Primary prevention lessons learned from those with HIV in Chennai, India.

BACKGROUND: As each HIV-infected individual represents a breakdown of HIV primary prevention measures, formative data from representative individuals living with HIV can help shape future primary prevention interventions. Little is known about sexual behaviours and other transmission risk factors of high-risk group members who are already HIV-infected in Chennai, India. METHODS: Semi-structured qualitative interviews were conducted with 27 HIV-infected individuals representing each high-risk group in Chennai (five men who have sex with men (MSM), five female commercial sex workers (CSW), four truckers and other men who travel for business, four injecting drug users (IDU), five married male clients of CSW, and four wives of CSW clients, MSM, truckers, and IDU). RESULTS: Themes relevant to HIV primary prevention included: (1) HIV diagnosis as the entry into HIV education and risk reduction, (2) reluctance to undergo voluntary counselling and testing, (3) gender and sexual roles as determinants of condom use, (4) misconceptions about HIV transmission, and (5) framing and accessibility of HIV education messages. CONCLUSIONS: These qualitative data can be used to develop hypotheses about sexual risk taking in HIV-infected individuals in South India, inform primary prevention intervention programs, and improve primary prevention efforts overall.

Predictors of nonadherence to highly active antiretroviral therapy among HIV-infected South Indians in clinical care: implications for developing adherence interventions in resource-limited settings.

In light of the increasing availability of generic highly active antiretroviral therapy (HAART) in India, further data are needed to examine variables associated with HAART nonadherence among HIV-infected Indians in clinical care. We conducted a cross-sectional analysis of 198 HIV-infected South Indian men and women between January and April 2008 receiving first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based HAART. Nonadherence was defined as taking less than 95% of HAART doses in the last 1 month, and was examined using multivariable logistic regression models. Half of the participants reported less than 95% adherence to HAART, and 50% had been on HAART for more than 24 months. The median CD4 cell count was 435 cells per microliter. An increased odds of nonadherence was found for participants with current CD4 cell counts greater than 500 cells per microliter (adjusted odds ratio [AOR]: 2.22 [95% confidence interval {CI}: 1.04-4.75]; p = 0.038), who were on HAART for more than 24 months (AOR: 3.07 [95% CI: 1.35-7.01]; p = 0.007), who reported alcohol use (AOR: 5.68 [95%CI: 2.10-15.32]; p = 0.001), who had low general health perceptions (AOR: 3.58 [95%CI: 1.20-10.66]; p = 0.021), and who had high distress (AOR: 3.32 [95%CI: 1.19-9.26]; p = 0.022). This study documents several modifiable risk factors for nonadherence in a clinic population of HIV-infected Indians with substantial HAART experience. Further targeted culturally specific interventions are needed that address barriers to optimal adherence.

A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected individuals.

OBJECTIVE: To evaluate cognitive-behavioral therapy to enhance medication adherence and reduce depression (CBT-AD) in individuals with HIV. DESIGN: A two arm, randomized, controlled, cross-over trial comparing CBT-AD to enhanced treatment as usual only (ETAU). ETAU, which both groups received, included a single-session intervention for adherence and a letter to the patient's provider documenting her or his continued depression. The intervention group also received 10 to 12 sessions of CBT-AD. MAIN OUTCOME MEASURES: Adherence to antiretroviral therapy as assessed by Medication Event Monitoring Systems (MEMs) and depression as assessed by blinded structured evaluation. RESULTS: At the acute outcome assessment (3-months), those who received CBT-AD evidenced significantly greater improvements in medication adherence and depression relative to the comparison group. Those who were originally assigned to the comparison group who chose to cross over to CBT-AD showed similar improvements in both depression and adherence outcomes. Treatment gains for those in the intervention group were generally maintained at 6- and 12-month follow-up assessments. By the end of the follow-up period, those originally assigned CBT-AD demonstrated improvements in plasma HIV RNA concentrations, though these differences did not emerge before the cross-over, and hence there were not between-groups differences. CONCLUSIONS: CBT-AD is a potentially efficacious approach for individuals with HIV struggling with depression and adherence. Replication and extension in larger efficacy trials are needed.

Participants' perspectives on cognitive-behavioral therapy for adherence and depression in HIV.

As part of the process of developing cognitive-behavioral therapy (CBT) for medical adherence and depression (Safren, Gonzalez, & Soroudi, 2007), the authors conducted exit interviews among 14 HIV-infected patients who received the intervention, and transcribed, coded, and analyzed these data. The authors concluded that CBT was structured yet flexible, developed self-awareness emphasized social support, and involved therapist empathy and supportiveness. Limitations included the discomfort of discussing personal information and the impact of feeling ill on attendance and homework completion. Suggestions included more sessions, more flexibility in scheduling appointments, and more realistic and clear expectations regarding homework. These results provide insights about strengths and limitations of this psychotherapy with medically ill patients and may help to maximize intervention effectiveness and client acceptability.

Sexual behaviors of individuals with HIV living in South India: a qualitative study.

Formative data on the sexual behaviors of HIV-infected individuals in regions disproportionately affected by the epidemic can help generate hypotheses about sexual risk taking in HIV-infected individuals and shape interventions to prevent further transmission. India is home to the highest number of HIV-infected individuals in the world, and very little information is available about the sexual behaviors of HIV-infected Indians. The present qualitative study presents themes from individual in-depth interviews with 30 HIV-infected individuals in South India. The sample included individuals from demographic groups that may experience different risk factors (five individuals each: from men who have sex with men, sex workers, married men, married women, injection drug users, and truck drivers ormen who travel for work). Across the groups, the three most frequently discussed themes involved (a) sexual behavior change (sexual risk reduction after HIV diagnosis, sexual behavior remaining safe after initiation of ART treatment), (b) motivations to reduce risk (motivation to protect one's self against further infection, to protect others from infection), and (c) barriers to reduce risk (complexity and stigma associated with condom negotiation, perception of HIV-infected peers being less concerned about protecting others, condom use as linked to gender and sexual roles, condom use as inconvenient or unappealing). This qualitative data can be used to generate hypotheses about sexual risk taking in HIV-infected individuals in South India, to inform models of risky behaviors of HIV-infected individuals for quantitative studies, and to lay the groundwork for secondary prevention intervention efforts that enhance facilitators and reduce barriers of safer sex articulated by the interviewees.

Barriers and facilitators to antiretroviral medication adherence among patients with HIV in Chennai, India: a qualitative study.

Antiretroviral therapy (ART) for HIV is increasingly being introduced and utilized in diverse areas of the world. However, little research exists on adherence to ART in different cultural settings, particularly in developing countries such as India. This formative qualitative study examined barriers and facilitators of ART adherence among 60 (49 men, 11 women; 33 taking ART, 27 not currently taking ART) patients receiving HIV primary care at YRG CARE, a nongovernmental organization, in Chennai, India. The average participant reported becoming HIV infected through heterosexual transmission, was between 31 and 40 years old, had over ninth class standard education, was married, and generally had access to medical care; however, we obtained some qualitative data from various other risk categories. Trained ethnographers at the study site conducted in-depth interviews in the local language. These interviews were analyzed for content and ethnographic data. Almost all of the participants discussed the cost of ART as a barrier, with many reporting extended drug holidays, turning to family and/or friends, or taking drastic measures (i.e., selling family jewels, property) for financial assistance. Other barriers centered on privacy and stigma issues, such as disclosure of HIV inhibiting pill-taking and social support. Frequently discussed facilitators of adherence included perceived benefits of ART and proper adherence, perceptions about the consequences of nonadherence, and social support, if available. These data highlight the importance of reducing the cost of antiretroviral medications, involving family members in HIV care, and addressing privacy issues and stigma in counseling interventions in this setting.