exertion. Higher overall perceived benefits were reported by women ≥43 years and women reporting higher levels of depression. There was no difference in overall barriers associated with age and depression level, but women with depression felt more fatigued by exercise. The results of this study can be helpful when designing and implementing PA interventions in women living with HIV in the deep south.

Women’s decision-making about self-protection during sexual activity in the deep south of the USA: a grounded theory study

Abstract Many women continue to become infected with HIV, particularly in the Southeastern USA, despite widespread knowledge about methods to prevent its sexual transmission. This grounded theory investigation examined the decision-making process women use to guide their use or non-use of self-protective measures when engaging in sexual activity. Participants included women in the Mississippi cohort of the Women’s Interagency HIV Study who were infected with or at high risk for HIV. Theoretical sampling was used to recruit a sample of 20 primarily African American women aged between 26 and 56 years, living in rural and urban areas. Data were analysed using constant comparative method to generate a theory of the process that guided women’s self-protective decisions. Three key themes were identified: (1) sexual silence, an overall context of silence around sexuality in their communities and relationships; (2) the importance of relationships with male partners, including concepts of ‘love and trust’, ‘filling the void’ and ‘don’t rock the boat’; and (3) perceptions of risk, including ‘it never crossed my mind’, ‘it couldn’t happen to me’ and ‘assumptions about HIV’. These themes impacted on women’s understandings of HIV-related risk, making it difficult to put self-protection above other interests and diminishing their motivation to protect themselves.

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.