A qualitative description of service providers' experiences of ethical issues in HIV care.

BACKGROUND: Managing HIV treatment is a complex multi-dimensional task because of a combination of factors such as stigma and discrimination of some populations who frequently get infected with HIV. In addition, patient-provider encounters have become increasingly multicultural, making effective communication and provision of ethically sound care a challenge. PURPOSE: This article explores ethical issues that health service providers in the United States and Botswana encountered in their interaction with patients in HIV care. RESEARCH DESIGN: A descriptive qualitative design was used to collect data from health service providers and patients using focused group discussions. This article is based on responses from health service providers only. PARTICIPANTS AND CONTEXT: This article is based on 11 focused group discussions with a total sample of 71 service providers in seven US sites and one Botswana site. ETHICAL CONSIDERATIONS: Ethical review boards at all the study sites reviewed the study protocol and approved it. Ethical review boards of the study's coordinating centers, Rutgers University and the University of California at San Francisco, also approved it. The study participants provided a written informed consent to participate. FINDINGS: HIV service providers encountered ethical challenges in all the four Beauchamp and Childress' biomedical ethics of respect for patients' autonomy, beneficence, justice, and nonmaleficence. DISCUSSION: The finding that HIV service providers encounter ethical challenges in their interaction with patients is supported by prior studies. The ethical challenges are particularly prominent in multicultural care and resource-constrained care environments. CONCLUSION: Provision of HIV care is fraught with ethical challenges that tend to pose different issues depending on a given care environment. It is important that strong partnerships are developed among key stakeholders in HIV care. In addition, health service providers need to be provided with resources so they can provide quality and ethically sound care.

Sexual transmission-risk behaviour among HIV-positive persons: a multisite study using social action theory.

AIM: Sexual risk behaviour was explored and described using Social Action Theory. BACKGROUND: The sexual transmission of HIV is complex and multi-factorial. Social Action Theory provides a framework for viewing self-regulation of modifiable behaviour such as condom use. Condom use is viewed within the context of social interaction and interdependence. DESIGN: Cross-sectional survey. METHODS: Self-report questionnaire administered to adults living with HIV/AIDS, recruited from clinics, service organizations and by active outreach, between 2010 - 2011. FINDINGS: Having multiple sex partners with inconsistent condom use during a 3-month recall period was associated with being male, younger age, having more years of education,substance use frequency and men having sex with men being a mode of acquiring HIV. In addition, lower self-efficacy for condom use scores were associated with having multiple sex partners and inconsistent condom use. CONCLUSION: Social Action Theory provided a framework for organizing data from an international sample of seropositive persons. Interventions for sexually active, younger, HIV positive men who have sex with men, that strengthen perceived efficacy for condom use, and reduce the frequency of substance use, may contribute to reducing HIV-transmission risk.

A multinational qualitative investigation of the perspectives and drivers of exercise and dietary behaviors in people living with HIV.

Globally, people living with HIV (PLWH) are at remarkably high risk for developing chronic comorbidities. While exercise and healthy eating reduce and mitigate chronic comorbidites, PLWH like many others, often fail to engage in recommended levels. We qualitatively examined the perspectives and contextual drivers of diet and exercise reported by PLWH and their health care providers. Two hundred and six participants across eight sites in the United States, Puerto Rico and Botswana described one overarching theme, Arranging Priorities, and four subthemes Defining Health, Perceived Importance of Diet and Exercise, Competing Needs, and Provider Influence. People living with HIV and their health care providers recognize the importance of eating a healthy diet and engaging in regular exercise. Yet there are HIV-specific factors limiting these behaviors that should be addressed. Health care providers have an important, and often underutilized opportunity to support PLWH to make improvements to their exercise and diet behavior.

Impact of anxiety and depressive symptoms on perceptions of stigma in persons living with HIV disease in rural versus urban North Carolina.

This analysis examined the relationships between HIV-related stigma, depression, and anxiety in rural and urban sites. Participants were HIV-positive urban (n = 100) and rural (n = 100) adult residents of a US southern state, drawn from a sample for a larger international study of self-esteem and self-compassion. Measures included demographic and health information, the HIV Stigma Scale, the Center for Epidemiology Studies Depression Scale (CES-D), and the Symptom Checklist 90 Revised (SCL-R-90) anxiety scale. Independent sample t-tests showed no significant differences between urban/rural groups on measures of HIV-related stigma, anxiety, or depression, except that rural participants reported greater disclosure concerns (t = 2.11, df = 196, p = .036). Both groups indicated high levels of depression and anxiety relative to published norms and clinically relevant cut-off scores. Hierarchical regression analyses were conducted for the HIV Stigma Scale including its four subscales and total stigma scores. Block 1 (control) contained health and demographic variables known to predict HIV-related stigma. Block 2 included the CES-D and the SCL-R-90, and Block 3 was urban/rural location. Mental health symptom scores contributed a significant amount to explained variance in total stigma scores (5.5%, FΔ = 6.020, p < .01), personalized stigma (4.8%, FΔ = 5.035, p < .01), negative self-image (9.7%, FΔ = 12.289, p < .001), and concern with public attitudes (4.9%, FΔ = 5.228, p < .01), but not disclosure concerns. Urban/rural location made significant additional contributions to the variance for total stigma (1.7%, FΔ = 3.899, p < .05), disclosure concerns (2.6%, FΔ = 5.446, p < .05), and concern with public attitudes (1.9%, FΔ = 4.169, p < .05) but not personalized stigma or negative self-image. Depression scores consistently and significantly predicted perceived stigma total and subscale scores. Findings suggest that mental health symptoms and urban/rural location play important roles in perceived stigma, and treatment implications are presented.

Self-compassion and risk behavior among people living with HIV/AIDS.

Sexual risk behavior and illicit drug use among people living with HIV/AIDS (PLWHA) contribute to poor health and onward transmission of HIV. The aim of this collaborative multi-site nursing research study was to explore the association between self-compassion and risk behaviors in PLWHA. As part of a larger project, nurse researchers in Canada, China, Namibia, Puerto Rico, Thailand and the US enrolled 1211 sexually active PLWHA using convenience sampling. The majority of the sample was male, middle-aged, and from the US. Illicit drug use was strongly associated with sexual risk behavior, but participants with higher self-compassion were less likely to report sexual risk behavior, even in the presence of illicit drug use. Self-compassion may be a novel area for behavioral intervention development for PLWHA.

Associations between the legal context of HIV, perceived social capital, and HIV antiretroviral adherence in North America.

BACKGROUND: Human rights approaches to manage HIV and efforts to decriminalize HIV exposure/transmission globally offer hope to persons living with HIV (PLWH). However, among vulnerable populations of PLWH, substantial human rights and structural challenges (disadvantage and injustice that results from everyday practices of a well-intentioned liberal society) must be addressed. These challenges span all ecosocial context levels and in North America (Canada and the United States) can include prosecution for HIV nondisclosure and HIV exposure/transmission. Our aims were to: 1) Determine if there were associations between the social structural factor of criminalization of HIV exposure/transmission, the individual factor of perceived social capital (resources to support one's life chances and overcome life's challenges), and HIV antiretroviral therapy (ART) adherence among PLWH and 2) describe the nature of associations between the social structural factor of criminalization of HIV exposure/transmission, the individual factor of perceived social capital, and HIV ART adherence among PLWH. METHODS: We used ecosocial theory and social epidemiology to guide our study. HIV related criminal law data were obtained from published literature. Perceived social capital and HIV ART adherence data were collected from adult PLWH. Correlation and logistic regression were used to identify and characterize observed associations. RESULTS: Among a sample of adult PLWH (n = 1873), significant positive associations were observed between perceived social capital, HIV disclosure required by law, and self-reported HIV ART adherence. We observed that PLWH who have higher levels of perceived social capital and who live in areas where HIV disclosure is required by law reported better average adherence. In contrast, PLWH who live in areas where HIV transmission/exposure is a crime reported lower 30-day medication adherence. Among our North American participants, being of older age, of White or Hispanic ancestry, and having higher perceived social capital, were significant predictors of better HIV ART adherence. CONCLUSIONS: Treatment approaches offer clear advantages in controlling HIV and reducing HIV transmission at the population level. These advantages, however, will have limited benefit for adherence to treatments without also addressing the social and structural challenges that allow HIV to continue to spread among society's most vulnerable populations.

Keloidal atypical fibroxanthoma of the scalp.

Atypical fibroxanthoma (AFX) is a rare low-grade sarcoma that occurs mainly in the elderly and may recur locally. There are multiple variants including keloidal AFX (KAF). KAF is characterised by a proliferation of atypical spindled and epithelioid cells admixed with bizarre pleomorphic cells. These cells intersect among broad bands of keloidal collagen. AFX is a diagnosis of exclusion so a broad panel of immunohistochemical staining should be applied to rule out other differentials (squamous cell carcinoma (SCC), melanoma, leiomyosarcoma, etc). There is added difficulty with the diagnosis of KAF as it may mimic multiple keloidal lesions, including exuberant scarring, as in this case. p53 immunohistochemistry staining can be useful in highlighting the presence of tumour cells. Additionally, next generation sequencing can detect genetic mutations identified in clonal proliferations consistent with tumour formation. KAF is easily overlooked and it should be included in the differential diagnosis for keloidal lesions showing even mild atypia.

Chlorate Levels in Dairy Products Produced and Consumed in Ireland.

In recent years, chlorate has become a residue of concern internationally, due to the risk that it poses to thyroid gland function. However, little is known about its occurrence in dairy products of Irish origin. To address this, a study was conducted in which samples of milk (n = 317), cream (n = 199), butter (n = 178), cheese (n = 144) and yoghurt (n = 440) were collected from grocery stores in the Republic of Ireland. Sampling was conducted across spring, summer, autumn and winter of 2021. Samples from multiple manufacturers of each respective dairy product were procured and analysed for chlorate using UPLC-MS/MS. Chlorate was detected in milk, cream, natural, blueberry, strawberry and raspberry yoghurts. Mean chlorate levels detected in these products were 0.0088, 0.0057, 0.055, 0.067, 0.077 and 0.095 mg kg-1, respectively. Chlorate was undetected in butter and cheese (<0.01 mg kg-1). All products sampled, except yoghurt, were found to be compliant with the EU limit for chlorate in milk (0.10 mg kg-1). Some manufacturers produced product with greater incidence and levels of chlorate. Chlorate levels from samples tested at different times of the year did not differ significantly, with the exception of strawberry and raspberry yoghurts which had higher chlorate levels in the winter period.

Prevalence and levels of Campylobacter in broiler chicken batches and carcasses in Ireland in 2017-2018.

In 2008, an EU wide baseline survey of broilers revealed a high Campylobacter prevalence. To assist with industry-wide controls, updated data were required. The primary objective of this study was to establish up-to-date data on Campylobacter carriage and carcass contamination in Irish broilers. Monthly samples were collected from the three largest broiler processing plants in Ireland over a twelve-month period. Samples were taken from both first and final thin birds (partial and full depopulation) from 358 batches of broilers. From each batch, a composite sample of 10 caecal contents (n = 358) and 5 neck skins (n = 1790) were collected and numbers of Campylobacter in each sample were determined. Of the 1790 neck skin samples tested, 53% were Campylobacter positive. Campylobacter was detected in the caecal contents of 66% of all batches tested. Depopulation and/or age had a significant effect on Campylobacter prevalence with 67% of final thin broilers yielding Campylobacter-positive neck skin samples in contrast to 38% of first thin broilers that yielded positive neck skin samples (P ≤ 0.002). A significant seasonal variation was observed in the rate of Campylobacter-positive caecal samples with higher prevalence seen in July (85%) than the colder months of November (61%), December (50%), January (61%) March (57%) and April (59%). Neck skin samples were 7 times more likely to be Campylobacter positive if the caecal contents from the same batch were positive (odds ratio = 7.1; P ≤ 0.0001). The decrease in Campylobacter prevalence observed in neck skin and caecal contents demonstrates the improvements and progress made in reducing prevalences of this important enteropathogen in the Irish poultry industry since the 2008 EU baseline survey. It also provides further supporting data on the impact of thinning, the processing environment and season on Campylobacter prevalence.

Experiences of women in obtaining human immunodeficiency virus testing and healthcare services.

PURPOSE: Over a decade ago, the U.S. Public Health Service recommended routine human immunodeficiency virus (HIV) testing for pregnant women. Despite this recommendation, nearly 30% of pregnant women report not being tested. The purpose of this qualitative study was to describe personal experiences of women in obtaining HIV testing and healthcare services in east Texas. DATA SOURCES: A secondary data analysis was conducted using audiotapes and transcriptions from structured group interview data obtained from HIV-positive and high-risk negative women residing in east Texas (n = 64). CONCLUSIONS: Content analysis revealed three patterns: living with stigma; struggling to be healthy; and getting along, day by day. Additional findings indicated that women are more likely to access HIV testing if they are assured of confidentiality and women living with HIV are more likely to remain in the healthcare system if healthcare professionals are supportive, knowledgeable, and nonjudgmental. IMPLICATIONS FOR PRACTICE: Healthcare professionals must engage in self-reflection to conscientiously uncover their true feelings related to caring for women with or at risk for HIV disease. Once providers acknowledge that their beliefs and values differ from their clients, they will be able to minimize personal biases that interfere with HIV testing and healthcare services.

Understanding Health Literacy for People Living With HIV: Locations of Learning.

Health literacy, including people's abilities to access, process, and comprehend health-related information, has become an important component in the management of complex and chronic diseases such as HIV infection. Clinical measures of health literacy that focus on patients' abilities to follow plans of care ignore the multidimensionality of health literacy. Our thematic analysis of 28 focus groups from a qualitative, multisite, multinational study exploring information practices of people living with HIV (PLWH) demonstrated the importance of location as a dimension of health literacy. Clinical care and conceptual/virtual locations (media/Internet and research studies) were used by PLWH to learn about HIV and how to live successfully with HIV. Nonclinical spaces where PLWH could safely discuss issues such as disclosure and life problems were noted. Expanding clinical perspectives of health literacy to include location, assessing the what and where of learning, and trusted purveyors of knowledge could help providers improve patient engagement in care.

Posttraumatic Stress Disorder and Stressful Life Events Among Rural Women With HIV Disease.

Posttraumatic stress disorder (PTSD) and stressful life events are frequent and distressing problems for women living with HIV (WLWH). Studies have independently focused on the impact of these problems, but little work has examined the relationship between PTSD and stressful life events. Our cross-sectional study examined relationships between PTSD and recent stressful life events in WLWH. A sample of 60 women recruited through HIV community agencies in southeastern North Carolina completed the Stressful Life Events Questionnaire and the PTSD Checklist-Civilian Version (PCL-C). PTSD prevalence was high (43.2%). Two-thirds (66%) reported three or more recent life stressors. Women who experienced a higher number of recent life stressors scored higher on the PCL-C than those with fewer life stressors (p < .001). Recent stressful life events may accelerate PTSD symptoms. Findings underscore the importance of addressing mental health issues in HIV treatment settings. Implications for nursing practice are provided.

Building Trust and Relationships Between Patients and Providers: An Essential Complement to Health Literacy in HIV Care.

Health literacy is important for access to and quality of HIV care. While most models of health literacy acknowledge the importance of the patient-provider relationship to disease management, a more nuanced understanding of this relationship is needed. Thematic analysis from 28 focus groups with HIV-experienced patients (n = 135) and providers (n = 71) identified a long-term and trusting relationship as an essential part of HIV treatment over the continuum of HIV care. We found that trust and relationship building over time were important for patients with HIV as well as for their providers. An expanded definition of health literacy that includes gaining a patient's trust and engaging in a process of health education and information sharing over time could improve HIV care. Expanding clinical perspectives to include trust and the importance of the patient-provider relationship to a shared understanding of health literacy may improve patient experiences and engagement in care.

Language and Culture in Health Literacy for People Living with HIV: Perspectives of Health Care Providers and Professional Care Team Members.

Low health literacy has been linked to inadequate engagement in care and may serve as a contributor to poor health outcomes among people living with HIV and AIDS. The purpose of this paper was to examine the perspectives of health care providers and professional care team members regarding health literacy in HIV disease. A secondary data analysis was conducted from a qualitative study aimed at understanding factors that help an HIV positive person to manage their HIV disease. Data were collected from sites in Botswana, the US, and Puerto Rico. In the parent study, data were collected through focus group discussions with 135 people living with HIV, 32 HIV health care providers (HCPs), and 39 HIV professional care team members (PCTMs). SPSS was used to analyze quantitative data while ATLAS.ti was used to analyze qualitative data. The findings from analyses of the perspectives of HCPs/PCTMs suggested that linguistic and cultural factors were important themes in the exchange of HIV information between health care providers and PLHIV. These themes included ineffective communication, health seeking behavior, cultural facilitators, and complementary and alternative/traditional healing methods. Thus, this study suggests that language and culture have a major role in health literacy for PLHIV.

The intersection of intimate partner violence and HIV in U.S. women: a review.

The purposes of this study were to (a) review original research in the United States on the intersection of HIV risk and intimate partner violence (IPV) in women, and (b) identify trends that promote nursing and public health prevention and intervention strategies. Twenty-three original, peer-reviewed articles in the medical literature from 2008 to April 2012 were reviewed. Articles were eligible for inclusion if they addressed both HIV and IPV in women. Studies identified relationships between intimate partner victimization and HIV risk behaviors. Other factors compounding the complex relationship between IPV and increased HIV risk in women included sexual decision-making, male behavior, and substance use. A promising trend was found in the publication of studies addressing interventions. Prospective studies are needed to determine causality and temporal associations. Nursing interventions should focus on identifying women at risk for IPV, assessing HIV exposure risks, and providing culturally sensitive interventions and preventive measures.

Predictors of medication adherence among HIV-positive women in North America.

OBJECTIVE: To explore the relationships among contextual, environmental, and regulatory factors with antiretroviral (ARV) medication adherence to assist care providers in improving care for women living with HIV. DESIGN: Descriptive, multicenter study. SETTING: Sixteen HIV clinics and service organizations in North America. PARTICIPANTS: This convenience sample was drawn from a larger study of 2,182 persons living with HIV recruited from clinics and service from September 2009 to January 2011. We included 383 women living with HIV who were taking ARV medications. METHODS: We assessed the relationship of contextual, environmental, and psychological factors specific to women living with HIV in relation to adherence to ARV medication. Descriptive and multivariate statistics were used to examine the effects of these factors on self-reported ARV drug adherence. RESULTS: Age, depression symptoms, stigma, engagement with health care provider, and four psychological factors were correlated with self-reported ARV medication adherence (p = .01). Regression analysis indicated that adherence self-efficacy and depression symptoms accounted for 19% for 3-day and 22% for 30-day self-reported medication adherence. CONCLUSIONS: Adherence self-efficacy and depression symptoms predict ARV medication adherence in women and should be evaluated by nurses. Future research is needed to identify antecedents to and interventions that support adherence self-efficacy and decrease depression symptoms.

Engagement with Health Care Providers Affects Self- Efficacy, Self-Esteem, Medication Adherence and Quality of Life in People Living with HIV.

The engagement of patients with their health care providers (HCP) improves patients' quality of life (QOL), adherence to antiretroviral therapy, and life satisfaction. Engagement with HCP includes access to HCP as needed, information sharing, involvement of client in decision making and self-care activities, respect and support of the HCP for the client's choices, and management of client concerns. This study compares country-level differences in patients' engagement with HCP and assesses statistical associations relative to adherence rates, self-efficacy, self-esteem, QOL, and symptom self-reporting by people living with HIV (PLHIV). A convenience sample of 2,182 PLHIV was enrolled in the United States, Canada, Puerto Rico, Namibia, and China. Cross-sectional data were collected between September 2009 and January 2011. Inclusion criteria were being at least 18 years of age, diagnosed with HIV, able to provide informed consent, and able to communicate in the local language with site researchers. In the HCP scale, a low score indicated greater provider engagement. Country comparisons showed that PLHIV in Namibia had the most HCP engagement (OR 2.80, p < 0.001) and that PLHIV in China had the least engagement (OR -7.03, p < 0.0001) compared to the PLHIV in the Western countries. Individuals having better HCP engagement showed better self-efficacy for adherence (t = -5.22, p < 0.0001), missed fewer medication doses (t = 1.92, p ≤ 0.05), had lower self-esteem ratings (t = 2.67, p < 0.01), fewer self-reported symptoms (t = 3.25, p < 0.0001), and better overall QOL physical condition (t = -3.39, p < 0.001). This study suggests that promoting engagement with the HCP is necessary to facilitate skills that help PLHIV manage their HIV. To improve ART adherence, HCPs should work on strategies to enhance self-efficacy and self-esteem, therefore, exhibiting fewer HIV-related symptoms and missing less medication doses to achieve better QOL.