Mallory O. Johnson

Theory-Guided, Empirically Supported Avenues for Intervention on HIV Medication Nonadherence: Findings from the Healthy Living Project

OBJECTIVES Adherence to antiretroviral therapy (ART) remains a challenge in efforts to maximize HIV treatment benefits. Previous studies of antiretroviral adherence are limited by low statistical power, homogeneous samples, and biased assessment methods. Based on Social Action Theory and using a large, diverse sample of men and women living with HIV, the objectives of the current study are to clarify correlates of nonadherence to ART and to provide theory-guided, empirically supported direction for intervening on ART nonadherence. DESIGN Cross-sectional interview study utilizing a computerized interview. SETTING Recruited from clinics, agencies, and via media ads in four U.S. cities from June 2000 to January 2002. PARTICIPANTS Two thousand seven hundred and sixty-five HIV-positive adults taking ART. MAIN OUTCOME MEASURE Computer-assessed self-reported antiretroviral adherence. RESULTS Thirty-two percent reported less than 90% adherence to ART in the prior 3 days. A number of factors were related to nonadherence in univariate analysis. Multivariate analyses identified that being African American, being in a primary relationship, and a history of injection drug use or homelessness in the past year were associated with greater likelihood of nonadherence. Furthermore, adherence self-efficacy, and being able to manage side effects and fit medications into daily routines were protective against nonadherence. Being tired of taking medications was associated with poorer adherence whereas a belief that nonadherence can make the virus stronger was associated with better adherence. CONCLUSIONS Results support the need for multifocused interventions to improve medication adherence that address logistical barriers, substance use, attitudes and expectancies, as well as skills building and self-efficacy enhancement. Further exploration of issues related to adherence for African Americans and men in primary relationships is warranted.

Characteristics of Successful and Failed Mentoring Relationships: A Qualitative Study Across Two Academic Health Centers

Purpose To explore the mentor–mentee relationship with a focus on determining the characteristics of effective mentors and mentees and understanding the factors influencing successful and failed mentoring relationships. Method The authors completed a qualitative study through the Departments of Medicine at the University of Toronto Faculty of Medicine and the University of California, San Francisco, School of Medicine between March 2010 and January 2011. They conducted individual, semistructured interviews with faculty members from different career streams and ranks and analyzed transcripts of the interviews, drawing on grounded theory. Results The authors completed interviews with 54 faculty members and identified a number of themes, including the characteristics of effective mentors and mentees, actions of effective mentors, characteristics of successful and failed mentoring relationships, and tactics for successful mentoring relationships. Successful mentoring relationships were characterized by reciprocity, mutual respect, clear expectations, personal connection, and shared values. Failed mentoring relationships were characterized by poor communication, lack of commitment, personality differences, perceived (or real) competition, conflicts of interest, and the mentor’s lack of experience. Conclusions Successful mentorship is vital to career success and satisfaction for both mentors and mentees. Yet challenges continue to inhibit faculty members from receiving effective mentorship. Given the importance of mentorship on faculty members’ careers, future studies must address the association between a failed mentoring relationship and a faculty member’s career success, how to assess different approaches to mediating failed mentoring relationships, and how to evaluate strategies for effective mentorship throughout a faculty member’s career.

HIV transmission risk behavior among men and women living with HIV in 4 cities in the United States.

Summary:Determining rates of HIV transmission risk behavior among HIV-positive individuals is a public health priority, especially as infected persons live longer because of improved medical treatments. Few studies have assessed the potential for transmission to the partners of HIV-positive persons who engage in high-risk activities. A total of 3723 HIV-infected persons (1918 men who have sex with men [MSM], 978 women, and 827 heterosexual men) were interviewed in clinics and community-based agencies in Los Angeles, Milwaukee, New York City, and San Francisco from June 2000 to January 2002 regarding sexual and drug use behaviors that confer risk for transmitting HIV. Less than one quarter of women and heterosexual men had 2 or more sexual partners, whereas 59% of MSM reported having multiple partners. Most unprotected vaginal and anal sexual activity took place in the context of relationships with other HIV-positive individuals. Approximately 19% of women, 15.6% of MSM, and 13.1% of heterosexual men engaged in unprotected vaginal or anal intercourse with partners who were HIV-negative or whose serostatus was unknown. The majority of sexually active participants disclosed their serostatus to all partners with whom they engaged in unprotected intercourse. An estimated 30.4 new infections (79.7% as a result of sexual interactions with MSM) would be expected among the sex partners of study participants during the 3-month reporting period. Eighteen percent of 304 participants who injected drugs in the past 3 months reported lending their used injection equipment to others. In addition to the more traditional approaches of HIV test counseling and of focusing on persons not infected, intensive prevention programs for persons with HIV infection are needed to stem the future spread of the virus.

Effects of a behavioral intervention to reduce risk of transmission among people living with HIV: The Healthy Living Project randomized controlled study

Context:The US Centers for Disease Control and Prevention (CDC) strongly recommend comprehensive risk counceling and services for people living with HIV (PLH); yet, there are no evidence-based counseling protocols. Objective:To examine the effect of a 15-session, individually delivered, cognitive behavioral intervention on a diverse sample of PLH at risk of transmitting to others. Design:This was a multisite, 2-group, randomized, controlled trial. Participants:Nine hundred thirty-six HIV-infected participants considered to be at risk of transmitting HIV of 3818 persons screened were randomized into the trial. Participants were recruited in Los Angeles, Milwaukee, New York, and San Francisco. Intervention:Fifteen 90-minute individually delivered intervention sessions were divided into 3 modules: stress, coping, and adjustment; safer behaviors; and health behaviors. The control group received no intervention until the trial was completed. Both groups completed follow-up assessments at 5, 10, 15, 20, and 25 months after randomization. Main Outcome Measure:Transmission risk, as measured by the number of unprotected sexual risk acts with persons of HIV-negative or unknown status, was the main outcome measure. Results:Overall, a significance difference in mean transmission risk acts was shown between the intervention and control arms over 5 to 25 months (χ2 = 16.0, degrees of freedom = 5; P = 0.007). The greatest reduction occurred at the 20-month follow-up, with a 36% reduction in the intervention group compared with the control group. Conclusion:Cognitive behavioral intervention programs can effectively reduce the potential of HIV transmission to others among PLH who report significant transmission risk behavior.

Throwing the dice: pregnancy decision-making among HIV-positive women in four U.S. cities.

CONTEXT Although AIDS-related deaths among U.S. women have decreased, the number of HIV-positive women, especially of reproductive age, has increased. A better understanding of the interaction between HIV and family planning is needed, especially as antiretroviral medications allow HIV-positive women to live longer, healthier lives. METHODS Qualitative methods were used to examine pregnancy decision-making among 56 HIV-positive women in four U.S. cities. Biomedical, individual and sociocultural themes were analyzed in groups of women, categorized by their pregnancy experiences and intentions. RESULTS Regardless of womens pregnancy experiences or intentions, reproductive decision-making themes included the perceived risk of vertical transmission, which was often overestimated; beliefs about vertical transmission risk reduction strategies; desire for motherhood; stigma; religious values; attitudes of partners and health care providers; and the impact of the mothers health and longevity on the child. Most women who did not want children after their diagnosis cited vertical transmission risk as the reason, and most of these women already had children. Those who became pregnant or desired children after their diagnosis seemed more confident in the efficacy of risk reduction strategies and often did not already have children. CONCLUSIONS Future studies may help clarify the relationship between factors that influence pregnancy decision-making among HIV-positive women. HIV-positive and at-risk women of childbearing age may benefit from counseling interventions sensitive to factors that influence infected womens pregnancy decisions.

Intricacies and inter-relationships between HIV disclosure and HAART: A qualitative study

This study aimed to understand whether and how highly active antiretroviral treatment (HAART) affects views and patterns of disclosure and how disclosure interacts with treatment decisions. One hundred and fifty-two HIV-positive adults (52 MSM, 56 women and 44 IDU men) from four US cities participated in two to three-hour, semi-structured interviews in 1998–99. Results indicate that HAART interacts with and shapes HIV disclosure issues in several ways. Medications may ‘out’ people living with HIV. Thus, in different settings (e.g. work, prisons, drug rehabs and public situations), some try to hide medications or modify dosing schedules, which can contribute to non-adherence, and affect sexual behaviours. Disclosure of HIV and/or HAART may also result in antagonism from others who hold negative attitudes and beliefs about HAART, potentially impeding adherence. Observable side effects of medications can also ‘out’ individuals. Conversely, medications may improve appearance, delaying or impeding disclosure. Some wait until they are on HAART and look ‘well’ before disclosing; some who look healthy as a result of medication deny being HIV-positive. Alternatively, HIV disclosure can lead to support that facilitates initiation of, and adherence to, treatment. HIV disclosure and adherence can shape one another in critical ways. Yet these interactions have been under-studied and need to be further examined. Interventions and studies concerning each of these domains have generally been separate, but need to be integrated, and the importance of relationships between these two areas needs to be recognized.

Correlates of suicidal ideation among HIV-positive persons.

Objectives:The present investigation sought to determine the extent to which demographic characteristics, illness-related burdens, alcohol and other substance use, and psychosocial factors are independently associated with suicidal ideation in HIV-positive individuals. Design:HIV-positive individuals in four US cities (San Francisco, Los Angeles, Milwaukee, and New York City) were screened between July 2000 and January 2002 for recruitment into a randomized behavioral prevention trial. Utilizing data from this screening visit, rates and correlates of suicidal ideation were examined in a diverse sample of 2909 HIV-positive individuals. Methods:Using binary logistic regression study sites, demographic characteristics, illness-related burdens, alcohol and substance use, and psychosocial factors were entered as predictors of suicidal ideation. This cross-sectional model thus examined the independent effects of each factor. Results:Approximately one-fifth (19%) of participants reported thoughts of suicide in the past week. We observed that participants who were not heterosexual, rated HIV-related symptoms and medication side effects as more severe, reported regular marijuana use, and described elevated affective symptoms of depression were those who were more likely to report suicidal ideation. Conversely, participants who identified as Hispanic/Latino, individuals in a primary romantic relationship, and those who reported greater self-efficacy for coping were less likely to report suicidal ideation. Conclusion:Suicidal ideation among HIV-positive individuals is relatively common and is associated with multiple factors. These independent correlates may assist with identifying HIV-positive individuals who are at increased risk of suicidal ideation so that they may be assessed regularly and referred for psychological treatment when appropriate.

Psychiatric risk factors for HIV disease progression: the role of inconsistent patterns of antiretroviral therapy utilization.

Background:In the era of antiretroviral therapy (ART), depression and substance use predict hastened HIV disease progression, but the underlying biological or behavioral mechanisms that explain these effects are not fully understood. Methods:Using outcome data from 603 participants enrolled in a randomized controlled trial of a behavioral intervention, binary logistic and linear regression were employed to examine whether inconsistent patterns of ART utilization partially mediated the effects of depression and substance use on higher HIV viral load over a 25-month follow-up. Results:Elevated affective symptoms of depression independently predicted ART discontinuation [adjusted odds ratio = 1.39, 95% confidence interval (CI) = 1.08 to 1.78], and use of stimulants at least weekly independently predicted intermittent ART utilization (adjusted odds ratio = 2.62, 95% CI = 1.45 to 4.73). After controlling for the average self-reported percentage of ART doses taken and baseline T-helper (CD4+) count, elevated depressive symptoms predicted a 50% higher mean viral load, and weekly stimulant use predicted a 137% higher mean viral load. These effects became nonsignificant after accounting for inconsistent patterns of ART utilization, providing evidence of partial mediation. Conclusions:Inconsistent patterns of ART utilization may partially explain the effects of depression and stimulant use on hastened HIV disease progression.

Barriers and Facilitators to Engagement and Retention in Care among Transgender Women Living with Human Immunodeficiency Virus

BackgroundTransgender women have 49 times the odds of human immunodeficiency virus (HIV) infection compared to other groups, yet they are disproportionately underserved by current treatment efforts.PurposeThis study aimed to examine culturally unique barriers and facilitators to engagement and retention in HIV care and strengthen efforts to mitigate health disparities, guided by the Models of Gender Affirmation and Health Care Empowerment.MethodsThrough 20 interviews and five focus groups (n = 38), transgender women living with HIV discussed their experiences and life contexts of engagement in and adherence to HIV care and treatment.ResultsOur participants faced substantial challenges to adhering to HIV care and treatment, including avoidance of healthcare due to stigma and past negative experiences, prioritization of hormone therapy, and concerns about adverse interactions between antiretroviral treatment for HIV and hormone therapy. Receiving culturally competent, transgender-sensitive healthcare was a powerful facilitator of healthcare empowerment.ConclusionsRecommendations are offered to inform intervention research and guide providers, emphasizing gender affirming HIV care that integrates transition-related healthcare needs.

Predicting HIV transmission risk among HIV-infected men who have sex with men: findings from the healthy living project.

Objective:To examine the predictors of transmission risk among HIV-infected men who have sex with men (MSM) in 4 US cities. Method:Individual computer-assisted interviews assessing psychologic measures and sexual behavior with the 5 most recent male and female partners were conducted with a diverse sample of 1910 HIV-infected MSM recruited from community and clinic settings in San Francisco, New York, Los Angeles, and Milwaukee. Transmission-risk events were defined as unprotected vaginal or anal sex with a partner who was HIV negative or of unknown status. Results:A small but not insignificant proportion of MSM (12.7%) reported at least 1 transmission-risk event in the previous 3 months, with 57% of those events taking place with casual as opposed to steady partners. Multivariate predictors of transmission risk with casual partners were stimulant (eg, crystal methamphetamine) and other drug use, having low coping self-efficacy, and not having disclosed ones HIV serostatus to all partners. Stimulant use and failing to disclosing ones serostatus to all partners were associated with risk in primary relationships. Conclusions:Responding to HIV transmission risk in MSM requires different strategies for primary and casual partners.