Determinants of antiretroviral therapy adherence in northern Tanzania: a comprehensive picture from the patient perspective.

BACKGROUND: To design effective, tailored interventions to support antiretroviral therapy (ART) adherence, a thorough understanding of the barriers and facilitators of ART adherence is required. Factors at the individual and interpersonal level, ART treatment characteristics and health care factors have been proposed as important adherence determinants. METHODS: To identify the most relevant determinants of adherence in northern Tanzania, in-depth interviews were carried out with 61 treatment-experienced patients from four different clinics. The interviews were ad-verbatim transcribed and recurrent themes were coded. RESULTS: Coding results showed that the majority of patients had basic understanding of adherence, but also revealed misconceptions about taking medication after alcohol use. Adherence motivating beliefs were the perception of improved health and the desire to live like others, as well as the desire to be a good parent. A de-motivating belief was that stopping ART after being prayed for was an act of faith. Facilitators of adherence were support from friends and family, and assistance of home based care (HBC) providers. Important barriers to ART adherence were the use of alcohol, unavailability of food, stigma and disclosure concerns, and the clinics dispensing too few pills. Strategies recommended by the patients to improve adherence included better Care and Treatment Centre (CTC) services, recruitment of patients to become Home Based Care ( HBC) providers, and addressing the problem of stigma through education. CONCLUSION: This study underscores the importance of designing tailored, patient-centered adherence interventions to address challenges at the patient, family, community and health care level.

Measuring adherence to antiretroviral therapy in northern Tanzania: feasibility and acceptability of the Medication Event Monitoring System.

BACKGROUND: An often-used tool to measure adherence to antiretroviral therapy (ART) is the Medication Event Monitoring System (MEMS), an electronic pill-cap that registers date and time of pill-bottle openings. Despite its strengths, MEMS-data can be compromised by inaccurate use and acceptability problems due to its design. These barriers remain, however, to be investigated in resource-limited settings. We evaluated the feasibility and acceptability of using MEMS-caps to monitor adherence among HIV-infected patients attending a rural clinic in Tanzania's Kilimanjaro Region. METHODS: Eligible patients were approached and asked to use the MEMS-caps for three consecutive months. Thereafter, qualitative, in-depth interviews about the use of MEMS were conducted with the patients. MEMS-data were used to corroborate the interview results. RESULTS: Twenty-three of the 24 patients approached agreed to participate. Apart from MEMS-use on travel occasions, patients reported no barriers regarding MEMS-use. Unexpectedly, the MEMS-bottle design reduced the patients' fear for HIV-status disclosure. Patients indicated that having their behavior monitored motivated them to adhere better. MEMS-data showed that most patients had high levels of adherence and there were no bottle-openings that could not be accounted for by medication intake. Non-adherence in the days prior to clinic visits was common and due to the clinic dispensing too few pills. CONCLUSION: MEMS-bottle use was readily accepted by patients. Although the MEMS-bottle was used accurately by most patients, patients need to be more explicitly instructed to continue MEMS-use when travelling. Even HIV-clinics with sufficient staff and free medication may impose structural adherence barriers by supplying an insufficient amount of pills.

First same-sex partner and the internet.

The present study examined the first episode of anal intercourse of young gay and bisexual men (YGBM) who were in the midst of their coming-out. Cross-sectional data regarding the first episode of anal intercourse were extracted from Outcomes, a longitudinal study on coming-out and sexual behavior of YGBM in the Netherlands. Overall, 45% of respondents reported unprotected anal intercourse (UAI) with their first same-sex partner. Rates of UAI did not significantly differ between meeting place (offline vs. online) and partner status (steady, regular or casual).

Social-cognitive determinants of condom use in a cohort of young gay and bisexual men.

The aim of this prospective study was to identify relevant determinants of young gay and bisexual men's (YGBM) condom use when having anal sex with casual partners. Respondents (185 YGBM in the midst of their coming-out; mean age 18.9 years) completed an online questionnaire on social-cognitive determinants of condoms use derived from the theory of planned behavior (Ajzen, 1991) at Wave 1. At six months follow-up (Wave 2) sexual behavior with casual partners was assessed. A total of 63 YGBM reported sex with a casual partner in the six months between Waves 1 and 2, of whom 49% (N=31) had anal sex. Of the YGBM who had anal sex, 42% (N=13) had unprotected anal sex. Condom use with casual partners was best predicted by the intention to always use condoms. Furthermore, attitude, descriptive and personal norms, and perceived control significantly predicted intention to always use condoms. Interventions, targeting YGBM, aiming to promote condom use with casual partners should focus on increasing attitudes and strengthening skills to negotiate and use condoms.

Effects of a short individually tailored counselling session for HIV prevention in gay and bisexual men receiving Hepatitis B vaccination.

BACKGROUND: There is currently a trend towards unsafe unprotected anal intercourse (UAI) among men who have sex with men. We evaluated a short individual counselling session on reducing UAI among gay and bisexual men. METHODS: A quasi-experimental design was used to evaluate the counselling session. This session was conducted during consulting hours at four municipal health clinics during a Hepatitis B vaccination campaign. These clinics offered free vaccination to high-risk groups, such as gay and bisexual men.All gay and bisexual men attending health clinics in four cities in the Netherlands were asked to participate. Each participant in the intervention group received a fifteen-minute individual counselling based on the Theory of Planned Behaviour and Motivational Interviewing. Changes in UAI were measured over a 5-months period, using self-administered questionnaires. UAI was measured separately for receptive and insertive intercourse in steady and casual partners. These measures were combined in an index-score (range 0-8). RESULTS: While UAI in the counselling group remained stable, it increased in the controls by 66% from 0.41 to 0.68. The results show that the intervention had a protective effect on sexual behaviour with steady partners. Intervention effects were strongest within steady relationships, especially for men whose steady-relationship status changed during the study. The intervention was well accepted among the target group. CONCLUSION: The fifteen-minute individually tailored counselling session was not only well accepted but also had a protective effect on risk behaviour after a follow-up of six months.

Early associations with palatable foods in overweight and obesity are not disinhibition related but restraint related.

Obese people prefer and overconsume high-fat foods. At the same time they often attempt to lose weight. In two studies we investigated relations between palatable high-fat food words and disinhibition related concepts (study 1) and palatable high-fat food words and restraint related concepts (study 2) within the semantic priming paradigm. In study 1, 24 overweight/obese and 19 healthy weight women participated. There was no association between palatable high-fat food words and disinhibition. In study 2, 27 obese and 29 healthy weight women participated. The presentation of palatable high-fat food words facilitated the accessibility of restraint related concepts as hypothesized, but independent of weight status. Clearly, early associations with palatable high-fat food words are restraint related in both healthy weight and obese people.

Characteristics of subjects counseled and tested for HIV in an Indonesian hospital; factors associated with HIV-status and CD4 cell-count.

AIM: to identification the predictors of HIV-seropositivity and level of immunosuppression. METHODS: in a cross-sectional study, we examined HIV-testing practice, HIV-knowledge, perceived risk of being HIV-positive, and health status among out-patients enrolled in voluntary counseling and testing (VCT), and in-patients who underwent provider-initiated testing (PITC) in the largest teaching hospital in West Java, Indonesia. RESULTS: among 202 respondents, 47% were HIV+, and the median CD4 of HIV+ was 193/mm³ among VCT (n=124) and 11/mm³ among PITC (n=78). HIV/AIDS related knowledge among those entering VCT was significantly higher than among those in PITC, but perceived risk of being HIV-infected was lower. Logistic regression analysis predicting HIV status revealed a significant main effect for oral thrush and chronic diarrhea and for Hepatitis C status (p<.01). For those who are HIV positive, weight loss was strongly predictive of a low CD4 cell count (p<.01). CONCLUSION: in this setting, the HIV-seroprevalence is high and many HIV-infected subjects are symptomatic. Increasing HIV knowledge may lead to earlier HIV-detection. Health care workers play an important role in referral for VCT and PITC, and several symptoms, alone or in combination, can help identify those who are at highest risk for HIV.

HIV prevention through drugs and sex education in junior high schools in Bandung West Java: the teachers' perspective.

AIM: to explore the teacher perspective on needs (in terms of knowledge, skills and curriculum content), attitudes, beliefs and self-efficacy related to teaching and implementation of a reproductive health (RH)/drug education (DE) program at their own junior high school. METHODS: one hundred and thirty-three teachers participated in a survey, from February to April 2009, measuring: socio demographic, behavioral intention, perceived behavior control, content knowledge, school climate, reproductive health knowledge and school drug education. RESULTS: all teachers had a high intention to teach RH and DE, especially the younger RH teachers had a high intention to teach about teenage pregnancy and sexually transmitted infections. DE teachers had a high intention facts/effects of drugs, first-time drug use dealing with peer pressure. Perceived beliefs of teachers, parents, school management and perceived self-efficacy were strong predictors for the intention of RH teaching and DE. CONCLUSION: the high intention of the RH and DE teacher offers a great opportunity to build and implement a DE and RH curriculum in junior high school. Before a curriculum is developed and implemented there is a need to assess and strengthen the teacher's skills and effectiveness in teaching RH and DE.

Behavioral aspects of HIV prevention and care in Indonesia: A plea for a multi-disciplinary, theory- and evidence-based approach.

Projections estimate 1,000,000 HIV infected by 2015 in Indonesia. Key behaviors to HIV prevention and care are determined by a complex set of individual/ environmental factors. This paper presents empirical data, local evidence and theoretical concepts to determine the role of social sciences in HIV prevention/care. Injecting Drug Use (IDU) is a social and very risky activity: 95% injected in the presence of peers and 49% reported needles sharing. 82% of IDUs do not use condoms consistently. Poor adherence to ARV treatment is related to a complex set of, mostly behavioral, factors beyond effective influence by standard professional skills of medical staff. Meta-analysis indicated that about 1/3 of the variance in behaviour can be explained by the combined effect of intention and perceived behavioral control, the two cornerstones of the Theory of Planned Behavior (TPB). It is advisable to adapt TPB in the light of the Indonesian context. Current theories of behavior and behavior change give professionals of all disciplines, working in HIV prevention and care, effective tools to change behavior and to improve HIV prevention and access and quality of HIV care.

Sexual risk behavior among HIV-positive men who have sex with men: a literature review.

OBJECTIVE: To review research on sexual risk behavior among HIV-positive men who have sex with men (MSM) after the year 2000. METHOD: The review included 53 published studies that reported on unprotected anal intercourse (UAI) in cross-sectional and longitudinal surveys of HIV-positive MSM and MSM of mixed HIV status. RESULTS: The findings indicate high levels of UAI among HIV-positive MSM, particularly with HIV-negative or HIV status unknown partners. In studies of MSM of mixed HIV status, we found that the rate of UAI among HIV-positive MSM was much higher than that of HIV-negative MSM. Furthermore, the prevalence of UAI among HIV-positive MSM has increased in recent years. CONCLUSION: Although studies indicate that HIV-positive MSM have adopted risk reduction strategies, roughly two in five HIV-positive MSM continue to engage in UAI, which represents a risk for continued HIV and STI (sexually transmitted infection) transmission. PRACTICE IMPLICATIONS: Prevention efforts targeting HIV-positive MSM to assist them in adopting and maintaining safer sexual behaviors need to be intensified.

Predicting adherence to combination antiretroviral therapy for HIV in Tanzania: A test of an extended theory of planned behaviour model.

OBJECTIVES: Combination antiretroviral therapy (cART) for HIV is widely available in sub-Saharan Africa. Adherence is crucial to successful treatment. This study aimed to apply an extended theory of planned behaviour (TPB) model to predict objectively measured adherence to cART in Tanzania. DESIGN: Prospective observational study (n = 158) where patients completed questionnaires on demographics (Month 0), socio-cognitive variables including intentions (Month 1), and action planning and self-regulatory processes hypothesised to mediate the intention-behaviour relationship (Month 3), to predict adherence (Month 5). MAIN OUTCOME MEASURES: Taking adherence was measured objectively using the Medication Events Monitoring System (MEMS) caps. Model tests were conducted using regression and bootstrap mediation analyses. RESULTS: Perceived behavioural control (PBC) was positively (ß = .767, p < .001, R2 = 57.5%) associated with adherence intentions. Intentions only exercised an indirect effect on adherence (B = 1.29 [0.297-3.15]) through self-regulatory processes (B = 1.10 [0.131-2.87]). Self-regulatory processes (ß = .234, p = .010, R2 = 14.7%) predicted better adherence. CONCLUSION: This observational study using an objective behavioural measure, identified PBC as the main driver of adherence intentions. The effect of intentions on adherence was only indirect through self-regulatory processes, which were the main predictor of objectively assessed adherence.

"Serosorting" in casual anal sex of HIV-negative gay men is noteworthy and is increasing in Sydney, Australia.

This paper addresses the question of whether HIV-negative gay men engage in "serosorting" in casual encounters. Serosorting, defined as engaging in unprotected anal intercourse with casual partners who they report to be HIV negative, has been increasing among HIV-negative gay men in Sydney. Prevention and intervention programmes are urgently needed to alert HIV-negative gay men to the risks associated with "serosorting", and remind them of the need for consistent condom use.

Overweight and obesity: the significance of a depressed mood.

OBJECTIVE: Comorbid depression has been found to increase morbidity in a variety of disorders. This study aimed to investigate whether the presence of depressive symptoms in overweight and obese people is related to increased specific eating psychopathology and decreased self-esteem. METHODS: Overweight/obese people seeking dietary treatment were grouped according to their scores on the Beck Depression Inventory (BDI), resulting in a mildly to moderately depressed group (BDI > or = 10; n = 66; the symptomatic group) and a non-depressed group (BDI < 10; n = 83). Eating psychopathology was measured by the Eating Disorder Examination-Questionnaire (EDE-Q); self-esteem was measured by the Rosenberg Self-Esteem Scale. RESULTS: Symptomatic people had more shape, weight and eating concerns (P-values < 0.001); scored higher on restraint (P < 0.01); had lower self-esteem (P < 0.001); and had a higher BMI (P < 0.05) than non-depressed people. Furthermore, the percentage of bingers was higher in the symptomatic group (P < 0.01). CONCLUSION: Symptomatic participants suffered more than non-depressed participants, and not only from their depression. PRACTICE IMPLICATIONS: For dieticians treating overweight and obese people, the BDI is a useful instrument for identifying the subgroup with depressive symptoms--the group that is at risk for (eating) psychopathology.

Systematic development of a self-help and motivational enhancement intervention to promote sexual health in HIV-positive men who have sex with men.

The objective of this study was to describe the application of a systematic process-Intervention Mapping-to developing a theory- and evidence-based intervention to promote sexual health in HIV-positive men who have sex with men (MSM). Intervention Mapping provides a framework that gives program planners a systematic method for decision-making in each phase of intervention development. In Step 1, we focused on the improvement of two health-promoting behaviors: satisfactory sexual functioning and safer sexual behavior. These behaviors were then linked with selected personal and external determinants, such as attitudes and social support, to produce a set of proximal program objectives. In Step 2, theoretical methods were identified to influence the proximal program objectives and were translated into practical strategies. Although theoretical methods were derived from various theories, self-regulation theory and a cognitive model of behavior change provided the main framework for selecting the intervention methods. The main strategies chosen were bibliotherapy (i.e., the use of written material to help people solve problems or change behavior) and motivational interviewing. In Step 3, the theoretical methods and practical strategies were applied in a program that comprised a self-help guide, a motivational interviewing session and a motivational interviewing telephone call, both delivered by specialist nurses in HIV treatment centers. In Step 4, implementation was anticipated by developing a linkage group to ensure involvement of program users in the planning process and conducting additional research to understand how to implement our program better. In Step 5, program evaluation was anticipated based on the planning process from the previous Intervention Mapping steps.

A new meeting place: chatting on the Internet, e-dating and sexual risk behaviour among Dutch men who have sex with men.

OBJECTIVE: To describe the process of Internet chatting, and subsequent dating and sexual (risk) behaviour among Dutch men who have sex with men (MSM), and to compare the demographic profile of the Internet sample with a traditional Dutch MSM sample. DESIGN: A self-selected anonymous Internet sample. METHODS: Enrolment via a prominent gay chat room. Potential respondents were asked to complete an online questionnaire about chatting and dating, and sexual (risk) behaviour with their last date via chatting (e-date). In 26 days, 5302 questionnaires were returned. Of these, 4984 were evaluated as reliable and were used in the analyses. RESULTS: Eighty-two per cent chatted at least once a week, 88% had ever dated through chatting, and of these 89% had had sex with one or more e-dates. With respect to the last e-date, almost 50% had had anal sex with their last e-date, and 15% reported unprotected anal sex. Especially among HIV-positive men, a high percentage of unprotected anal sex was reported (39%). After correcting for the disclosure of HIV status, this percentage remained twice as high compared with HIV-negative and never-tested men (28 versus 14%). Compared with a traditional MSM sample, the Internet sample was significantly younger, and comprised more non-Dutch and bisexual men, whereas the level of sexual risk behaviour with casual partners was comparable. CONCLUSION: The Internet is a popular new meeting place for MSM, and attracts men with a different demographic profile. The level of risk behaviour warrants that opportunities for interventions on the Internet are explored, with special attention to HIV-positive chatters.

Sexuality and sexual risk behavior in HIV-positive men who have sex with men.

The purpose of this study was to examine the psychological processes pertaining to sexuality and sexual risk behavior among HIV-positive men who have sex with men (MSM). The authors analyzed transcripts of 30 semistructured interviews. Findings suggest that sexual problems in HIV-positive MSM might be primarily caused by the perceived risk of transmitting HIV to others. Furthermore, safer sexual behavior seems to be related to feelings of personal responsibility for safer sex. This study illustrates that although some men might have a clear notion of personal responsibility for safer sex, contextual factors can influence whether behavior is consistent with their norms of personal responsibility. The implications of the study are discussed for the practice of HIV prevention for HIV-positive MSM.

The effects of AIDS prevention programs by lay health advisors for migrants in The Netherlands.

Two studies describe the effectiveness of acquired immunodeficiency syndrome (AIDS) prevention programs by lay health advisors (LHAs) for migrants in The Netherlands. The effects of such AIDS programs were evaluated (Study 1) and compared with the effects of professional health advisors (PHAs, i.e. medical doctors or nurses) (Study 2). The first study concerned Turkish and Moroccan migrants and showed positive effects on knowledge, behavioral control, and social norm towards condom use. Iraqi refugees participated in the second study that concerned a direct comparison of LHA- and PHA-based programs. Both programs result in positive effects in terms of attitude change and knowledge, but the LHA program resulted in a stronger intention to discuss AIDS with children. Analyses predicting intention to use condoms provide evidence that LHA programs lead to a stronger relation between attitudes and intention. This suggests that LHA-based AIDS programs are more successful in inducing internally motivated intentions to safe sex practices, such as condom use.

Stigma, disclosure, coping, and medication adherence among people living with HIV/AIDS in Northern Tanzania.

This study examines a proposed theoretical model examining the interrelationships between stigma, disclosure, coping, and medication adherence among 158 HIV-infected patients on antiretroviral therapy (ART) in northern Tanzania. Perceived and self-stigma, voluntary and involuntary disclosure, positive and negative coping, and demographics were assessed by trained interviewers, and self-reported adherence was collected during 5 months follow-up. Data were examined using correlation and regression analyses. The analyses showed that perceived stigma is primarily related to involuntary disclosure, whereas self-stigma is related to voluntary disclosure. Religious coping positively relates to acceptance, whereas perceived stigma explains higher levels of denial of HIV status. Lastly, adherence was negatively affected by alcohol use, self-stigma, and denial. We conclude that adherence is predominantly predicted by negative rather than positive coping mechanisms. Therefore, substituting maladaptive coping mechanisms like denial and alcohol use with a more adaptive coping style may be an important strategy to improve long-term ART adherence and well-being of patients. Moreover, this study showed that it is useful to examine both involuntary and voluntary disclosure when studying its relation with stigma.

HIV-related knowledge and attitudes among Indonesian prison officers.

PURPOSE: Prison officers have a vital role in running a secure and healthy living environment for the inmates. The purpose of this article is to examine the relationship between HIV/AIDS-related knowledge and attitude towards inmates living with HIV among the officers in an Indonesian narcotics prison. DESIGN/METHODOLOGY/APPROACH: A total of 93 officers from a narcotics prison in Bandung, Indonesia voluntarily participated in this cross-sectional study by completing a self-reported questionnaire. A Prior focus group discussion was also held among selected participants. FINDINGS: Statistical data analyses indicate that all domains of HIV/AIDS-related knowledge, i.e. knowledge of HIV-transmission, general HIV/AIDS knowledge and knowledge of HIV-prevention, have substantial positive correlations with the prison officers' attitude towards inmates living with HIV. These results show that the more knowledgeable the officers are, the less likely they are to respond in an unfavourable manner to inmates living with HIV and vice versa. RESEARCH LIMITATIONS/IMPLICATIONS: Despite the limited participants involved in this study, the knowledge gaps that are identified in this study should be the starting point for the development of educational interventions for prison officers. PRACTICAL IMPLICATIONS: Sufficient educational programs and the latest materials need to be made available within the prison. SOCIAL IMPLICATIONS: Commitment from prison authorities as well as a proper policy are also needed. ORIGINALITY/VALUE: This study helped prison authorities to identify areas for knowledge development of the officers. Hopefully the positive attitude towards inmates living with HIV will be developed.

Internalised homonegativity predicts HIV-associated risk behavior in European men who have sex with men in a 38-country cross-sectional study: some public health implications of homophobia.

OBJECTIVES: Internalised homonegativity (IH) is hypothesised to be associated with HIV risk behaviour and HIV testing in men who have sex with men (MSM). We sought to determine the social and individual variables associated with IH and the associations between IH and HIV-related behaviours. DESIGN AND SETTING: We examined IH and its predictors as part of a larger Internet-delivered, cross-sectional study on HIV and health in MSM in 38 European countries. PARTICIPANTS: 181 495 MSM, IH data analysis subsample 144 177. All participants were male, over the age of consent for homosexual activity in their country of domicile, and have had at least one homosexual contact in the past 6 months. METHODOLOGY: An anonymous Internet-based questionnaire was disseminated in 25 languages through MSM social media, websites and organisations and responses saved to a UK-based server. IH was measured using a standardised, cross-culturally appropriate scale. RESULTS: Three clusters of European countries based on the level of experienced discrimination emerged. IH was predicted by country LGB (lesbian, gay and bisexual) legal climate, Gini coefficient and size of place of settlement. Lower IH was associated with degree the respondent was 'out' as gay to others and older age. 'Outness' was associated with ever having an HIV test and age, education and number of gay friends, while IH (controlling for the number of non-steady unprotected sex partners and perceived lack of control over safe sex) was associated with condom use for anal intercourse. CONCLUSIONS: IH is associated with LGB legal climate, economic development indices and urbanisation. It is also associated with 'outness' and with HIV risk and preventive behaviours including HIV testing, perceived control over sexual risk and condom use. Homonegative climate is associated with IH and higher levels of HIV-associated risk in MSM. Reducing IH through attention to LGB human rights may be appropriate HIV reduction intervention for MSM.