Addressing HIV stigma in healthcare, community, and legislative settings in Central and Eastern Europe.

INTRODUCTION: Surging HIV prevalence across countries of Central and Eastern Europe (CEE) is largely a result of poor HIV care engagement and a lack of comprehensive support for key populations. This is fostered by widespread stigma across healthcare, community, and legislative settings. DISCUSSION: Throughout CEE, HIV stigma and intersectional stigma are serious obstacles to providing adequate medical care to people living with HIV. Anticipated and enacted (experienced) stigma from healthcare professionals, and fears of breaches in confidentiality, deter individuals from having an HIV test and engaging in HIV care. Furthermore, negative connotations surrounding HIV infection can lead to discrimination from family, friends, colleagues, and the public, leading to internalized stigma and depression. Key populations that have higher HIV prevalence, such as men who have sex with men, people who inject drugs, transgender individuals, and sex workers, experience additional stigma and discrimination based on their behaviour and identities. This contributes to the concentrated HIV epidemics seen in these populations in many CEE countries. The stigma is exacerbated by punitive legislation that criminalizes HIV transmission and penalizes sexual orientation, drug use, gender identities, and sex work. Despite high levels of HIV stigma and intersectional stigma, there are many evidence-based interventions that have reduced stigma in other parts of the world. Here, we discuss the interventions that are currently being enacted in various countries of CEE, and we suggest additional effective, evidence-based interventions that will tackle stigma and lead to increased HIV care engagement and higher rates of viral suppression. We cover the promotion of the undetectable = untransmittable (U = U) message, stigma-reduction education and training for healthcare professionals, patient-centric approaches for testing and treatment, and advocacy for non-discriminatory legislation, policies, and practices. We also consider targeted stigma-reduction interventions that acknowledge the wider challenges faced by marginalized populations. CONCLUSIONS: HIV stigma and intersectional stigma in CEE drive poor engagement with HIV testing services and care. Widespread adoption of evidence-based interventions to tackle stigma highlighted in this review will improve the quality of life of people living with HIV, improve HIV care engagement, and ultimately slow the surging HIV prevalence and concentrated epidemics occurring throughout CEE.

Translation and cultural adaptation of a romanian version of the communication assessment tool (CAT_Ro).

BACKGROUND: The communication between health providers and patients influences the quality of medical care. The Communication Skills Assessment (CAT) is a reliable, validated tool, which was developed to assess interpersonal communication skills between physicians and patients. The purpose of this study was to obtain a Romanian version of the CAT (CAT_Ro), using a controlled and systematic process to translate and cross-culturally adapt the original questionnaire, since there are no validated instruments to assess healthcare professionals' communication capability in Romania. METHODS: The study was conducted in two Departments of Internal Medicine and Rheumatology from Bucharest, Romania, using a rigorous scientific methodology for the translation process, according to literature recommendations, implicating conceptual evaluation, semantics, and cultural adaptation, which involved several steps. The updated version was pre-tested in a pilot study, which included 89 outpatients. RESULTS: The results showed a narrow range of variability in item interpretation, without differences in patients' responses according to variables such as age, gender, education, disease type, number of previous visits with the same doctor. CONCLUSION: CAT-Ro is the result of a comprehensive process study. It represents the first translation and cultural adaptation in Romanian of an instrument able to assess the health providers' communication skills, which was validated in a pilot study and is to be used in more extensive studies with patients from several specialties.

Where we are now and how we can improve: a qualitative study of practitioners' perspectives on providing ART adherence support in Romania.

Supporting medication adherence is a priority in HIV care worldwide as low adherence threatens the effectiveness of antiretroviral treatment (ART). While evidence on adherence causes and consequences has steadily accumulated, investigating current practice and relevant determinants of practitioners' behaviors has only recently been highlighted as essential for developing effective and sustainable interventions. In Romania, ART adherence is low despite universal access to HIV care, and improving support services is a priority. We report a qualitative exploration of practitioners' experiences and views on ART adherence support, guided by current behavioral theory. Semi-structured interviews were performed with 10 practitioners from six HIV centers, aiming for maximum variation sampling on professional experience, location, and organization type. Questions addressed practitioners' views and experiences on assessing patients' adherence behaviors and determinants, content and format of adherence support, and perceived influences on their capacity to deliver support. Verbatim transcripts were analyzed via template analysis. Results show that adherence support is provided in Romania by trained psychologists in multidisciplinary teams that operate flexibly and perform multiple HIV care activities. Assessment of adherence behaviors and determinants is primarily interview-based, and practitioners use mostly psychotherapeutic techniques and theories with a degree of intervention tailoring. Practitioners' descriptions covered a broad range of common determinants and behavior change techniques, but showed limited use of behavioral theory. Participants also described difficulties to cope with limited resources, and lack of support for managing practical and emotional challenges. Several opportunities for improvement were identified, such as standardizing patient profiling and intervention delivery, conceptualizing and recording active intervention content based on behavioral theory, and actively monitoring intervention effectiveness. This qualitative inquiry provided valuable information for improving adherence support in this clinical context. Understanding practitioners' perspectives based on behavioral theory-informed analyses can help intervention developers increase intervention fidelity by integrating current practice information in program design.

Birth outcome in HIV vertically-exposed children in two Romanian centers.

BACKGROUND: The Romanian HIV epidemic is characterized by a high prevalence among children born in the late '80s, perinatally infected. The impact of long-term treatment on their offspring is unknown. We evaluated the influence of prenatal care on the rate of premature birth among the HIV-exposed children of heavily treated HIV-infected mothers in two Romanian centers. METHODS: We retrospectively analyzed data on all patients born by HIV-infected mothers between 2006 and 2012 followed up in two main regional centers. We compared the rate of premature birth and the differences between the sites regarding children and maternal demographic characteristics and antiretroviral exposure in pregnant women. RESULTS: A total of 358 children born to 315 women were enrolled between 2006-2012, 262 children from the National Institute for Infectious Diseases "Prof. Dr. Matei Bals" Bucharest (NIID) and 96 children from the Clinical Infectious Diseases Hospital Constanta (IDHC). Gender rate in newborns and mean age in mothers were similar. We recorded statistically significant differences between centers in the rate of HIV vertical transmission (16.8% vs. 6.2%, p=0.002) and prematurity (25.2 vs. 14.6%, p=0.023). The most used antiretroviral combination during pregnancy in IDHC was boosted lopinavir and fixed dose zidovudine-lamivudine (66% of cases), while in NIID a greater diversity of antiretrovirals were used. Women from IDHC were more frequently treated during pregnancy (83.3% vs. 68.6%, p=0.004). HCV coinfection and illegal drug use were associated with prematurity in the NIID cohort (p=0.037, p=0.024). CONCLUSION: We found a higher rate of premature birth and HIV infection in NIID. In IDHC we found a higher rate of low birth weight in children and a higher rate of heavily treated women. Prematurity was associated with hepatitis C infection and illegal drug use in the NIID cohort.

Nine-year follow-up of HIV-infected Romanian children and adolescents receiving lopinavir/ritonavir-containing highly active antiretroviral therapy.

INTRODUCTION: Many Romanian children were infected nosocomially with human immunodeficiency virus (HIV) in the late 1980s. The Romanian-American Children's Center of Excellence in Constanta continues to follow approximately 450 of these patients. In 2001, 414 of these patients were initiated on triple therapy including lopinavir/ritonavir. Data from this cohort treated through August 2006 were published in April 2007 demonstrating that the treatment was well tolerated, with 337 children (81%) remaining on therapy after a median duration of >4 years. The current article describes the results of continued analysis of this cohort through end 2010. The objective of the study was to determine the long-term clinical outcomes of children and adolescents commenced on antiretroviral therapy (ART) including lopinavir/ritonavir. METHODS: Data were extracted retrospectively from the charts of the 336 patients remaining on lopinavir/ritonavir in August 2006. The following outcomes were analyzed: mortality, current patient status, viral load (VL), CD4 counts and reasons for discontinuation of lopinavir/ritonavir. RESULTS: The median age at initiation of lopinavir/ritonavir was 14.0 years (range 5.4 to 20.0 years). The median time on lopinavir/ritonavir treatment was 7.5 years (interquartile range 5.7 to 8.6 years). Overall mortality was 13.5%. Of the original 414 patients started on lopinavir/ritonavir in 2001, 199 (48.1%) remained on this therapy at the end of 2010 and of these 63.8% had undetectable viral load. CONCLUSION: Despite initial suboptimal ART, a significant proportion of patients subsequently treated with a lopinavir/ritonavir based regimen remained on this therapy for up to nine years.

Adherence to ARV medication in Romanian young adults: self-reported behaviour and psychological barriers.

Adherence to antiretroviral (ARV) treatment during adolescence and young adulthood is a significant clinical issue for the current management of the HIV/AIDS epidemic in Romania. Understanding patients' own perceptions of their adherence behaviours and related psychological barriers is instrumental for developing robust interventions, and developing psychometrically sound instruments is essential for measuring adherence in this population. We adapted to Romanian an internationally validated questionnaire for the evaluation of ARV treatment adherence. We subsequently conducted a cross-sectional survey to examine its psychometric properties and investigate the relations between self-reported aspects of adherence and established indicators of adherence and health status: Pill count, doctor's assessment of patient's adherence and viral load. Results suggest that low self-reported adherence is particularly associated with experiencing side effects and emotional distress, as well as perceptions of high treatment difficulty and time demands, low self-efficacy, low treatment efficacy and low treatment satisfaction. Perceptions of improvements in health status were overall associated with increased adherence, but feeling good physically sometimes preceded non-adherence behaviours. The questionnaire proved psychometrically sound according to classical test theory criteria (e.g., Cronbach's α = 0.77, significant associations with adherence and health status indicators). Addressing adherence barriers in clinical practice with this population may help reduce their potential impact on behaviours.

Long-term follow-up of 414 HIV-infected Romanian children and adolescents receiving lopinavir/ritonavir-containing highly active antiretroviral therapy.

BACKGROUND: There are no published reports of the long-term safety and effectiveness of highly active antiretroviral therapy for children and adolescents living in resource-limited settings or of large cohorts of HIV-infected children and adolescents treated long-term (>48 weeks) with lopinavir/ritonavir-containing highly active antiretroviral therapy. OBJECTIVES: The purpose of this work was to evaluate the long-term outcomes of treatment of HIV-infected children and adolescents with lopinavir/ritonavir-containing highly active antiretroviral therapy in a resource-limited setting. METHODS: We studied an inception cohort of 414 HIV-infected children receiving lopinavir/ritonavir-containing highly active antiretroviral therapy between November 2001 and August 2006 at the Romanian-American Children's Center in Constanta, Romania. The center provides comprehensive primary and HIV specialty care and treatment to all known HIV-infected children and adolescents living in Constanta. We measured safety and effectiveness by the percentage of children remaining on treatment, rates of mortality, and changes in plasma HIV RNA concentrations and CD4+ lymphocyte counts. RESULTS: The study population consisted predominantly of antiretroviral drug-experienced older children and adolescents with advanced HIV disease. Treatment was well tolerated, with 337 children (81%) remaining on therapy after a median duration of >4 years. Thirty-seven deaths occurred; the death rate compared favorably to prospectively collected historical data. The most recent on-treatment plasma HIV RNA concentration was <400 copies per milliliter in 192 of 265 children tested. The mean baseline CD4+ lymphocyte count was 292 cells per microliter (n = 299); the mean change from baseline was +266 (n = 284), +317 (n = 260), +343 (n = 176), and +270 cells per microliter (n = 121) after 1, 2, 3, and 4 years of treatment, respectively. CONCLUSIONS: Highly active antiretroviral therapy can be administered safely and effectively to children and adolescents in resource-limited settings. Lopinavir/ritonavir-containing highly active antiretroviral therapy is a safe, effective, and durable treatment option for antiretroviral drug-experienced older children and adolescents with advanced HIV disease.