Tamar Grebler

Stress and Poverty Predictors of Treatment Adherence among People with Low-Literacy Living with HIV/AIDS

Objective: To examine the association of social, health, and poverty-related stressors in relation to antiretroviral therapy adherence in a sample of people with low-literacy living with HIV/AIDS in the southeastern United States. Emotional distress is among the more common factors associated with HIV treatment adherence. Typical barriers to adherence may be overshadowed by poverty experiences in the most disadvantaged populations of people living with HIV/AIDS, such as people with lower-literacy skills. Methods: One hundred eighty-eight men and women living with HIV/AIDS who demonstrated poor health literacy completed measures of social and health-related stress, indicators of extreme poverty, as well as other factors associated with nonadherence. HIV treatment adherence was monitored prospectively, using unannounced pill counts. Results: Two-thirds of the sample demonstrated adherence <85% of pills taken. Multivariable analyses showed that food insufficiency and hunger predicted antiretroviral therapy nonadherence over and above depression, internalized stigma, substance use, and HIV-related social stressors. Conclusions: Interventions for HIV treatment nonadherence with the most socially disadvantaged persons in developed countries should be reconceptualized to directly address poverty, especially food insufficiency and hunger, as both a moral and public health imperative. ART = antiretroviral therapy; CES-D = Centers for Epidemiologic Studies Depression; PI = protease inhibitor; TOFHLA = Test of Functional Health Literacy for Adults.

Adherence to antiretroviral therapy and HIV transmission risks: implications for test-and-treat approaches to HIV prevention.

HIV transmission may be prevented by effectively suppressing viral replication with antiretroviral therapy (ART). However, adherence is essential to the success of ART, including for reducing HIV transmission risk behaviors. This study examined the association of nonadherence versus adherence with HIV transmission risks. Men (n = 226) living with HIV/AIDS and receiving ART completed confidential computerized interviews and telephone-based unannounced pill counts for ART adherence monitoring. Data were collected between January 2008 and June 2009. Results showed that nonadherence to ART was associated with greater number of sex partners and engaging in unprotected and protected anal intercourse. These associations were not moderated by substance use. The belief that having an undetectable viral load leads to lower infectiousness was associated with greater number of partners, including nonpositive partners, and less condom use. Men who had an undetectable viral load and believed that having an undetectable viral load reduces their infectiousness, were significantly more likely to have contracted a recent STI. Programs aimed at testing and treating people living with HIV/AIDS for prevention require attention to adherence and sexual behaviors.

Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: an initial test of concept trial.

Affordable and effective antiretroviral therapy (ART) adherence interventions are needed for many patients to promote positive treatment outcomes and prevent viral resistance. We conducted a two-arm randomized trial (n = 40 men and women receiving and less than 95% adherent to ART) to test a single office session followed by four biweekly cell phone counseling sessions that were grounded in behavioral self-management model of medication adherence using data from phone-based unannounced pill counts to provide feedback-guided adherence strategies. The control condition received usual care and matched office and cell phone/pill count contacts. Participants were baseline assessed and followed with biweekly unannounced pill counts and 4-month from baseline computerized interviews (39/40 retained). Results showed that the self-regulation counseling delivered by cell phone demonstrated significant improvements in adherence compared to the control condition; adherence improved from 87% of pills taken at baseline to 94% adherence 4 months after baseline, p < 0.01. The observed effect sizes ranged from moderate (d = 0.45) to large (d = 0.80). Gains in adherence were paralleled with increased self-efficacy (p < 0.05) and use of behavioral strategies for ART adherence (p < 0.05). We conclude that the outcomes from this test of concept trial warrant further research on cell phone-delivered self-regulation counseling in a larger and more rigorous trial.

Randomized clinical trial of HIV treatment adherence counseling interventions for people living with HIV and limited health literacy.

Background:Limited health literacy is a known barrier to medication adherence among people living with HIV. Adherence improvement interventions are urgently needed for this vulnerable population. Purpose:This study tested the efficacy of a pictograph-guided adherence skills-building counseling intervention for limited literacy adults living with HIV. Methods:Men and women living with HIV and receiving antiretroviral therapy (N = 446) who scored <90% correct on a test of functional health literacy were partitioned into marginal and lower literacy groups and randomly allocated to 1 of 3 adherence-counseling conditions: (1) pictograph-guided adherence counseling, (2) standard adherence counseling, or (3) general health improvement counseling. Participants were followed for 9 months postintervention with unannounced pill count adherence and blood plasma viral load as primary end points. Results:Preliminary analyses demonstrated the integrity of the trial and >90% of participants were retained. Generalized estimating equations showed significant interactions between counseling conditions and levels of participant health literacy across outcomes. Participants with marginal health literacy in the pictograph-guided and standard-counseling conditions demonstrated greater adherence and undetectable HIV viral loads compared with general health counseling. In contrast and contrary to hypotheses, participants with lower health literacy skills in the general health improvement counseling demonstrated greater adherence compared with the 2 adherence counseling conditions. Conclusions:Patients with marginal literacy skills benefit from adherence counseling regardless of pictographic tailoring, and patients with lower literacy skills may require more intensive or provider-directed interventions.

Medication Adherence and Health Outcomes of People Living with HIV Who Are Food Insecure and Prescribed Antiretrovirals That Should Be Taken with Food

IntroductionFood insecurity is a well-established predictor of poor health outcomes. Antiretroviral therapies (ARTs) that should be taken with food to increase bioavailability may further challenge food insecure patients. This study examined factors associated with antiretroviral adherence and HIV viral suppression among people living with HIV who are food insecure and prescribed medications that require food.MethodsA community sample of 313 men and 105 women who experienced food insecurity in the previous month and were currently taking ART completed computerized interviews, urine screening for drug use, prospective biweekly unannounced pill count adherence assessments, and obtained their HIV viral load and CD4 cell counts from medical records.ResultsIndividuals taking ART regimens that should be taken with food were significantly more likely to be unemployed, were living longer with an HIV diagnosis, had lower CD4 cell counts, poorer HIV suppression, and endorsed more beliefs that taking medications was necessary for their health. Multivariable regression models controlling for potential confounding factors showed that receiving ART that requires food was significantly related to poorer ART adherence and unsuppressed HIV in this food insecure sample.ConclusionPeople living with HIV who are food insecure likely experience multiple facets of poverty that challenge their medication adherence, but food insecurity is the only such factor that is directly related to the pharmacokinetics of some antiretroviral medications. Achieving optimal treatment outcomes for HIV infection will require routine assessment of access to food when determining patient-tailored ART regimens.

Reducing Numbers of Sex Partners: Do We Really Need Special Interventions for Sexual Concurrency?

Multiple and overlapping sexual relationships, commonly referred to as sexual concurrency, are often believed to account for the rapid spread of HIV infection. (1–2) Research shows that concurrent sex partners are prevalent in several populations hit hardest by AIDS including gay communities, commercial sex workers, and throughout sub-Saharan Africa. Recent research shows sexual concurrency may be playing a role in resurgent HIV infections among gay and bisexual men in North America (3) and emerging epidemics in Asia.(4) In addition to epidemiological trends, the potential impact of concurrent sex partners on the spread of HIV transmission is biologically grounded. Sexual concurrency is thought to afford the rapid turnover of HIV when multiple partners are exposed to the virus during the brief and highly infectious period of acute infection.(5) Mathematical models suggest that concurrent sex partners during acute HIV infection are a driving force in heterosexually transmitted HIV epidemics of southern Africa. (6–7) While stimulating great interest, the existing empirical research on the role of sexual concurrency in HIV epidemics is not definitive. In the February 2010 issue of AIDS and Behavior (volume 14, Number 1) Lurie and Rosenthal (2, 8) pointed out that sexual concurrency has not yet been empirically shown to increase HIV transmission beyond what would be expected from multiple sex partnerships that do not overlap in time. They also note that epidemiological evidence is mixed as to whether sexual concurrency is propelling HIV in southern Africa and that there is even evidence that polygamy, certainly an example of concurrency, can protect against HIV transmission. (8–10) At the heart of the controversy surrounding the role of sexual concurrency in HIV epidemics is the question of whether limited HIV prevention resources should be directed at interventions to target sexual concurrency. Furthermore, even if interventions are designed to specifically target sexual concurrency, it is not clear how they would differ from programs that aim to reduce not-necessarily concurrent multiple sex partners. The jury may be out on whether sexual concurrency is necessary for the rapid spread of HIV, but there is no disputing that multiple sex partners, whether concurrent or serial, are important in HIV epidemics. Recognizing the need for behavioral interventions that reduce numbers of sex partners regardless of their temporal sequencing is not new. Throughout the 1980s and 1990s social marketing campaigns for HIV prevention in US gay communities commonly promoted reducing numbers of sex partners. Indeed, many of the early HIV prevention successes in gay communities and countries like Uganda are attributed to aggressive efforts aimed at reducing numbers of sex partners. (11–12) Because mass public health messages result in behavior change for only a segment of a population, more intensive behavioral interventions have been geared toward reducing numbers of partners. Several controlled intervention trials have demonstrated significant reductions in numbers of sex partners. Table 1 summarizes the findings from 15 selected prevention trials that report decreased numbers of sex partners over time. All of these studies found evidence for reductions in numbers of sex partners, with eleven trials demonstrating an experimental intervention that reduced numbers of partners to a significantly greater degree than a control condition. The interventions varied in their content and duration, with some lasting several hours and conducted over several sessions while others had only one brief session. All of the interventions included a heavy dose of interactive training for communication and preventive behavioral skills. The interventions were tested in various settings and with a wide range of populations including men who have sex with men, women, substance users, adolescents, and sexually transmitted infection clinic patients. The magnitude of partner reduction varied, with some studies showing more than a three-fold reduction in numbers of sex partners over time. Table 1 Partner reduction outcomes from selected behavioral HIV prevention interventions. Examining the outcomes reported within these trials suggests that reducing numbers of sex partners may not be any more difficult to achieve than changing other sexual behaviors, such as increasing condom use. In addition, reductions in sexually transmitted infections (STI) has not been directly linked to partner reductions relative to other changes in behavior. Research is needed to better understand motivations for maintaining multiple sex partners and how the meaning of multiple partners differs by gender, sexual orientation, and culture. The importance of multiple sex partners in facilitating the spread of HIV is indisputable. The importance of acute HIV infection in HIV transmission also applies to multiple partners even if non-overlapping and should therefore remain a focus in HIV prevention. Interventions that have shown promise in reducing numbers of sex partners are available and should be implemented in places with high HIV prevalence and high rates of multiple partners, concurrent or not.

Intentional Medication Nonadherence Because of Interactive Toxicity Beliefs Among HIV-Positive Active Drug Users.

Background:Drug use poses significant challenges to medical management of HIV infection. Although most research has focused on the influence of intoxication on unintentional adherence to HIV treatment, drug use may also lead to intentional nonadherence, particularly when individuals believe that mixing medications with drugs is harmful. This study examined whether interactive toxicity beliefs predict nonadherence to antiretroviral therapy (ART) over a prospective period of adherence monitoring. Methods:Men and women living with HIV who screened positive for drug use and were being treated with ART (n = 530) completed computerized self-interviews and 3 prospective unannounced pill counts to measure ART adherence and provided urine specimens for drug screening and HIV viral load results from medical records. Results:Results showed that 189 (35%) participants indicated that they intentionally miss their ART when they are using drugs. These participants also reported common beliefs regarding the perceived hazards of mixing HIV medications with alcohol and other drugs. Multivariable models controlled for demographic and health characteristics and frequency of alcohol use showed that intentional nonadherence predicted poorer ART adherence over the prospective month and also predicted poorer treatment outcomes as indexed by unsuppressed HIV viral load. Conclusions:These findings extend previous research to show that interactive toxicity beliefs and intentional nonadherence play a significant role in medication nonadherence for a substantial number of people living with HIV and should be actively addressed in HIV clinical care.

Assumed infectiousness, treatment adherence and sexual behaviours: applying the Swiss Statement on infectiousness to HIV-positive alcohol drinkers.

The success of antiretroviral therapy (ART) for treating HIV infection is now being turned towards HIV prevention. The Swiss Federal Commission for HIV/AIDS has declared that HIV‐positive persons who are treated with ART, have an undetectable viral load, and are free of co‐occurring sexually transmitted infections (STIs) should be considered noninfectious for sexual transmission of HIV. This study examined the implications of these assumptions in a sample of HIV‐positive individuals who drink alcohol.

Dimensions of Poverty and Health Outcomes Among People Living with HIV Infection: Limited Resources and Competing Needs.

Abstract HIV infection is concentrated in populations living in poverty. We examined the overlapping and independent effects of multiple poverty indicators on HIV-related health status. Because substance use can create competing survival needs when resources are limited, we also sought to objectively measure expenditures on food relative to alcohol and tobacco products. To achieve these aims, 459 men and 212 women living with HIV infection in Atlanta, GA completed measures of socio-demographic and heath characteristics as well as multiple indicators of poverty including housing stability, transportation, food insecurity, and substance use. Participants were given a

Trauma symptoms, internalized stigma, social support, and sexual risk behavior among HIV-positive gay and bisexual MSM who have sought sex partners online

30 grocery gift card for their participation and we collected receipts which were coded for alcohol (beer, wine, liquors) and tobacco purchases. Results showed that participants with unsuppressed HIV replication were significantly more likely to experience multiple indicators of poverty. In addition, one in four participants purchased alcohol or tobacco products with their gift cards, with as much as one-fourth of money spent on these products. A multivariable logistic regression model showed that food insecurity was independently associated with unsuppressed HIV, and purchasing alcohol or tobacco products did not moderate this association. Results confirm previous research to show the primacy of food insecurity in relation to HIV-related health outcomes. Competing survival needs, including addictive substances, should be addressed in programs that aim to alleviate poverty to enhance the health and well-being of people with HIV infection.