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Research has documented associations between relationship stigma, relationship quality and adverse health outcomes among sexual and gender minority couples. However, this work focused primarily on one aspect of an individual's or a couple's identity rather than understanding the intersections of multiple, stigmatized social identities. As part of a larger project focused on testing the efficacy of a couples-based intervention to improve HIV medication adherence, 144 couples completed measures of relationship stigma, relationship quality, mental health, and substance use. A subset of 25 participants completed in-depth interviews to better understand the phenomenon of relationship stigma and its impact on their relationships. Quantitative results demonstrated that greater relationship stigma was associated with reduced relationship satisfaction and commitment, as well as greater closeness discrepancy and depressive symptoms. Qualitative findings provided nuanced insights into forms of relationship stigma that often intersected with other types of stigma and related forces of social and structural violence. Results also demonstrated the differential impact that relationship stigma had on couples and the ways in which individuals make adjustments to cope with or actively combat societal stigma. Findings illustrate the importance of attending to intersecting forms of stigma in addressing the well-being of sexual and gender minority couples.
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INTRODUCTION: Advances in HIV treatment have proven to be effective in increasing virological suppression, thereby decreasing morbidity, and increasing survival. Medication adherence is an important factor in reducing viral load among people living with HIV (PLWH) and in the elimination of transmission of HIV to uninfected partners. Achieving optimal medication adherence involves individuals taking their medications every day or as prescribed by their provider. However, not all PLWH in the USA are engaged in care, and only a minority have achieved suppressed viral load (viral load that is lower than the detectable limit of the assay). Sexual and gender minorities (SGM; those who do not identify as heterosexual or those who do not identify as the sex they were assigned at birth) represent a high-risk population for poor clinical outcomes and increased risk of HIV transmission, as they face barriers that can prevent optimal engagement in HIV care. Research in dyadic support, specifically within primary romantic partnerships, offers a promising avenue to improving engagement in care and treatment outcomes among SGM couples. Dyadic interventions, especially focused on primary romantic partnerships, have the potential to have a sustained impact after the structured intervention ends. METHODS AND ANALYSIS: This paper describes the protocol for a randomised control trial of a theory-grounded, piloted intervention (DuoPACT) that cultivates and leverages the inherent sources of support within primary romantic relationships to improve engagement in HIV care and thus clinical outcomes among persons who are living with HIV and who identify as SGM (or their partners). Eligible participants must report being in a primary romantic relationship for at least 3 months, speak English, at least one partner must identify as a sexual or gender minority and at least one partner must be HIV+ with suboptimal engagement in HIV care, defined as less than excellent medication adherence, having not seen a provider in at least the past 8 months, having a detectable or unknown viral load or not currently on antiretroviral therapy. Eligible consenting couples are allocated equally to the two study arms: a structured six-session couples counselling intervention (DuoPACT) or a three-session individually-delivered HIV adherence counselling intervention (LifeSteps). The primary aim is to evaluate the efficacy of DuoPACT on virological suppression among HIV+ members of SGM couples with suboptimal engagement in care. The DuoPACT study began its target enrolment of 150 couples (300 individuals) in August 2017, and will continue to enrol until June 2021. ETHICS AND DISSEMINATION: All procedures are approved by the Institutional Review Board at the University of California, San Francisco. Written informed consent is obtained from all participants at enrolment, and study progress is reviewed twice yearly by an external Safety Monitoring Committee. Dissemination activities will include formal publications and report back sessions with the community. TRIAL REGISTRATION NUMBER: NCT02925949; Pre-results.
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Infecções por HIV , Aconselhamento , Infecções por HIV/tratamento farmacológico , Humanos , Recém-Nascido , Adesão à Medicação , Ensaios Clínicos Controlados Aleatórios como Assunto , Literatura de Revisão como Assunto , São Francisco , Carga ViralRESUMO
Background: Text messaging is a promising strategy to support human immunodeficiency virus (HIV) care engagement, but little is known about its efficacy in urban safety-net HIV clinics. Methods: We conducted a randomized controlled trial of a supportive and motivational text messaging intervention, Connect4Care (C4C), among viremic patients who had a history of poor retention or were new to the clinic. Participants were randomized (stratified by new or established HIV diagnosis status) to receive either of the following for 12 months: (1) thrice-weekly intervention messages, plus texted primary care appointment reminders and a monthly text message requesting confirmation of study participation or (2) texted reminders and monthly messages alone. Viral load was assessed at 6 and 12 months. The primary outcome was virologic suppression (<200 copies/mL) at 12 months, estimated via repeated-measures log-binomial regression, adjusted for new-diagnosis status. The secondary outcome was retention in clinic care. Results: Between August 2013 and November 2015, a total of 230 participants were randomized. Virologic suppression at 12 months was similar in intervention and control participants (48.8% vs 45.8%, respectively), yielding a rate ratio of 1.07 (95% confidence interval, .82-1.39). Suppression was higher in those with newly diagnosed infection (78.3% vs 45.3%). There were no intervention effects on the secondary outcome. Exploratory analyses suggested that patients with more responses to study text messages had better outcomes, regardless of arm. Conclusions: The C4C text messaging intervention did not significantly increase virologic suppression or retention in care. Response to text messages may be a useful way for providers to gauge risk for poor HIV outcomes. Clinical Trials Registration: NCT01917994.
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Agendamento de Consultas , Infecções por HIV/terapia , Retenção nos Cuidados , Resposta Viral Sustentada , Envio de Mensagens de Texto , Adulto , Idoso , Instituições de Assistência Ambulatorial , Telefone Celular , Intervenção Médica Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Motivação , Projetos de Pesquisa , São Francisco , População Urbana , Carga Viral , Viremia/prevenção & controle , Adulto JovemRESUMO
In the United States, little is known about interventions that rely on mobile phones and/or text messaging to improve engagement in HIV care for vulnerable populations. Domestic studies using these technologies as part of the National Institute on Drug Abuse "Seek, Test, Treat, Retain" research initiative were queried regarding intervention components, implementation issues, participant characteristics, and descriptive statistics of mobile phone service delivery. Across five studies with 1,135 predominantly male, minority participants, implementation challenges occurred in three categories: (1) service interruptions; (2) billing/overage issues, and; (3) the participant user experience. Response rules for automated text messages frequently frustrated participants. The inability to reload minutes/texting capacity remotely was a significant barrier to intervention delivery. No study encountered confidentiality breaches. Service interruption was common, even if studies provided mobile phones and plans. Future studies should attend to the type of mobile phone and service, the participant user experience, and human subjects concerns.
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Telefone Celular , Continuidade da Assistência ao Paciente , Infecções por HIV/tratamento farmacológico , Avaliação de Programas e Projetos de Saúde , Envio de Mensagens de Texto , Populações Vulneráveis , Adulto , Idoso , Fármacos Anti-HIV/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistemas de Alerta , Telemedicina , Estados Unidos , Populações Vulneráveis/psicologia , Populações Vulneráveis/estatística & dados numéricosRESUMO
BACKGROUND: Few data exist on the use of text messaging as a tool to promote retention in HIV care and virologic suppression at the clinic level in the United States. We describe the protocol for a study designed to investigate whether a text messaging intervention that supports healthy behaviors, encourages consistent engagement with care, and promotes antiretroviral persistence can improve retention in care and virologic suppression among patients in an urban safety-net HIV clinic in San Francisco. METHODS/DESIGN: Connect4Care (C4C) is a single-site, randomized year-long study of text message appointment reminders vs. text message appointment reminders plus thrice-weekly supportive, informational, and motivational text messages. Eligible consenting patients are allocated 1:1 to the two arms within strata defined by HIV diagnosis within the past 12 months (i.e. "newly diagnosed") vs. earlier. Study participants must receive primary care at the San Francisco General Hospital HIV clinic, speak English, possess a cell phone and be willing to send/receive up to 25 text messages per month, a have viral load >200 copies/µL, and be either new to the clinic or have a history of poor retention. The primary efficacy outcome is virologic suppression at 12 months and the key secondary outcome, which will also be examined as a mediator of the primary outcome, is retention in HIV care, as operationalized by kept and missed primary care visits. Process outcomes include text message response rate and percent of time in study without cell phone service. Generalized estimating equation log-binomial models will be used for intent to treat, per protocol, and mediation analyses. An assessment of the cost and cost-effectiveness of the intervention is planned along with a qualitative evaluation of the intervention. DISCUSSION: Findings from this study will provide valuable information about the use of behavioral-theory based text messaging to promote retention in HIV care and virologic suppression, further elucidate the challenges of using texting technology with marginalized urban populations, and help guide the development of new mobile health strategies to improve HIV care cascade outcomes. TRIAL REGISTRATION: NCT01917994.
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Agendamento de Consultas , Infecções por HIV/terapia , Sistemas de Alerta , Provedores de Redes de Segurança , Envio de Mensagens de Texto , Carga Viral , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Fármacos Anti-HIV/uso terapêutico , Telefone Celular , Análise Custo-Benefício , Regulação para Baixo/efeitos dos fármacos , Feminino , Infecções por HIV/economia , Infecções por HIV/epidemiologia , Infecções por HIV/virologia , Comportamentos Relacionados com a Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Motivação , Participação do Paciente , Sistemas de Alerta/economia , Provedores de Redes de Segurança/economia , Provedores de Redes de Segurança/estatística & dados numéricos , São Francisco/epidemiologia , Envio de Mensagens de Texto/economia , Estados Unidos/epidemiologia , População Urbana/estatística & dados numéricos , Carga Viral/efeitos dos fármacos , Adulto JovemRESUMO
Injection drug use (IDU) into central veins, most common among long-term IDUs with no other options, can lead to severe infectious, vascular, and traumatic medical consequences. To follow-up on anecdotal reports of femoral vein injection and related medical problems in Seattle, we analyzed data from the annual survey of a community-based syringe exchange program. A total of 276 (81%) of 343 program attendees completed the survey in August 2010. Among 248 IDUs, 66% were male, 78% white, and 86% primarily injected opiates. One hundred respondents (40%) had injected into the femoral vein, 55% of whom were actively doing so, and 58% of whom reported medical complications that they attributed to the practice. Most (66%) used the femoral vein due to difficulty accessing other veins, although 61% reported other veins they could access and 67% reporting using other sites since initiating femoral injection. While injecting into muscle was more frequent among older IDUs with longer injection careers, the prevalence of femoral injection was highest among respondents in their late twenties with 2.5-6 years of injecting drugs. Multivariate analysis demonstrated an increased risk of initiating femoral injection each calendar year after 2007. Injecting into the femoral vein was also associated with white versus other race (odds ratio [OR] 2.7, 95% CI 1.3-5.4) and injection of primarily opiates versus other drugs (OR 6.3, 95% CI 1.2-32.9) and not associated with age, length of IDU career, or a history of injecting into muscle. These findings suggest a secular trend of increasing femoral injection among Seattle-area IDUs with a high rate of related medical problems. Interventions, such as education regarding the hazards of central venous injection and guidance on safe injection into peripheral veins, are needed to minimize the health consequences of femoral injection.
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Usuários de Drogas/estatística & dados numéricos , Uso Comum de Agulhas e Seringas/estatística & dados numéricos , Abuso de Substâncias por Via Intravenosa/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Adulto , Estudos Transversais , Feminino , Veia Femoral , Humanos , Injeções , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Uso Comum de Agulhas e Seringas/efeitos adversos , Programas de Troca de Agulhas , Prevalência , Inquéritos e Questionários , Washington/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Genital ulcer disease (GUD), including syphilis, is an important cause of morbidity in low and middle income (LMI) countries and syphilis transmission is associated with HIV transmission. METHODS: We conducted a literature review to evaluate syphilis infection among drug users in LMI countries for the period 1995-2007. Countries were categorized using the World Bank Atlas method [The World Bank. (2007). Data and statistics: Country groups. Retrieved online October 18, 2007 at http://go.worldbank.org/D7SN0B8YU0] according to 2006 gross national income per capita. RESULTS: Thirty-two studies were included (N=13,848 subjects), mostly from Southeast Asia with some from Latin America, Eastern Europe, Central and East Asia, North Africa and the Middle East but none from regions such as Sub-Saharan Africa. The median prevalence of overall lifetime syphilis (N=32 studies) was 11.1% (interquartile range: 6.3-15.3%) and of HIV (N=31 studies) was 1.1% (interquartile range: 0.22-5.50%). There was a modest relation (r=0.27) between HIV and syphilis prevalence. Median syphilis prevalence by gender was 4.0% (interquartile range: 3.4-6.6%) among males (N=11 studies) and 19.9% (interquartile range: 11.4-36.0%) among females (N=6 studies). There was a strong relation (r=0.68) between syphilis prevalence and female gender that may be related to female sex work. CONCLUSION: Drug users in LMI countries have a high prevalence of syphilis but data are limited and, in some regions, entirely lacking. Further data are needed, including studies targeting the risks of women. Interventions to promote safer sex, testing, counselling and education, as well as health care worker awareness, should be integrated in harm reduction programs and health care settings to prevent new syphilis infections and reduce HIV transmission among drug users and their partners in LMI countries.