Ancillary service needs among persons new to HIV care and the relationship between needs and late presentation to care.

Ancillary service needs likely influence time to diagnosis and presentation for HIV care. The effect of both met and unmet needs on late presentation to HIV care is not well understood. We used baseline data from 348 people with HIV (PWH) with no prior HIV care who enrolled in iENGAGE (a randomized controlled trial (RCT) of an intervention to support retention in care) at one of four HIV clinics in the US. A standardized baseline questionnaire collected information on ancillary service needs, and whether each need was presently unmet. We examined covariates known to be associated with disease stage at presentation to care and their association with needs. We subsequently assessed the relationship of needs with CD4 accounting for those other covariates by estimating prevalence ratios (PR) using inverse probability weights. Most patients enrolling in the RCT were male (79%) and the majority were Black (62%); median age was 34 years. Prevalence of any reported individual need was 69%. One-third of the sample had a baseline CD4 cell count <200, 42% between 200 and 499 and 27% ≥500. There was no statistically significant association between need or unmet need and baseline CD4. In general, psychiatric health and SU issues (depression, anxiety, and drug use) were consistently associated with higher prevalence of need (met and unmet). Additionally, the Black race was associated with higher basic resource needs (housing: PR 1.67, 95%CI 1.08-2.59; transportation: PR 1.65, 95% CI 1.12-2.45). Ancillary service needs (met and unmet) were common among patients new to HIV care and impacted vulnerable subgroups. However, we found no evidence that reporting a specific individual need, whether met or unmet, was associated with a timely presentation to HIV care. The impact of needs on subsequent steps of the HIV care continuum will be examined with longitudinal data.

When "need plus supply" does not equal demand: challenges in uptake of depression treatment in HIV clinical care.

OBJECTIVE: Depression is common among patients in HIV care and is associated with worse HIV-related health behaviors and outcomes. Effective depression treatment is available, yet depression remains widely underdiagnosed and undertreated in HIV care. METHODS: As part of a multisite, randomized trial of depression treatment in HIV clinical care, the proportion of positive depression screens that resulted in study enrollment and reasons for nonenrollment were examined. RESULTS: Over 33 months, patients completed 9,765 depression screens; 19% were positive for depression, and of these 88% were assessed for study eligibility. Of assessed positive screens, 11% resulted in study enrollment. Nonenrollment after a positive screen was sometimes dictated by the study eligibility criteria, but it was often related to potentially modifiable provider- or patient-level barriers. CONCLUSIONS: Addressing patient- and provider-level barriers to engaging in depression treatment will be critical to maximize the reach of depression treatment services for HIV patients.

Health status of HIV-infected women entering care: baseline medical findings from the women of color initiative.

The WOC Initiative is a prospective study of 921 women of color (WOC) entering HIV care at nine (three rural, six urban) sites across the US. A baseline interview was performed that included self-reported limitation(s) in activity, health conditions, and the CDC's health-related quality of life measures (Healthy Days). One-third of the WOC reported limiting an activity because of illness or a health condition and those with an activity limitation reported 13 physically and 14 mentally unhealthy days/month, compared with 5 physically and 9 mentally unhealthy days/month in the absence of an activity limitation. Age was associated with a three- to fourfold increased risk of an activity limitation but only for WOC in the urban sites. Diabetes was associated with a threefold increased risk of a limitation among women at rural sites. Cardiac disease was associated with a six- to sevenfold increased risk of an activity limitation for both urban and rural WOC. HIV+ WOC reported more physically and mentally unhealthy days than the general US female population even without an activity limitation. Prevention and treatment of diabetes and cardiovascular disease will need to be a standard part of HIV care to promote the long-term health and HRQOL for HIV-infected WOC.

Experiences with HIV testing, entry, and engagement in care by HIV-infected women of color, and the need for autonomy, competency, and relatedness.

Self-determination theory examines the needs of people adopting new behaviors but has not been applied to the adoption of HIV healthcare behaviors. The current study applied self-determination theory to descriptions of healthcare behaviors adopted by ethnic minority women after an HIV diagnosis. Women of color were asked to describe their experiences with HIV testing, entry, and engagement-in-care in qualitative interviews and focus groups. Participants were mostly African-American (88%), over 40 years old (70%), had been diagnosed for more than 6 years (87%) and had disclosed their HIV infection to more than 3 people (73%). Women described unmet self-determination needs at different time points along the HIV Continuum of Care. Women experienced a significant loss of autonomy at the time of HIV diagnosis. Meeting competency and relatedness needs assisted women in entry and engagement-in-care. However, re-establishing autonomy was a key element for long-term engagement-in-care. Interventions that satisfy these needs at the optimal time point in care could improve diagnosis, entry-to-care, and retention-in-care for women living with HIV.

SafeTalk, a multicomponent, motivational interviewing-based, safer sex counseling program for people living with HIV/AIDS: a qualitative assessment of patients' views.

With the continued transmission of HIV each year, novel approaches to HIV prevention are needed. Since 2003, the U.S. HIV prevention focus has shifted from primarily targeting HIV-negative at-risk persons to including safer sex programs for people already infected with HIV. At least 20-30% of people infected with HIV engage in risky sexual practices. Based on these data, policymakers have recommended that interventionists develop strategies to help HIV-infected people reduce their risky sexual behaviors. In the past, the few safer sex interventions that targeted HIV-infected people met with limited success because they basically adapted strategies previously used with HIV-uninfected individuals. In addition, often these adaptations did not address issues of serostatus disclosure, HIV stigma, or motivation to protect others from HIV. We had previously tested, in a demonstration project named the Start Talking About Risks (STAR) Program, a monthly three-session motivational interviewing (MI)-based intervention to help people living with HIV practice safer sex. In this study, we refined that program by enhancing its frequency and intensity and adding written and audio components to support the counseling. We theorized that an intervention such as MI, which is tailored to each individual's circumstances more than standardized prevention messages, would be more successful when supplemented with other components. We qualitatively assessed participants' perceptions, reactions, and preferences to the refined prevention with positives counseling program we called SafeTalk and learned that participants found the SafeTalk MI counseling and educational materials appealing, understandable, and relevant to their lives.

Delivery of an HIV prevention counseling program in an infectious diseases clinic: implementation process and lessons learned.

Current national guidelines recommend that all HIV care providers routinely counsel their HIV-infected patients about reducing HIV transmission behaviors. In this article we identify the challenges and lessons learned from implementing a provider-delivered HIV transmission risk-reduction intervention for HIV-infected patients (Positive Steps). Based on a multi-site Centers for Disease Control and Prevention (CDC) initiative, we integrated the Positive Steps program into an infectious diseases clinic in North Carolina. Of the nearly 1200 HIV-infected patients, 59% were African American, 44% were white, 33% were women, and over 50% were between 25 and 44 years of age. We obtained feedback from a community advisory board, input from clinic staff, and conducted formative interviews with clinic patients and providers to achieve overall acceptance of the program within the clinic. Clinic providers underwent training to deliver standardized prevention counseling. During program implementation we conducted a quality assessment of program components, including reviewing whether patients were screened for HIV transmission risk behaviors and whether providers counseled their patients. Once Positive Steps was implemented, on average, 69% of patients were screened and 77% of screened patients were counseled during the first 12 months. In analyses of quarterly exit surveys of patients after their medical exams, on average, 73% of respondents reported being asked about safer sex and 51% reported having safer-sex discussions with their providers across six quarterly periods. Of those who had discussions, 91% reported that those discussions were "very" or "moderately helpful." Providers reported time and competing medical priorities as barriers for discussing prevention with patients, however, provider-delivered counseling was routinely performed for 12 months. Overall, the findings indicate that the Positive Steps program was successfully integrated in an infectious diseases clinic and received well by patients.