Marcia McDonnell Holstad

Using motivational interviewing to promote adherence to antiretroviral medications: A randomized controlled study

Abstract The primary aim of this study was to test an intervention to support antiretroviral medication adherence among primarily low-income men and women with HIV. The study was a randomized controlled trial (Get Busy Living) with participants assigned to treatment (Motivational Interviewing [MI]) and control groups. Participants were recruited from an HIV/AIDS clinic in Atlanta, Georgia, US. Of those referred to the study, 247 completed a baseline assessment and were enrolled with 125 randomized to the intervention group and 122 to the control group. Participants were patients beginning antiretroviral therapy or changing to a new drug regimen. The intervention consisted of five MI sessions delivered by registered nurses in individual counselling sessions. Participants were paid for each session attended. The intervention sought to build confidence, reduce ambivalence and increase motivation for ART medication-taking. Medication adherence was measured by the Medication Event Monitoring System (MEMS®) from the time of screening until the final follow-up conducted approximately 12 months following the baseline assessment. Participants in the intervention condition showed a trend towards having a higher mean percent of prescribed doses taken and a greater percent of doses taken on schedule when compared to the control group during the months following the intervention period. This effect was noted beginning at about the eighth month of the study period and was maintained until the final study month. Although the finding was weaker for overall percent of prescribed doses taken, the results for the percent of doses taken on schedule suggests that the MI intervention may be a useful approach for addressing specific aspects of medication adherence, such as adherrence to a specified dosing schedule.

Spiritual Well-Being, Depressive Symptoms, and Immune Status Among Women Living with HIV/AIDS

Spirituality is a resource some HIV-positive women use to cope with HIV, and it also may have positive impact on physical health. This cross-sectional study examined associations of spiritual well-being, with depressive symptoms, and CD4 cell count and percentages among a non-random sample of 129 predominantly African-American HIV-positive women. Significant inverse associations were observed between depressive symptoms and spiritual well-being (r = −.55, p = .0001), and its components, existential well-being (r = −.62, p = .0001) and religious well-being (r = −.36, p = .0001). Significant positive associations were observed between existential well-being and CD4 cell count (r = .19, p < .05) and also between spiritual well-being (r = .24, p < .05), religious well-being (r = .21, p < .05), and existential well-being (r = .22, p < .05) and CD4 cell percentages. In this sample of HIV-positive women, spiritual well-being, existential well-being, and religious well-being accounted for a significant amount of variance in depressive symptoms and CD4 cell percentages, above and beyond that explained by demographic variables, HIV medication adherence, and HIV viral load (log). Depressive symptoms were not significantly associated with CD4 cell counts or percentages. A significant relationship was observed between spiritual/religious practices (prayer/meditation and reading spiritual/religious material) and depressive symptoms. Further research is needed to examine relationships between spirituality and mental and physical health among HIV-positive women.

Factors associated with risky sexual behaviors in older adults.

&NA; This cross‐sectional, correlational study, guided by the information‐motivation‐behavioral skills model and self‐efficacy theory, investigated factors that may help to assess the HIV prevention needs of older adults. The nonrandom sample (N = 106) included single men and women, 50–74 years of age, who were either sexually active or had plans to be sexually active. Participants were recruited from community sites. Data were collected with questionnaires. Data analysis revealed that the participants had moderate levels of HIV knowledge, were highly motivated, and highly confident but continued to practice risky behaviors such as not using condoms with every sexual encounter (67.9%) and having multiple sex partners (34.6%). Higher perceived effectiveness to perform safer sexual behaviors, being female, and condom use were the only independent predictors of fewer risky sexual behaviors. Findings from this study may provide a foundation for future age‐appropriate interventions to decrease HIV in older adults.

The Meaning and Use of Spirituality Among African American Women Living With HIV/AIDS

The purpose of this qualitative study was to explore the meaning and use of spirituality among African American (AA), predominantly Christian women with HIV. A nonrandom sample of 20 AA women from a large infectious disease clinic in Metro-Atlanta participated in the study. The study used focus groups and individual interviews to interview women about their lived spiritual experience. Content analysis and NUDIST software were used to analyze transcripts. The findings revealed the spiritual views and practices of AA women with HIV. The following themes (and subthemes) emerged: Spirituality is a process/journey or connection (connection to God, higher power, or spirit and HIV brought me closer to God), spiritual expression (religion/church attendance, prayer, helping others, having faith), and spiritual benefits (health/healing, spiritual support, inner peace/strength/ability to keep going, and here for a reason or purpose/a second chance). Findings highlight the importance of spirituality in health and well-being among AA women with HIV/AIDS.

An Examination of the Psychometric Properties of the Antiretroviral General Adherence Scale (AGAS) in Two Samples of HIV-Infected Individuals

&NA; This article reports on the development and psychometric properties of the Antiretroviral General Adherence Scale (AGAS) in two National Institutes of Health‐funded projects: the Get Busy Living Project, a behavioral clinical trial to promote consistent use of antiretroviral therapy, and the KHARMA (Keeping Healthy and Active with Risk Reduction and Medication Adherence) Project, which addressed issues of adherence and risk reduction behavior in women. AGAS assesses the ease and ability of participants to take antiretroviral therapy according to a health care providers recommendations. Data were analyzed from completed baseline assessments of the two studies. The AGAS was internally consistent in both samples. Content, construct, and criterion validity were established using factor analysis and correlations of total AGAS scores with two measures of adherence: electronic drug monitoring and an Adult AIDS Clinical Trials Group adherence scale. Viral load, CD4 cell counts, and depression scores were also examined. Reliability and validity of the AGAS were supported in both samples.

The psychological well-being of people living with HIV/AIDS and the role of religious coping and social support.

Objective: This study examined correlates of depressive symptoms, particularly the role of religious coping (RCOPE), among people living with HIV/AIDS (PLWHA). The study also examined social support as a possible mediator of the proposed association between religious coping and depressive symptoms and the impact of depressive symptomatology on health outcomes such as HIV medication adherence, immune function, and health-related quality of life (HRQOL) among PLWHA. Method: A convenience sample of 292 PLWHA were recruited from an out-patient infectious disease clinic and AIDS-service organizations in the Southeastern United States. Results: 56.7% reported depressive symptoms. PLWHA with depressive symptomatology reported significantly poorer health outcomes, including poorer HIV medication adherence, lower CD4 cell count, and poorer HRQOL. The odds of being depressed was significantly associated with birth sex (female: OR = 0.43, 95% CI = .23-.80), sexual orientation (gay/bisexual: OR = 1.95, 95% CI = 1.04–3.65), marital status (single: OR =.52, 95% CI =.27-.99), social support satisfaction (OR = 0.65, 95% CI = .49-.86), and negative RCOPE (OR = 1.22, 95% CI = 1.14–1.31). Social support partially mediated the relationship between religious coping and depressive symptoms. Conclusions: High rates of depressive symptoms are present in PLWHA, which negatively impact health outcomes. Religious coping, perceived stress, and social support satisfaction serve an important role in depressive symptomatology among PLWHA. These findings underscore the need for healthcare providers to regularly screen PLWHA for and adequately treat depression and collaborate with mental health providers, social workers, and pastoral care counselors to address PLWHAs mental, social, and spiritual needs and optimize their HIV-related outcomes.

Adherence, Sexual Risk, and Viral Load in HIV-Infected Women Prescribed Antiretroviral Therapy

Abstract The purpose of this study was to determine if there was a connection between adherence to antiretroviral therapy (ART) and use of risk reduction behaviors (RRB) in HIV-infected women who were prescribed antiretroviral therapy. The sample consisted of 193 predominately African American women with an average age of 44 who had been on ARV for approximately 9 years and had low annual incomes. All women were participating in a behavioral clinical trial focused on these dual outcomes. Using a risk index developed for this study, we examined the relationship of a composite of risk behaviors to electronically measured and self-reported adherence over the approximately 13-month study period. Women were categorized based on levels of adherence and risky behaviors, and we sought to determine if these classifications were associated with clinical outcomes of HIV viral load and CD4 counts. High levels of adherence were correlated with low risk behaviors (abstinence, consistent use of condoms, etc.). Those classified as high adherence and low-risk behavior (HALR) as well as those classified as high adherence and high-risk behavior (HAHR) had lower mean viral loads and higher CD4 counts than those in the other categories. Women in the low adherence and high-risk category (LAHR) had detectable viral loads and the lowest CD4 counts and are at higher risk for transmitting HIV to partners and unborn children. Our findings underscore the importance of addressing adherence to both ART and RRB in HIV clinical settings to improve clinical outcomes and reduce HIV transmission.

Predictors of frequency of condom use and attitudes among sexually active female military personnel in Nigeria.

Background Despite awareness of condom efficacy, in protecting against both human immunodeficiency virus/sexually transmitted diseases (HIV/STDs) and unintended pregnancy; some females find it difficult to use or permit condom use consistently because of the power imbalances or other dynamics operating in their relationships with males. The purpose of this study was to determine the factors that predict the frequency of condom use and attitudes among sexually active female military personnel in Nigeria. Methods This study used a cross-sectional design in which a total of 346 responses were obtained from consenting female military personnel in two cantonments in Southwestern Nigeria between 2006 and 2008. The study instrument was designed to assess HIV/acquired immunodeficiency syndrome (AIDS) knowledge (HAK), HIV risk behaviors (HRB), alcohol and drug use, condom attitudes and barriers (CAS) condom use self-efficacy (CUS) and social support to condom use (SSC). The sociodemographic characteristics of participants were also captured. Univariate analysis and multivariable logistic regression were used for modeling the predictors of condom use. Results The results showed that 63% of the respondents reported using condoms always, 26% sometimes used condoms and 11% never used condoms during a sexual encounter in the past three months. Univariate analysis revealed that significant associations existed between CAB (P < 0.05), HRB (P < 0.01) and SSC (P < 0.01) with the frequency of condom use. The following sociodemographic variables: age, marital status, number of children, employment status and type of sexual relationship were also significantly (P ≤ 0.05) associated with consistent condom use in the study group. Multivariate analysis indicated that marital status, type of relationship and CAB were the only significant predictors (r2 = 0.37; P ≤ 0.05) of condom use behaviors after adjusting for all other factors in the model. Conclusions Findings indicate that consistent condom use could be enhanced through gender-specific intervention programs that incorporate the predictor variables identified. These are likely to be successful in decreasing sexual risk behaviors in the subpopulation.

An integrative review of the efficacy of motivational interviewing in HIV management

OBJECTIVE The purpose of this integrative review is to examine the use of motivational interviewing (MI) to improve health outcomes in persons living with HIV (PLWH). METHODS We reviewed the existing literature, using the PRISMA model. The PubMed, Web of Science, Embase, and CINAHL databases were searched for all relevant studies, using the terms HIV, AIDS, and motivational interviewing. RESULTS Of 239 articles identified initially, 19 met our criteria for synthesis. These studies were conducted throughout the world, including the U.S., Thailand, and South Africa. In general, studies that used MI, either alone or in conjunction with other interventions, reported improved adherence, decreased depression, and decreased risky sexual behaviors. CONCLUSION This review demonstrates a positive relationship between MI-based interventions and behavioral change, which may lead to improved health outcomes in PLWH. PRACTICE IMPLICATIONS Motivational interviewing can be an effective method of therapeutic communication for PLWH, who struggle with adherence, depression, and risky sexual behaviors.

An Integrated Service Delivery Model to Identify Persons Living with HIV and to Provide Linkage to HIV Treatment and Care in Prioritized Neighborhoods: A Geotargeted, Program Outcome Study.

Background Recent studies have demonstrated that high human immunodeficiency virus (HIV) prevalence (2.1%) rates exist in “high-risk areas” of US cities that are comparable to rates in developing nations. Community-based interventions (CBIs) have demonstrated potential for improving HIV testing in these areas, thereby facilitating early entry and engagement in the HIV continuum of care. By encouraging neighborhood-based community participation through an organized community coalition, Project LINK sought to demonstrate the potential of the CBI concept to improve widespread HIV testing and referral in an area characterized by high poverty and HIV prevalence with few existing HIV-related services. Objective This study examines the influence of Project LINK to improve linkage-to-care and HIV engagement among residents of its target neighborhoods. Methods Using a venue-based sampling strategy, survey participants were selected from among all adult participants aged 18 years or more at Project LINK community events (n=547). We explored multilevel factors influencing continuum-of-care outcomes (linkage to HIV testing and CBI network referral) through combined geospatial-survey analyses utilizing hierarchical linear model methodologies and random-intercept models that adjusted for baseline effect differences among zip codes. The study specifically examined participant CBI utilization and engagement in relation to individual and psychosocial factors, as well as neighborhood characteristics including the availability of HIV testing services, and the extent of local prevention, education, and clinical support services. Results Study participants indicated strong mean intention to test for HIV using CBI agencies (mean 8.66 on 10-point scale [SD 2.51]) and to facilitate referrals to the program (mean 8.81 on 10-point scale [SD 1.86]). Individual-level effects were consistent across simple multiple regression and random-effects models, as well as multilevel models. Participants with lower income expressed greater intentions to obtain HIV tests through LINK (P<.01 across models). HIV testing and CBI referral intention were associated with neighborhood-level factors, including reduced availability of support services (testing P<.001), greater proportion of black/African Americans (testing and referral P<.001), and reduced socioeconomic capital (testing P=.017 and referral P<.001). Across models, participants expressing positive attitudes toward the CBI exhibited greater likelihood of engaging in routine HIV testing (P<.01) and referring others to HIV care (P<.01). Transgender individuals indicated greater intent to refer others to the CBI (P<.05). These outcomes were broadly influenced by distal community-level factors including availability of neighborhood HIV support organizations, population composition socioeconomic status, and high HIV prevalence. Conclusions Project LINK demonstrated its potential as a geotargeted CBI by evidencing greater individual intention to engage in HIV testing, care, and personal referrals to its coalition partner organizations. This study highlights important socioecological effects of US-based CBIs to improve HIV testing and initiate acceptable mechanisms for prompt referral to care among a vulnerable population.