Matching social support to individual needs: a community-based intervention to improve HIV treatment adherence in a resource-poor setting.

From December 2005 to April 2007, we enrolled 60 adults starting antiretroviral therapy (ART) in Lima, Peru to receive community-based accompaniment with supervised antiretrovirals (CASA), consisting of 12 months of DOT-HAART, as well as microfinance assistance and/or psychosocial support group according to individuals' need. We matched 60 controls from a neighboring district, and assessed final clinical and psychosocial outcomes at 24 months. CASA support was associated with higher rates of virologic suppression and lower mortality. A comprehensive, tailored adherence intervention in the form of community-based DOT-HAART and matched economic and psychosocial support is both feasible and effective for certain individuals in resource-poor settings.

Validation and abbreviation of an HIV stigma scale in an adult spanish-speaking population in urban Peru.

The purpose of this study was to validate the Spanish version of the Berger HIV Stigma Scale in an urban Spanish-speaking population in Peru and create a valid and reliable abridged version of the scale. Participants were HIV-infected adults enrolled in an observational study to examine the effectiveness of a community-based antiretroviral therapy adherence intervention. Approximately half of participants were female, and the median age at enrollment was 30.5 years. The Spanish version of the full HIV Stigma Scale was internally reliable, demonstrated good construct validity, and was sensitive to change over time. The full HIV Stigma Scale was abbreviated by removing items that impaired subscale internal reliability, did not correlate with other subscale items, or demonstrated low factor correlations. The resulting abridged scale contained 21 of the 40 original items and revealed properties similar to the full Spanish version.

Community-based DOT-HAART accompaniment in an urban resource-poor setting.

From December 2005 to April 2007, we enrolled 60 adults starting antiretroviral therapy (ART) in a health district of Lima, Peru to receive community-based accompaniment with supervised antiretroviral (CASA). Paid community health workers performed twice-daily home visits to directly observe ART and offered additional medical, social and economic support to CASA participants. We matched 60 controls from a neighboring district by age, CD4 and primary referral criteria (TB status, female, neither). Using validated instruments at baseline and 12 months (time of DOT-HAART completion) we measured depression, social support, quality of life, HIV-related stigma and self-efficacy. We compared 12 month clinical and psychosocial outcomes among CASA versus control groups. CASA participants experienced better clinical and psychosocial outcomes at 12 months, including proportion with virologic suppression, increase in social support and reduction in HIV-associated stigma.

Challenges of diagnosis and management of tuberculosis and HIV coinfection in resource-limited settings: a case report from Lima, Peru.

We present a Peruvian human immunodeficiency virus (HIV)-positive patient receiving first-line therapy for tuberculosis who presents with neurological complications to highlight some of the major issues in the diagnosis and management of human immunodeficiency virus-related central nervous system complications in resource-poor settings. These include limited options for diagnosing extrapulmonary and drug-resistant tuberculosis; the importance of central nervous system . imaging; and the management conundrum when faced with a broad differential diagnosis. This patient was with drug-resistant tuberculosis of the brain, unmasked by immunologic recovery in the setting of recent initiation of antiretroviral treatment. We argue that aggressive and timely empiric multidrug-resistant tuberculosis treatment is important in cases where drug-resistant tuberculosis is suspected. Knowledge gaps include a limited understanding of immune reconstitution and the optimal timing of antiretroviral treatment in the setting of drug-resistant tuberculosis.

Psychosocial impact of poverty on antiretroviral nonadherence among HIV-TB coinfected patients in Lima, Peru.

OBJECTIVE: Tuberculosis and HIV coinfection poses unique clinical and psychosocial complexities that can impact nonadherence to highly active antiretroviral treatment (HAART). METHODS: This was a prospective case series to identify risk factors for HAART nonadherence among 43 patients with HIV and tuberculosis (TB) in Lima, Peru. Nonadherence was defined by patient self-report. RESULTS: The median initial CD4 and HIV viral load were 63 and 159,000, respectively. Patients had received a median of 6.1 months of ART. Univariable analysis found low social support, substance use, and depression to be associated with nonadherence. In multivariable analysis, low social support was associated with nonadherence. CONCLUSIONS: In the authors' urban cohort of HIV-TB coinfected individuals in Lima, Peru, substance use, depression, and lack of social support were key barriers to adherence. These findings suggest that adherence interventions may be unsuccessful unless they target the underlying psychosocial challenges faced by patients living with TB and AIDS.

Mental Health Burden Among Impoverished HIV-Positive Patients in Peru.

HIV and poor mental health are intricately related. In settings of poverty, both are often rooted in structural factors related to material and social deprivation. We performed a qualitative analysis to understand factors contributing to poor emotional health and its impact among impoverished Peruvian HIV-infected individuals. We conducted focus group discussions with patients and providers consisting of semistructured, open-ended questions. Qualitative analysis provided insight into the profound impact of depression, isolation, stigma, and lack of social support among these patients. Living with HIV contributed significantly to mental health problems experienced by HIV-positive individuals; furthermore, long-standing stressors-such as economic hardship, fragmented family relationships, and substance use-shaped patients' outlooks, and may have contributed not only to current emotional hardship but to risk factors for contracting HIV as well. Once diagnosed with HIV/AIDS, many patients experienced hopelessness, stigma, and socioeconomic marginalization. Patients tended to rely on informal sources of support, including peers and community health workers, and rarely used formal mental health services. In resource-poor settings, the context of mental health problems among HIV-positive individuals must be framed within the larger structural context of poverty and social exclusion. Optimal strategies to address the mental health problems of these individuals should include integrating mental health services into HIV care, task shifting to utilize community health workers where human resources are scarce, and interventions aimed at poverty alleviation.

How does directly observed therapy work? The mechanisms and impact of a comprehensive directly observed therapy intervention of highly active antiretroviral therapy in Peru.

From December 2005 through August 2008, we provided community-based accompaniment with supervised antiretroviral therapy (CASA) to impoverished individuals starting highly active antiretroviral therapy. Adherence support was provided for 18 months by a community-based team comprised of several nurses and two types of community health workers: field supervisors and directly observed therapy (DOT) volunteers. To complement our quantitative data collection in 2008 using purposive sampling, we conducted two gender-mixed focus group discussions with 13 CASA patient participants and 13 DOT volunteers from Lima, Peru to identify the mediating mechanisms by which CASA improved well-being, and to understand the benefits of the intervention, as perceived by these individuals. Using standard qualitative methods for the review and analysis of transcripts and interview notes, we identified central themes and developed a coding scheme for categorising participants' statements. Two individuals blinded to each other's coding, coded interview transcripts for theme and content from which a third reviewer compared their coding to arbitrate discrepancies. Additional domains were added if necessary and all domains were integrated into a theoretical scheme. Among the forms of support delivered by the CASA team, DOT volunteers reported emotional support, instrumental support, directly observed therapy, building trust, education, advocacy, exercise of moral authority and preparation for transition off CASA support. CASA participants described outcomes of improved adherence, ability to resume social roles, increased self-efficacy, hopefulness, changes in non-HIV-related behaviour, reduced internalised and externalised stigma, as well as ability to disclose. Both sets of focus group participants highlighted remaining challenges after completion of CASA support: stigma in the community, difficulties achieving economic recovery and persistent barriers to health services. Based on our prior quantitative and qualitative outcomes reported here, we argue that DOT of highly active antiretroviral therapy could be designed to optimise psychosocial recovery during the period of DOT.

Microfinance: a general overview and implications for impoverished individuals living with HIV/AIDS.

Microfinance among people living with HIV/AIDS (PLWHA) faces some opposition and remains understudied. This literature review examines microfinance's evolution and impact on a variety of social and health indicators and its emerging implementation as a primary prevention tool for HIV and economic intervention for PLWHA. There is an abundance of literature supporting the apparent utility of microfinance. However, our understanding of the subject remains clouded by the heterogeneity and methodological limitations of existing impact studies, and access limitations to microfinance curbs our understanding of microfinance for this population. Existing literature suggests PLWHA could attain economic stability from microfinance and achieve successful repayment rates in some settings. The precarious socioeconomic and health issues of PLWHA pose unique challenges to minimizing loan default risk. Carefully-designed clinical studies are needed to assess whether PLWHA can be as successful with microfinance as healthy individuals.

Burden of depression among impoverished HIV-positive women in Peru.

OBJECTIVES: In resource-poor settings, the mental health burden among HIV-positive women is exacerbated by poverty. We sought to describe the extent, risk factors, and experience of depression among impoverished HIV-positive women living in Lima, Peru. METHODS: This is a case series of 78 HIV-positive women in Lima, Peru. We measured depression, stigma, and social support and performed a multivariable analysis to identify factors associated with depression. RESULTS: Among 78 HIV-positive patients, 68% were depressed. Depression and suicidal ideation were rarely diagnosed by providers. In multivariable analysis, HIV-related stigma and food scarcity were associated with depression. CONCLUSIONS: In our cohort of HIV-positive women in Lima, Peru, poverty and socioeconomic vulnerability contributed to depression. Findings highlight the heavy burden of depression in this cohort of poor women and the need to incorporate mental health services as an integral component of HIV care.