Erika Aaron

A mixed methods evaluation of the effect of the protect and respect intervention on the condom use and disclosure practices of women living with HIV/AIDS.

This mixed methods study evaluated the efficacy of an intervention to increase HIV status disclosure and condom use among 184 women living with HIV/AIDS (WLH/A). Participants were recruited from an HIV clinic and randomly assigned to: (1) a comparison group, who received brief messages from their health care providers (HCPs), or; (2) an intervention group, who received messages from HCPs, a group-level intervention, and peer-led support groups. Participants completed risk surveys at baseline, 6-, 12-, and 18-months. Quantitative analyses using hierarchical generalized linear models within a repeated measures framework indicated that intervention participants had significantly higher odds of reporting condom use with sexual partners in months 6 and 18. Grounded Theory-based qualitative analyses suggested that the opportunity to discuss the social context of their lives in addition to HIV/AIDS, including continued stigma and fear related to disclosure, are also essential components of a prevention strategy for WLH/A.

The importance of identifying and treating depression in HIV infected, pregnant women: a review

Women make up approximately half of all HIV infections worldwide. A substantial number of women living with HIV in the United States are of childbearing age and many of these women will become pregnant each year. These women must navigate the complexities of two health concerns (HIV infection and pregnancy) and the complexities of two health care provision systems (obstetrics and infectious disease). The goal of HIV treatment during pregnancy is to optimize health of the mother and minimize risk of vertical transmission. To realize these goals, high levels of adherence to antiretroviral therapy (ART) and periodic contact with medical professionals are required. Depression is not uncommon in pregnant women and has been identified as a robust predictor of non-adherence to ART and implicated in difficulty utilizing prenatal care. The purpose of the current article is to review evidence in support of diagnosis and treatment, when appropriate, of unipolar depression in HIV positive, pregnant women in developed nations. The article begins by defining the scope of the problem. Assessment and treatment options are discussed, followed by suggestions for future research.

Rates and predictors of prenatal depression in women living with and without HIV

Depression is a significant mental health and public health concern, and women living with HIV are at increased risk for depression. This risk may be especially elevated during pregnancy; however, few studies have attempted to identify rates and predictors of depression in pregnant, HIV-infected women. The purpose of the present study was to investigate rates and predictors of prenatal depression, such as history of depression, childhood sexual abuse (CSA), and social support among HIV-infected and HIV-uninfected women in Philadelphia, Pennsylvania. It was hypothesized that pregnant women with HIV will have higher rates of depressive symptoms and will exhibit a greater number of mood disorder diagnoses as compared to HIV-uninfected pregnant women. It was also hypothesized that HIV status, history of depression, CSA, and inadequate social support will emerge as predictors of depressive symptoms. A sample of 163 women, 31% (n=50) of whom were HIV-infected and 69% (n=113) of whom were HIV-uninfected, were recruited from an obstetrics/gynecology clinic affiliated with an urban university hospital. The Center for Epidemiological Studies-Depression Scale (CES-D) was used to identify depressive symptoms, and Modules A and D of the Structured Clinical Interview for DSM-IV (SCID) confirmed the presence of a mood disorder. Findings demonstrated that rates of depressive symptoms and mood disorder diagnoses during pregnancy did not differ according to HIV serostatus. History depression, CSA, and inadequate social support predicted depressive symptoms during pregnancy in this sample. Due to their association with depressive symptoms, history of depression, CSA, and inadequate social support may be important to identify during pregnancy.

Preconception and Contraceptive Care for Women Living with HIV

Women living with HIV have fertility desires and intentions that are similar to those of uninfected women, and with advances in treatment most women can realistically plan to have and raise children to adulthood. Although HIV may have adverse effects on fertility, recent studies suggest that antiretroviral therapy may increase or restore fertility. Data indicate the increasing numbers of women living with HIV who are becoming pregnant, and that many pregnancies are unintended and contraception is underutilized, reflecting an unmet need for preconception care (PCC). In addition to the PCC appropriate for all women of reproductive age, women living with HIV require comprehensive, specialized care that addresses their unique needs. The goals of PCC for women living with HIV are to prevent unintended pregnancy, optimize maternal health prior to pregnancy, improve maternal and fetal outcomes in pregnancy, prevent perinatal HIV transmission, and prevent HIV transmission to an HIV-uninfected sexual partner when trying to conceive. This paper discusses the rationale for preconception counseling and care in the setting of HIV and reviews current literature relevant to the content and considerations in providing PCC for women living with HIV, with a primary focus on well-resourced settings.

Preexposure prophylaxis for the prevention of HIV transmission to women.

The Food and Drug Administration (FDA) recently approved a new preexposure prophylaxis (PrEP) indication for emtricitabine/tenofovir for men and women, allowing a new effective HIV prevention intervention. Recent clinical trials have demonstrated the efficacy of PrEP in reducing the risk of HIV acquisition among women. Its efficacy depends largely on adherence. Perception of HIV risk appears to drive adherence to PrEP. What motivates PrEP use is specific to the population and its unique vulnerabilities. Future interventions exploring the efficacy of PrEP must include a behavioral arm that is specific to the unique vulnerabilities of the population being studied.There are an estimated 140 000 heterosexual serodiscordant couples in the United States; approximately, half of these couples desire conception. HIV-uninfected women in serodiscordant couples seeking conception may prove to be an ideal population for PrEP. Periconceptional PrEP in highly motivated couples could be not only effective but also affordable and feasible.In order to make PrEP accessible to those populations most vulnerable to HIV infection, the following steps need to occur: PrEP needs to be affordable, particularly for those uninsured; HIV providers, primary care practitioners, and reproductive healthcare providers need to welcome PrEP as a component of their scope of practice; clinicians need to take adequate sexual histories of all their patients in order to identify those at risk and best candidates for PrEP; and identifying ways to promote adherence must include population-specific PrEP adherence interventions.

Adverse Events in a Cohort of HIV Infected Pregnant and Non-Pregnant Women Treated with Nevirapine versus Non-Nevirapine Antiretroviral Medication

Background Predictors of adverse events (AE) associated with nevirapine use are needed to better understand reports of severe rash or liver enzyme elevation (LEE) in HIV+ women. Methodology AE rates following ART initiation were retrospectively assessed in a multi-site cohort of 612 women. Predictors of onset of rash or LEE were determined using univariate and multivariate analyses. Principal Findings Of 612 subjects, 152 (24.8%) initiated NVP-based regimens with 86 (56.6%) pregnant; 460 (75.2%) initiated non-NVP regimens with 67 (14.6%) pregnant. LEE No significant difference was found between regimens in the development of new grade ≥2 LEE (p = 0.885). Multivariate logistic regression demonstrated an increased likelihood of LEE with HCV co-infection (OR 2.502, 95% CI: 1.04 to 6, p = 0.040); pregnancy, NVP-based regimen, and baseline CD4 >250 cells/mm3 were not associated with this toxicity. Rash NVP initiation was associated with rash after controlling for CD4 and pregnancy (OR 2.78; 95%CI: 1.14–6.76), as was baseline CD4 >250 cells/mm3 when controlling for pregnancy and type of regimen (OR 2.68; 95% CI: 1.19–6.02 p = 0.017). Conclusions CD4 at initiation of therapy was a predictor of rash but not LEE with NVP use in HIV+ women. Pregnancy was not an independent risk factor for the development of AEs assessed. The findings from this study have significant implications for women of child-bearing age initiating NVP-based ART particularly in resource limited settings. This study sheds more confidence on the lack of LEE risk and the need to monitor rash with the use of this medication.

The Protect and Respect Program: A Sexual Risk Reduction Intervention for Women Living with HIV/AIDS

In 2003 the Centers for Disease Control and Prevention (CDC) launched a new HIV prevention strategy that focused prevention efforts on people living with HIV. In response to a Health Resources and Services Administration (HRSA)/Special Projects of National Significance (SPNS) initiative, a program development team in Philadelphia created the Protect and Respect program. The program integrates multiple-level prevention strategies and is tailored to address the strengths of HIV-positive women and the challenges they face to implementing behavior changes. The goal of Protect and Respect is to decrease sexual behavior that puts HIV-positive women at risk for sexually transmitted infections (STIs) and puts others at risk for HIV transmission. The three components of the program are: brief HIV prevention messages delivered by clinicians in the context of routine medical visits; a group-level intervention (GLI) delivered by a Health Educator; and a Peer-led support group. This paper details the process of developing the three program components and describes the valuable lessons learned through the development and implementation process.

Small-for-Gestational-Age Births in Pregnant Women with HIV, due to Severity of HIV Disease, Not Antiretroviral Therapy

Objectives. To determine rate and factors associated with small-for-gestational-age (SGA) births to women with HIV. Methods. Prospective data were collected from 183 pregnant women with HIV in an urban HIV prenatal clinic, 2000–2011. An SGA birth was defined as less than the 10th or 3rd percentile of birth weight distribution based upon cut points developed using national vital record data. Bivariate analysis utilized chi-squared and t-tests, and multiple logistic regression analyses were used. Results. The prevalence of SGA was 31.2% at the 10th and 12.6% at the 3rd percentile. SGA at the 10th (OR 2.77; 95% CI, 1.28–5.97) and 3rd (OR 3.64; 95% CI, 1.12–11.76) percentiles was associated with cigarette smoking. Women with CD4 count >200 cells/mm3 at the first prenatal visit were less likely to have an SGA birth at the 3rd percentile (OR 0.29; 95% CI, 0.10–0.86). Women taking NNRTI were less likely to have an SGA infant at the 10th (OR 0.28; 95% CI, 0.10–0.75) and 3rd (OR 0.16; 95% CI, 0.03–0.91) percentiles compared to those women on PIs. Conclusions. In this cohort with high rates of SGA, severity of HIV disease, not ART, was associated with SGA births after adjusting for sociodemographic, medication, and disease severity.

Providing Sensitive Care for Adult HIV-Infected Women With a History of Childhood Sexual Abuse

&NA; Childhood sexual abuse (CSA) is a serious public health issue. Women with HIV who have a history of CSA are at increased risk for sporadic medical treatment, nonadherence to HIV medications, and HIV risk behaviors. These associations pose a challenge to providing health care for this population and are complicated by the possible psychological sequelae of CSA, such as anxiety, depression, dissociation, and posttraumatic stress disorder. This article reviews the effects of CSA on the health status of women with HIV, barriers to treatment adherence, suggested components of trauma‐sensitive medical care, and mental health approaches. A trauma‐informed, trauma‐sensitive care model that addresses barriers associated with health care for women with a history of CSA is suggested. Specific recommendations are offered for the provision of effective clinical care for women with HIV who also have a history of CSA to help HIV care providers better recognize and appreciate the distinct needs of this patient population.

Knowledge, Attitudes, and Acceptability of Pre-Exposure Prophylaxis among Individuals Living with HIV in an Urban HIV Clinic

Introduction Pre-exposure prophylaxis (PrEP) is an effective tool to reduce HIV transmission. The primary objective of this study was to assess awareness of PrEP by individuals living with HIV (HIV+) and acceptance of its use for their HIV negative (HIV-) partners. Methods A cross sectional survey was conducted among individuals living with HIV who received care at an urban HIV clinic between January 2013 and June 2013. The survey examined knowledge, attitudes, and acceptability of PrEP, and perception of transmission risk of HIV. Chi-Square test and Fishers Exact test were used to compare proportions. Results Among 206 subjects living with HIV, 15.3% (32) had heard of PrEP. Men who have sex with men (MSM) were more likely to be aware of PrEP than all others (p = 0.003). Once educated about PrEP those who believed PrEP would reduce their partner’s risk for HIV were more likely to recommend PrEP to their partner (p<0.001). 92% of all respondents said they would be “extremely likely/likely” to discuss PrEP use with their provider. Of 159 subjects whose main partner was HIV-, MSM (p = 0.007), male participants (p = 0.044), and those who were consistently taking meds (p = 0.049) were more likely to be aware of PrEP. Those who perceived they were at risk of transmitting HIV (p<0.001) and those who were consistently taking meds (0.049) were more likely to agree that PrEP could reduce the risk of HIV to their partners. Conclusion This study illustrates a low awareness of PrEP but once educated the willingness of a cohort of individuals living with HIV to recommend PrEP to their partners. Our findings demonstrate the importance of providers informing their patients living with HIV about PrEP, as these persons are an underutilized link to support the uptake of PrEP by their HIV- partners.