Disparities in Retention in Care Among Adults Living with HIV/AIDS: A Systematic Review.

As national HIV prevention goals aim to increase the proportion of persons living with HIV, determining existing disparities in retention in care will allow for targeted intervention. The purpose of this systematic review was to identify existing disparities in retention in care. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) 2015 guided this systematic review. Electronic databases, including PubMed/MEDLINE, CINAHL, Sociological Collection, PsychInfo, and Cab Direct/Global Health, were systematically searched and twenty studies were included. This review identified disparities in retention in care that have been documented by race, gender, age, HIV exposure, incarceration history, place of birth, and U.S. geographic location. Research is necessary to further identify existing disparities in retention in care and to better understand determinants of health disparities. Additionally, interventions must be tailored to meet the needs of health disparate populations and should be assessed to determine their effectiveness in reducing health disparities.

A Path Analysis of Patient and Social-Level Factors on Health Literacy and Retention in Care Among African Americans Living with HIV.

Low health literacy and poor retention in care may contribute to HIV health disparities among African Americans, but causal pathways have not been examined. We utilized an adapted health literacy model to examine the role of health literacy on racial disparities in retention in care. Retention in care for 699 participants was assessed 24-months post survey and operationalized as 100% visit adherence versus less than 100% visit adherence. Most participants were African American (60%) and virally suppressed (93%). Results from a path analysis revealed that non-African American race was related to greater health literacy (p = .023) and to 100% visit adherence (p = .024). Greater health literacy was associated with 100% visit adherence (p = .008), which was in turn related to viral suppression (p < .001). Findings indicate that health literacy partially mediates the relationship between race and retention in care and are among the first to suggest these causal pathways.

The Psychosocial and Clinical Well-Being of Women Living with Human Immunodeficiency Virus/AIDS.

This study examined factors impacting the psychological well-being of women living with human immunodeficiency virus/AIDS and the impact of depression on clinical outcomes. Nearly two-thirds of participants in this cross-sectional study reported significant depressive symptoms. Compared with women living with human immunodeficiency virus/AIDS without depressive symptoms, those with depression reported significantly poorer health outcomes. Health care providers should regularly screen these women for and adequately treat depression, and must collaborate with mental health providers and pastoral care counselors to address the mental health needs of women living with human immunodeficiency virus/AIDS to optimize their human immunodeficiency virus-related outcomes.

Longitudinal study of falls among HIV-infected and uninfected women: the role of cognition.

BACKGROUND: Although fracture rates are higher in HIV+ than HIV- women, whether HIV infection increases risk of falls is unclear. We determined the longitudinal occurrence and risk factors for falls in the Women's Interagency HIV Study (WIHS), and explored associations with cognitive complaints. METHODS: Recent (prior 6 months) self-reported falls were collected in 1,816 (1,250 HIV+; 566 HIV-) women over 24 months. Generalized estimating equation models using stepwise selection determined odds of any fall (versus none). RESULTS: HIV+ women were older than HIV- women (median 49 versus 47 years; P=0.0004), more likely to report neuropathy (20% versus 16%; P=0.023), and had greater central nervous system (CNS) medication use. At least one fall was reported in 41% HIV+ versus 42% HIV- women, including ≥2 falls in 25% HIV+ and 24% HIV- (overall P=0.30). Cognitive complaints were associated with falls among HIV+ (odds ratio [OR] 2.38; 95% CI 1.83, 3.09) and HIV- women (OR 3.43; 95% CI 2.37, 4.97); in adjusted models, cognitive complaints remained significant only in HIV- women (adjusted [aOR] 2.26; 95% CI 1.46, 3.48). Factors associated with any fall in adjusted analyses included: depressive symptoms and neuropathy (both HIV+ and HIV-); age, marijuana use, multiple CNS medications, and HCV infection (HIV+ only); and cognitive complaints, quality of life, hypertension and obesity (HIV- only). CONCLUSIONS: Middle-aged HIV+ and HIV- women had similar fall rates. Among HIV+ women, factors affecting cognition such as age, depressive symptoms, marijuana use and multiple CNS medications were important predictors of falls, however, cognitive complaints were not.

A Motivational Interviewing Intervention by Pharmacy Students to Improve Medication Adherence.

BACKGROUND: Diabetes mellitus (DM) patients with comorbid hypertension (HTN) are at a higher risk of developing microvascular and macrovascular DM complications. Through guideline-driven recommendations, angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are highly recommended for these patients. Unfortunately, medication adherence to these products, though crucial to achieving therapeutic benefit, is frequently suboptimal. Motivational interviewing (MI) is a patient-centered collaborative communication style that is used to strengthen internal motivation for change that may prove effective in enhancing adherence. OBJECTIVE: To examine the effect of an MI telephone intervention conducted by pharmacy students in improving adherence to ACEIs/ARBs among Medicare Advantage Plan (MAP) patients with both DM and HTN. METHODS: A prospective study was conducted among patients enrolled in a Texas MAP. Medical claims data were used to identify patients with DM and HTN, and pharmacy claims were observed to recognize those who filled either an ACEI or an ARB during June 2014. Patients with a 6-month proportion of days covered (PDC) < 0.80 in the previous 6 months were determined nonadherent, and 75% of those were randomly selected to serve as potential subjects for the intervention, while 25% were randomly selected to serve as potential subjects for the control group. The intervention was a telephone call by a pharmacy student on rotation at the health plan, and 5 monthly follow-up calls. Before implementing calls, participating students attended a 3-day MI training course, where their proficiency for MI skills was evaluated. Refill data during the 6-month postintervention were evaluated to examine the intervention effect measured on 3 outcomes: PDC; PDC ≥ 0.80 versus < 0.80; and discontinuation versus continuation. Multivariate linear and logistic regression models were constructed to adjust for any imbalances in baseline characteristics, including age, gender, number of other medications, regimen complexity, health low-income subsidy status, prescriber specialty, comorbidities, 6-month previous hospitalization, baseline 6-month PDC, and Centers for Medicare & Medicaid Services risk score. RESULTS: A total of 11 students participated in the intervention implementation. Patients receiving calls were randomly selected from those potential subjects for the intervention arm until a target of 250 was reached; 500 controls were randomly selected from the potential subjects for the control arm. The final cohort included in multivariate models consisted of 743 patients. Patients completing the initial call and at least 2 follow-ups were less likely to discontinue (OR = 0.29; 95% CI = 0.15-0.54; P < 0.001) and more likely to be adherent in the linear regression model (ß = 0.0604, P < 0.001) and the logistic regression model (OR = 1.53; 95% CI = 1.02-2.28; P = 0.009). Other factors significantly associated with better adherence included higher baseline PDC and number of medications. Depression status was significantly associated with lower adherence. CONCLUSIONS: Patients receiving 2 or more calls had significantly better adherence and less discontinuation during the 6 months following initial calls compared with those who did not receive calls. This finding indicates that an MI-based telephone intervention by pharmacy students may be a promising intervention to improve adherence. Future research should examine the sustainability of the intervention effect for longer time periods and its influence on associated clinical outcomes. DISCLOSURES: This project was supported by the Pharmaceutical Research and Manufacturers of America Foundation (PhRMA). The content is solely the responsibility of the authors and does not necessarily represent the official views of PhRMA. The funding agency was not involved in research design, analysis, or reporting results. Funding was obtained by Abughosh. Holstad provided a consultation regarding the MI guide and provided the MI training. Study concept and design were contributed by Abughosh and Fleming, along with Serna, Esse, and Holstad. Serna, Esse, Mann, Holstad, and Masilamani collected the data, and data interpretation was performed by Abughosh, Wong, and Esse. The manuscript was written by Abughosh, Wong, and Esse and revised by Masilamani and Holstad, along with the other authors.

Examination of the Role of Religious and Psychosocial Factors in HIV Medication Adherence Rates.

Optimal adherence to antiretroviral therapy (ART) is associated with favorable HIV outcomes, including higher CD4 cell counts, HIV virus suppression and a lower risk of HIV transmission. However, only 25% of people living with HIV/AIDS (PLWH) in the USA are virally suppressed. Sub-optimal adherence (<90-95%) contributes to antiretroviral resistance and worse medical outcomes, including more rapid progression to AIDS and death. Psychosocial factors and religion/spirituality (R/S) have a significant impact on ART adherence, but the findings are mixed. The purpose of this study was to examine religious and psychosocial correlates and predictors of ≥90% ART adherence in PLWH. A cross-sectional study was conducted with a sample of 292 outpatient PLWH in the Southeastern USA. Participants completed computerized surveys. The mean ART adherence percentage was 80.9% and only about half reported ≥90% adherence. There were statistically significant differences in ART adherence rates based on age, depressive symptom status and frequency of religious attendance and prayer. Praying at least once a day was significantly associated with ≥90% ART adherence (OR = 2.26, 95% CI [1.06-4.79], p < 0.05). Social support satisfaction was also significantly associated with ART adherence (OR = 1.52, 95% CI [1.11-2.08], p < 0.05) and energy/fatigue/vitality (OR = 1.03, 95% CI [1.00-1.05], p < 0.05).

Healthy Aging in Older Women Living with HIV Infection: a Systematic Review of Psychosocial Factors.

Due to life-enhancing effects of antiretroviral therapy, HIV-positive persons have the potential for long life comparable to their uninfected peers. Older women (age 50+) living with HIV (OWLH) are often an under-recognized aging group. We conducted a systematic review to examine psychosocial factors that impact how OWLH live, cope, and age with HIV. Initial key word search yielded 1527 records, and 21 studies met our inclusion criteria of original quantitative or qualitative research published between 2013 and 2016 with results specific to OWLH. These focused on health care and self-management, sexual health and risk, stigma, loneliness, mental health (depression, substance use), and protective factors (coping, social support, well-being). Due to the scarcity of studies on each topic and inconclusive findings, no clear patterns of results emerged. As the number of OWLH continues to grow, more research, including longitudinal studies, is needed to fully characterize the psychosocial factors that impact aging with HIV.

Falls among middle-aged women in the Women's Interagency HIV Study.

BACKGROUND: To determine the frequency and risk factors for falls among middle-aged HIV+ and HIV- women in the Women's Interagency HIV Study (WIHS). METHODS: We quantified self-report of any and multiple (≥2) falls in the prior 6 months among 1,412 HIV+ and 650 HIV- women with mean age 48 years. Logistic regression was used to evaluate associations of demographics, behavioural factors, comorbid conditions and medications with odds of any fall (versus none) and multiple falls (versus ≤1 fall). RESULTS: At least one fall was reported in 263 HIV+ (19%) versus 119 HIV- (18%) women, and ≥2 falls reported in 133 HIV+ (9%) versus 65 HIV- (10%) women. HIV infection was not associated with falls in multivariate analyses. Factors independently associated with any fall included age (adjusted odds ratio [aOR] 1.71, 95% CI 1.17, 2.49 age 50-59 versus <39 years; aOR 2.26, 95% CI 1.38, 3.71 age ≥60 versus <39), current marijuana use (aOR 2.19, 95% CI 1.53, 3.13) depressive symptoms (aOR 1.57, 95% CI 1.21, 2.05 for Center for Epidemiology Studies Depression score ≥16), subjective cognitive complaints (aOR 2.19, 95% CI 1.56, 3.08), neuropathy (aOR 1.59, 95% CI 1.19, 2.13), obesity (aOR 1.39, 95% CI 1.08, 1.80), number of central nervous system active agents (aOR 2.98, 95% CI 1.90, 4.68 for ≥3 agents versus 0) and WIHS site. Factors associated with ≥2 falls included age, marijuana use, number of central nervous system active agents, subjective cognitive complaints, depressive symptoms, neuropathy and study site. CONCLUSIONS: Falls were associated with factors affecting cognition, but not HIV status in this large cohort of women. Longitudinal studies are needed to determine the incidence and consequences of falls by HIV status as women age.

Psychosocial Characteristics Associated with Both Antiretroviral Therapy Adherence and Risk Behaviors in Women Living with HIV.

The purpose of this study was to identify key psychosocial characteristics of HIV-infected women who exhibit different levels of both ART adherence and risk behaviors. We analyzed baseline data from 193 predominately African American HIV-infected women participating in a behavioral clinical trial. Women were categorized into high/low groups based on levels of adherence and risky behaviors. There was a significant interaction effect for internal motivation for adherence. Women at high risk for poor health and transmitting HIV (low adherence/high risk group) had the lowest levels of internal motivation and also reported more difficult life circumstances. Gender roles, caretaking and reliance on men for economic and other support may promote external versus internal motivation as well as riskier behaviors in this group. The highest levels of internal motivation were found in those with High Adherence/High Risk behaviors. This group was highly knowledgeable about HIV and had the lowest VL. Compared to others, this group seems to tolerate risky behaviors given their high level of adherence. Adherence and risk reduction behaviors are key to individual and public health. Motivation and risk compensation should be addressed when providing interventions to women living with HIV.

Age, Stigma, Adherence and Clinical Indicators in HIV-Infected Women.

Stigma has become a gendered phenomenon that affects increasing numbers of HIV-infected women worldwide. This study examined the role of age as a possible moderator of the relationship between stigma and antiretroviral therapy adherence, CD4% and viral load among 120 HIV-infected women. A secondary analysis was conducted using data from the Keeping Healthy and Active with Risk Reduction and Medication Adherence (KHARMA) Project, an National Institutes of Health (NIH) funded randomized controlled trial to improve Antiretroviral treatment (ART) adherence and reduce risky behaviors in HIV-infected women at five clinical sites in a South-eastern city from 2005 to 2008. Stigma was measured using the Perceived Personal Stigma of Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV/AIDS) scale. Among participants <50 years old (n=90), age was significantly associated with viral load (rho=-.24, p=.02) and stigma was negatively associated with CD4% (r =-.26, p=.02). For the 30 participants >50 years old, age was not significantly associated with viral load, stigma or CD4%, and there was no significant association between stigma and CD4% (r=.07, p=.70). These findings indicate the need for further study regarding this potential moderating effect and possible interventions to address the susceptibility of younger women to the harmful effects of stigma.

Religious and Psychosocial Covariates of Health-Related Quality of Life in People Living with HIV/AIDS.

HIV/AIDS is a chronic, highly stigmatized illness that requires significant lifestyle adjustments, including consistent adherence to Antiretroviral Therapy (ART) in order for People Living With HIV/AIDS (PLWH) to survive and maintain good immune health. PLWH often report poor or moderate Health-Related Quality of Life (HRQoL) that is worse than the general population. This may be related to the psychological and physiological demands of HIV disease and the sociodemographic stressors associated with it. The role of religious coping, religiosity, and social support in the mental and physical dimensions of HRQoL is less known, although recent studies highlight that PLWH rely on spirituality/religion to cope with HIV-associated stressors. This study examined the effects of religious coping, religiosity, depressive symptoms, medication adherence, and social support satisfaction in various dimensions of Health- Related Quality of Life (HRQoL) in a sample of 292 PLWH. Majority of participants were African-American (90.1%) and 56.2% were male. Mean age was 45 years and, on average, participants lived with HIV for nearly 11 years. Descriptive statistics, correlations, Analysis of Variance (ANOVA), and hierarchical multiple linear regression were used to analyze the data. Income, sex (ß= .14), age (ß= -.14), depressive symptoms (ß= -.27), and social support satisfaction (ß= .17) significantly predicted physical HRQoL. Results indicate that income (ß= .13), sex (ß= .14), medication adherence (ß= .13), negative religious coping (ß= -.18), religious attendance (ß= .13), religiousness (ß= .16), and social support satisfaction (ß= .27) significantly predicted mental HRQoL. Depressive symptoms (ß= -.38), positive religious coping (ß= .24), and social support satisfaction (ß= .16) significantly predicted general HRQoL. Participants, who were female, prayed less than daily, attended religious services less than weekly or who were non/less religious had significantly poorer HRQoL. The findings confirm the importance of religion, mental health, medication adherence and social support in the HRQoL of PLWH, which should all be routinely assessed by clinicians.

The LIVE Network: a music-based messaging program to promote ART adherence self-management.

We developed and pilot-tested the efficacy, acceptability, and feasibility of a music program, The LIVE Network (LN), compared to standard care on outcomes of ART adherence, clinical indicators, and self-efficacy. The study was powered to detect differences at p < 0.1. We enrolled and followed 77 participants for 12 weeks (T3). Mean monthly pill counts (PC) declined over time in both groups. Although not significant, the LN had higher PC and a larger proportion had plasma antiretroviral trough levels within therapeutic range. The LN group did have significantly (p < 0.1) increased levels of adherence self-efficacy and decrease in viral loads.

The Impact of a Health Promotion Educational Program on Cardiovascular Risk Factors for HIV Infected Women on Antiretroviral Therapy.

This study investigates the efficacy of a health promotion educational program on improving cardiovascular risk factors of weight, Body Mass Index, and waist to hip ratio in 76 predominately African American HIV-infected women. The health promotion educational program was the control group (that focused on improving self-efficacy for nutrition, exercise, stress reduction and women's health behaviors) of a NIH-funded study. The majority of participants was overweight, obese, or at high risk based on waist hip ratio at the beginning of the study. There were no statistically significant improvements in body mass index or waist hip ratio from pre intervention to up to 9 months post intervention. There were significant changes in waist hip ratio and body mass index in both directions (improvement and worsened) for a small group of participants. The health promotion program did not affect significant changes in cardiovascular risk and should be revised, lengthened, and refocused on nutrition, diet, exercise, and long term goal commitments to reduce the high risk for cardiovascular disease in this group.

The psychological well-being of people living with HIV/AIDS and the role of religious coping and social support.

OBJECTIVE: This study examined correlates of depressive symptoms, particularly the role of religious coping (RCOPE), among people living with HIV/AIDS (PLWHA). The study also examined social support as a possible mediator of the proposed association between religious coping and depressive symptoms and the impact of depressive symptomatology on health outcomes such as HIV medication adherence, immune function, and health-related quality of life (HRQOL) among PLWHA. METHOD: A convenience sample of 292 PLWHA were recruited from an out-patient infectious disease clinic and AIDS-service organizations in the Southeastern United States. RESULTS: 56.7% reported depressive symptoms. PLWHA with depressive symptomatology reported significantly poorer health outcomes, including poorer HIV medication adherence, lower CD4 cell count, and poorer HRQOL. The odds of being depressed was significantly associated with birth sex (female: OR = 0.43, 95% CI = .23-.80), sexual orientation (gay/bisexual: OR = 1.95, 95% CI = 1.04-3.65), marital status (single: OR = .52, 95% CI = .27-.99), social support satisfaction (OR = 0.65, 95% CI = .49-.86), and negative RCOPE (OR = 1.22, 95% CI = 1.14-1.31). Social support partially mediated the relationship between religious coping and depressive symptoms. CONCLUSIONS: High rates of depressive symptoms are present in PLWHA, which negatively impact health outcomes. Religious coping, perceived stress, and social support satisfaction serve an important role in depressive symptomatology among PLWHA. These findings underscore the need for healthcare providers to regularly screen PLWHA for and adequately treat depression and collaborate with mental health providers, social workers, and pastoral care counselors to address PLWHA's mental, social, and spiritual needs and optimize their HIV-related outcomes.

Factors associated with risky sexual behaviors in older adults.

This cross-sectional, correlational study, guided by the information-motivation-behavioral skills model and self-efficacy theory, investigated factors that may help to assess the HIV prevention needs of older adults. The nonrandom sample (N = 106) included single men and women, 50-74 years of age, who were either sexually active or had plans to be sexually active. Participants were recruited from community sites. Data were collected with questionnaires. Data analysis revealed that the participants had moderate levels of HIV knowledge, were highly motivated, and highly confident but continued to practice risky behaviors such as not using condoms with every sexual encounter (67.9%) and having multiple sex partners (34.6%). Higher perceived effectiveness to perform safer sexual behaviors, being female, and condom use were the only independent predictors of fewer risky sexual behaviors. Findings from this study may provide a foundation for future age-appropriate interventions to decrease HIV in older adults.

The meaning and use of spirituality among African American women living with HIV/AIDS.

The purpose of this qualitative study was to explore the meaning and use of spirituality among African American (AA), predominantly Christian women with HIV. A nonrandom sample of 20 AA women from a large infectious disease clinic in Metro-Atlanta participated in the study. The study used focus groups and individual interviews to interview women about their lived spiritual experience. Content analysis and NUDIST software were used to analyze transcripts. The findings revealed the spiritual views and practices of AA women with HIV. The following themes (and subthemes) emerged: Spirituality is a process/journey or connection (connection to God, higher power, or spirit and HIV brought me closer to God), spiritual expression (religion/church attendance, prayer, helping others, having faith), and spiritual benefits (health/healing, spiritual support, inner peace/strength/ability to keep going, and here for a reason or purpose/a second chance). Findings highlight the importance of spirituality in health and well-being among AA women with HIV/AIDS.

Motivational groups support adherence to antiretroviral therapy and use of risk reduction behaviors in HIV positive Nigerian women: a pilot study.

Nigerian women comprise the fastest growing group of persons with AIDS in Africa. Antiretroviral therapy has transformed the course of HIV/AIDS to a treatable, chronic illness worldwide. The purpose of this pilot study was to assess the efficacy of a group intervention using motivational interviewing (MI) to promote adherence to antiretroviral therapy (ART) and use of risk reduction behaviors (RRB) among HIV-infected women in Nigeria. Recruited participants (n=60) were randomly assigned to the motivational group or the health promotion program (HPP) control group. The 6 month follow-up results indicate that, compared to the control group, MI participants reported significantly higher levels of adherence to ART, higher knowledge of HIV, higher use of condoms/protection during sexual encounters and decision-making not to have sex when no protection was available. The MI participants also had fewer mean number of sexual partners. MI in group format shows promise in promoting adherence to ART and use of RRB in HIV-infected Nigerian women.

Focus Group Evaluation of the LIVE Network-An Audio Music Program to Promote ART Adherence Self-Management.

We present the results of 3 focus groups conducted to assess the utility, appeal, and feasibility of the LIVE Network (LN), a 70-minute audio music program developed to educate and motivate HIV-infected persons to adhere to antiretroviral therapy (ART) and self-manage medication-related side effects. Participants included 15 African American, 2 caucasian, and 1 race unknown HIV-infected persons who had been taking ART for at least 6 months. In general, the LN was well liked, relevant, educational, and motivational. It empowered and motivated participants to be responsible for their adherence self-care. One of the more surprising findings was how freely focus group participants shared the program with family and friends as a means of education and also as a means of disclosure. Moreover, the positive reception of the LN by individuals outside of the focus groups, especially children and adolescents, speaks well for the potential broad appeal of this type of program.