Articles tagged as "People living with HIV"

The hope and reality of injecting drug use among people living with HIV in Ukraine

Attitudes toward addiction, methadone treatment, and recovery among HIV-infected Ukrainian prisoners who inject drugs: incarceration effects and exploration of mediators.  

Polonsky M, Rozanova J, Azbel L, Bachireddy C, Izenberg J, Kiriazova T, Dvoryak S, Altice FL. AIDS Behav. 2016 Dec;20(12):2950-2960.

In this study, we use data from a survey conducted in Ukraine among 196 HIV-infected people who inject drugs, to explore attitudes toward drug addiction and methadone maintenance therapy (MMT), and intentions to change drug use during incarceration and after release from prison. Two groups were recruited: Group 1 (n = 99) was currently incarcerated and Group 2 (n = 97) had been recently released from prison. This paper's key finding is that MMT treatment and addiction recovery were predominantly viewed as mutually exclusive processes. Group comparisons showed that participants in Group 1 (pre-release) exhibited higher optimism about changing their drug use, were less likely to endorse methadone, and reported higher intention to recover from their addiction. Group 2 participants (post-release), however, reported higher rates of HIV stigma. Structural equation modeling revealed that in both groups, optimism about recovery and awareness of addiction mediated the effect of drug addiction severity on intentions to recover from their addiction.

Abstract access 

Editor’s notes: Despite reductions in HIV incidence and mortality globally, the epidemic in Ukraine remains volatile and continues to expand, especially among people who inject drugs.  People who inject drugs account for more than 40% of people living with HIV.  At 20%, HIV prevalence among Ukrainian people living in prisons is the highest in Europe, with drug injection of opioids being the major driver of transmission. This is due to a concentration of people who inject drugs among prisoners and other incarcerated people, especially people living with HIV. Programmes focusing on prisoners and other incrcerated people may play a central role in HIV prevention since nearly all of them transition back to the community. Opioid agonist therapies including methadone maintenance therapy have been shown to have many benefits including reducing HIV transmission by over 50% among people who inject drugs.  Despite these benefits, moral biases, stigma and ideological prejudices are barriers to opioid agonist therapies scale-up globally including in Ukraine.  Opioid agonist therapies are available free of charge through national and external Global Fund support. However, scale up of opioid agonist therapies and treatment retention in Ukraine have been low, with only about 2.7% of people who inject drugs enrolled. This has constrained HIV prevention efforts.  Adoption of opioid agonist therapies has been especially slow among criminal justice populations. This study compares attitudes towards opioid agonist therapies among currently and previously incarcerated opioid-dependent people living with HIV in Ukraine.

The study uses data from a survey of people living with HIV conducted in Ukraine to explore attitudes to methadone treatment and intentions to change drug use behaviour before and after release from prison.

This study has important implications for future management of people who inject drugs who are living with HIV.  While staff attitudes may undermine the successful opioid agonist therapies delivery in prisons, the findings of this study suggest that prisoners and other incarcerated people are important foci for programmes that should be done in parallel with staff-based activities. The findings also suggest that optimism about recovery while in prison is falsely elevated. This may contribute to individual inability to comprehend addiction as a chronic relapsing condition, which in the absence of treatment, results in 85% relapsing within 12 months of release. Future programmes should take advantage of individuals’ sobriety while in prison and cultivate their ability to recognise the cycle of addiction and incarceration. This optimism should also be channelled to focus on evidence-based programmes, e.g., methadone maintenance therapy that has been associated with reduced illicit drug relapse, HIV risk-taking and reincarceration. Considerable health marketing work also needs to be done to focus on negative attitudes and prejudices about methadone maintenance therapy at both individual and societal level. This would importantly involve rebranding methadone maintenance therapy as a medical treatment for a chronic relapsing condition.

Europe
Ukraine
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The Affordable Care Act at work – increasing health care access for people living with HIV in California

Implementation and operational research: affordable care act implementation in a California health care system leads to growth in HIV-positive patient enrollment and changes in patient characteristics.

Satre DD, Altschuler A, Parthasarathy S, Silverberg MJ, Volberding P, Campbell CI. J Acquir Immune Defic Syndr. 2016 Dec 15;73(5):e76-e82.

Objectives: This study examined implementation of the Affordable Care Act (ACA) in relation to HIV-positive patient enrollment in an integrated health care system; as well as changes in new enrollee characteristics, benefit structure, and health care utilization after key ACA provisions went into effect in 2014.

Methods: This mixed-methods study was set in Kaiser Permanente Northern California (KPNC). Qualitative interviews with 29 KPNC leaders explored planning for ACA implementation. Quantitative analyses compared newly enrolled HIV-positive patients in KPNC between January and December 2012 ("pre-ACA," N = 661) with newly enrolled HIV-positive patients between January and December 2014 ("post-ACA," N = 880) on demographics; medical, psychiatric, and substance use disorder diagnoses; HIV clinical indicators; and type of health care utilization.

Results: Interviews found that ACA preparation focused on enrollment growth, staffing, competition among health plans, concern about cost sharing, and HIV pre-exposure prophylaxis (PrEP) services. Quantitative analyses found that post-ACA HIV-positive patient enrollment grew. New enrollees in 2014 were more likely than 2012 enrollees to be enrolled in high-deductible plans (P < 0.01) or through Medicaid (P < 0.01), and marginally more likely to have better HIV viral control (P < 0.10). They also were more likely to be diagnosed with asthma (P < 0.01) or substance use disorders (P < 0.05) and to have used primary care health services in the 6 months postenrollment (P < 0.05) than the pre-ACA cohort.

Conclusions: As anticipated by KPNC interviewees, ACA implementation was followed by HIV-positive patient enrollment growth and changing benefit structures and patient characteristics. Although HIV viral control improved, comorbid diagnosis findings reinforced the importance of coordinated health care.

Abstract access  

Editor’s notes: This paper provides a very useful assessment of the Affordable Care Act (ACA) (commonly called ‘Obama-Care’) coverage for people living with HIV in part of California. As the authors note, a goal of the Affordable Care Act was to increase health-care coverage for people with chronic conditions. They also note that before the implementation of the ACA, many people living with HIV lacked health-care insurance covering HIV-medications and HIV medical care. It has the potential to make a difference to people with chronic conditions. The ACA has removed exclusions for insurance access, like pre-existing conditions. It has also removed caps on costs and provides financial support for health care premiums. 

As anticipated by the authors, the passing of the ACA had provided greater access to care for people living with HIV. However, challenges exist in supporting people living with HIV who have co-morbidities. The authors note that people living with HIV in need of psychiatric care, or because of substance use, were not always reached. This is partly because people do not come forward for care.  The authors suggest that integrated care where HIV-care is provided with support for other chronic conditions can help reach more people to come forward.

At a time of change in the United States, this paper is timely in highlighting the value of the Affordable Care Act for people living with HIV.  

Northern America
United States of America
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Adolescents’ concerns: psychosocial needs of young people living with HIV in Thailand

Psychosocial needs of perinatally HIV-infected youths in Thailand: lessons learnt from instructive counseling.

Manaboriboon B, Lolekha R, Chokephaibulkit K, Leowsrisook P, Naiwatanakul T, Tarugsa J, Durier Y, Aunjit N, Punpanich Vandepitte W, Boon-Yasidhi V. AIDS Care. 2016 Dec;28(12):1615-1622. Epub 2016 Jun 26.

Identifying psychosocial needs of perinatally HIV-infected (pHIV) youth is a key step in ensuring good mental health care. We report psychosocial needs of pHIV youth identified using the "Youth Counseling Needs Survey" (YCS) and during individual counseling (IC) sessions. pHIV youth receiving care at two tertiary-care hospitals in Bangkok or at an orphanage in Lopburi province were invited to participate IC sessions. The youths' psychosocial needs were assessed using instructive IC sessions in four main areas: general health, reproductive health, mood, and psychosocial concerns. Prior to the IC session youth were asked to complete the YCS in which their concerns in the four areas were investigated. Issues identified from the YCS and the IC sessions were compared. During October 2010-July 2011, 150 (68.2%) of 220 eligible youths participated in the IC sessions and completed the YCS. Median age was 14 (range 11-18) years and 92 (61.3%) were female. Mean duration of the IC sessions was 36.5 minutes. One-hundred and thirty (86.7%) youths reported having at least one psychosocial problem discovered by either the IC session or the YCS. The most common problems identified during the IC session were poor health attitude and self-care (48.0%), lack of life skills (44.0%), lack of communication skills (40.0%), poor antiretroviral (ARV) adherence (38.7%), and low self-value (34.7%). The most common problems identified by the YCS were lack of communication skills (21.3%), poor health attitude and self-care (14.0%), and poor ARV adherence (12.7%). Youth were less likely to report psychosocial problems in the YCS than in the IC session. Common psychosocial needs among HIV-infected youth were issues about life skills, communication skills, knowledge on self-care, ARV adherence, and self-value. YCS can identify pHIV youths' psychosocial needs but might underestimate issues. Regular IC sessions are useful to detect problems and provide opportunities for counseling.

Abstract access  

Editor’s notes: The study reports on the psychological needs of young people who acquired HIV in the perinatal period.  The needs were highlighted during counselling sessions and in a survey conducted as part of the Happy-Teen Programme in Thailand. Young people (age 11-18) who have perinatally acquired HIV were recruited in two hospitals and from a service run by an orphanage linked to one of the hospitals. Young people took part in two individual ‘instructive counselling’ sessions, and two survey sessions for a needs-assessment questionnaire. Participants reported higher levels of needs in the counselling sessions compared to the questionnaire. Key areas of need identified included: health attitudes and self-care (e.g., diet, sleep, drug use); issues with sexual risk and difficulties communicating with sexual partners; HIV treatment adherence problems; concerns about HIV-associated stigma; and concerns about peer pressure. The study illustrates the difference in the quality of findings obtained from data collected via the questionnaire in comparison with data collected via sessions with counsellors. The counsellors were people that the young people knew for some time and trusted. The study highlights the importance of counselling with young people to improve self-esteem and health-associated behaviours.  Counsellors are also important to provide referrals for more severe mental health issues. 

Asia
Thailand
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Dolutegravir in the real world – more intolerance than first thought?

Intolerance of dolutegravir-containing combination antiretroviral therapy regimens in real-life clinical practice.

de Boer MG, van den Berk GE, van Holten N, Oryszcyn JE, Dorama W, Moha DA, Brinkman K. AIDS. 2016 Nov 28;30(18):2831-2834.

Objective: Dolutegravir (DGV) is one of the preferred antiretroviral agents in first-line combination antiretroviral therapy (cART). Though considered to be a well tolerated drug, we aimed to determine the actual rate, timing and detailed motivation of stopping DGV in a real-life clinical setting.

Design: A cohort study including all patients who started DGV in two HIV treatment centers in The Netherlands.

Methods: All cART-naive and cART-experienced patients who had started DGV were identified from the institutional HIV databases. Clinical data, including motivation and timing of discontinuation of DGV, were extracted from the patient files. Factors that potentially influenced discontinuation of DGV were compared between patients who stopped or continued DGV by multivariate and Kaplan-Meier analyses.

Results: In total, 556 patients were included, of whom 102 (18.4%) were cART-naive at initiation of DGV. Median follow-up time was 225 days. Overall, in 85 patients (15.3%), DGV was stopped. In 76 patients (13.7%), this was due to intolerability. Insomnia and sleep disturbance (5.6%), gastrointestinal complaints (4.3%) and neuropsychiatric symptoms such as anxiety, psychosis and depression (4.3%) were the predominant reasons for switching DGV. In regimens that included abacavir, DGV was switched more frequently (adjusted relative risk 1.92, 95% confidence interval 1.09-3.38, P log-rank 0.01). No virologic failures were observed.

Conclusion: A relatively high rate of preliminary discontinuation of DGV due to intolerability was detected in our patient population. In particular, DGV was stopped more frequently if the regimen included abacavir. Multiple factors may explain these unexpected postmarketing observations, which warrant further investigation.

Abstract access  

Editor’s notes: The integrase inhibitor dolutegravir has been billed as a very important milestone in the treatment of HIV. Randomized controlled trials reported that not only was it a highly effective antiviral agent, but it also had a high barrier to resistance. Trial data also suggested an excellent safety profile. Trial participants experienced fewer side effects with dolutegravir use compared to many other drugs. For these reasons, dolutegravir is recommended as one of the preferred options for first-line treatment in European and United States treatment guidelines. In addition, it is increasingly becoming a key component in global efforts to expand access to HIV-positive people in low-income countries.

However, with increased use of dolutegravir beyond clinical trials, evidence is growing to suggest that the incidence of side effects is greater than trial data would predict. This study describes the two-year experience of a cohort spanning two medical centres in the Netherlands. It explores the rate and cause of discontinuation of dolutegravir-containing regimes in both antiretroviral therapy naïve and experienced individuals. Of 556 receiving a dolutegravir-containing regimen, just over 15% stopped its use over two years. Adverse effects were cited as the cause in a sizeable 13%. These rates of discontinuation are over five times higher than was reported from clinical trials. The predominant side effects were sleep disturbance and insomnia. Other reactions included gastrointestinal disturbances, anxiety, depression and general malaise. In terms of factors associated with increased risk of discontinuation, only the concomitant use of abacavir was identified.

These results do not detract from the importance of dolutegravir as an antiretroviral agent. Indeed, it is reassuring that in this cohort no virologic failure occurred as result of its discontinuation. The results instead highlight the need for caution concerning recommendations for dolutegravir as a universal first line agent until further data are accrued from real-world experience.

Europe
Netherlands
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Comparing different methods to measure HIV incidence in a sub-Saharan African population

Estimating HIV incidence using a cross-sectional survey: comparison of three approaches in a hyperendemic setting, Ndhiwa sub-county, Kenya, 2012.

Blaizot S, Kim AA, Zeh C, Riche B, Maman D, DeCock K, Etard JF, Ecochard R. AIDS Res Hum Retroviruses. 2016 Dec 13. [Epub ahead of print]

Objectives: Estimating HIV incidence is critical for identifying groups at risk for HIV infection, planning and targeting interventions, and evaluating these interventions over time. The use of reliable estimation methods for HIV incidence is thus of high importance. The aim of this study was to compare methods for estimating HIV incidence in a population-based cross-sectional survey.

Design/methods: The incidence estimation methods evaluated included assay-derived methods, a testing history-derived method, and a probability-based method applied to data from the Ndhiwa HIV Impact in Population Survey (NHIPS). Incidence rates by sex and age and cumulative incidence as a function of age were presented.

Results: HIV incidence ranged from 1.38 [95% confidence interval (CI) 0.67-2.09] to 3.30 [95% CI 2.78-3.82] per 100 persons-years overall; 0.59 [95% CI 0.00-1.34] to 2.89 [95% CI 0.11-5.68] in men; and 1.62 [95% CI 0.16-6.04] to 4.03 [95% CI 3.30-4.77] per 100 persons-years in women. Women had higher incidence rates than men for all methods. Incidence rates were highest among women aged 15-24 and 25-34 years and highest among men aged 25-34 years.

Conclusion: Comparison of different methods showed variations in incidence estimates, but they were in agreement to identify most-at-risk groups. The use and comparison of several distinct approaches for estimating incidence are important to provide the best-supported estimate of HIV incidence in the population.

Abstract access

Editor’s notes: The estimation of HIV incidence is important both for planning effective HIV prevention strategies, and also to provide a proximal measure of changes in HIV epidemics both in general populations and in higher risk sub-groups. Further development of methods for accurately measuring HIV incidence that can be applied in routine monitoring settings is necessary.

This study compares three assay-based incidence estimation methods with approaches using self-reported testing history and a probabilistic technique on age and sex stratified sero-prevalence data. Two of the assays, BioRad and Lag, use antibody markers and a recent infection testing algorithm (RITA). The BioRad assay allowed for a longer time window for detection post-infection than the Lag. Recent infections were reclassified using results from HIV viral load tests and self-reported ART use, as appropriate. The other assay detected trace levels of HIV RNA in HIV seronegative individuals. The results for the two RITA assays were very similar at 1.38 [95% CI 0.67 – 2.09] infections per 100 person years (PY) for the BioRad and 1.46 [95% CI 0.71 – 2.22] per 100 PY for Lag. Combining these with HIV-RNA results led to small increases in each incidence estimate. The results for the probability-based incidence assays were very close to those derived from the combination of the RITA and HIV-RNA assays. However, the testing history-derived approach estimated incidence as almost double that from the other methods and this is likely to be in large part due to reporting/recall bias.

Despite the limitations of the methods, it was possible to identify population sub-groups defined by age and sex at higher risk of HIV infection. 

Africa
Kenya
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Rape and ARV uptake/adherence

Impact of sexual trauma on HIV care engagement: perspectives of female patients with trauma histories in Cape Town, South Africa.

Watt MH, Dennis AC, Choi KW, Ciya N, Joska JA, Robertson C, Sikkema KJ. AIDS Behav. 2016 Nov 19. [Epub ahead of print]

South African women have disproportionately high rates of both sexual trauma and HIV. To understand how sexual trauma impacts HIV care engagement, we conducted in-depth qualitative interviews with 15 HIV-infected women with sexual trauma histories, recruited from a public clinic in Cape Town. Interviews explored trauma narratives, coping behaviors and care engagement, and transcripts were analyzed using a constant comparison method. Participants reported multiple and complex traumas across their lifetimes. Sexual trauma hindered HIV care engagement, especially immediately following HIV diagnosis, and there were indications that sexual trauma may interfere with future care engagement, via traumatic stress symptoms including avoidance. Disclosure of sexual trauma was limited; no woman had disclosed to an HIV provider. Routine screening for sexual trauma in HIV care settings may help to identify individuals at risk of poor care engagement. Efficacious treatments are needed to address the psychological and behavioral sequelae of trauma.

Abstract access  

Editor’s notes: Few studies have examined the impact of violence exposure on ART uptake and adherence. There is also a paucity of studies from low- and middle-income countries. South African women face a dual burden of HIV and violence risk, especially in areas characterized by extreme poverty, substance abuse and gender inequality. This study used qualitative interviews with 15 women living with HIV with histories of sexual trauma and attending an HIV-treatment clinic. The authors explore the intersections between sexual trauma experience, HIV infection and engagement with HIV care services.

Women reported complex sexual trauma histories, with repeated abuse from childhood into adulthood. This abuse was usually from family members or ‘lovers’. Sexual violence was usually accompanied by physical and emotional abuse. Women described symptoms of post-traumatic stress disorder and depression. Many associated their HIV infection with their sexual trauma / abusive relationship(s). For some, the HIV diagnosis and taking treatment reminded them of their rape and triggered feelings of shame. Women described their sexual violence experience as more stressful and shameful than their HIV status. None had disclosed their trauma history to their HIV care provider. The findings from this study suggest that women with a sexual trauma history may have poorer uptake and adherence to ARVs than women without. Additional research is necessary in low- and middle-income countries to explore this further. There is insufficient support and counselling services for women who have experienced sexual trauma and other abuse. Implementing such services may relieve symptoms of post-traumatic stress disorder and depression and support ART uptake and adherence. 

Africa
South Africa
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Disbelief, stigma, ‘strong blood’ and inevitability affect seroconversion among HIV serodiscordant couples in Uganda

'People say that we are already dead much as we can still walk': a qualitative investigation of community and couples' understanding of HIV serodiscordance in rural Uganda.

Kim J, Nanfuka M, Moore D, Shafic M, Nyonyitono M, Birungi J, Galenda F, King R. BMC Infect Dis. 2016 Nov 10;16(1):665.

Background: Stable, co-habiting HIV serodiscordant couples are a key population in terms of heterosexual transmission in sub-Saharan Africa. Despite the wide availability of antiretroviral treatment and HIV educational programs, heterosexual transmission continues to drive the HIV epidemic in Africa. To investigate some of the factors involved in transmission or maintenance of serodiscordant status, we designed a study to examine participants' understanding of HIV serodiscordance and the implications this posed for their HIV prevention practices.

Methods: In-depth interviews were conducted with 28 serodiscordant couples enrolled in a treatment-as-prevention study in Jinja, Uganda. Participants were asked questions regarding sexual behaviour, beliefs in treatment and prevention, participants' and communities' understanding and context around HIV serodiscordance. Qualitative framework analysis capturing several main themes was carried out by a team of four members, and was cross-checked for consistency.

Results: It was found that most couples had difficulty explaining the phenomenon of serodiscordance and tended to be confused regarding prevention. Many individuals still held beliefs in pseudoscientific explanations for HIV susceptibility such as blood type and blood "strength". The participants' trust of treatment and medical services were well established. However, the communities' views of both serodiscordance and treatment were more pessimistic and wrought with mistrust. Stigmatization of serodiscordance and HIV-positive status were reported frequently.

Conclusions: The results indicate that despite years of treatment and prevention methods being available, stigmatization and mistrust persist in the communities of HIV-affected individuals and may directly contribute to new cases and seroconversion. We suggest that to optimize the effects of HIV treatment and prevention, clear education and support of such methods are sorely needed in sub-Saharan African communities.

Abstract  Full-text [free] access 

Editor’s notes: Expanded access to antiretroviral treatment has significantly reduced HIV-associated mortality. It has also contributed to reduced HIV incidence including in the most highly affected region of sub-Saharan Africa. Most new infections in this region are due to heterosexual transmission, with transmission within HIV serodiscordant couples in marriage or cohabitation thought to account for most new infections. This qualitative study explores the perceptions of members of HIV serodiscordant couples in terms of their understanding of serodiscordance or eventual seroconversion. The authors also explore how this understanding affects their sexual behaviour and adherence to antiretroviral therapy (for people living with HIV).

This sub-study was part of the Highly Active Antiretroviral therapy as Prevention (HAARP) study of treatment as prevention (TasP) among serodiscordant couples. In-depth interviews were conducted between June 2013 and August 2014.  All couples were initially serodiscordant upon recruitment into treatment. Over the course of the study, 14 HIV seronegative participants seroconverted. These individuals and their partners were selected for the sub-study and gender-matched to control subjects who were HIV seropositive participants whose partners did not seroconvert during the study.

The results of the HPTN 052 trial demonstrated a 96% reduction in HIV transmission within serodisordant couples associated with early use of antiretroviral therapy.  In this rural Ugandan setting, the phenomenon of serodiscordance remains poorly understood by people affected by it and the communities surrounding them. Despite extensive education campaigns and communication about HIV prevention various factors affect understanding of serodiscordance. Medication, confusion, mistrust, stigma, and a resulting sense of inevitability may negatively affect couples’ understanding and belief in the phenomenon of serodiscordance. For a variety of reasons, some serodisordant couples also report lack of consistent condom use. This is of particular concern where abstinence has proved to be an unachievable option for many couples. Improved education regarding serodiscordance and ART treatment will be required to address heterosexual transmission and ensure the maintenance of serodiscordance in affected couples.

Africa
Uganda
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‘I wish I could have a life like others’: mental health challenges for young people living with HIV in Tanzania

A qualitative exploration of the mental health and psychosocial contexts of HIV-positive adolescents in Tanzania.

Ramaiya MK, Sullivan KA, K OD, Cunningham CK, Shayo AM, Mmbaga BT, Dow DE. PLoS One. 2016 Nov 16;11(11):e0165936. doi: 10.1371/journal.pone.0165936. eCollection 2016.

Although 85% of HIV-positive adolescents reside in sub-Saharan Africa, little is known about the psychosocial and mental health factors affecting their daily well-being. Identifying these contextual variables is key to development of culturally appropriate and effective interventions for this understudied and high-risk population. The purpose of this study was to identify salient psychosocial and mental health challenges confronted by HIV-positive youth in a resource-poor Tanzanian setting. A total of 24 qualitative interviews were conducted with a convenience sample of adolescents aged 12-24 receiving outpatient HIV care at a medical center in Moshi, Tanzania. All interviews were audio-recorded, transcribed, and coded using thematic analysis. Psychosocial challenges identified included loss of one or more parents, chronic domestic abuse, financial stressors restricting access to medical care and education, and high levels of internalized and community stigma among peers and other social contacts. Over half of youth (56%) reported difficulties coming to terms with their HIV diagnosis and espoused related feelings of self-blame. These findings highlight the urgent need to develop culturally proficient programs aimed at helping adolescents cope with these manifold challenges. Results from this study guided the development of Sauti ya Vijana (The Voice of Youth), a 10-session group mental health intervention designed to address the psychosocial and mental health needs of HIV-positive Tanzanian youth.

Abstract  Full-text [free] access 

Editor’s notes: This article presents the findings of a mixed-methods study with young people living with HIV and accessing care in Moshi, Tanzania. The study was conducted as part of a larger study assessing mental health needs in this population. The article reports on themes from individual qualitative interviews with 24 young people (aged 13-23) who had mental health difficulties that were previously assessed with the scales used in the larger project. Young people reported a wide range of psychosocial issues leading to ongoing mental health challenges.  These were challenges for which they had received little or no psychological support. Issues included internalized, feared and experienced HIV stigma, loss and bereavement from being orphaned.  Additional challenges were stress from poverty and insecurity in the household, isolation and difficulties with disclosure of their HIV status, and direct and vicarious experiences of violence and abuse. Young people also discussed finding strength in spirituality, friendships and especially peer-support from other young people living with HIV. Findings from the overall study are being used to inform the development of a mental health activity model that, if effective, could be scaled up in other low-income settings. 

Africa
United Republic of Tanzania
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Longitudinal HIV viral load measures give insights into disease burden and transmission risk in the USA

Durable viral suppression and transmission risk potential among persons with diagnosed HIV infection: United States, 2012-2013.

Crepaz N, Tang T, Marks G, Mugavero MJ, Espinoza L, Hall HI. Clin Infect Dis. 2016 Oct 1;63(7):976-83. doi: 10.1093/cid/ciw418. Epub 2016 Jun 29.

Background: We examined durable viral suppression, cumulative viral load (VL) burden, and transmission risk potential among human immunodeficiency virus (HIV)-diagnosed persons in care.

Methods: Using data from the National HIV Surveillance System from 17 jurisdictions with complete reporting of VL test results, we determined the percentage of persons in HIV care who achieved durable viral suppression (all VL results <200 copies/mL) and examined viremia copy-years and time spent above VL levels that increase the risk of HIV transmission during 2012-2013.

Results: Of 265 264 persons in HIV care in 2011, 238 641 had at least 2 VLs in 2012-2013. The median number of VLs per individual during the 2-year period was 5. Approximately 62% had durable viral suppression. The remaining 38% had high VL burden (geometric mean of viremia copy-years, 7261) and spent an average of 438 days, 316 days, and 215 days (60%, 43.2%, and 29.5% of the 2-year period) above 200, 1500, and 10 000 copies/mL. Women, blacks/African Americans, Hispanics/Latinos, persons with HIV infection attributed to transmission other than male-to-male sexual contact, younger age groups, and persons with gaps in care had higher viral burden and transmission risk potential.

Conclusions: Two-thirds of persons in HIV care had durable viral suppression during a 2-year period. One-third had high VL burden and spent substantial time above VL levels with increased risk of onward transmission. More intervention efforts are needed to improve retention in care and medication adherence so that more persons in HIV care achieve durable viral suppression.

Abstract access  

Editor’s notes: Virologic suppression is the ultimate goal of HIV care. It determines health outcomes and transmission risk. Most analyses assess viral suppression by considering a single viral load measure. However, adherence to antiretroviral therapy and engagement in HIV care are often not straightforward, but rather complex and dynamic. People living with HIV may transition in and out of treatment and care throughout their lifetime. Therefore, a single undetectable viral load may not equate to true virologic suppression in an individual, but rather only a snapshot. This has the potential for an inaccurate picture of HIV burden and transmission risk in a population.

Within this study, researchers used the longitudinal measures of durable viral suppression, viraemia copy years and time without viral load suppression to assess disease burden and HIV transmission risk in the United States of America. The analysis involved people ages 13 years or older diagnosed with HIV before 2011 and in care in one of 17 jurisdictions that reported complete CD4 and viral load data to the Centers for Disease Control and Prevention’s National HIV Surveillance System. Everyone had at least one viral load test in 2011 and at least two between 2012-2013, and all were alive at the end of 2013.

Of the 251 649 persons included, two thirds had durable viral suppression with all viral load values being <200 copies/mL over the two-year period. Of note, during the same time period an additional 20% (total 83%) of the cohort had a suppressed viral load on their latest test. This would have potentially underestimated disease burden if analysed in isolation. The remaining one-third, without durable viral suppression, had high plasma burden and spent substantial time without virologic suppression, increasing the risk of HIV transmission.  As would be expected, the percentages of persons with durable viral suppression were lower among people with gaps in care. Disparities in disease burden and transmission risk potential were seen in several other subgroups.

The use of longitudinal measures broadens insight into disease burden and transmission risk in this population. Of further interest would have been people that had no evidence of being in care in 2011 but had an unsuppressed viral load between 2012-13, thus contributing to the population disease burden. These people were unfortunately not included in the analyses but may increase overall population transmission risk over the two years.

The findings underscore the recognised need for focused care and treatment efforts to address these disparities in virologic suppression and improve retention in care in the United States of America. The study also encourages the use of longitudinal markers in informing public health planning and resource allocation.

Northern America
United States of America
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Improving programmes: a thematic synthesis of qualitative studies of treatment adherence programmes

Barriers and facilitators of interventions for improving antiretroviral therapy adherence: a systematic review of global qualitative evidence.

Ma Q, Tso LS, Rich ZC, Hall BJ, Beanland R, Li H, Lackey M, Hu F, Cai W, Doherty M, Tucker JD. J Int AIDS Soc. 2016 Oct 17;19(1):21166. doi: 10.7448/IAS.19.1.21166. eCollection 2016.

Introduction: Qualitative research on antiretroviral therapy (ART) adherence interventions can provide a deeper understanding of intervention facilitators and barriers. This systematic review aims to synthesize qualitative evidence of interventions for improving ART adherence and to inform patient-centred policymaking.

Methods: We searched 19 databases to identify studies presenting primary qualitative data on the experiences, attitudes and acceptability of interventions to improve ART adherence among PLHIV and treatment providers. We used thematic synthesis to synthesize qualitative evidence and the CERQual (Confidence in the Evidence from Reviews of Qualitative Research) approach to assess the confidence of review findings.

Results: Of 2982 references identified, a total of 31 studies from 17 countries were included. Twelve studies were conducted in high-income countries, 13 in middle-income countries and six in low-income countries. Study populations focused on adults living with HIV (21 studies, n=1025), children living with HIV (two studies, n=46), adolescents living with HIV (four studies, n=70) and pregnant women living with HIV (one study, n=79). Twenty-three studies examined PLHIV perspectives and 13 studies examined healthcare provider perspectives. We identified six themes related to types of interventions, including task shifting, education, mobile phone text messaging, directly observed therapy, medical professional outreach and complex interventions. We also identified five cross-cutting themes, including strengthening social relationships, ensuring confidentiality, empowerment of PLHIV, compensation and integrating religious beliefs into interventions. Our qualitative evidence suggests that strengthening PLHIV social relationships, PLHIV empowerment and developing culturally appropriate interventions may facilitate adherence interventions. Our study indicates that potential barriers are inadequate training and compensation for lay health workers and inadvertent disclosure of serostatus by participating in the intervention.

Conclusions: Our study evaluated adherence interventions based on qualitative data from PLHIV and health providers. The study underlines the importance of incorporating social and cultural factors into the design and implementation of interventions. Further qualitative research is needed to evaluate ART adherence interventions.

Abstract  Full-text [free] access 

Editor’s notes: This is a review of studies using qualitative methods to explore the experiences of people living with HIV and healthcare providers involved in programmes to support antiretroviral treatment adherence. The thematic synthesis is presented in two ways. First, the reviewed studies are categorised by types of adherence programmes, such as task shifting, education, or directly observed therapy. Secondly, the authors present themes that are common across all reviewed studies. These include: the benefits and challenges of employing lay healthcare workers; the need to maintain confidentiality in adherence programmes; the benefits of supporting empowerment and social relationships for people living with HIV; and the need for culturally appropriate information and practice. Overall the review illustrates that adherence programmes can have more impact if they address confidentiality, strengthen social ties among people living with HIV and their communities; provide adequate compensation and training for lay healthcare workers; and sensitively reflect local social, cultural and religious norms and beliefs. 

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