Co-designing health services for people living with HIV who have multimorbidity: a feasibility study.

This study explored the feasibility of using an experience-based co-design service improvement methodology to develop a new approach to managing multimorbidity in people living with HIV. Patients with HIV and multimorbidity and staff were recruited from five hospital departments and general practice. Staff and patient experiences were gathered through semi-structured interviews, filmed patient interviews, non-participant observation and patient diaries. A composite film developed from interviews illustrated the touchpoints in the patient journey, and priorities for service improvement were identified by staff and patients in focus groups. Twenty-two people living with HIV and 14 staff took part. Four patients completed a diary and 10 a filmed interview. Analysis identified eight touchpoints, and group work pinpointed three improvement priorities: medical records and information sharing; appointment management; and care co-ordination and streamlining. This study demonstrates that experience-based co-design is feasible in the context of HIV and can inform healthcare improvement for people with multimorbidity.

"You will eat shoe polish if you think it would help"-Familiar and lesser-known themes identified from mixed-methods analysis of a cluster headache survey.

OBJECTIVE: To characterize patient-reported ideas and concerns about cluster headache, treatment options, and management strategies. BACKGROUND: Cluster headache patients experience severe pain and often suffer additional consequences from their disease. Patients have identified methods to cope with and combat cluster headache that are not widely known. METHODS: Secondary analysis was performed using deidentified data from the online Clusterbusters Medication Use survey, wherein 10 questions allowed for freely written comments. Using mixed-methods techniques, neurologists with expertise in headache medicine identified themes from these comments. Subgroup analysis sought to identify variables associated with specific themes. RESULTS: Among 2274 free-text responses from 493 adult participants, 23 themes were identified. Themes commonly discussed in the literature included such topics as "nothing worked" (24.7%, 122/493), "side effects" (12.8%, 63/493), and difficulties with "access/cost" (2.4%, 12/493). Less widely recognized themes included the use of "illicit substances" (35.5%, 175/493) and "vitamins/supplements" (12.2%, 60/493) in disease management. Lesser-known themes included "coffee" (5.3%, 26/493) and "exercise/physical activity" (4.7%, 23/493). Using strict significance criteria, no subgroup was associated with any theme. Several poignant quotes highlighted patient thoughts and experiences. CONCLUSIONS: This mixed-methods analysis identified challenges endured by cluster headache patients, as well as a variety of patient-directed disease management approaches. The volunteered information spotlights pharmacological, physiological, and psychological aspects of cluster headache that warrant further exploratory and interventional investigation.

Headache in Patients With Severe Acute Respiratory Syndrome Coronavirus 2 Infection: A Narrative Review.

OBJECTIVE: To summarize available literature regarding headache as a manifestation of coronaviruses and to describe potential underlying mechanisms. REVIEW METHODS: References for this review were identified by searches within PubMed without any date restrictions. The search terms used were coronavirus disease 2019 (COVID-19) clinical manifestation, COVID-19 epidemiology, neurologic findings in COVID-19, headache in COVID-19, neurologic manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and headache in SARS-CoV-2. RESULTS: Headache is one of the most common neurologic complaints in patients with SARS-CoV-2. While the pathophysiological connection between headache and SARS-CoV-2 is unclear, inflammatory mechanisms may play a key role. One of the mechanisms cited in the literature of migraine and other headache disorders is the activation of nociceptive sensory neurons by cytokines and chemokines. A similar mechanism has been reported in SARS-CoV-2 with the release of cytokines and chemokines by macrophages throughout the course of infection. Other mechanisms for headache in SARS-CoV-2 include (1) viral neuroinvasion as seen with viral encephalitis; (2) hypoxemia due to the well-described pulmonary manifestations of the disease; and (3) thrombosis secondary to COVID-19 induced hypercoagulable states. CONCLUSION: According to the Centers for Disease Control, common symptoms of human coronavirus include fever, cough, runny nose, sore throat, and headache. In the case of SARS-CoV-2, there are limited reports about headaches, one of the most common clinical manifestations. There are currently no studies that focus specifically on headache among patients with SARS-CoV-2 infection.

Mind Matters: Treatment Concerns Predict the Emergence of Antiretroviral Therapy Side Effects in People with HIV.

The aim of this analysis of historical data was to determine whether patients' pre-treatment beliefs about antiretroviral therapy (ART) predict the subsequent reporting of side effects. Data were collected as part of a prospective, 12-month follow-up study. Of 120 people starting ART, 76 completed follow-up assessments and were included in the analyses. Participants completed validated questionnaires assessing their beliefs about ART, beliefs about medicines in general, perceived sensitivity to adverse effects of medicines, depression and anxiety before initiating ART and after 1 and 6 months of treatment. Adherence was assessed at 1, 6 and 12 months. Pre-treatment concerns about ART were associated with significantly more side effects at 1 month (p < 0.05) and 6 months (p < 0.005). Side effects at 6 months predicted low adherence at 12 months (p < 0.005). These findings have implications for the development of interventions to support patients initiating ART by providing a mechanism to pre-empt and reduce side effects.

A Qualitative Study to Identify Perceptual Barriers to Antiretroviral Therapy (ART) Uptake and Adherence in HIV Positive People from UK Black African and Caribbean Communities.

To inform the development of interventions to increase uptake and adherence to antiretroviral therapy (ART), we explored perceptions of ART in semi-structured interviews with 52 men and women from UK black African and black Caribbean communities. Verbatim transcripts were analyzed using framework analysis. Perceptions of ART could be grouped into two categories: doubts about the personal necessity for ART and concerns about potential adverse effects. Doubts about necessity stemmed from feeling well, doubts about the efficacy of ART, religious beliefs and the belief that treatment was futile because it could not cure HIV. Concerns about adverse effects included the fear that attending HIV services and taking treatment would lead to disclosure of HIV, feeling overwhelmed at the prospect of starting treatment soon after diagnosis, fears about side effects and potential long-term effects, and physical repulsion. The findings will facilitate the development of interventions to increase uptake and adherence to ART.

Measuring empowerment among people living with HIV: a systematic review of available measures and their properties.

A systematic review was conducted to identify and appraise measures of empowerment used in peer-reviewed research with people living with HIV. Thirty articles reporting on 12 scales were identified via keyword and citation searches of electronic databases and hand searching of reference lists. The instruments captured a wide range of constructs, including self-efficacy, perceived knowledge/information seeking, self-management behaviours, belief in an active patient role and tolerance of uncertainty. While the majority of instruments were focused exclusively on self-efficacy to manage HIV, the Patient Activation Measure (PAM-13 and PAM-22) and the Health Empowerment Inventory were broader in scope. Most of the identified measures had acceptable construct validity, however there were insufficient data to determine the reliability or responsiveness of many of the scales. The findings highlight the need for a more concrete definition of empowerment and for further validation of existing measures with people living with HIV.

Factors associated with testing for HIV in people aged ≥50 years: a qualitative study.

BACKGROUND: Despite a decline in the number of new HIV infections in the UK overall, the number and proportion of new HIV diagnoses in people aged ≥50 years continues to increase. People aged ≥50 years are disproportionately affected by late diagnosis, which is associated with poorer health outcomes, increased treatment complexity and increased healthcare costs. Late HIV diagnosis also has significant public health implications in terms of onward HIV transmission. It is not fully understood what factors affect the decision of an older person to test for HIV. The aim of this study was to identify factors associated with testing for HIV in people aged ≥50 years who tested late for HIV. METHODS: We interviewed 20 people aged ≥50 years diagnosed late with HIV to identify factors associated with HIV testing. Interviews were audio recorded, transcribed verbatim and thematically analysed. RESULTS: Seven themes associated with HIV testing in people aged ≥50 years were identified: experience of early HIV/AIDS campaigns, HIV knowledge, presence of symptoms and symptom attribution, risk and risk perception, generational approaches to health and sexual health, stigma, and type of testing and testing venue. CONCLUSION: Some factors associated with testing identified in this study were unique to older individuals. People aged ≥50 years often do not perceive themselves to be at risk of HIV. Further, stigma and a lack of knowledge of how to access HIV testing suggest a need for health promotion and suggest current sexual health services may need to adapt to better meet their needs.

Theory-Based Digital Interventions to Improve Asthma Self-Management Outcomes: Systematic Review.

BACKGROUND: Asthma is a chronic disease requiring effective self-management to control it and prevent mortality. The use of theory-informed digital interventions promoting asthma self-management is increasing. However, there is limited knowledge concerning how and to what extent psychological theory has been applied to the development of digital interventions, or how using theory impacts outcomes. OBJECTIVE: The study aimed to examine the use and application of theory in the development of digital interventions to enhance asthma self-management and to evaluate the effectiveness of theory-based interventions in improving adherence, self-management, and clinical outcomes. METHODS: Electronic databases (CENTRAL, MEDLINE, EMBASE, and PsycINFO) were searched systematically using predetermined terms. Additional studies were identified by scanning references within relevant studies. Two researchers screened titles and abstracts against predefined inclusion criteria; a third resolved discrepancies. Full-text review was undertaken for relevant studies. Those meeting inclusion criteria were assessed for risk of bias using the Cochrane Collaboration tool. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Study outcomes were classified as medication adherence, self-management, asthma control, clinical markers of health, quality of life, other quality of life outcomes, and health care utilization. Effectiveness was calculated as an average outcome score based on the study's reported significance. The Theory Coding Scheme (TCS) was used to establish the extent to which each intervention had applied theory and which theoretical constructs or behavioral determinants were addressed. Associations between TCS scores and asthma outcomes were described within a narrative synthesis. RESULTS: Fourteen studies evaluating 14 different digital interventions were included in this review. The most commonly cited theories were Social Cognitive Theory, Health Belief Model, and Self-Efficacy Theory. A greater use of theory in the development of interventions was correlated with effective outcomes (r=.657; P=.01): only the 3 studies that met >60% of the different uses of theory assessed by the TCS were effective on all behavioral and clinical outcomes measured. None of the 11 studies that met ≤60% of the TCS criteria were fully effective; however, 3 interventions were partially effective (ie, the intervention had a significant impact on some, but not all, of the outcomes measured). Most studies lacked detail on the theoretical constructs and how they were applied to the development and application of the intervention. CONCLUSIONS: These findings suggest that greater use of theory in the development and application of digital self-management interventions for asthma may increase their effectiveness. The application of theory alone may not be enough to yield a successful intervention, and other factors (eg, the context in which the intervention is used) should be considered. A systematic approach to the use of theory to guide the design, selection, and application of intervention techniques is needed.

Measuring quality of life among people living with HIV: a systematic review of reviews.

AIM: A systematic review of reviews was conducted to identify and appraise brief measures of health-related quality of life (HRQoL) that have been used in peer-reviewed research with people living with HIV. METHODS: The review was conducted in two stages: 1) search of electronic databases to identify systematic reviews of tools used to measure HRQoL in adults living with HIV, published since the year 2000; 2) selection of HRQol scales from those identified in the reviews. Inclusion criteria included scales that could be self-administered in 10 min or less, covering at least 3 domains of quality of life (physical function, social/role function and mental/emotional function). For generic scales, inclusion criteria included the availability of normative data while for HIV-specific scales, patient input into the development of the scale was required. RESULTS: Ten reviews met the inclusion criteria. Nine generic scales met the inclusion criteria: the EuroQol five dimensions questionnaire (EQ-5D); Health Utilities Index; McGill Quality of Life questionnaire; Medical Outcomes Study (MOS) Short Form (SF)-12; SF-36; World Health Organisation Quality of Life (WHOQOL- BREF), Questions of Life Satisfaction (FLZM) and SF-20. Available psychometric data supported the EQ-5D and SF-36. Seven HIV-specific scales met the inclusion criteria: the AIDS Clinical Trials Group (ACTG)-21; HIV-QL-31; MOS-HIV; Multidimensional Quality of Life Questionnaire for Persons with HIV/AIDS (MQOL-HIV), PROQOL-HIV, Symptom Quality of Life Adherence (HIV-SQUAD) and the WHOQOL-HIV BREF. Of the HIV -specific measures, the MOS-HIV was considered to have the most well-established psychometric properties, however limitations identified in the reviews included insufficient input from people living with HIV in the development of the scale, cross-cultural relevance and continued applicability. Two relatively new measures, the WHOQOL-HIV BREF and PROQOL-HIV, were considered to have promising psychometric properties and may have more relevance to people living with HIV. CONCLUSION: The findings highlight the need for further validation of HRQoL measures in people living with HIV. The choice of one measure over another is likely to be influenced by the purpose of the quality of life assessment and the domains of HRQoL that are most relevant to the specific research or clinical question.

Factors associated with HIV testing in people aged ⩾50 years: an integrated qualitative analysis of patients and healthcare providers.

Background: Older people continue to be disproportionately affected by late HIV diagnosis, which results in increased morbidity and mortality. Despite high acceptance of HIV testing generally, older people are less likely to undergo testing than younger people. Two previous studies have been conducted, one focussing on patient-related and one focussing on clinician-related factors associated with HIV testing in older age (⩾50 years). Objective: This study is an integrated analysis from two linked studies - one focussed on patients, and one focussed on clinicians - to understand overlap in views and experiences of HIV testing in older age, to outline the clinical implications of the findings, and to highlight potential interventions to improve testing in this group. Methods: This qualitative study utilised semi-structured interviews conducted with 20 clinicians who were not HIV care specialists, but who had recently seen an older person prior to their HIV diagnosis, and 20 people who had been diagnosed late with HIV aged 50+. Interviews were audio recorded, transcribed verbatim and thematically analysed. The combined synthesis reported here was planned a priori as part of a sequential design. Results: Seven clinician- and seven patient-related themes were associated with undergoing HIV testing in older age. This article discusses the four themes that were common to both groups: poor knowledge, incorrect symptom attribution, inaccurate perception of risk, and stigma. Conclusion: Both clinician and patient factors associated with testing will have to be addressed in order to increase HIV testing in older people, and reduce the likelihood of late diagnosis. Findings from overlapping themes suggest several areas for intervention: (1) routine screening as part of existing clinical contacts aimed at older people to eliminate the need to attribute symptoms to HIV or assess risk; (2) specific and tailored education materials for clinicians and older people which utilise appropriate modalities; (3) tailored HIV testing services: either specific clinics for older people at existing sexual health services, or dedicated services in primary care.

The development of an intervention to support uptake and adherence to antiretroviral therapy in people living with HIV: the SUPA intervention. A brief report.

The effectiveness of antiretroviral therapy (ART) depends on prompt uptake of treatment and a high level of adherence over the long-term, yet these behaviors are suboptimal. Previous interventions have significantly improved adherence but effect sizes are generally small. The aim of this article is to describe the design and content of an intervention to support uptake and adherence to treatment in HIV positive patients (SUPA intervention), utilizing cognitive behavioral and motivational interviewing (MI) techniques. The intervention was developed in line with Medical Research Council (MRC) guidance for the development of complex interventions and informed by the NICE (National Institute for Health and Care Excellence) Guidelines for adherence, empirical evidence and focus groups. Behavior change techniques were mapped to perceptual and practical barriers to uptake and adherence to ART, identified in previous research. Intervention materials were designed and later discussed within focus groups, where feedback enabled an iterative process of development. We conclude it is possible to transparently report the design and content of a theory-based intervention to increase uptake and adherence to ART. The intervention has been evaluated within a randomized controlled trial (RCT) at 10 HIV clinics in England, the results of which will be reported elsewhere.

Factors associated with offering HIV testing to people aged ≥ 50 years: A qualitative study.

BACKGROUND: Individuals aged ≥ 50 years continue to be disproportionately affected by late HIV diagnosis, which is associated with poorer health outcomes and onward transmission. Despite HIV testing guidelines and high acceptability of HIV testing among all patients, clinicians are less likely to offer a test to an older individual. The aim of this study was to identify clinician-related factors associated with offering HIV testing to patients aged ≥ 50 years. METHODS: Twenty clinicians who had been involved in the care of an older patient diagnosed late with HIV were interviewed. RESULTS: Thematic analysis identified seven factors associated with offering HIV testing to older people: knowledge, stigma, stereotyping and perception of risk, symptom attribution, discussing HIV with patients, consent procedures and practical issues. CONCLUSIONS: Although some factors are not unique to older patients, some are unique to this group. Many clinicians lack up-to-date HIV-related knowledge, feel anxious discussing HIV with older patients and perceive asexuality in older age. In order to increase the offer of HIV testing to this group, we identified clinician-related barriers to test offer that need to be addressed.

Beliefs about antiretroviral therapy, treatment adherence and quality of life in a 48-week randomised study of continuation of zidovudine/lamivudine or switch to tenofovir DF/emtricitabine, each with efavirenz.

Adherence may be facilitated by reducing perceptual and practical barriers to antiretroviral therapy (ART). Practical barriers include the complexity of daily dosing, while perceptual barriers include perceptions of the need for treatment and concerns about adverse effects. The study aim was to assess the effect of switching zidovudine plus lamivudine twice-daily (Combivir, CBV) to once-daily tenofovir DF plus emtricitabine (Truvada, TVD), each plus efavirenz (EFZ), on adherence, beliefs about ART and quality of life (QoL). Subjects stable on CBV + EFV were randomised 1:1 to continue this regimen or switch to TVD + EFV. Adherence was measured using the Medication Adherence Self-Report Inventory at 4, 12, 24 and 48 weeks. Beliefs about ART (perceptions of necessity and concerns about adverse effects), treatment intrusiveness and QoL were measured by questionnaire at baseline 4, 12, 24 and 48 weeks. Viral load was assessed at each visit. Two hundred and thirty-four subjects initiated treatment. At week 48, the proportion of subjects reporting high adherence (≥95% taken as prescribed) was significantly greater in the TVD arm (p=0.049). Low adherence (reporting taking <95% as prescribed, discontinuing the study or having missing data) was associated with doubts about necessity (p=0.020), stronger concerns about adverse effects (p=0.010), greater treatment intrusiveness (p=0.010) and poorer mental health related QoL (p=0.008). At week 48, both concerns about ART (p=0.038) and treatment intrusiveness (p=0.004) were lower among those who switched to TVD. Furthermore, there was a decline in both concerns about ART (p=0.007) and treatment intrusiveness (p=0.057) over the 48 weeks among those who switched to TVD. There were no significant differences in necessity beliefs, QoL or viral load between randomised groups. Switching from CBV to TVD may improve patient reported outcomes including slightly better adherence, a greater reduction in concerns about adverse effects and less treatment intrusiveness.

Dietary glycemic index and load in relation to cardiovascular disease risk factors in Cuban American population.

OBJECTIVE: To examine whether dietary glycemic index (GI) or glycemic load (GL) had an effect on the cardiovascular disease (CVD) risk factors and whether the effects were dependent on the diabetes status in the Cuban American population. DESIGN: A case­control, single-time-point study. METHODS: A total of 324 middle-aged Cuban American adults had completed data on fasting blood lipids, physical activity level and usual dietary intake using a validated food frequency questionnaire. Published GI values were assigned to food items and average dietary GI and GL were calculated per participant. RESULTS: Subjects without type 2 diabetes (T2D) were 3.3 times more likely to be in the recommended, highest high-density lipoprotein-cholesterol category if they were in the second dietary GL tertile as compared with those in the first dietary GL tertile (P = 0.042, 95% confidence interval = 1.94, 10.78). CONCLUSIONS: The results of the present study suggest that in this sample of Cuban Americans a high GI or GL diet do not adversely affects blood lipids, especially among subjects without T2D.

Practical Barriers to Medication Adherence: What Do Current Self- or Observer-Reported Instruments Assess?

INTRODUCTION: Practical adherence barriers (e.g., medication frequency) are generally more amenable to intervention than perceptual barriers (e.g., beliefs). Measures which assess adherence barriers exist, however these tend to measure a mix of factors. There is a need to identify what practical barriers are captured by current measures. AIM: To identify and synthesise the practical adherence barriers which are assessed by currently available self- or observer-report adherence measures. METHODS: A search for systematic reviews of self- or observer-report report adherence measures was conducted. Three electronic databases (Embase, Ovid Medline, and PsycInfo) were searched using terms based on adherence, adherence barriers and measures. Systematic reviews reporting on adherence measures which included at least one self- or observer-report questionnaire or scale were included. Adherence measures were extracted and coded on whether they addressed perceptual or practical barriers, or both. Practical items were then analysed thematically. RESULTS: Following screening of 272 initial abstracts, 20 full-text papers were reviewed. Four were excluded after full-text review, leaving 16 systematic reviews for data extraction. From these, 187 different adherence measures were extracted and coded, and 23 unique measures were identified as assessing practical barriers and included in the final analysis. Seven key themes were identified: formulation; instructions for use; issues with remembering; capability-knowledge and skills; financial; medication supply and social environment. CONCLUSION: Existing adherence measures capture a variety of practical barriers which can be grouped into seven categories. These findings may be used to inform the development of a measure of practical adherence barriers.

Prescribing and using self-injectable antiretrovirals: how concordant are physician and patient perspectives?

BACKGROUND: The selection of agents for any treatment regimen is in part influenced by physician and patient attitudes. This study investigated attitudinal motivators and barriers to the use of self-injectable antiretroviral agents among physicians and patients and measured the degree of concordance between physician and patient perspectives. METHODS: Attitudes toward prescribing and usage of self-injectable antiretroviral therapy (SIAT) were assessed by structured interview in 2 cohorts sampled from the European Union and the USA: 499 HIV-treating physicians and 603 treatment-experienced HIV-infected patients. Motivators and barriers to prescribing SIAT were identified from statistical analysis of the associations between physicians' ratings of enfuvirtide-based therapy compared to standard oral-based therapy and 2 indicators of enfuvirtide prescribing behavior. Patients' attitudes were assessed by their responses to a written profile of enfuvirtide and their ratings of the likelihood of accepting a treatment offer. RESULTS: Both indicators of SIAT prescribing behavior were predicted by the same pattern of physician beliefs. Nonprescribing was associated with: (1) the belief that offering enfuvirtide would be perceived negatively by patients, leading to treatment refusal and nonadherence; (2) the belief that prescribing enfuvirtide is harder to justify in terms of time/resources; and (3) a lack of confidence in the efficacy and use of enfuvirtide in practice (all p < 0.05). However, physicians' beliefs were not in concordance with patients' views. After reading a profile of enfuvirtide, 76% patients said that they would be moderately or highly likely to accept a treatment offer, although most (72%) had not discussed enfuvirtide with their doctor. Patients' beliefs predicted the likelihood of accepting enfuvirtide. CONCLUSION: Physician and patient beliefs about SIAT influence prescribing behavior and compliance yet may not be concordant, with patients having more positive attitudes towards SIAT than anticipated by physicians.

Use of a Retrospective Methodology to Examine the Process of Care Surrounding Serious Medical Events in HIV-Positive Patients: A Feasibility Study.

INTRODUCTION: Comorbidities are increasingly common among people living with HIV (PLWH) as they age. There is no evidence regarding models of care. We aimed to assess feasibility of a novel methodology to investigate care processes for serious medical events in PLWH. METHOD: The method was based on the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Data were extracted from medical records and questionnaires completed by general practitioners (GPs), HIV physicians, and non-HIV specialist physicians. A panel reviewed anonymized cases and gave feedback on the review process. RESULTS: Eleven of 13 patients consented to the study. Questionnaires were completed by 64% of HIV physicians, 67% of non-HIV specialist physicians, and 55% of GPs. The independent review panel (IRP) advised improvement in the methodology including data presentation and timing. CONCLUSION: This method was acceptable to patients and secondary care physicians. Further work is needed to the improve GP responses and facilitate IRP.

Initiation of therapy with a subcutaneously administered antiretroviral in treatment-experienced HIV-infected patients: understanding physician and patient perspectives.

Enfuvirtide (Fuzeon) is the first self-injectable antiretroviral (ARV) therapy approved for the treatment of HIV. This study was undertaken to explore the perceptions of injectable ARVs among physicians and treatment-experienced HIV-infected patients and identify potential motivators or barriers to the initiation of injectable ARV therapies. This empirical study was conducted based on qualitative field research conducted in multiple centres in five European countries and the US. A purposive sampling strategy was employed and structured interviews carried out with physicians and patients. Discussion guides for these interviews focused on attitudinal responses to a range of key areas. For physicians, these areas included HIV treatment, treatment-experienced patients and their relationships with them and injectable therapy usage, while for patients - some of whom were receiving enfuvirtide therapy - the focus included relationships with their physicians and attitudes towards injectable ARV therapy. Sixty-eight physicians and 43 patients were interviewed. Qualitative analysis of the interview responses revealed a number of recurring themes among physician and patient perceptions of HIV and its treatment. Physicians tended to view injectable ARVs as a last resort, with only limited suitability among treatment-experienced patients and a low level of patient acceptability. In contrast, patients generally perceived the potential value of effective injectable ARV therapy, if recommended to them by their physicians, indicating that its benefits could outweigh the drawbacks associated with its administration. This study identified some potential disconnects between physician and patient perceptions of injectable therapy. Our findings emphasize the need for patients to discuss their treatment goals with their physicians so that they can work together to find the regimen that is most likely to achieve these goals.

Determinants of non-adherence to treatment for tuberculosis in high-income and middle-income settings: a systematic review protocol.

INTRODUCTION: Treatment for tuberculosis (TB) is highly effective if taken according to prescribed schedules. However, many people have difficulty adhering to treatment which can lead to poorer clinical outcomes, the development of drug resistance, increased duration of infectivity and consequent onward transmission of infection. A range of approaches are available to support adherence but in order to target these effectively a better understanding of the predictors of poor adherence is needed. This review aims to highlight the personal, sociocultural and structural factors that may lead to poor adherence in high-income and middle-income settings. METHODS AND ANALYSIS: Seven electronic databases, Medline, EMBASE, CINAHL, PsycInfo, The Cochrane Library, Scopus and Web of Science, will be searched for relevant articles using a prespecified search strategy. Observational studies will be targeted to explore factors that influence adherence to treatment in individuals diagnosed with TB. Screening title and abstract followed by full-text screening and critical appraisal will be conducted by two researchers. Data will be extracted using the Population, Exposure, Comparator, Outcomes, Study characteristics framework. For cross-study assessment of strength of evidence for particular risk factors affecting adherence we will use the Grading of Recommendations, Assessment, Development and Evaluation tool modified for prognostic studies. A narrative synthesis of the studies will be compiled. A meta-analysis will be considered if there are sufficient numbers of studies that are homogenous in study design, population and outcomes. DISSEMINATION: A draft conceptual framework will be identified that (A) identifies key barriers to adherence at each contextual level (eg, personal, sociocultural, health systems) and (B) maps the relationships, pathways and mechanisms of effect between these factors and adherence outcomes for people with TB. The draft conceptual framework will guide targeting of adherence interventions and further research. PROSPERO REGISTRATION NUMBER: CRD42017061049.

Patients' perspectives on the development of HIV services to accommodate ageing with HIV: a qualitative study.

The objective of this study was to identify the aspects of healthcare that are most valued by people with HIV and to describe their concerns and preferences for the future delivery of services for non-HIV-related illness. Twelve focus groups of people receiving HIV care were conducted in community settings in South-East England. Groups were quota sampled based on age, gender, sexual orientation and ethnicity. Data were analysed using Framework Analysis. The results showed that among the 74 respondents (61% male), a preference for maintaining all care within specialist HIV clinics was commonplace, but was highest among participants with more extensive histories of HIV and comorbidities. Participants valued care-coordination, inter-service communication and timely updates to medical notes. There were high levels of concern around HIV skills in general practices and the capacity of general practitioners to manage patient confidentiality or deal appropriately with the emotional and social challenges of living with HIV. Participants valued, and had an overall preference for, the specialist knowledge and skills of HIV services, suggesting that non-HIV-specialist services will need to build their appeal if they are to have a greater future role in the care of people with HIV. Particular concerns that should be addressed include: patient confidence in the HIV knowledge and skills of non-specialist service providers; clear processes for prescribing and referrals; improved levels of care-coordination and communication between services and increased patient confidence in the capacity of primary care to maintain confidentiality and to appreciate the stigma associated with HIV.