Michele P. Andrasik

Peer support and pager messaging to promote antiretroviral modifying therapy in Seattle: a randomized controlled trial.

Objective:To determine the relative efficacy of peer support and pager messaging strategies versus usual care to improve medication adherence and clinical outcomes among HIV-positive outpatients initiating or switching to a new highly active antiretroviral therapy regimen. Design:A 2 × 2 factorial randomized controlled trial of a 3-month intervention with computer-assisted self-interviews and blood draws administered at baseline, 3, 6, and 9 months. Methods:HIV-positive patients at a public HIV specialty clinic in Seattle, WA (N = 224) were randomly assigned to peer support, pager messaging, both strategies, or usual care. The main outcomes were adherence according to self-report and electronic drug monitoring, CD4 count, and HIV-1 RNA viral load. Results:Intent-to-treat analyses suggested the peer intervention was associated with greater self-reported adherence at immediate postintervention. However, these effects were not maintained at follow-up assessment; nor were there significant differences in biological outcomes. The pager intervention, on the other hand, was not associated with greater adherence but was associated with improved biological outcomes at postintervention that were sustained at follow-up. Conclusions:Analyses indicate the potential efficacy of peer support and pager messaging to promote antiretroviral adherence and biological outcomes, respectively. More potent strategies still are needed.

Buffering Effects of General and Medication-Specific Social Support on the Association Between Substance Use and HIV Medication Adherence

The success of highly active antiretroviral therapy (HAART) among persons living with HIV is largely dependent on strict medication adherence. Recent research suggests that alcohol and other drug use (AOD) may be an important barrier to HAART adherence. In this study, we examined the impact of AOD on HAART adherence as well as the moderating effects of general and medication-specific social support. The data were collected as part of a longitudinal randomized control trial with 224 HIV-positive patients at an HIV primary care clinic in the northwestern United States. Findings indicated that AOD use was negatively associated with HAART adherence and that medication-specific (but not general) social support moderated the AOD-adherence association at 3 (but not at 6 or 9) months. Results indicate the importance of medication-specific social support to treat comorbid AOD use and HIV; implications for future research and intervention programs for HIV-positive AOD users are discussed.

Stress management effects on perceived stress and cervical neoplasia in low-income HIV-infected women.

OBJECTIVE Risk for developing cervical neoplastic disease is greatly increased in women infected with oncogenic sexually transmitted human papillomaviruses (HPVs) and who have lowered cellular immunity due to coinfection with human immunodeficiency virus (HIV) infection. The majority of these individuals are low-income minority women. Factors associated with promotion of HPV to cervical neoplasia in HIV-infected populations include degree of immunosuppression as well as behavioral factors such as tobacco smoking and psychological stress. This study examined the effects of a cognitive behavioral stress management (CBSM) intervention on life stress and cervical neoplasia in HIV+ minority women. METHODS Participants were 39 HIV+ African-American, Caribbean, and Hispanic women with a recent history of an abnormal Papanicolaou smear. Participants underwent colposcopic examination, psychosocial interview, and peripheral venous blood draw at study entry and 9 months after being randomly assigned to either a 10-week CBSM group intervention (n=21) or a 1-day CBSM workshop (n=18). RESULTS Women assigned to the 10-week group-based CBSM intervention reported decreased perceived life stress and had significantly lower odds of cervical neoplasia over a 9-month follow-up. CBSM effects on life stress and neoplasia appeared independent of presence of neoplasia at study entry, HPV type, CD4+CD3+ cell count, HIV viral load, and substance use. Furthermore, CBSM intervention effects on cervical neoplasia were especially pronounced among women with residual life stress at follow-up. CONCLUSION These findings suggest that stress management decreases perceived life stress and may decrease the odds of cervical neoplasia in women with HIV and a history of abnormal Papanicolaou smears. Although preliminary, these findings suggest the utility of stress management as a cancer prevention strategy in this high-risk population.

Two-Way Text Messaging for Health Behavior Change Among Human Immunodeficiency Virus–Positive Individuals

BACKGROUND text-messaging systems have been used to promote a range of health behaviors, including medication adherence among human immunodeficiency virus-positive individuals. However, little is currently known about the specific characteristics of messaging systems that promote user engagement. OBJECTIVE using data from a randomized controlled trial involving a pager-based text messaging system, this study sought to examine the overall usability of the system, user evaluation of the system, demographic and psychosocial correlates of usability, and its performance as an adherence assessment tool. MATERIALS AND METHODS the messaging system consisted of an alphanumeric pager capable of sending and receiving individualized text messages and the software necessary to program and track communication. The system was evaluated using behavioral outcomes (pager message response rate), self-report survey responses, focus group discussions, and data from electronic medication monitoring pill bottles. RESULTS Although the majority of participants reported that the system was effective in reminding them to take medication doses, the overall response rate to system messages was relatively low (42.8%) and dropped significantly over the course of the 3-month intervention period. In addition, user engagement did not differ significantly by most demographic and psychosocial variables. CONCLUSIONS the pager-based text messaging system was received well by participants and appears to be applicable to a broad population; however, the system did not actively engage all participants over the course of the trial. Future research should determine whether systems customized to personal preference in notification style, frequency, and user device can increase use and provide further assistance to achieve optimal medication adherence.

Exploring barriers and facilitators to participation of male-to-female transgender persons in preventive HIV vaccine clinical trials.

Observed seroincidence and prevalence rates in male-to-female (MTF) transgender individuals highlight the need for effective targeted HIV prevention strategies for this community. In order to develop an effective vaccine that can be used by transgender women, researchers must understand and address existing structural issues that present barriers to this group’s participation in HIV vaccine clinical trials. Overcoming barriers to participation is important for ensuring HIV vaccine acceptability and efficacy for the MTF transgender community. To explore barriers and facilitators to MTF transgender participation in preventive HIV vaccine clinical trials, the HIV Vaccine Trials Network conducted focus groups among transgender women in four urban areas (Atlanta, Boston, Philadelphia, and San Francisco). Barriers and facilitators to engagement of transgender women in preventive HIV vaccine clinical trials led to the following recommendations: (a) transgender cultural competency training, (b) creating trans-friendly environments, (c) true partnerships with local trans-friendly organizations and health care providers, (d) protocols that focus on transgender specific issues, and (e) data collection and tracking of transgender individuals. These results have implications for the conduct of HIV vaccine trials, as well as engagement of transgender women in research programs in general.

Barriers to cervical cancer screening among low-income HIV-positive African American women.

This study elucidates the perspective of low-income HIV-positive African American women who have not received cervical cancer screening for five or more years, on the barriers they face in accessing and using reproductive health care. We focused on how women who live in a severely economically depressed and racially segregated neighborhood experience barriers to cervical cancer screening. Andersen’s Behavioral Model of Health Services Use, which allows for the organization of conditions and situations that bar utilization of health services, served as the theoretical framework. Findings from individual semi-structured interviews with 35 participants revealed the importance of psychological and emotional barriers as well as the more commonly reported economic, social, and health care system barriers. We suggest how access to care for this population can be increased by including psychological and emotional components in intervention efforts.

Enhancing Diversity in the Public Health Research Workforce: The Research and Mentorship Program for Future HIV Vaccine Scientists

OBJECTIVES We developed and evaluated a novel National Institutes of Health-sponsored Research and Mentorship Program for African American and Hispanic medical students embedded within the international, multisite HIV Vaccine Trials Network, and explored its impact on scientific knowledge, acquired skills, and future career plans. METHODS Scholars conducted social, behavioral, clinical, or laboratory-based research projects with HIV Vaccine Trials Network investigators over 8 to 16 weeks (track 1) or 9 to 12 months (track 2). We conducted an in-depth, mixed-methods evaluation of the first 2 cohorts (2011-2013) to identify program strengths, areas for improvement, and influence on professional development. RESULTS A pre-post program assessment demonstrated increases in self-reported knowledge, professional skills, and interest in future HIV vaccine research. During in-depth interviews, scholars reported that a supportive, centrally administered program; available funding; and highly involved mentors and staff were keys to the programs early success. CONCLUSIONS A multicomponent, mentored research experience that engages medical students from underrepresented communities and is organized within a clinical trials network may expand the pool of diverse public health scientists. Efforts to sustain scholar interest over time and track career trajectories are warranted.

Tribally-Driven HIV/AIDS Health Services Partnerships: Evidence-Based Meets Culture-Centered Interventions

This paper describes a successful HIV/AIDS prevention and treatment project that combined medical, support, and educational services, thereby improving care in a rural American Indian tribe in the southwestern United States. Using the methods of community-based participatory evaluation and motivational interviewing, the 5-year, multiparty collaborative project improved health care access and medical regimen adherence of people with HIV/AIDS and increased the risk- and protective-factor knowledge of tribal members at high risk for the disease. The success of the collaborative in achieving all these goals highlights the importance of tribal control, collaboration, and incorporation of tradition and culture in HIV/AIDS diagnostic, treatment, and prevention efforts.

Bridging the Divide: HIV Prevention Research and Black Men Who Have Sex With Men

OBJECTIVES We obtained contextual information regarding documented barriers to HIV clinical trial participation among Black men who have sex with men (MSM), and explored current preventive HIV clinical trial attitudes, beliefs, and perceptions among Black MSM leaders in the United States. METHODS We conducted 2 focus groups with Black MSM leaders attending an annual African American MSM Leadership Conference on HIV/AIDS. Focus group questions explored biomedical research perceptions and attitudes, barriers to participation in biomedical prevention research, and steps that need to be taken to address these barriers. A feedback and member checking (participants presented with final themes to provide feedback and guidance) session was also held at the 2012 conference. RESULTS Three distinct themes emerged regarding Black MSM engagement and participation in HIV vaccine research: (1) community-based organizations as true partners, (2) investment in the Black gay community, and (3) true efforts to inform and educate the community. CONCLUSIONS A key focus for improving efforts to engage the Black MSM community in preventive HIV clinical trials is building and maintaining equitable and reciprocal partnerships among research institutions, Black-led AIDS service organizations and community-based organizations, and community members.

Intentions to use preexposure prophylaxis among current phase 2B preventive HIV-1 vaccine efficacy trial participants.

Abstract:In November 2010, the iPrEx study reported that preexposure prophylaxis (PrEP) with daily tenofovir disoproxil fumarate/emtricitabine reduced HIV infections by 44% among men who have sex with men and subsequent trials corroborated efficacy among heterosexual men and women. During regularly scheduled follow-up visits from January to March 2011, participants in an ongoing phase 2b vaccine efficacy trial completed an anonymous Web survey about PrEP. Among 376 respondents, 17% reported they were very likely to use PrEP in the next year. Nonwhite participants were more likely to use PrEP. Among those with some level of interest, intent to use PrEP was greatest if the drug were available through the clinical trial or health insurance. Most (91%) believed taking PrEP would not change their willingness to stay in the vaccine trial and few thought it would affect recruitment. As key stakeholders, currently enrolled trial participants can offer vital input about emerging prevention technologies that may affect the design of future HIV vaccine and nonvaccine prevention trials.