Great Expectations: HIV Risk Behaviors and Misperceptions of Low HIV Risk among Incarcerated Men.

Incarcerated populations have relatively high HIV prevalence but little has been reported about their aggregate HIV risk behaviors or perceptions of risk. A random selection of HIV-negative men (n = 855) entering a US state prison system were surveyed to assess five risk behaviors and his self-perceived HIV risk. Using multivariate logistic regression, we identified factors associated with having elevated actual but low perceived risk (EALPR). Of the 826 men with complete data, 88% were at elevated risk. While 64% of the sample had risk perceptions concordant with their actual risk, 14% had EALPR (with the remainder at low actual but high perceived risk). EALPR rates were lower in those with a pre-incarceration HIV test but higher for those with a negative prison entry HIV test. HIV testing counseling should assess for discordance between actual and perceived risk and communicate the continued risk of HIV despite a negative result.

Feasibility and acceptability of a web-based HIV/STD prevention program for adolescent girls targeting sexual communication skills.

Adolescent girls are at substantial risk of sexually transmitted diseases including HIV. To reduce these risks, we developed Health Education And Relationship Training (HEART), a web-based intervention focused on developing sexual assertiveness skills and enhancing sexual decision-making. This study assessed the feasibility and acceptability of this new program and examined if perceived acceptability varied according to participant ethnicity, sexual orientation or sexual activity status. Participants were part of a randomized controlled trial of 222 10th-grade girls (Mage = 15.26). The current analyses included those in the intervention condition (n = 107; 36% white, 27% black and 29% Hispanic). HEART took approximately 45 min to complete and was feasible to administer in a school-based setting. Participants found the program highly acceptable: 95% liked the program and learned from the program, 88% would recommend the program to a friend and 94% plan to use what they learned in the future. The primary acceptability results did not vary by the ethnicity, sexual orientation or sexual activity status of participants, suggesting broad appeal. Results indicate that this new online program is a promising method to reach and engage adolescents in sexual health education.

On the front line of HIV virological monitoring: barriers and facilitators from a provider perspective in resource-limited settings.

Scale-up of viral load (VL) monitoring for HIV-infected patients on antiretroviral therapy (ART) is a priority in many resource-limited settings, and ART providers are critical to effective program implementation. We explored provider-perceived barriers and facilitators of VL monitoring. We interviewed all providers (n = 17) engaged in a public health evaluation of dried blood spots for VL monitoring at five ART clinics in Malawi. All ART clinics were housed within district hospitals. We grouped themes at patient, provider, facility, system, and policy levels. Providers emphasized their desire for improved ART monitoring strategies, and frustration in response to restrictive policies for determining which patients were eligible to receive VL monitoring. Although many providers pled for expansion of monitoring to include all persons on ART, regardless of time on ART, the most salient provider-perceived barrier to VL monitoring implementation was the pressure of work associated with monitoring activities. The work burden was exacerbated by inefficient data management systems, highlighting a critical interaction between provider-, facility-, and system-level factors. Lack of integration between laboratory and clinical systems complicated the process for alerting providers when results were available, and these communication gaps were intensified by poor facility connectivity. Centralized second-line ART distribution was also noted as a barrier: providers reported that the time and expenses required for patients to collect second-line ART frequently obstructed referral. However, provider empowerment emerged as an unexpected facilitator of VL monitoring. For many providers, this was the first time they used an objective marker of ART response to guide clinical management. Providers' knowledge of a patient's virological status increased confidence in adherence counseling and clinical decision-making. Results from our study provide unique insight into provider perceptions of VL monitoring and indicate the importance of policies responsive to individual and environmental challenges of VL monitoring program implementation. Findings may inform scale-up by helping policy-makers identify strategies to improve feasibility and sustainability of VL monitoring.

STI/HIV Sexual Risk Behavior and Prevalent STI Among Incarcerated African American Men in Committed Partnerships: The Significance of Poverty, Mood Disorders, and Substance Use.

African Americans face disproportionate sexually transmitted infection including HIV (STI/HIV), with those passing through a correctional facility at heightened risk. There is a need to identify modifiable STI/HIV risk factors among incarcerated African Americans. Project DISRUPT is a cohort study of incarcerated African American men recruited from September 2011 through January 2014 from prisons in North Carolina who were in committed partnerships with women at prison entry (N = 207). During the baseline (in-prison) study visit, participants responded to a risk behavior survey and provided a urine specimen, which was tested for STIs. Substantial proportions reported multiple partnerships (42 %), concurrent partnerships (33 %), and buying sex (11 %) in the 6 months before incarceration, and 9 % tested positive for an STI at baseline (chlamydia: 5.3 %, gonorrhea: 0.5 %, trichomoniasis: 4.9 %). Poverty and depression appeared to be strongly associated with sexual risk behaviors. Substance use was linked to prevalent STI, with binge drinking the strongest independent risk factor (adjusted odds ratio: 3.79, 95 % CI 1.19-12.04). There is a continued need for improved prison-based STI testing, treatment, and prevention education as well as mental health and substance use diagnosis.

Sexual Behaviors of US Women at Risk of HIV Acquisition: A Longitudinal Analysis of Findings from HPTN 064.

We describe the sexual behaviors of women at elevated risk of HIV acquisition who reside in areas of high HIV prevalence and poverty in the US. Participants in HPTN 064, a prospective HIV incidence study, provided information about individual sexual behaviors and male sexual partners in the past 6 months at baseline, 6- and 12-months. Independent predictors of consistent or increased temporal patterns for three high-risk sexual behaviors were assessed separately: exchange sex, unprotected anal intercourse (UAI) and concurrent partnerships. The baseline prevalence of each behavior was >30 % among the 2,099 participants, 88 % reported partner(s) with >1 HIV risk characteristic and both individual and partner risk characteristics decreased over time. Less than high school education and food insecurity predicted consistent/increased engagement in exchange sex and UAI, and partner's concurrency predicted participant concurrency. Our results demonstrate how interpersonal and social factors may influence sustained high-risk behavior by individuals and suggest that further study of the economic issues related to HIV risk could inform future prevention interventions.

Adherence to PEG/ribavirin treatment for chronic hepatitis C: prevalence, patterns, and predictors of missed doses and nonpersistence.

Adherence to treatment for hepatitis C virus (HCV) maximizes treatment efficacy. Missed doses and failing to persist on treatment are two patient-level processes that are rarely defined or analysed separately from other factors affecting treatment adherence. We evaluated the prevalence and patterns of missed doses and nonpersistence, and identified patient characteristics associated with these outcomes. Missed doses of ribavirin (RBV) and peginterferon (PEG), measured prospectively in Virahep-C using electronic monitoring technology, were analysed using generalized estimating equations. Cox proportional hazards models analysed time to nonpersistence from baseline to week 24 (N = 401) and from week 24 to 48 in Responders (N = 242). Average proportion of PEG- and RBV-missed doses increased over time from 5% to 15% and 7% to 27%, respectively. Patients who were younger, African-American, unemployed, or unmarried were at greater risk of missing PEG from week 0 to 24; higher baseline depression predicted missing PEG from weeks 24 to 48. Patients who were younger or African-American were more likely to miss daily RBV from weeks 0 to 24; and those without private insurance or employment were more likely to miss RBV from weeks 24 to 48. Fifty-two patients failed to persist on treatment for patient-driven deviations. Predictors of nonpersistence from weeks 0 to 24 included younger age, lower education, public or no insurance, or worse baseline headaches. In conclusion, electronic monitoring and the prospective Virahep-C design afforded a unique opportunity to evaluate missing doses and nonpersistence separately, and identify patients at risk of nonadherence. These processes will be important to investigate as the dosing schedules of antiviral regimens become increasingly complex.

Association between use of specific drugs and antiretroviral adherence: findings from MACH 14.

To determine the association between individual substances of abuse and antiretroviral adherence, analyses require a large sample assessed using electronic data monitoring (EDM). In this analysis, EDM data from 1,636 participants in 12 US adherence-focused studies were analyzed to determine the associations between recent use of various substances and adherence during the preceding 4 weeks. In bivariate analyses comparing adherence among patients who had used a specific substance to those who had not, adherence was significantly lower among those who had recently used cocaine, other stimulants or heroin but not among those who had used cannabis or alcohol. In multivariate analyses controlling for sociodemographics, amount of alcohol use and recent use of any alcohol, cocaine, other stimulants and heroin each was significantly negatively associated with adherence. The significant associations of cocaine, other stimulants, heroin, and alcohol use with adherence suggest that these are important substances to target with adherence-focused interventions.

Psychometric properties of the PROMIS short form measures in a U.S. cohort of 961 patients with chronic hepatitis C prescribed direct acting antiviral therapy.

BACKGROUND: To better understand symptoms experienced by patients infected with chronic hepatitis C virus (HCV), valid and reliable patient-reported outcome (PRO) measures are needed. AIM: To assess the reliability and validity of 10 patient-reported outcomes measurement information system (PROMIS) measures and the Headache Impact Test-6 (HIT-6) in a large national sample of patients with HCV. METHODS: Pre-treatment data from 961 patients with HCV starting direct acting antiviral therapy at 11 U.S. liver centers were analyzed. Internal reliability was evaluated using Cronbach's alpha coefficient; frequency distributions were examined for floor and ceiling effects; structural validity was investigated via item-response-theory models; convergent validity was evaluated using correlations with theoretically-similar items from the HCV-PRO and memorial symptom assessment scale (MSAS); and known-groups validity was investigated by observing PRO differences by liver disease status and number of comorbidities. RESULTS: The HIT-6 and the majority of the PROMIS measures yielded excellent reliability (alphas ≥ 0.87). Ceiling effects were infrequent ( < 4%), while 30%-59% of patients reported no symptoms (floor effects). The data supported structural validity of the HIT-6 and most PROMIS measures. The PROMIS measures showed moderate to strong correlations with theoretically-similar items from the HCV-PRO and MSAS (0.39-0.77). Trends were observed between worse PRO scores and advanced cirrhosis and greater number of comorbidities, lending support for known-groups validity. CONCLUSIONS: The psychometric properties of the HIT-6 and PROMIS measures performed satisfactorily in this large cohort of patients with HCV starting direct acting antiviral therapy. Opportunities exist for further refinement of these PROs. Evaluation of performance over time and in under-represented subgroups is needed.

The role of patient participation in the doctor visit. Implications for adherence to diabetes care.

For patients, treatment of diabetes involves complex changes in basic behaviors and adherence to complicated regimens. Understanding the factors that enable patients to adhere to diabetes treatment is the first step to designing effective interventions. Researchers of diabetes care have postulated that increasing diabetic patients' participation in medical decision making during the doctor visit is likely to improve their adherence to self-care. However, a critical review of the impact of patient participation on diabetic patients adherence to self-care is absent from the literature. We review the subject of patient participation in medical decision making and its effect on adherence to self-care for patients with diabetes. We introduce a model of the determinants of adherence to diabetes self-care that incorporates the effects of patient participation in medical decision making. In this model, we suggest three ways that patient participation can affect adherence to self-care: 1) it may have a direct effect; 2) it may affect adherence to self-care indirectly by affecting patients' understanding of their treatment regimen or the fit of their regimen with their lifestyle; and 3) perceived omissions of participation can affect adherence to self-care indirectly through an effect on patient satisfaction. Research is needed to identify more clearly which components of patient participation affect adherence to self-care and in what ways. Distinguishing patient and physician behaviors that contribute to the process of patient participation would provide a means to develop specific behavioral interventions.

A prospective study of patient-physician communication about resuscitation.

OBJECTIVE: To evaluate prospectively seriously ill patients' characteristics, perceptions, and preferences associated with discussing resuscitation (CPR) with their physicians. DESIGN: Prospective cohort. SETTING: Five academic medical centers. PARTICIPANTS: Patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments who had not communicated with their physicians about CPR at admission to a hospital for life-threatening illness (n = 1288). MEASUREMENTS: Baseline surveys of patients' characteristics, health status, desires for participation in medical decision making, and cardiopulmonary resuscitation. Two month follow-up surveys of patients' communication of resuscitation preference. Chart reviews for clinical indicators. RESULTS: Thirty percent of patients communicated their resuscitation preference to their physician during a 2 month-period following hospital admission. Patients whose preference was to forego CPR (odds ratio (OR) 2.9;(95% CI, 1.9-4.2)) and whose preference had changed from desiring to foregoing CPR (OR 1.6; (95% CI, 1.1-2.4)) were more likely to communicate their preference than patients who continued to prefer to receive CPR. However, only 50% of patients who maintained a preference to forego CPR communicated this over a 2-month period. Having an advance directive and remaining in the hospital at 2-month follow-up were also independently associated with communication, whereas patients' preference for participation in decision-making, health status, and prognostic estimate were not. CONCLUSIONS: Communication about resuscitation preferences occurred infrequently after hospital admission for a serious illness, even among patients wishing to forego resuscitation. Factors such as declining quality of life, which were expected to be associated with communication, were not. An invitation to communicate about CPR preference is important after hospital admission for a serious illness. Novel approaches are needed to promote physician-patient discussions about resuscitation.

A diabetes-specific measure of patient desire to participate in medical decision making.

PURPOSE: The goal of this study was to develop a diabetes-specific scale of patient desire to participate in medical decision making (DPMD) and examine its internal consistency reliability, stability, and validity (content, discriminant, convergent, and construct). METHODS: In a cross-sectional study, 65 patients with type 2 diabetes from a teaching hospital's general medical clinic were interviewed at baseline and 2 weeks later to measure their DPMD scores. Data were collected on demographic/clinical features, health value, social support, desire to make a final decision, and value of patient autonomy. RESULTS: Of the 11 DPMD items, 2 distinct factors emerged representing desire for discussion and desire for information. The DPMD scale had high internal consistency reliability, was stable over 2 weeks and demonstrated good content validity. DPMD scale items were more correlated with each other than with health value or social support. Overall, patients who obtained diabetes education reported greater desire to participate in decisions. Younger patients had a greater overall desire for discussion. The DPMD desire for discussion subscale correlated with patients' desire to make the final treatment decision but not with patients' value of autonomy. CONCLUSIONS: The DPMD is a brief, reliable, valid measure for assessing patient desire to participate in diabetes medical decision making.

Adaptation of a U.S. evidence-based Positive Prevention intervention for youth living with HIV/AIDS in Kinshasa, Democratic Republic of the Congo.

Effective HIV prevention programs for people living with HIV/AIDS (PLWH) are important to reduce new infections and to ensure PLWH remain healthy. This paper describes the systematic adaptation of a U.S.-developed Evidence Based Intervention (EBI) using the Centers for Disease Control and Prevention (CDC) Map of Adaption Process for use at a Pediatric Hospital in Kinshasa, Democratic Republic of the Congo (DRC). The adapted intervention, Supporting Youth and Motivating Positive Action or SYMPA, a six-session risk reduction intervention targeted for youth living with HIV/AIDS (YLWH) in Kinshasa was adapted from the Healthy Living Project and guided by the Social Action Theory. This paper describes the process of implementing the first four steps of the ADAPT framework (Assess, Select, Prepare, and Pilot). Our study has shown that an EBI developed and implemented in the U.S. can be adapted successfully for a different target population in a low-resource context through an iterative process following the CDC ADAPT framework. This process included reviewing existing literature, adapting and adding components, and focusing on increasing staff capacity. This paper provides a rare, detailed description of the adaptation process and may aid organizations seeking to adapt and implement HIV prevention EBIs in sub-Saharan Africa and beyond.

Feasibility Analysis of an evidence-based positive prevention intervention for youth living with HIV/AIDS in Kinshasa, Democratic Republic of the Congo.

We evaluated the feasibility of a Positive Prevention intervention adapted for youth living with HIV/AIDS (YLWH) ages 15-24 in Kinshasa, Democratic Republic of the Congo. We conducted in-depth interviews and focus group discussions with intervention facilitators and YLWH participants on the following four areas of a feasibility framework: acceptability, implementation, adaptation, and limited-efficacy. The adapted intervention was suitable, satisfying, and attractive to program facilitators and participants and able to be implemented effectively. It performed well with a new population and showed preliminary efficacy. However, we identified certain aspects of the intervention that must be addressed prior to wider implementation such as: (1) including more content on navigating marriage while living with HIV and disclosure; (2) adjusting intervention timing and session length; and (3) simplifying the more complicated content. An adapted evidencebased intervention was found to be feasible and lessons learned can be applied to YLWH in other low-resource settings.

Barriers to Provider-Delivered Sexual Behavior Counseling for Youth Living with HIV/AIDS in the Democratic Republic of the Congo.

AIMS: The study aimed to understand providers' role in delivering HIV transmission prevention counseling to youth living with HIV (YLWH). METHODS: We conducted 14 in-depth interviews with providers in Kinshasa, DRC. RESULTS: Providers' lack of knowledge and comfort in talking to youth about sex because of cultural and religious beliefs about sexuality, coupled with confusion about legal issues related to youth and contraception, made it difficult for them to effectively counsel youth. IMPLICATIONS FOR PRACTICE AND POLICY: In order for providers to deliver effective prevention counseling to YLWH, clinics should follow adolescent-friendly clinic standards, provide counseling in an adolescent-friendly style, and institute an effective referral system for additional prevention services. CONCLUSION: HIV prevention services can be improved through the creation of an adolescent-friendly environment and by providing "values clarification" and skill-based trainings so that providers are able to assess the role of their own beliefs and learn new skills.

Barriers to accessing HIV/AIDS care in North Carolina: rural and urban differences.

Many HIV-positive individuals face multiple barriers to care and therefore frequently experience unmet medical and support services needs. Rural areas often lack the infrastructure to support the delivery of comprehensive HIV services; however, few studies have examined service barriers faced by rural residents with HIV/AIDS, particularly in the South where two-thirds of people living with HIV/AIDS in rural areas reside. We surveyed North Carolina HIV/AIDS case managers (N = 111) employed at state-certified agencies regarding barriers to medical and support services that influence medication adherence for their rural and urban-living clients. For each of the seven barriers assessed (long travel for care, HIV-related stigma, and a lack of transportation; HIV-trained medical practitioners; housing; mental health services and substance abuse treatment), a substantial proportion of case managers (29-67%) reported it was a 'major problem'. For five of the seven barriers, rural case managers were significantly more likely to identify the barrier as a 'major problem'. Multivariate analysis revealed that rural case managers and case managers with more female clients reported a greater number of barriers. Because unmet medical and support service needs may result in poorer outcomes for HIV-positive individuals, barriers to these services must be identified and addressed, particularly in rural areas which may be highly underserved.

A comparison study of multiple measures of adherence to HIV protease inhibitors.

BACKGROUND: Poor adherence to HIV protease inhibitors may compromise the effectiveness of treatment. Few studies have compared methods for measuring adherence or have related adherence measures to a clinical outcome. OBJECTIVE: To examine the relationship among a composite score of adherence, the three primary measures of adherence, and HIV virologic response. DESIGN: Longitudinal cohort study. SETTING: Public HIV clinic. PATIENTS: 108 HIV-infected adults receiving protease inhibitors or non-nucleoside reverse transcriptase inhibitors who were monitored for 666 monthly intervals. MEASUREMENTS: Medication Event Monitoring System (MEMS), pill count, and interview combined into a composite adherence score (CAS), and HIV viral load. RESULTS: Mean antiretroviral adherence differed by adherence measure (MEMS, 0.63; pill count, 0.83; interview, 0.93; and CAS, 0.76). Composite adherence score decreased significantly over time. Composite adherence score, MEMS values, pill values, and interview values were statistically significantly associated with achievement of an undetectable viral load within 6 months of initiating therapy. Composite adherence score showed the strongest predictive relationship (odds ratios for a 10% increase in adherence for CAS, MEMS, pill count, and interview, respectively, were 1.26 [95% CI, 1.16 to 1.37], 1.13 [CI, 1.06 to 1.21], 1.10 [CI, 1.02 to 1.19], and 1.35 [CI, 0.94 to 1.94]). CONCLUSIONS: Different measures applied to the same patient suggest different levels of adherence. Adherence may be underestimated by MEMS and overestimated by pill count and interview. A summary measure combining several measures is more strongly related to a clinical response, but more practical measurement methods are needed for clinical use.