Jeffrey A. Kelly

Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease

New treatments for HIV can improve immune functioning and decrease mortality. However, lapses in adherence may render these complex regimens ineffective. Sixty-three men and 9 women on highly active antiretroviral therapy completed measures of medication adherence, psychological characteristics, and barriers to adherence. HIV viral load, a health outcome measure of virus amount present in blood, was also obtained. The sample was 36% African American and 56% Caucasian, with 35% reporting disability. Nearly one third of patients had missed medication doses in the past 5 days, and 18% had missed doses weekly over the past 3 months. Frequency of missed doses was strongly related to detectable HIV viral loads. Depression, side-effect severity, self-efficacy, and social support distinguished patients with good and poor adherence. Barriers also varied with adherence level. Implications for interventions promoting HIV treatment adherence are discussed.

HIV risk behavior reduction following intervention with key opinion leaders of population: an experimental analysis.

BACKGROUND AND PURPOSE Peer norms influence the adoption of behavior changes to reduce risk for HIV (human immunodeficiency virus) infection. By experimentally intervening at a community level to modify risk behavior norms, it may be possible to promote generalized reductions in HIV risk practices within a population. METHODS We trained persons reliably identified as popular opinion leaders among gay men in a small city to serve as behavior change endorsers to their peers. The opinion leaders acquired social skills for making these endorsements and complied in talking frequently with friends and acquaintances. Before and after intervention, we conducted surveys of men patronizing gay clubs in the intervention city and in two matched comparison cities. RESULTS In the intervention city, the proportion of men who engaged in any unprotected anal intercourse in a two-month period decreased from 36.9 percent to 27.5 percent (-25 percent from baseline), with a reduction from 27.1 percent to 19.0 percent (-30 percent from baseline) for unprotected receptive anal intercourse. Relative to baseline levels, there was a 16 percent increase in condom use during anal intercourse and an 18 percent decrease in the proportion of men with more than one sexual partner. Little or no change was observed among men in the comparison cities over the same period of time. CONCLUSIONS Interventions that employ peer leaders to endorse change may produce or accelerate population behavior changes to lessen risk for HIV infection.

Randomised, controlled, community-level HIV-prevention intervention for sexual-risk behaviour among homosexual men in US cities

BACKGROUND Community-level interventions may be helpful in population-focused HIV prevention. If members of populations at risk of HIV infection who are popular with other members can be engaged to advocate the benefits of behaviour change to peers, decreases in risk behaviour may be possible. We assessed a community-level intervention to lower the risk of HIV infection, focusing on men patronising gay bars in eight small US cities. METHODS We used a randomised community-level field design. Four cities received the intervention and four control cities did not. Participants were men from each city who went to gay bars. Men completed surveys about their sexual behaviour on entering the bars during 3-night periods at baseline and at 1-year follow-up. In the control cities, HIV educational materials were placed in the bars. In the intervention cities, we recruited popular homosexual men in the community and trained them to spread behaviour-change endorsements and recommendations to their peers through conversation. FINDINGS Population-level of risk behaviour decreased significantly in the intervention cities compared with the control cities at 1-year follow-up, after exclusion of surveys completed by transients and men with exclusive sexual partners in a city-level analysis, in the intervention cities we found a reduction in the mean frequency of unprotected anal intercourse during the previous 2 months (baseline 1.68 occasions; follow-up 0.59: p = 0.04) and an increase in the mean percentage of occasions of anal intercourse protected by condoms (baseline 44.7%; follow-up 66.8%, p = 0.02). Increased numbers of condoms taken from dispensers in intervention-city bars corroborated risk-behaviour self-reports. INTERPRETATION Popular and well-liked members of a community who systematically endorse and recommend risk-reduction behaviour can influence the sexual-risk practices of others in their social networks. Natural styles of communication, such as conversations, brought about population-level changes in risk behaviour.

Stigmatization of AIDS patients by physicians.

A randomly selected sample of physicians in three large cities was asked to read one of four vignettes describing a patient. They then completed a set of objective attitude measures eliciting their reactions to the patient described in the vignette. The vignettes were identical except that the patients illness was identified as either acquired immunodeficiency syndrome (AIDS) or leukemia and the patients sexual preference as either heterosexual or homosexual. Harsh attitude judgements were associated with the AIDS portrayals, as well as much less willingness to interact even in routine conversation when the patients illness was identified as AIDS. Increasing numbers of AIDS patients will be seeking medical attention from physicians in all areas of the country and it will be important for health care professions to develop programs which counter unreasonable stigma and prejudicial attitudes that may be associated with this illness.

The effects of HIV/AIDS intervention groups for high-risk women in urban clinics.

OBJECTIVE This study reports the results of a behavior change intervention offered to women at high risk for human immunodeficiency virus (HIV) infection seen in an urban primary health care clinic. METHODS Participants were 197 women randomly assigned to either an HIV/acquired immunodeficiency syndrome (AIDS) risk reduction group or a comparison group. Women in the HIV/AIDS intervention group attended five group sessions focusing on risk education; skills training in condom use, sexual assertiveness, problem solving, and risk trigger self-management; and peer support for change efforts. Women in the comparison group attended sessions on health topics unrelated to AIDS. RESULTS At the 3-month follow-up, women in the HIV/AIDS intervention group had increased in sexual communication and negotiation skills. Unprotected sexual intercourse had declined significantly and condom use had increased from 26% to 56% of all intercourse occasions. Women in the comparison group showed no change. CONCLUSIONS Socially disadvantaged women can be assisted in reducing their risk of contracting HIV infection. Risk reduction behavior change interventions should be offered routinely in primary health care clinics serving low-income and high-risk patients.

Outcomes of a randomized community-level HIV prevention intervention for women living in 18 low-income housing developments

OBJECTIVES Women in impoverished inner-city neighborhoods are at high risk for contracting HIV. A randomized, multisite community-level HIV prevention trial was undertaken with women living in 18 low-income housing developments in 5 US cities. METHODS Baseline and 12-month follow-up population risk characteristics were assessed by surveying 690 women at both time points. In the 9 intervention condition housing developments, a community-level intervention was undertaken that included HIV risk reduction workshops and community HIV prevention events implemented by women who were popular opinion leaders among their peers. RESULTS The proportion of women in the intervention developments who had any unprotected intercourse in the past 2 months declined from 50% to 37.6%, and the percentage of womens acts of intercourse protected by condoms increased from 30.2% to 47.2%. Among women exposed to intervention activities, the mean frequency of unprotected acts of intercourse in the past 2 months tended to be lower at follow-up (mean = 4.0) than at baseline (mean = 6.0). These changes were corroborated by changes in other risk indicators. CONCLUSIONS Community-level interventions that involve and engage women in neighborhood-based HIV prevention activities can bring about reductions in high-risk sexual behaviors.

Popular opinion leaders and HIV prevention peer education: resolving discrepant findings, and implications for the development of effective community programmes

A series of community-level trials undertaken in the United States over the past 10 years established the effectiveness of an HIV prevention intervention that systematically identifies, recruits, trains, and engages the popular opinion leaders (POLs) of a population to serve as behaviour change endorsers. Recently, several investigators reported unsuccessful attempts to implement peer education programmes for men who have sex with men in the United Kingdom and raised questions about whether peer-based programmes are effective or feasible. However, POL is a theory-based and very specialized intervention, and the UK peer education programmes did not incorporate many of POLs core or essential elements. Consequently, they were not evaluations of POL. In this article, core elements of the popular opinion leader model are presented; interpretations are made of possible reasons for the discrepant findings of the UK peer education and US POL interventions; and practical issues for applied programme development are discussed.

Sensation seeking as an explanation for the association between substance use and HIV-related risky sexual behavior

Past research has shown that recreational drug use correlates with sexual behaviors that confer high risk for human immunodeficiency virus (HIV) infection. The present study tested the hypothesis that sensation seeking, a disposition characterized by the tendency to pursue novel, exciting, and optimal levels of arousal, accounts for a majority of the variance in associations between substance use and high-risk sexual behavior. Ninety-nine homosexually active men completed measures of sensation seeking, self-reported sexual behavior, and substance use. Path analysis and hierarchical regression analyses demonstrated that sensation seeking accounts for the observed relationship between substance use and high-risk sexual behavior. We conclude that personality characteristics, often ignored in high-risk sexual episodes, predict risk behavior over and above substance use, and may be useful in tailoring HIV prevention interventions.

Factors associated with severity of depression and high-risk sexual behavior among persons diagnosed with human immunodeficiency virus (HIV) infection.

Whereas some people appear to cope after learning that they have human immunodeficiency virus (HIV) infection, others experience depression and suicidal ideation. In this study, 142 persons with HIV infection were administered the Center for Epidemiological Studies Depression Scale (CES-D). High levels of depression were predicted by lower perceived social support, attributions that health was influenced more by chance, high-risk sexual behavior practices, and greater number of HIV illness symptoms and greater duration of time knowing of ones own positive serostatus. Ongoing high-risk sexual behavior practices were predicted by higher levels of recreational drug use and of depression. These findings highlight the need for improved mental health services for persons with HIV conditions.

Protease inhibitor combination therapies and perceptions of gay men regarding AIDS severity and the need to maintain safer sex.

Background:Advances in the treatment of HIV disease with protease inhibitor combination therapies have been widely documented in the media. Objectives:To investigate perceptions concerning the severity of HIV/AIDS and the need to maintain safer sex practices in the light of recent HIV treatment advances. Methods:A survey eliciting demographic characteristics, HIV serostatus and treatment information, and HIV/AIDS severity and safer sex perceptions was administered to a community sample of 379 homo-/bisexual men who reported awareness of combination therapy regimens. Results:Ten per cent of all respondents agreed or strongly agreed with the statement that ‘AIDS is now very nearly cured’ and 13% felt that the threat of AIDS is less serious than in the past. HIV-positive men were more likely to perceive AIDS as a less serious threat or as very nearly cured. Overall, 8% of men in the sample indicated that they practice safer sex less often since new AIDS treatments came along; 18% of HIV-positive men on combination therapy regimens said they practice safer sex less frequently since treatments have advanced. Regardless of serostatus, nearly 20% of men indicated they would stop practicing safer sex if an AIDS cure was announced. Conclusion:It is essential to integrate behavior change counseling into HIV treatment programs and to temper optimism concerning treatment advances with recognition that the threat of HIV/AIDS remains great.