Pharmacy Refill Data are Poor Predictors of Virologic Treatment Outcomes in Adolescents with HIV in Botswana.

In adults living with HIV, pharmacy refill data are good predictors of virologic failure (VF). The utility of pharmacy refill data for predicting VF in adolescents has not been reported. We evaluated data from 291 adolescents on antiretroviral therapy. The main outcome measure was VF, defined as two consecutive HIV viral load measurements ≥ 400 copies/mL during 24-months of follow-up. Pharmacy refill non-adherence was defined as two consecutive refill adherence measurements < 95% during the same period. Fifty-three (18%) adolescents experienced VF. One hundred twenty-eight (44%) adolescents had refill non-adherence. Refill non-adherence had poor discriminative ability for indicating VF (receiver operating characteristic AUC = 0.60). Sensitivity and specificity for predicting VF was poor (60% (95% CI 46-74%) and 60% (95% CI 53-66%), respectively). The lack of a viable surrogate for VF in adolescents highlights the urgent need for more access to virologic testing and novel methods of monitoring adolescent treatment adherence.

Life-sustaining treatment decisions: a social work response to meet needs of health care surrogates.

Surrogates must possess essential patient information prior to legitimately exercising legal and moral obligations to act on patients' medical care preferences. This descriptive, in vivo study examined factors influencing surrogate and proxy decisions (N = 132) following life-sustaining treatment decisions. Patient communication and self-efficacy variables accounted for approximately 38% of the variance in surrogates' perceptions of benefits/barriers associated with decision making. Guided by patients' advanced communication, respondents (97.8%) expressed high self-reliance and significant appreciation of benefits associated with their decisions. Clarifying surrogates' and providers' understanding of patient care preferences during ICU/CCU admission may facilitate better adherence to patient wishes.

AIDS stigma in health services in the Eastern Caribbean.

Stigma obstructs HIV/AIDS prevention and care worldwide, including in the Caribbean, where the prevalence of AIDS is second only to sub-Saharan Africa. To contextualise the experience of AIDS stigma in health services in Grenada and Trinidad and Tobago, we conducted eight focus groups with 51 people living with HIV/AIDS (PLHA), families, and service providers. Quasi-deductive content analysis revealed consonance with Western and Northern conceptualisations of AIDS stigma wherein stigma is enacted upon marginalized populations and reinforced through psycho-sociological processes comparing 'in' and 'out' groups. Socially constructed to be physically contagious and socially deviant, PLHA are scorned by some service providers, especially when they are perceived to be gay or bisexual. PLHA and providers identified passive neglect and active refusal by hospital and clinic staff to provide care to PLHA. Institutional practices for safeguarding patient confidentiality are perceived as marginally enforced. Interventions are needed to reduce provider stigma so the public will access HIV testing and PLHA will seek treatment.

Awareness, acceptance, and action: an emerging framework for understanding AIDS stigmatizing attitudes among community leaders in Barbados.

AIDS stigma must be acknowledged and reduced to advance HIV prevention and HIV/AIDS care in a variety of settings worldwide, including in the West Indies where national epidemics are thought to be growing rapidly. Regarded by international health organizations as a formidable barrier to service delivery and receipt, AIDS stigma refers to prejudice and discrimination directed toward people living with HIV/AIDS (PLHA), persons perceived as being at risk for HIV infection, and the informal and formal service providers who care for PLHA. However, there is little evidence of successful antistigma interventions in the literature. Furthermore, beyond studies of willingness in various professions to serve clients or patients with HIV/AIDS, the stigmatizing attitudes and behaviors of service delivery personnel, paraprofessionals and volunteers have been inadequately studied. This paper uses data obtained during an AIDS awareness workshop with sports coaches in Barbados to illustrate principles of an antistigma intervention framework being developed for social service and health personnel. The Awareness/Acceptance/Action Model (AAAM) draws on principles of mindfulness, rooted in ancient Asian traditions, and recently adapted to a range of physical and mental health interventions in Western contexts. Mindfulness techniques encourage awareness of one's current state and environment, acceptance of the implications of one's attitudes and behaviors, and the development of intentional responses rather than habitually patterned reactions. In this initial effort, community leaders were guided through a series of self-reflective exercises focusing AAAM principles on their tendencies toward AIDS stigma, and exploring more compassionate and functional alternatives.

Measuring stigma among health care and social service providers: The HIV/AIDS Provider Stigma Inventory.

Initial validation of the HIV/AIDS Provider Stigma Inventory (HAPSI), piloted on a sample of 174 nursing students, supported the psychometric qualities of a suite of measures capturing tendencies to stigmatize and discriminate against people living with HIV/AIDS (PLHA). Derived from social psychology and mindfulness theories, separate scales addressing awareness, acceptance, and action were designed to include notions of labeling, stereotyping, outgrouping, and discriminating. These were enhanced to capture differences associated with personal characteristics of PLHA that trigger secondary stigma (e.g., sexual orientation, injection drug use, multiple sex partners) and fears regarding instrumental and symbolic stigma. Reliabilities were strong (coefficients α for 16 of 19 resulting measures ranged from 0.80 to 0.98) and confirmatory factor analyses indicated good model fit for two multidimensional (Awareness and Acceptance) and one unidimensional (Action) measure. Evidence of convergent construct validity supported accuracy of primary constructs. Implications for training and professional socialization in health care are discussed.

Factors affecting life-sustaining treatment decisions by health care surrogates and proxies: assessing benefits and barriers.

Terri Schiavo's life and death placed international focus on social workers' need to better understand and serve health care surrogates and proxies making life-sustaining treatment decisions on behalf of medical patients. This study (N = 132) reports initial validation of a new measure, the Acceptance of Treatment Choice Inventory (ATCI), designed to evaluate benefits and barriers considered by health care surrogates and proxies prior to making a life-sustaining treatment decision about CPR, tube-feedings, dialysis, and ventilation. Affirming a two-factor model with acceptable reliability and preliminary construct validity, surrogates sought decision support and desired to represent patients' wishes adequately.

Validation of the health care surrogate preferences scale.

Recent advances in health care technology have increased the number of health care decisions made by acute care patients and those who act on their behalf, known as health care surrogates. This study reports on the validation of a new measure, the Health Care Surrogate Preferences Scale. Designed to assess the willingness of adults to perform and convey the duties required to communicate patient preferences, the scale offers a promising tool for use by social workers in health care settings. Development, evaluation, application of the new measure, and future research needs are discussed.