Beliefs in Antiretroviral Treatment and Self-Efficacy in HIV Management are Associated with Distinctive HIV Treatment Trajectories.

An online survey was conducted among people living with HIV (PLHIV) in Australia to discern key factors associated with distinctive ART use patterns. The sample (N = 358), was further divided into three groups: those on ART continuously since initiation (n = 208, 58.1%); those on ART intermittently (n = 117, 32.7%); and those not on ART at the time of survey (n = 33, 9.2%). ART non-users were the most likely to hold serious concerns about ART that outweighed perceived necessities (benefits) from ART (AOR = 0.13; 95% CI 0.06-0.29; p < 0.001). They were also the least self-efficacious in HIV disease management (AOR = 0.29; 95% CI 0.09-0.87; p = 0.028). Intermittent ART users were more likely to receive their HIV diagnosis prior to 2003 (AOR = 0.38; 95% CI 0.28-0.53; p < 0.001) and perceive lower HIV management self-efficacy (AOR = 0.50, 95% CI 0.28-0.87; p = 0.015) than continuous users. ART-related beliefs and perceived self-efficacy in HIV self-management play an important role in achieving universal treatment uptake and sustained high levels of adherence.

HIV Treatment as Prevention: Implications for Health Promotion.

Evidence has been accumulating in recent years that individuals with HIV who are effectively treated with antiretroviral drugs are highly unlikely to transmit the virus to their sexual partners. This approach has great potential to contribute to ongoing prevention efforts and has been termed 'treatment as prevention'. International political momentum has been building in recent years to attempt to significantly reduce new HIV infections globally and end the epidemic by 2030. In pursuit of such aims a number of local health authorities and communities have adopted intensified 'test and treat' strategies to quickly diagnose infections and reduce the risk of onward transmission through an immediate offer of treatment. These have most commonly been driven through enhancements to clinical services and health promoters have been engaged in limited ways. People with HIV often have high rates of health literacy and are now expressing interest in knowing more about how treatment as prevention might work to reduce their individual risk of sexual transmission. For some this represents an added risk reduction measure and for others it may replace condoms. There is currently an opportunity for health promotors to engage with this approach both to exploit its prevention benefits and to counter the stigma that attaches to HIV infectiousness. It is hoped that any reduction in stigma and fear of transmission will help improve the quality of social and sexual relationships among affected groups.

The Positive Outlook Study: A Randomised Controlled Trial Evaluating Online Self-Management for HIV Positive Gay Men.

The aim of this paper was to evaluate the effectiveness of an online self-management program in improving health outcomes and well-being for gay men living with HIV in Australia. The online Positive Outlook Program was based on self-efficacy theory and used a self-management approach to enhance HIV-positive gay men's skills, confidence and abilities to manage the psychosocial issues associated with HIV in daily life. The 7-week program was delivered in closed groups and comprised information modules, action-planning activities, moderated discussion boards, and weekly peer-facilitated 'live chats'. A randomised controlled trial was conducted to establish the effectiveness of the Positive Outlook program compared to a 'usual care' control. Participants were HIV-positive gay men 18 years or older living in Australia. Primary outcomes were evaluated at three time-points (baseline, post-intervention and 12-week's post-intervention follow-up) and included HIV-related quality of life (PROQOL-HIV), outcomes of health education (HeiQ) and HIV specific self-efficacy (Positive Outlook Self-Efficacy Scale). A total of 132 gay men with HIV in Australia were randomly allocated to the intervention (n = 68) or usual care control (n = 64) groups. Maximum likelihood marginal-linear modelling indicated significant improvement in the intervention group on the PROQOL-HIV subscales of body change (p = 0.036), social relationships (p = 0.035) and emotional distress (p = 0.031); the HeiQ subscales of health-directed activity (p = 0.048); constructive attitudes and approaches (p = 0.015); skill and technique acquisition (p = 0.046) and health service navigation (p = 0.008); and the Positive Outlook Self-Efficacy Scale on the subscales of relationships (p = 0.019); social participation (p = 0.006); and emotions (p = 0.041). Online delivery of self-management programs is feasible and has the potential to improve quality of life, self-management skills and domain specific self-efficacy for gay men with HIV.

HealthMap: a cluster randomised trial of interactive health plans and self-management support to prevent coronary heart disease in people with HIV.

BACKGROUND: The leading causes of morbidity and mortality for people in high-income countries living with HIV are now non-AIDS malignancies, cardiovascular disease and other non-communicable diseases associated with ageing. This protocol describes the trial of HealthMap, a model of care for people with HIV (PWHIV) that includes use of an interactive shared health record and self-management support. The aims of the HealthMap trial are to evaluate engagement of PWHIV and healthcare providers with the model, and its effectiveness for reducing coronary heart disease risk, enhancing self-management, and improving mental health and quality of life of PWHIV. METHODS/DESIGN: The study is a two-arm cluster randomised trial involving HIV clinical sites in several states in Australia. Doctors will be randomised to the HealthMap model (immediate arm) or to proceed with usual care (deferred arm). People with HIV whose doctors are randomised to the immediate arm receive 1) new opportunities to discuss their health status and goals with their HIV doctor using a HealthMap shared health record; 2) access to their own health record from home; 3) access to health coaching delivered by telephone and online; and 4) access to a peer moderated online group chat programme. Data will be collected from participating PWHIV (n = 710) at baseline, 6 months, and 12 months and from participating doctors (n = 60) at baseline and 12 months. The control arm will be offered the HealthMap intervention at the end of the trial. The primary study outcomes, measured at 12 months, are 1) 10-year risk of non-fatal acute myocardial infarction or coronary heart disease death as estimated by a Framingham Heart Study risk equation; and 2) Positive and Active Engagement in Life Scale from the Health Education Impact Questionnaire (heiQ). DISCUSSION: The study will determine the viability and utility of a novel technology-supported model of care for maintaining the health and wellbeing of people with HIV. If shown to be effective, the HealthMap model may provide a generalisable, scalable and sustainable system for supporting the care needs of people with HIV, addressing issues of equity of access. TRIAL REGISTRATION: Universal Trial Number (UTN) U111111506489; ClinicalTrial.gov Id NCT02178930 submitted 29 June 2014.

Chronic Disease Self-Management by People With HIV.

As HIV has transitioned into a chronic disease, reappraisal of clinical management has occurred with chronic disease self-management (CDSM) as one possibility. However, despite extensive work on CDSM across a range of diseases, little attention has focused on psychosocial contexts of the lives of people for whom programs are intended. This article reports semi-structured interviews used to explore health practices and motivations of 33 people with HIV (PWHIV) in Australia. Within participants' accounts, different forms of subjectivity and agency emerged with implications for how they understood and valued health-related behaviors. Four themes arose: health support and disclosure, social support and stigma, employment/structure, and health decisions beyond HIV. The experience of stigma and its intersection with CDSM remains relatively un-chartered. This study found stigma shapes agency and engagement with health. Decisions concerning health behaviors are often driven by perceived social and emotional benefit embedded in concerns of disclosure and stigma.

The impact of HIV treatment-related stigma on uptake of antiretroviral therapy.

HIV-related stigma has been linked to avoidance of health care services and suboptimal adherence to antiretroviral therapy (ART). However, less is known about concerns of stigma related specifically to the taking of ART in uptake of treatment. This study examines experiences of HIV treatment-related stigma and assesses if these experiences are associated with ART uptake, independent of general HIV-related stigma. People living with HIV (PLHIV; n = 697) were targeted to complete an online questionnaire measuring perceived HIV- and treatment-related stigma, social support, self-esteem, resilience, psychological distress, health satisfaction and quality of life. Findings suggest that experiences of general and treatment-related stigma were common, and that participants appear to experience greater stigma related to taking HIV treatment than general stigma associated with HIV. Neither general nor treatment-related stigma uniquely impacted HIV treatment uptake. Instead, treatment uptake was associated with being older (adjusted OR 1.05; 95% CIs: 1.03, 1.08), greater duration of HIV infection (adjusted OR 1.07; 95% CIs: 1.03-1.11) and having greater health satisfaction (adjusted OR 1.28; 95% CIs: 1.03, 1.59). Findings highlight that concerns around taking HIV treatment can be an added source of stigma for PLHIV, however other factors may be greater contributors to the likelihood of taking HIV treatment.

Evolving views and practices of antiretroviral treatment prescribers in Australia.

OBJECTIVE: To examine whether there have been recent changes in Australian antiretroviral treatment (ART) prescribers' perceptions and practices relating to early ART initiation, which was defined as commencing ART when a patient's CD4+ T-cell count approaches 500 cells/mm3 or immediately after a patient is diagnosed with HIV. DESIGN, PARTICIPANTS AND SETTING: Self-completed, anonymous, cross-sectional surveys, targeting all ART prescribers in Australia, were conducted online in 2012 and 2013. The surveys included questions on prescriber factors, CD4+ T-cell count at which prescribers would most strongly recommend ART initiation, and perceived patient characteristics that could change prescribers' practices of early initiation of ART. MAIN OUTCOME MEASURES: Proportions of ART prescribers recommending early ART initiation. RESULTS: We analysed responses from 108 participants in 2012 and 82 participants in 2013. In both years, more male than female prescribers participated. The median age of participants was 49 years in 2012 and 50 years in 2013. In both rounds, over 60% had more than 10 years' experience in treating HIV-positive patients. More prescribers in 2013 stated that they would most strongly recommend early ART initiation compared with those in 2012 (50.0% [95% CI, 38.7%-61.3%] v 26.9% [95% CI, 18.8%-36.2%]; P=0.001). The prescribers' primary concern was more about individual patient than public health benefit. Out of 824 patients for whom ART was initiated, as reported by prescribers in 2013, only 108 (13.1% [95% CI, 10.9%-15.6%]) were given ART primarily to prevent onward HIV transmission. The number of patients for whom ART was initiated was significantly associated with prescribers' HIV caseload even after adjusting for prescriber type (adjusted odds ratio, 1.73 [95% CI, 1.47-2.03]; P<0.001); of the 37 who had initiated ART for 10 or more patients, 29 had a high HIV caseload. In 2013, 60 prescribers (73.2% [95% CI, 62.2%-82.4%]) reported that they routinely recommended ART to treatment-naive, asymptomatic patients with a CD4+ T-cell count of 350-500 cells/mm3. CONCLUSION: Our findings show increasing acceptance of and support for early ART initiation primarily as treatment and not as prevention.

Informing the development of an online self-management program for men living with HIV: a needs assessment.

BACKGROUND: The aim of this mixed methods study was to conduct a multifaceted needs assessment to inform the development of an online self-management program for men living with HIV. The objectives were to describe the health-related quality of life for men living with HIV, the impact of living with HIV, and the perceived problem areas and service and support needs of these men. The needs assessment was conducted in accordance with the PRECEDE model for health promotion program planning. METHODS: A survey assessing the quality of life of men living with HIV (n = 72) was conducted and results were compared to Australian normative data. Focus groups were also undertaken with men living with HIV (n = 11) and a multidisciplinary team of service providers working in the area of HIV (n = 11). Focus groups enabled an in-depth description of the impact of HIV on quality of life and perceived problem areas in daily life. RESULTS: HIV-positive men experience significantly lower quality of life when compared with Australian normative data, particularly in those domains concerned with social and emotional aspects of quality of life. Qualitative focus groups yielded an overarching theme 'The psychosocial impact of HIV' which contained three sub-themes; (1) Life before and after HIV--a changed identity and its repercussions; (2) Resilience and the importance of social support; (3) Negotiating the practicalities--intimate relationships and disclosure. CONCLUSIONS: The findings from this needs assessment highlight the need to target socio-emotional contexts of HIV positive men's daily lives to improve quality of life and well-being. Intervention priorities for the proposed online self-management program include: (1) managing the emotional impact of HIV; (2) disclosing HIV status to family and friends; (3) maintaining social connectedness; (4) managing HIV within intimate relationships; and (5) disclosure of HIV status to intimate partners.

The positive outlook study- a randomised controlled trial evaluating the effectiveness of an online self-management program targeting psychosocial issues for men living with HIV: a study protocol.

BACKGROUND: The emergence of HIV as a chronic condition means that people living with HIV are required to take more responsibility for the self-management of their condition, including making physical, emotional and social adjustments. This paper describes the design and evaluation of Positive Outlook, an online program aiming to enhance the self-management skills of gay men living with HIV. METHODS/DESIGN: This study is designed as a randomised controlled trial in which men living with HIV in Australia will be assigned to either an intervention group or usual care control group. The intervention group will participate in the online group program 'Positive Outlook'. The program is based on self-efficacy theory and uses a self-management approach to enhance skills, confidence and abilities to manage the psychosocial issues associated with HIV in daily life. Participants will access the program for a minimum of 90 minutes per week over seven weeks. Primary outcomes are domain specific self-efficacy, HIV related quality of life, and outcomes of health education. Secondary outcomes include: depression, anxiety and stress; general health and quality of life; adjustment to HIV; and social support. Data collection will take place at baseline, completion of the intervention (or eight weeks post randomisation) and at 12 week follow-up. DISCUSSION: Results of the Positive Outlook study will provide information regarding the effectiveness of online group programs improving health related outcomes for men living with HIV. TRIAL REGISTRATION: ACTRN12612000642886.

Experiences of HIV stigma: the role of visible symptoms, HIV centrality and community attachment for people living with HIV.

For many people living with HIV (PLHIV), disclosure or concealment of their HIV status may be under their personal control; however, for PLHIV with visible symptoms of their illness, disclosure may no longer be a choice. Previous research suggests that those with visible HIV symptoms have poorer mental and physical health than those without visible HIV symptoms. This study aimed to extend these findings and assess the role of perceived centrality of HIV in the lives of PLHIV as well as the role of attachment to an HIV-positive community in understanding the negative effects on health and well-being for PLHIV with visible HIV symptoms. Participants were 697 PLHIV who completed an online survey that assessed symptom visibility, HIV-status disclosure, perceived stigma, health and well-being, how central HIV was to identity and HIV community attachment. Results indicate that those with visible symptoms experienced more HIV-related stigma and had poorer outcomes on a range of psychological and mental health measures than those who were able to conceal their stigma. These effects remained after controlling for length of time since diagnosis, time on HIV treatment, perceived health satisfaction and age. PLHIV with visible symptoms also reported that HIV was more central to their identity and reported greater attachment to an HIV-positive community. Furthermore, findings suggest that while HIV centrality appears to increase the negative effects of having visible symptoms associated with HIV, greater community attachment seems to ameliorate these effects. This suggests the need for a nuanced understanding of the implications of visible HIV symptoms for PLHIV. The study also highlights the potential benefits of HIV-positive community attachment in buffering PLHIV from the negative effect of visible HIV symptoms on their health and well-being.

Australian prescribers' perspectives on ART initiation in the era of "treatment as prevention".

This study explores Australian prescribers' attitudes towards Treatment as Prevention (TasP) and their practices around initiating combination antiretroviral treatment (cART) for HIV. A brief online survey was conducted nationally amongst antiretroviral treatment (ART) prescribers in Australia. The sample broadly represented ART prescribers in Australia (N = 108), with 40.7% general practitioners (GPs), 25.9% sexual health clinic-based physicians and 21.3% hospital-based infectious diseases physicians. About 60% of respondents had been treating HIV-positive patients for more than 10 years. Respondents estimated that about 70-80% of all their HIV-positive patients were receiving ART. Over half of the prescribers agreed very strongly that their primary concern in recommending cART initiation was clinical benefit to individual patients rather than any population benefit. A majority of the prescribers (68.5%) strongly endorsed cART initiation before CD4+ T-cell count drops below 350 cells/mm(3), and a further 22.2% strongly endorsed cART initiation before CD4+ T-cell count drops below 500 cells/mm(3). Regarding the optimal timing of cART initiation, this study shows that prescribers in Australia in 2012 focus primarily on the benefits for their individual patients. Prescribers may need more convincing evidence of individual health benefits or increased knowledge about the population health benefits for a TasP approach to be effective in Australia.

My body, my life, my choice: practices and meanings of complementary and alternative medicine among a sample of Australian people living with HIV/AIDS and their practitioners.

In this study we examine the sociocultural meaning and use of complementary and alternative medicine (CAM) by nine people living with HIV/AIDS (PLWHA) and four CAM practitioners. Analysis revealed five themes: focus on health not illness; resistance to antiretroviral therapy and adherence; allopathic medicine as narrow; difficulty disclosing to doctors; and a continuum of CAM that sometimes included conventional medicine and sometimes excluded it entirely. Literature on PLWHA in the West commonly describes them as sophisticated health consumers. We explore the concepts of individual responsibility in relation to health, holism, control and well-being in the context of CAM. We also consider the meaning and significance of CAM and western medicine to comment on the contemporary experience of HIV, including the possible impact of stigma and the perceived limits of allopathic medicine among some PLWHA. Understanding this will enable better insight into the treatment choices of PLWHA, particularly those who may be described as sceptical of conventional medical science.

The relationship between negative responses to HIV status disclosure and psychosocial outcomes among people living with HIV.

This report examines rates of HIV status disclosure and negative responses to disclosure among people living with HIV in Australia. Among 697 people living with HIV, most (>90%) had disclosed their status to friends, sexual partners and health providers. Almost a third had not disclosed to family, and half had not told any work colleagues. Negative responses to disclosure (e.g. blame, rejection) by all groups were associated with increased HIV-related stigma, psychological distress and diminished social support and health satisfaction. These results shed light on rates of disclosure among people living with HIV in Australia and the adverse health impacts of negative responses to disclosure.

HIV cure research: print and online media reporting in Australia.

OBJECTIVES: While still in its early stages, recent scientific research towards a cure for HIV has generated widespread media interest. The aim of this paper was to explore the ways in which this research has been represented in Australian print and online media and discuss implications of this. METHODS: A search of databases from four selected media outlets was conducted to identify published articles that directly discussed HIV cure research. Content analysis was used to explore the discursive framing of HIV cure research and identify the presence or absence of people living with HIV in articles. RESULTS: In total, 95 articles were identified that had been published in print or online between 2007 and 2015. Media reports tended to focus on research breakthroughs or the future potential of HIV cure research, rather than more immediate implications of research findings. While not inaccurate, this focus often implied the field of HIV cure research was more advanced than was generally the case. There was a notable absence of commentary from people living with HIV or community advocates in media reporting. CONCLUSIONS: Media reporting may generate unrealistic expectations of HIV cure research. This raises ethical concerns that media reporting may inadvertently contribute to therapeutic or curative misconceptions among potential participants in HIV cure-related trials. To address this, scientists, HIV advocates and people living with HIV will need to work collaboratively to engage with reporters and media outlets to provide more consistent input and guidance into reporting about research towards a cure for HIV.

Online self-management for gay men living with HIV: a pilot study.

UNLABELLED: Background The aim of this pilot study was to assess the feasibility, acceptability and effectiveness of Positive Outlook, an online self-management program for gay men living with HIV in Australia. METHODS: Two pilot studies were conducted, a small feasibility study (Pilot 1) followed by a pilot randomised controlled study (Pilot 2). Pilot 1 employed a pre and post-test design and included 10 men. Within- and between-group differences were evaluated in Pilot 2, which involved 37 participants randomly assigned to receive the Positive Outlook Program or usual care. We report on feasibility, acceptability and a range of preliminary efficacy outcomes, including health education impact, HIV-related quality of life and HIV-related self-efficacy. RESULTS: The program was well accepted by participants with some decline in engagement with the discussion boards witnessed over the duration of the program. Overall, intervention group participants demonstrated improvements in the majority of efficacy outcome measures, including HIV-related quality of life, self-efficacy, self-management skills, social support and adjustment to HIV. CONCLUSION: These pilot studies demonstrated that an online program to facilitate self-management among gay men living with HIV is both feasible and well accepted by participants who persisted with the program per protocol. Preliminary data suggest that the Positive Outlook program has the potential to enhance participants' quality of life, self-efficacy and health related outcomes, and demonstrates the need for further study with a larger sample.

'Not Until I'm Absolutely Half-Dead and Have To:' Accounting for Non-Use of Antiretroviral Therapy in Semi-Structured Interviews with People Living with HIV in Australia.

Current debates regarding the use of antiretroviral therapy (ART) to promote both individual- and population-level health benefits underscore the importance of understanding why a subpopulation of people with diagnosed HIV and access to treatment choose not to use it. Semi-structured interviews were conducted between 2012 and 2014 with 27 people living with HIV in Australia who were not using ART at the time of interview. Analytic triangulation permitted an appreciation of not only the varied personal reasons for non-use of treatment, but also underlying views on HIV treatment, and the ideal conditions imagined necessary for treatment initiation. Policy goals to increase the number of people with HIV using ART must recognize the diverse explanations for non-use of ART, which include concerns about the various impacts of committing to lifelong pharmaceutical treatment use. Our research identified distinctive subgroups among people who are not using antiretroviral therapy, with a range of individual and social needs that may affect treatment decisions. These findings challenge assumptions about treatment non-use in resource-rich settings, revealing persistent consumer fears about the potent and unknown effects of HIV medications that deserve greater recognition in policy debate on treatment uptake.

The impact of living with HIV: differences in experiences of stigma for heterosexual and homosexual people living with HIV in Australia.

UNLABELLED: Background HIV in Australia has been closely aligned with the gay community and continues to disproportionately affect members of this community. Although heterosexual transmission remains low, recently there has been an increase in new HIV diagnoses attributable to heterosexual sex. This highlights the need to address the health and social consequences for heterosexual people living with HIV (PLHIV). This subanalysis of a larger study compared the experiences of stigma, health and wellbeing of a sample of gay and heterosexual PLHIV. METHODS: Data were drawn from a study of experiences of stigma among PLHIV in Australia. All 49 participants who reported being heterosexual were included, as were 49 participants randomly selected from the 611 gay participants. The samples were compared on perceived HIV stigma, HIV treatment-related stigma, perceived negative reactions of others, HIV status disclosure, and health and wellbeing measures. RESULTS: The findings illustrate that heterosexual PLHIV have more negative experiences in terms of both general HIV stigma and treatment-related stigma than gay PLHIV. The heterosexual PLHIV also perceived greater negative reactions in relation to their HIV status by different people in their social environment and were less likely to access treatment than the gay PLHIV. There were no differences between the two groups in any of the health and wellbeing measures. CONCLUSIONS: This study shows that in the Australian context, heterosexual PLHIV may feel more stigmatised than gay PLHIV. In view of lower HIV treatment uptake in heterosexual PLHIV, addressing HIV-related stigma could contribute to increasing access to HIV treatment.