Enacted HIV-Related Stigma's Association with Anxiety & Depression Among People Living with HIV (PLWH) in Florida.

Research has shown that HIV-related stigma contributes to people living with HIV having a higher risk of mental health disorders. Our study examines the association between enacted HIV-related stigma and symptoms of anxiety and depression among PLWH. We used baseline data from 932 PLWH collected from the Florida Cohort study between 2014 and 2018. The sample was majority 45 + years of age (63.5%), male (66.0%), and Black (58.1%). The majority had previously experienced enacted HIV-related stigma (53.1%). Additionally, 56.6% and 65.2% showed mild to moderate/severe levels of anxiety and depression, respectively. Those who experienced any levels of enacted HIV-related stigma (vs none) had significantly greater odds of mild and moderate/severe levels of anxiety (vs no/minimal) (AOR[CI] 1.54[1.13, 2.10], p = 0.006; AOR[CI] 3.36[2.14, 5.26], p < 0.001, respectively) and depression (AOR[CI] 1.61[1.19, 2.18], p = 0.002; AOR[CI] 3.66[2.32, 5.77], p < 0.001, respectively). Findings suggest a need to evaluate interventions for PLWH to reduce the deleterious effects of enacted HIV-related stigma on mental health.

RESUMEN: Investigaciones previas han documentado que el estigma relacionado con el VIH contribuye al alto riesgo de trastornos de salud mental entre las personas que viven con VIH. Nuestro estudio examina la asociación entre el estigma declarado y síntomas de ansiedad y depresión entre las personas que viven con VIH. Utilizamos datos de referencia recopilados por el "Florida Cohort Study" de 932 personas que viven con VIH. La mayoría de la muestra sobrepasaba 45 años (63.5%), era masculina (66.0%), y racialmente negra (58.1%). La mayoría había experimentado estigma declarado (53.1%). Además, 56.5% y 65.2% mostro niveles de síntomas leves a moderados/severos de ansiedad y depresión, respectivamente. Aquellos que experimentaron cualquier nivel de estigma declarado (vs ninguno) tenían mayores probabilidades de niveles de síntomas leves y moderados/severos de ansiedad (vs ninguno) (ORa[IC] 1.54[1.13, 2.10], p = 0.006; ORa[IC] 3.36[2.14, 5.26], p < 0.001, respectivamente) y depresión (ORa[IC] 1.61[1.19, 2.18], p = 0.002; ORa[IC] 3.66[2.32, 5.77], p < 0.001, respectivamente). Los resultados sugieren la necesidad de evaluar las intervenciones para las personas que viven con VIH para reducir los efectos nocivos del estigma declarado en la salud mental.

The Florida Cohort study: methodology, initial findings and lessons learned from a multisite cohort of people living with HIV in Florida.

In 2013, Florida had the highest rate of new HIV infections and only 56% of persons living with HIV (PLWH) were virally suppressed. In response, we initiated a new HIV cohort in Florida to better understand issues affecting HIV health outcomes. This manuscript will describe the procedures of the Florida Cohort; summarize information regarding enrollment, follow-up, and findings to date; and discuss challenges and lessons learned during the establishment of a multisite cohort of PLWH. Florida Cohort participants were enrolled from eight clinics and community-based organizations geographically diverse counties across Florida. Data were obtained from participant questionnaires, medical records, and state surveillance data. From 2014-2018, 932 PLWH (44% ≥50 years, 64% male, 55% black, 20% Latinx) were enrolled. At baseline, 83% were retained in care and 75% were virally suppressed. Research findings to date have focused on outcomes such as the HIV care continuum, HIV-related comorbidities, alcohol and drug use, and mHealth interventions interest. Strengths included the diversity of the sample and the linkage of participant surveys with existing surveillance data. However, the study had several challenges during planning and follow-up. The lessons learned from this study can be helpful when initiating a new longitudinal cohort study.

HIV-related stigma and life goals among people living with HIV (PLWH) in Florida.

PURPOSE: Goals are an important component of quality of life (QoL) as they provide motivation to accomplish tasks we strive to achieve. Stigma has been identified as a factor that may be deleterious to achieving personal goals. People living with HIV(PLWH) continue to face HIV-related stigma. As HIV prevalence continues to grow in the U.S., it is important to focus on factors that can help improve the health and QoL of PLWH. This study aims to examine the association between HIV-related stigma and goal-setting behaviors among PLWH in Florida. METHODS: We used baseline data collected from the Marijuana and Potential Long-term Effects (MAPLE) observational cohort study. We collected life goals data using an abbreviated version of the Personal Projects Analysis inventory. Participants listed up to three goals in five domains and were asked about each goal's difficulty and importance. HIV-related stigma was measured using an abbreviated version of the Herek HIV-related stigma scale. Relative risk estimates and 95% confidence intervals were estimated using multivariate linear regression models. RESULTS: The overall sample (n = 232) was majority male (52.4%), Black (72.4%), and non-Latino (84.9%). HIV-related stigma was positively associated with the total number of listed goals (ß = 0.042[0.003, 0.082]; p = 0.037) and perceived goal difficulty (ß = 0.010[0.003, 0.017]; p = 0.004), but not significantly associated with perceived goal importance (ß = 0.001[- 0.002, 0.004]; p = 0.562). CONCLUSION: The results suggest that HIV-related stigma may be affecting the pursuit of goals among PLWH. There is a need to develop and evaluate QoL interventions that are tailored to PLWH and focused on achieving goals in the face of HIV-related stigma.

Recruitment, experience, and retention among women with HIV and hazardous drinking participating in a clinical trial.

BACKGROUND: Despite efforts by the NIH to enhance the participation of women and minorities in clinical research, women with HIV continue to remain underrepresented in alcohol intervention research. The purpose of this study is to better understand the reasons why women with HIV and hazardous drinking participated in the WHAT-IF? study and to discuss their experience (positive or negative) in the study. The WHAT-IF? study was a randomized clinical trial that evaluated pharmacotherapy for a reduction in drinking among women with HIV. METHODS: Convenience and theoretical sampling were used to recruit women with HIV and hazardous drinking to complete qualitative interviews. These women had previously completed a clinical alcohol intervention trial and had consented to be contacted in the future for study-related purposes. The biopsychosocial model was used to frame the interview questions that assessed multiple determinants of drinking behavior and helped explain linkages to broader health constructs. RESULTS: A total of 20 women with HIV and hazardous drinking completed the qualitative interview. Several factors were identified by the women as influential in their decision to participate in the WHAT-IF? study, such as the ability to quit or reduce their drinking to nonhazardous levels (biological), the ability to gain knowledge or a greater understanding of the negative effects of hazardous drinking on HIV disease progression (psychological), and peer pressure and monetary compensation (social). Also, the women identified factors (positive or negative) associated with their clinical trial experience, such as the effects of the study medication on the woman's body (biological), thoughts and feelings toward study procedures (i.e. medication, lab work, study assessments) and the length of the study (psychological), and the interactions with the WHAT-IF? study staff (social). CONCLUSION: Recruiting and retaining women with HIV in alcohol intervention research remains a challenge. Findings from this study suggest that women with HIV who are hazardous drinkers may benefit from participating in research studies that could help them to reduce or quit their drinking, increase their knowledge about specific behavior changes, and earn monetary compensation. Also, positive staff interactions may be instrumental in retaining minority women in alcohol intervention research.

Fall Prevention Decision Making of Acute Care Registered Nurses.

OBJECTIVE: The aim of this study was to examine acute care registered nurses' (RNs') fall prevention decision-making. BACKGROUND: The RN decision-making process related to fall prevention needs to be investigated to ensure that hospital policies align with nursing workflow and support nursing judgment. METHODS: Qualitative semistructured interviews based on the Critical Decision Method were conducted with RNs about their planning and decision making during their last 12-hour shift worked. RESULTS: Data saturation was achieved with 12 RNs. Nine themes emerged related to the RN decision-making process and included hospital-level (eg, fear of discipline), unit-level (eg, value of bed alarm technology), and nurse-level (eg, professional judgment) factors that could influence fall prevention. CONCLUSIONS: Nursing administrators should consider a multilevel approach to fall prevention policies that includes promoting a practice environment that embraces self-reporting adverse events without fear of shame or being reprimanded, evaluating unit-level practice and technology acceptance and usability, and supporting autonomous nursing practice.

Age, Sex, Race, Ethnicity, Sexual Orientation: Intersectionality of Marginalized-Group Identities and Enacted HIV-Related Stigma Among People Living with HIV in Florida.

HIV-related stigma is associated with many negative health outcomes among people living with HIV (PLHIV). The theory of intersectionality suggests that the interactions of social identities affect PLHIV's experiences of stigma. This study aims to identify individual and interactive marginalized-group identities correlated with enacted HIV-related stigma among PLHIV in Florida. The sample (n = 932) was majority male (66.6%), Black (58.5%), and non-Latino (80.2%) with 53% reporting experiences of HIV-related stigma. In multinomial regression models, the interaction between race and ethnicity was significant where non-White Latinos had higher odds of experiencing high levels of enacted stigma [AOR (CI) 7.71 (2.41, 24.73), p < 0.001] compared to white non-Latinos. Additionally, racial minorities were less likely to have experienced moderate or high levels of enacted stigma [AOR (CI) 0.47 (0.31, 0.72), p < 0.001; AOR (CI) 0.39 (0.22, 0.70), p = 0.002, respectively]. Moreover, women had higher odds of experiencing high levels of enacted stigma [AOR (CI) 2.04 (1.13, 3.67), p = 0.018]. The results suggest that intersectionality is important to consider in HIV-related stigma research and future interventions.

Interest in using mobile technology to help self-manage alcohol use among persons living with the human immunodeficiency virus: A Florida Cohort cross-sectional study.

BACKGROUND: Alcohol consumption at hazardous levels is more prevalent and associated with poor health outcomes among persons living with the human immunodeficiency virus (HIV; PLWH). Although PLWH are receptive to using technology to manage health issues, it is unknown whether a cell phone app to self-manage alcohol use would be acceptable among PLWH who drink. The objectives of this study were to determine factors associated with interest in an app to self-manage drinking and to identify differences in baseline mobile technology use among PLWH by drinking level. METHODS: The study population included 757 PLWH recruited from 2014 to 2016 into the Florida Cohort, an ongoing cohort study investigating the utilization of health services and HIV care outcomes among PLWH. Participants completed a questionnaire examining demographics, substance use, mobile technology use, and other health behaviors. Multivariable logistic regression was used to identify factors significantly associated with interest in an app to self-manage drinking. We also determined whether mobile technology use varied by drinking level. RESULTS: Of the sample, 40% of persons who drink at hazardous levels, 34% of persons who drink at nonhazardous levels, and 19% of persons who do not drink were interested in a self-management app for alcohol use. Multivariable logistic regression analysis indicated that nonhazardous drinking (adjusted odds ratio [AOR] = 1.78; confidence interval [CI 95%]: 1.10-2.88) and hazardous drinking (AOR = 2.58; CI: 1.60-4.16) were associated with interest, controlling for age, gender, education, and drug use. Regarding mobile technology use, most of the sample reported smartphone ownership (56%), text messaging (89%), and at least one cell phone app (69%). CONCLUSIONS: Regardless of drinking level, overall mobile technology use among PLWH was moderate, whereas PLWH who consumed alcohol expressed greater interest in a cell phone app to self-manage alcohol use. This indicates that many PLWH who drink would be interested in and prepared for a mobile technology-based intervention to reduce alcohol consumption.

A Systematic Review of Naltrexone for Attenuating Alcohol Consumption in Women with Alcohol Use Disorders.

Several clinical trials have evaluated naltrexone as a treatment for alcohol use disorders (AUDs), but few have focused on women. The aim of this review was to systematically review and summarize the evidence regarding the impact of naltrexone compared to placebo for attenuating alcohol consumption in women with an AUD. A systematic review was conducted using PubMed, Cochrane, Web of Science, CINAHL, and Alcohol Studies Database to identify relevant peer-reviewed randomized controlled trials (RCTs) published between January 1990 and August 2016. Seven published trials have evaluated the impact of naltrexone on drinking outcomes in women distinct from men; 903 alcohol-dependent or heavy drinking women were randomized to receive once daily oral or depot (injectable) naltrexone or placebo with/without behavioral intervention. Two studies examining the quantity of drinks per day observed trends toward reduction in drinking quantity among women who received naltrexone versus placebo. The 4 studies examining the frequency of drinking had mixed results, with 1 study showing a trend that favored naltrexone, 2 showing a trend that favored placebo, and 1 that showed no difference. Two of the 3 studies examining time to relapse observed trends that tended to favor naltrexone for time to any drinking and time to heavy drinking among women who received naltrexone versus placebo. While the growing body of evidence suggests a variety of approaches to treat AUD, the impact of naltrexone to combat AUD in women is understudied. Taken together, the results suggest that naltrexone may lead to modest reductions in quantity of drinking and time to relapse, but not on the frequency of drinking in women. Future research should incorporate sophisticated study designs that examine gender differences and treatment effectiveness among those diagnosed with an AUD and present data separately for men and women.

Marijuana use and viral suppression in persons receiving medical care for HIV-infection.

BACKGROUND: Marijuana use is common among persons living with HIV (PLWH), but studies on its effect on HIV clinical outcomes are limited. OBJECTIVES: We determined the association between marijuana use and HIV viral suppression among PLWH. METHODS: Data came from five repeated cross-sections (2009-2013) of the Florida Medical Monitoring Project, a population-based sample of PLWH in Florida. Data were obtained via interview and medical record abstraction (MRA). Weighted logistic regression models were used to determine the association between marijuana use (past 12 months) and durable viral suppression (HIV-1 RNA value of ≤ 200 copies/milliliter in all measurements within the past 12 months). RESULTS: Of the 1,902 PLWH receiving antiretroviral therapy, completed an interview, and had a linked MRA, 20% reported marijuana use (13% less than daily and 7% daily use) and 73% achieved durable viral suppression. In multivariable analysis, marijuana use was not significantly associated with durable viral suppression in daily [Adjusted Odds Ratio (AOR): 0.87, 95% confidence interval (CI): 0.58, 1.33] or in less than daily [AOR: 0.83, 95% CI: 0.51, 1.37] users as compared to non-users when adjusting for sociodemographic factors, time since HIV diagnosis, depressive symptoms, alcohol, cigarette and other substance use. CONCLUSION: In this sample of PLWH receiving medical care in Florida, there was no statistically significant association between marijuana use and viral suppression. However, as the limits of the confidence intervals include effects that may be considered to be clinically important, there is a need for additional evidence from other samples and settings that include more marijuana users.

Perceived benefits and negative consequences of alcohol consumption in women living with HIV: a qualitative study.

BACKGROUND: Women living with HIV have increased prevalence of medical and psychological comorbidities that could be adversely affected by alcohol consumption. Little is known about their unique motivations for drinking or perceptions of HIV-related consequences. In preparation for an alcohol intervention study, we sought to better understand reasons for drinking and perceived consequences of alcohol consumption among a sample of women living with HIV. METHODS: Four focus groups, with a total of 24 adult women (96% African-American, 88% HIV-positive), were conducted in Jacksonville, FL, Washington, DC and Chicago, IL. Focus group discussions were tape-recorded and transcribed verbatim; a conventional content analysis approach was used to identify themes, that were then grouped according to a biopsychosocial model. RESULTS: Regarding reasons for drinking, women described themes that included biological (addiction, to manage pain), psychological (coping, to escape bad experiences, to feel in control), and social (peer pressure, family). Themes related to consequences from alcohol included biological (damage to body, poor adherence to medications), psychological (risky or regrettable behavior, memory loss), and social (jail, loss of respect, poor choices). When discussing how their drinking impacted their health, women focused on broader issues, rather than HIV-specific issues. CONCLUSION: Many women living with HIV are drinking alcohol in order to self-manage pain or emotions, and their perceived consequences from drinking extend beyond HIV-specific medical issues. Most participants described themes related to psychological issues and situations that are common in women living with HIV. Interventions to address drinking should inquire more specifically about drinking to manage pain or emotion, and help women to recognize the potential adverse impact of alcohol on comorbid health issues, including their own HIV infection.

A Public Health Nursing Model Assists Women Receiving Temporary Assistance for Needy Families Benefits to Identify a Usual Source of Primary Care.

Women enrolled in Florida's Temporary Assistance for Needy Families (TANF) program experience high rates of chronic health problems and often lack a usual source of care. Thus, in this study, we aimed to identify variables related to being in a usual source of care at time of study enrollment and determine whether a public health nursing case management intervention affected the obtainment of a usual source of care. To achieve these aims, we conducted a secondary analysis of a randomized controlled trial of a public health nursing case management intervention, which included women with chronic health conditions enrolled in TANF (n = 432). Results indicated 35% of the women did not identify a usual source of care at time of study enrollment, and the public health nursing intervention was effective in helping women obtain a usual source of care (OR = 2.5, 95% CI 1.004-6.491). Thus, a public health nursing case management intervention is an effective way to connect TANF participants to a usual source of care, which may lead to improved health outcomes in this vulnerable population of women.

Perceptions and Use of Electronic Nicotine Delivery Systems Among Floridian Middle and High School Students: Secondary Analysis of Cross-sectional Survey Results.

INTRODUCTION: Rapid increase in youth use of Electronic Nicotine Delivery Systems (ENDS) led the state and the federal governments to implement minimum-age policies to restrict minors' access to vaping products. Limited success of the age restrictions fueled efforts to increase the distribution age of all tobacco products to 21 (ie, Tobacco 21 or T21 policies). With limited data on the T21 policies, the current study examines the prevalence of ENDS use and the perceptions about ENDS among youth in the pre- and post-policy-implementation periods for one of these bans in the state of Florida. METHODS: This study conducted secondary analysis on the responses from the 2014 and 2015 Florida Youth Tobacco Survey, which collected cross-sectional data. RESULTS: Compared to the data from spring of 2014, the minimum-age policy enacted on July 1, 2014 did not lead to a significant decrease in Florida's high school and middle school students' ever ENDS use (14.9% in 2014 vs 25.8% in 2015) and current ENDS use (7.5% in 2014 vs 12.4% in 2015). There was some ambiguity among students regarding the ENDS harm-more students in 2015 thought of ENDS as both equally (11.0% vs 7.7%) and less (32.4% vs 28%) harmful than cigarettes. There was a decrease in the proportion of students who were unsure about their answer to this question (51.5% vs 59.2%). CONCLUSIONS: Policy change alone may not be effective in shifting the trend of ENDS use among middle and high school students. Although students may know about some of the ENDS effects, many of them are still not aware about the harms. Interventions in school and in the community should be aiming to raise this awareness.

Designing Online and Mobile Diabetes Education for Fathers of Children With Type 1 Diabetes: Mixed Methods Study.

BACKGROUND: Fathers make unique and central contributions to the health of their children. However, research in type 1 diabetes (T1D) education largely ignores the needs of fathers, including during the development of online and mobile educational materials. OBJECTIVE: The purpose of this study was to solicit and incorporate input from fathers of children with T1D into the design, content, and infrastructure of a suite of online diabetes self-management education and support (DSMES) resources. METHODS: The study took part in three phases: (1) exploratory research, (2) website and subdomain development, and (3) evaluation. Fathers of children with T1D (n=30) completed surveys and semistructured qualitative interviews. Thematic content analysis was used to identify fathers' content and design preferences. An online DSMES website (T1DToolkit.org) and a separate mobile subdomain targeting fathers (Mobile Diabetes Advice for Dads, or mDAD) were developed. A prototype of the site for fathers was evaluated by 33 additional father participants. End user feedback was elicited via survey. RESULTS: Participants in the exploratory phase were enthusiastic about the online diabetes resources. Preferences included high-quality design, availability via mobile phone and tablet, brief text content supplemented with multimedia and interactive features, reminders via text or email, endorsement by medical professionals, and links to scientific evidence. The mDAD subdomain received high usability and acceptability ratings, with 100% of participants very likely or likely to use the site again. CONCLUSIONS: The development of eHealth educational platforms for fathers of children with T1D remains an unmet need in optimizing diabetes management. This study incorporated fathers' feedback into the development of a suite of online diabetes education resources. The findings will serve as the basis for future research to assess the clinical efficacy of the website, its subdomain targeting fathers, and additional subdomains targeting unique populations.

Types and delivery of emotional support to promote linkage and engagement in HIV care.

PURPOSE: Despite recommendations for early entry into human immunodeficiency virus (HIV) care, many people diagnosed with HIV delay seeking care. Multiple types of social support (ie, cognitive, emotional, and tangible) are often needed for someone to transition into HIV care, but a lack of emotional support at diagnosis may be the reason why some people fail to stay engaged in care. Thus, the purpose of this study was to identify how people living with HIV conceptualized emotional support needs and delivery at diagnosis. METHOD: We conducted a secondary analysis of qualitative data from 27 people living with HIV, many of whom delayed entry into HIV care. RESULTS: Participants described their experiences seeking care after an HIV diagnosis and identified components of emotional support that aided entry into care - identification, connection, and navigational presence. Many participants stated that these types of support were ideally delivered by peers with HIV. CONCLUSION: In clinical practice, providers often use an HIV diagnosis as an opportunity to educate patients about HIV prevention and access to services. However, this type of social support may not facilitate engagement in care if emotional support needs are not met.

Disclosure of HIV serostatus and condomless sex among men living with HIV/AIDS in Florida.

Despite campaigns to increase safer sex practices, there are people living with HIV/AIDS (PLWH) who do not disclose their HIV status to sexual partners and engage in condomless sex. The purpose of this research was to: 1) describe factors associated with disclosure of HIV status to sexual partners; and 2) determine if disclosure and/or receipt of prevention counseling are independently associated with condomless sex. We used the Florida Medical Monitoring Project to analyze data from 376 HIV positive men with more than one sexual partner. Results indicated that 55% consistently disclosed their HIV status to sexual partners, 30% inconsistently disclosed, 15% did not disclose, and 48% reported any condomless sex. The odds of having condomless sex was 3.3 (CI = 1.5, 7.3) times greater in men who disclosed to all partners. Results suggest that men who disclose are also those who are more likely to have condomless sex. More research is needed to better understand the complex nature of disclosure and sexual risk behaviors and how disclosure impacts sexual risk.

Complementary and Alternative Medicine Use for HIV Management in the State of Florida: Medical Monitoring Project.

OBJECTIVE: The aims of this study were to describe complementary and alternative medicine (CAM) use and to assess the relationships between CAM use and antiretroviral therapy (ART) adherence and human immunodeficiency virus (HIV) RNA viral load suppression among a sample of persons living with HIV (PLWH) engaged in care in the state of Florida. DESIGN: The Florida Medical Monitoring Project (n = 803) collected repeated cross-sectional data for surveillance of clinical outcomes among PLWH from 2009 to 2010. Past-year CAM use specifically for the management of HIV was measured via self-report. Logistic regression models were conducted to assess the effect of CAM use on ART adherence and viral load suppression, controlling for demographic and clinical factors using backwards stepwise deletion of factors with a p-value of >0.25. RESULTS: CAM use was reported in 53.3% (n = 428). In bivariate analysis, CAM use was the highest among those 40-49 years of age (61%; p < 0.05), males (56%; p < 0.01), whites (61%; p = 0.001), and those educated beyond high school (59%; p < 0.05). Among those using CAM, 63% and 37% reported one and two or more CAM modalities, respectively. CAM modalities included biologically based therapies (89%), mind-body medicine/manipulative body-based therapies (30%), spiritual healing (23%), energy therapies (6%), and whole medical systems (6%). In multivariable analyses, any CAM use and number of CAM methods used were not associated with ART adherence. Any CAM use was not associated with detectable viral load (adjusted odds ratio [aOR] 0.81; 95% confidence interval [CI] 0.58-1.12; p = 0.20). Those using two or more methods had significantly decreased risk for detectable viral load (aOR 0.60; 95% CI 0.39-0.92; p < 0.02). CONCLUSIONS: CAM use was not associated with negative effects on ART adherence. CAM users were less likely to have detectable viral load compared with non-users. Future research should focus on CAM use among PLWH not engaged in HIV care and the longitudinal patterns of CAM use and possible effects of long-term health outcomes.

Perspectives of linkage to care among people diagnosed with HIV.

Timely linkage to HIV care and treatment has led to improved individual and population benefits; however, 25%-31% of people diagnosed with HIV do not engage in care. Most linkage to care research has focused on larger metropolitan areas, but smaller metropolitan and rural areas encounter unique challenges to linkage to care. Our purpose was to examine factors influencing the decision to seek care by 27 people infected with HIV living in smaller metropolitan and rural areas of Florida. We used grounded theory methods to develop a theoretical model describing the decision-making process and participant recommendations within the context of stigma. Participants described support, defining care, activating care, conflicting messages of care, and pivotal events influencing the care decision. Findings highlight the complexities of HIV care and suggest a client-centered approach to address the multifaceted social and structural challenges people with HIV face in the journey from infection to care.