Understanding the relationship between social support and physical and mental well-being among jail detainees living with HIV.

Inmates face a disproportionate burden of HIV. This study sought to explore the relationship between social support and physical and mental well-being and the possibility that housing stability moderates this relationship among jail detainees living with HIV. Data for this cross-sectional analysis come from 438 clients who underwent a structured interview. Results indicate a significant positive relationship between social support and both types of well-being (ps < .05); the experience of homelessness was associated with less mental well-being (p < .01). There was no evidence of moderation. Results highlight the importance of social support and economic considerations in understanding well-being among HIV+ jail detainees.

Linking HIV-positive jail inmates to treatment, care, and social services after release: results from a qualitative assessment of the COMPASS Program.

Approximately 17% of individuals living with HIV/AIDS pass through the correctional system each year. Jails provide a unique opportunity to diagnose and treat HIV infection among high-risk, transient populations with limited access to medical services. In 2007, the US Health Resources and Services Administration funded a multi-site demonstration project entitled Enhancing Linkages to HIV Primary Care in Jail Settings that aims to improve diagnosis and treatment services for HIV-positive jail detainees and link them to community-based medical care and social services upon release. We performed an evaluation of the Rhode Island demonstration site entitled Community Partnerships and Supportive Services for HIV-Infected People Leaving Jail (COMPASS). Through in-depth qualitative interviews among 20 HIV-positive COMPASS participants in Rhode Island, we assessed how COMPASS impacted access to health care and social services utilization. Most individuals were receiving HIV treatment and care services upon enrollment, but COMPASS enhanced linkage to medical care and follow-up visits for HIV and other co-morbidities for most participants. Several participants were successfully linked to new medical services as a result of COMPASS, including one individual newly diagnosed with HIV and another who had been living with HIV for many years and was able to commence highly active antiretroviral therapy (HAART). While many individuals reported that COMPASS support prevented substance abuse relapse, ongoing substance abuse nevertheless remained a challenge for several participants. Most participants enrolled in one or more new social services as a result of COMPASS, including Medicaid, Supplemental Security Income, food assistance, and housing programs. The primary unmet needs of COMPASS participants were access to mental health services and stable housing. Intensive case management of HIV-positive jail detainees enhances access to medical and social support services and helps prevent relapse to substance abuse. Expanding intensive case management programs, public housing, and mental health services for recently released HIV-positive detainees should be public health priorities.

The feasibility of modified directly observed therapy for HIV-seropositive African American substance users.

Recently, modified directly observed therapy (MDOT) has emerged as a promising intervention to address nonadherence for hard-to-reach populations infected with HIV. To date, there are no existing data on MDOT focusing exclusively on African Americans. The present study sought to determine the feasibility of MDOT among 31 HIV-seropositive African American substance users in the South. An outreach worker observed the participants' medication intake 5 days per week (once per day) for a period of 3 months (intensive phase). This phase was followed by a transition phase of 3 months during which the frequency of MDOT was gradually tapered from 5 days to once weekly. Assessments to gather demographic information, HIV risk behaviors, substance use, depression, and medication adherence were conducted at baseline, 3 months, and 6 months. Results indicated that more participants adhered to their medication regimen and had viral loads of less than 400 copies per milliliter at 3 and 6 months compared to baseline. Participants reported significantly less depressive symptoms at the 6-month assessment compared to baseline and 3 months. With regard to acceptability, 95% of participants indicated they liked having the outreach visits, 100% reported MDOT helped them take their medications, and only 5% felt MDOT was a violation of privacy. These results suggest MDOT is feasible among African American substance users in the South and a larger controlled study of MDOT with this population is warranted.

A randomized clinical trial of community-based directly observed therapy as an adherence intervention for HAART among substance users.

BACKGROUND: Adherence interventions for HAART can impact challenging populations, such as active substance users. Community-based modified directly observed therapy (MDOT) is a promising approach that needs to be critically evaluated. METHODS: This study was a randomized clinical trial. HIV seropositive substance users were randomized to either standard of care (SOC) or MDOT, stratified by HAART experience. All participants were placed on a once-daily regimen and were met by an outreach worker for all 7 days during the first 3 months. We used an intent-to-treat analysis to evaluate differences in viral load suppression [> 2 log drop in plasma viral load (PVL) or PVL < 50] and changes in PVL and CD4 cell count from baseline to 3 months. RESULTS: A total of 87 participants were enrolled (43 in SOC, 44 in MDOT), Using repeated measures logistic regression, MDOT participants were more likely to achieve PVL suppression (odds ratio, 2.16; 95% confidence interval, 1.0-4.7), driven primarily by those HAART experienced (odds ratio, 2.88; 95% confidence interval, 1.2-7.0). A significant treatment effect was also found in CD4 cell count change (P < 0.05). No differences were found by arm in undetectable PVL. CONCLUSION: This study provides evidence that MDOT is an effective strategy to reduce viral load and increase CD4 cell counts in HAART experienced substance users. MDOT should be included in the spectrum of options to enhance adherence in this population.

Adherence among women with HIV infection in Puerto Rico: the potential use of modified directly observed therapy (MDOT) among pregnant and postpartum women.

Women are the fastest growing segment of the adult population acquiring HIV, and most women infected with HIV are in their reproductive years. The success of HAART is highly dependent upon the ability and willingness of the individual to adhere to complex antiretroviral regimens. Improved adherence among HIV-infected pregnant women will delay disease progression in the mother and should also reduce HIV transmission to the baby. Modified directly observed therapy (MDOT), may benefit this population. MDOT has been shown to be an acceptable and feasible intervention among HIV substance users; however, no-one has yet evaluated the use of MDOT in pregnant and postpartum women. Based on semi-structured interviews with 17 Latina women with HIV infection, we explored women's adherence patterns and barriers to adherence and their perceptions of a hypothetical MDOT program. The vast majority of women positively appraised the MDOT program as an effective means to increase and reinforce adherence to demanding drug regimens. Respondents cited the face-to-face contact, the supportive nature of the relationship, and the practical approach of the program as the primary reasons for the effectiveness of MDOT. Results indicate that MDOT could be an acceptable intervention for pregnant and postpartum Latina women to improve adherence to HAART.

The use of community-based modified directly observed therapy for the treatment of HIV-infected persons.

Directly observed therapy, which has been successful in the treatment of tuberculosis, is being adapted for the treatment of HIV to decrease long-term morbidity and mortality. We describe the experiences of 69 HIV-infected individuals who were enrolled in a community-based modified directly observed therapy (MDOT) program. Participants were referred by their primary care physicians based on nonadherence to antiretroviral therapy, and/or active substance use. A near-peer outreach worker initially delivered medications to participants 5 to 7 days per week, with visits subsequently tapered to 1 to 3 days per week after 3 or more months. Questionnaires were completed and laboratory values were obtained at baseline, 1 month, and every 3 months after enrollment. At enrollment, 96% of participants had a history of substance use, 71% had a history of incarceration, and 93% were experienced with highly active antiretroviral therapy (HAART). At the time of their 6-month assessment visit, 31 of 69 participants were receiving observed therapy visits. The median baseline plasma viral load (PVL) was 4.8 log, and the median individual change in PVL from baseline to 6 months among participants receiving MDOT was a decrease of 2.7 log. Reasons why participants were not receiving visits included medication holidays, hospitalization or assisted living, incarceration, discontinuation of program involvement, and death. These results support that MDOT should be included in the spectrum of options available to enhance adherence to HAART among patients who are unsuccessful with self-administration of their medications.