Retention, adherence, and compliance: special needs of HIV-infected adolescent girls and young women

Storyboarding HIV Infected Young People's Adherence to Antiretroviral Therapy in Lower- to Upper Middle-Income Countries: A New-Materialist Qualitative Evidence Synthesis

Young people living with perinatal infections of Human Immunodeficiency Virus (YLPHIV) face a chronic disease, with treatment including adherence to lifelong antiretroviral treatment (ART). The aim of this QES was to explore adherence to ART for YLPHIV as an assemblage within the framework of the biopsychosocial model with a new materialist perspective. We searched up to November 2021 and followed the ENTREQ and Cochrane guidelines for QES. All screening, data extraction, and critical appraisal were done in duplicate. We analysed and interpreted the findings innovatively by creating images of meaning, a storyboard, and storylines. We then reported the findings in a first-person narrative story. We included 47 studies and identified 9 storylines. We found that treatment adherence has less to do with humans' preferences, motivations, needs, and dispositions and more to do with how bodies, viruses, things, ideas, institutions, environments, social processes, and social structures assemble. This QES highlights that adherence to ART for YLPHIV is a multisensorial experience in a multi-agentic world. Future research into rethinking the linear and casual inferences we are accustomed to in evidence-based health care is needed if we are to adopt multidisciplinary approaches to address pressing issues such as adherence to ART.

Attrition from HIV care among youth initiating ART in youth-only clinics compared with general primary healthcare clinics in Khayelitsha, South Africa: a matched propensity score analysis

INTRODUCTION

Youth living with HIV (YLWH) are less likely to initiate antiretroviral therapy (ART) and remain in care than older adults. It is important to identify effective strategies to address the needs of this growing population and prevent attrition from HIV care. Since 2008, two clinics have offered youth-targeted services exclusively to youth aged 12-25 in Khayelitsha, a high HIV-prevalence, low-income area in South Africa. We compared ART attrition among youth in these two clinics to youth in regular clinics in the same area.

METHODS

We conducted a propensity score matched cohort study of individuals aged 12-25 years initiating ART at eight primary care clinics in Khayelitsha between 1 January 2008 and 1 April 2018. We compared attrition, defined as death or loss to follow-up, between those attending two youth clinics and those attending general primary healthcare clinics, using Cox proportional hazards regression. Follow-up time began at ART initiation and ended at attrition, clinic transfer or dataset closure. We conducted sub-analyses of patients attending adherence clubs.

RESULTS

The distribution of age, sex and CD4 count at ART initiation was similar across Youth Clinic A (N = 1383), Youth Clinic B (N = 1299) and general clinics (N = 3056). Youth at youth clinics were more likely than those at general clinics to have initiated ART before August 2011 (Youth Clinic A: 16%, Youth Clinic B: 23% and general clinics: 11%). Youth clinics were protective against attrition: HR 0.81 (95% CI: 0.71-0.92) for Youth Clinic A and 0.85 (0.74-0.98) for Youth Clinic B, compared to general clinics. Youth Clinic A club patients had lower attrition after joining an adherence club than general clinic patients in adherence clubs (crude HR: 0.56, 95% CI: 0.32-0.96; adjusted HR: 0.48, 95% CI: 0.28-0.85), while Youth Clinic B showed no effect (crude HR: 0.83, 95% CI: 0.48-1.45; adjusted HR: 1.07, 95% CI: 0.60-1.90).

CONCLUSIONS

YLWH were more likely to be retained in ART care in two different youth-targeted clinics compared to general clinics in the same area. Our findings suggest that multiple approaches to making clinics more youth-friendly can contribute to improving retention in this important group.

Brief Report: Efficacy and Safety of Bictegravir/Emtricitabine/Tenofovir Alafenamide in Females Living With HIV: An Integrated Analysis of 5 Trials

BACKGROUND

We characterized the efficacy and safety of bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) in a broad population of pediatric/adolescent/adult/elderly females living with HIV (FWH).

SETTING

Integrated analysis.

METHODS

Available data from 5 trials were integrated. Week 48 virologic suppression (HIV-1 RNA <50 copies/mL), resistance, adverse events (AEs), and laboratory parameters were assessed.

RESULTS

Three hundred and seventy-three FWH [304 virologically suppressed; 69 antiretroviral therapy (ART)-naive] received B/F/TAF [data from comparator regimens available for 306 individuals (236 virologically suppressed and 70 ART-naive participants)]. Virologic suppression rates with B/F/TAF at week 48 were high regardless of age in participants virologically suppressed at baseline (≥95%) and in ART-naive participants (≥87%). Virologic suppression rates were similar in B/F/TAF and comparator regimens (both virologically suppressed and ART-naive groups). Treatment-emergent resistance was not detected in the B/F/TAF group. AEs considered related to study drugs were experienced by 9.2% (B/F/TAF) and 5.5% (comparator regimen) of virologically suppressed participants and 15.9% (B/F/TAF) and 31.4% (comparator regimen) of ART-naive participants. For virologically suppressed and ART-naive FWH combined, only 1 of the 373 B/F/TAF-treated and 2 of the 306 comparator-regimen participants discontinued because of AEs (none were bone/renal/hepatic AEs); grade 3/4 AEs were experienced by 5.1% (B/F/TAF) and 7.8% (comparator regimen); and grade 3/4 elevation of low-density lipoprotein/total cholesterol occurred in 2.7%/0.3% (B/F/TAF) and 5.9%/2.0% (comparator regimen). At week 48, median changes from baseline estimated glomerular filtration rate in adults were <5 mL/min; results were similar in B/F/TAF and comparator-regimen groups.

CONCLUSION

B/F/TAF treatment was effective and well tolerated over 48 weeks, confirming B/F/TAF as an option for a broad population of FWH.

Usage activity, perceived usefulness, and satisfaction in a web-based acceptance and commitment therapy program among Finnish ninth-grade adolescents

Understanding adolescent usage activity and experiences in web-based psychological intervention programs helps in developing universal programs that can be adopted for promotion of adolescent well-being and prevention of mental health problems. This study examined the usage activity, perceived usefulness (i.e., learning of mindfulness, acceptance and value-related skills), and program satisfaction of 157 Finnish ninth-grade adolescents, who participated in a school-based five-week universal acceptance and commitment therapy web intervention called Youth Compass. Individual and growth environment-related antecedents were measured before the five-week intervention, adolescents' usage activity during the intervention, and perceived usefulness and satisfaction after the intervention. The results showed that female adolescents and adolescents with high self-regulation were more active program users and had more positive experiences of the program. Most of the adolescents used the program on at least a moderate level and perceived it to be moderately or highly useful and satisfactory. Four subgroups of adolescents were identified based on their usage activity, perceived usefulness, and satisfaction: adolescents in the satisfied group (41%) had average activity and high perceived usefulness and intervention satisfaction, the dissatisfied group (18%) had low activity and very low perceived usefulness and intervention satisfaction, the active group (8%) had very high activity and average perceived usefulness and intervention satisfaction, and the moderate group (33%) had average activity, perceived usefulness and intervention satisfaction. Gender, academic achievement, closeness to mother and teacher, and conflict with teacher were significantly related to subgroup membership. The results suggested that adolescent usage activity, perceived usefulness, and satisfaction with the Youth Compass program may to some extent be predicted based on different factors.

"Growing up and growing old with HIV": HIV+ adolescents' experiences of disclosing statuses to romantic partners in Bulawayo, Zimbabwe

This article explores the experiences of HIV-positive adolescents disclosing their status to romantic partners in Bulawayo, Zimbabwe. Disclosure of HIV status continues to be one of the most pressing issues facing adolescents, especially those in relationships, yet health care workers have minimal tailored guidance on how to approach this except to encourage full disclosure. Motives for disclosure were: guilty conscience; legal and ethical obligations; preventing partners being infected; and supportive people, honesty and trust. Disclosure was done on a one-on-one basis in public spaces such as roadsides where the adolescents usually met, or in health care facilities through the help of health care workers, and through mobile phones using WhatsApp. Results revealed that disclosure was associated with negative and positive outcomes ranging from disruption of relationships, depression, breaches of confidential information and, in some instances, relationship and marriage assurance. However, results clearly showed that adolescents living with HIV struggle with disclosure because the process is complex and loaded with emotions and the outcomes can be unpredictable and difficult to handle. Optimism towards treatment, social support, rationalisation, and social comparison through attributing new meanings to the disease were employed to deal with negative outcomes of disclosure. Therefore, the development and implementation of evidence-based initiatives to raise awareness and train the youth to disclose is recommended. Through their experiences, we can learn what works well and what needs to be strengthened.

Viral suppression and viral rebound among young adults living with HIV in Canada

Describe the prevalence and covariates of viral suppression and subsequent rebound among younger (≤29 years old) compared with older adults.A retrospective clinical cohort study; eligibility criteria: documented HIV infection; resident of Canada; 18 years and over; first antiretroviral regimen comprised of at least 3 individual agents on or after January 1, 2000.Viral suppression and rebound were defined by at least 2 consecutive viral load measurements <50 or >50 HIV-1 RNA copies/mL, respectively, at least 30 days apart, in a 1-year period. Time to suppression and rebound were measured using the Kaplan-Meier method and Life Table estimates. Accelerated failure time models were used to determine factors independently associated with suppression and rebound.Younger adults experienced lower prevalence of viral suppression and shorter time to viral rebound compared with older adults. For younger adults, viral suppression was associated with being male and later era of combination antiretroviral initiation (cART) initiation. Viral rebound was associated with a history of injection drug use, Indigenous ancestry, baseline CD4 cell count >200, and initiating cART with a protease inhibitor (PI) containing regimen.The influence of age on viral suppression and rebound was modest for this cohort. Our analysis revealed that key covariates of viral suppression and rebound for young adults in Canada are similar to those of known importance to older adults. Women, people who use injection drugs, and people with Indigenous ancestry could be targeted by future health interventions.

Out of focus: tailoring the cascade of care to the needs of women living with HIV

Around half of the global adult HIV-positive population are women, yet historically women have been under-represented in clinical studies of antiretroviral therapy (ART) and there has been minimal exploration of gender-specific factors related to the response to and appropriateness of treatment choices in women living with HIV (WLWH). There are several key issues pertaining to the cascade of HIV care that make it important to differentiate WLWH from men living with HIV. Factors that are gender specific may impact on the status of WLWH, affecting access to diagnosis and treatment, optimal clinical management, ART outcomes, retention in care, and the overall long-term wellbeing of WLWH. In this review, we discuss the results of recently reported women-only clinical trials and highlight the key unmet needs of WLWH as they pertain to the cascade of HIV care across World Health Organization European Region countries. As significant knowledge gaps remain, the review identifies key areas where further research is required, in order to support improved management of WLWH and guide informed clinical decision-making, including addressing psychosocial factors as part of comprehensive care.

Social, Psychological and Health Concerns of People Living with HIV/AIDS in Mysore District, Karnataka

INTRODUCTION

One of the significant health and social problem the world facing today is Acquired immune deficiency syndrome (AiDS). The patients affected with HIV and their family may face various psychosocial problems during diagnosis and treatment due to the stigma associated with this disease.

AIM

The objective of the study was to identify social, psychological and health concerns of people living with HIV/AIDS (PLWHA) and its association with the demographic factors in Mysore District, Karnataka, India.

MATERIALS AND METHODS

A questionnaire based study was conducted among 194 participants in Mysore District, Karnataka state who were receiving care and support services. A 22-item questionnaire provided information regarding social, psychological and health concerns of PLWHA in Mysore district. A general linear regression model was used for assessing the predictors of social, psychological and health concerns.

RESULTS

The main social concern was that of "Fear of Losing a loved one" whereas the main psychological concern was "Too much worry", "No cure for AIDS" was the highly rated health concern. Males had more social, psychological and health concerns when compared to females but was not statistically significant. Employed people were having fewer psychological concerns when compared to unemployed people. Unemployed people were having fewer health concerns than employed people. For every unit increase in age there were fewer social and health concerns and both these findings were statistically significant.

CONCLUSION

PLWHA in the present study reported that they were concerned about social, psychological and health issues in spite of the fact they were attending counseling. Health care workers, including those in public health sector should be educated about the importance of these factors that influence the health of the population they are caring for.

Depression and HIV Serostatus Disclosure to Sexual Partners Among Newly HIV-Diagnosed Men Who Have Sex with Men

HIV disclosure to sexual partners facilitates joint decision-making and risk reduction strategies for safer sex behaviors, but disclosure may be impacted by depression symptoms. Disclosure is also associated with disclosure self-efficacy, which in turn may also be influenced by depressive symptoms. This study examined the relationship between depression and HIV disclosure to partners following diagnosis among men who have sex with men (MSM), mediated by disclosure self-efficacy. Newly HIV-diagnosed MSM (n=92) who reported sexual activity after diagnosis completed an assessment soon after diagnosis which measured depressive symptoms, and another assessment within 3 months of diagnosis that measured disclosure self-efficacy and disclosure. Over one-third of the sample reported elevated depressive symptoms soon after diagnosis and equal proportions (one-third each) disclosed to none, some, or all partners in the 3 months after diagnosis. Depressive symptoms were negatively associated with disclosure self-efficacy and disclosure to partners, while disclosure self-efficacy was positively associated with disclosure. Disclosure self-efficacy partially mediated the relationship between depression and disclosure, accounting for 33% of the total effect. These findings highlight the importance of addressing depression that follows diagnosis to enhance subsequent disclosure to sexual partners.

Disease disclosure, treatment adherence, and behavioural profile in a cohort of vertically acquired HIV-infected adolescents. NeuroCoRISpeS study

Advances in care and antiretroviral treatment, improved life expectancy and quality of life in children with perinatally-acquired human immunodeficiency virus (HIV) infection. There is increasing interest in the chronic effects of growing up with HIV. The aim of this study was to assess the psychosocial, emotional and behavioural functioning in a cohort of perinatally-acquired HIV-infected adolescents. Data were obtained through semi-structured interviews and the Strengths and Difficulties Questionnaire (SDQ) for emotional and behavioural disorders screening.

RESULTS

A total of 95 patients (58% women) were assessed with a median age of 15 years (11-19.1) and a median age at diagnosis of 1.7 years (0-12.2). The median CD4 count, at the inclusion, was 626 cells/mm(3) (132-998), with 34% (10-52%). Viral load was <50 copies/ml in 72% of patients. Eighty-one per cent knew their diagnosis and optimal adherence was achieved in 53%. Passive coping was reported in 58.4% of the adolescents. Only 7.7% of teenagers had a complete and adequate knowledge of their disease and only 18.2% had shared it with their friends. Six unwanted pregnancies occurred (11% of women). Most of them (90%) attended school but 60% had been held back one or more school years. Overall, SDQ scored a risk of behavioural and emotional problems in 24.5%. The report of behaviours associated with hyperactivity was high in 14.9% of the population and borderline in 18.1%. Adolescents with encephalopathy accounted for 44% of those whose total scores fell in either the abnormal and borderline ranges for emotional difficulties (p = .038).

CONCLUSION

Perinatally-acquired HIV-infected adolescents showed significant psychosocial and behavioural health risks that should bring attention to prevention and health care programmes. An earlier disclosure to children could favour a better psychological adjustment and a better treatment adherence. Future studies are needed to assess the relationship between vertically acquired HIV-infection and hyperactivity.

Psychosocial challenges and strategies for coping with HIV among adolescents in Uganda: a qualitative study

Although more than 90% of youth perinatally infected with HIV live in sub-Saharan Africa, little is known about the psychosocial factors that impact their wellbeing, or how these youth cope with these challenges. The purpose of this study was to identify the psychosocial challenges and coping strategies among perinatal HIV-infected adolescents in Uganda. In-depth interviews were conducted with a purposive sample of 38 HIV-infected adolescents aged 12-19 years at a large HIV treatment center in Kampala. Data were analyzed thematically to identify themes and domains related to stressors and specific coping strategies. Psychosocial challenges included stigma/discrimination, relationship challenges such as HIV status disclosure, and medication difficulties. Coping strategies included medication adherence, concealment or limited disclosure of HIV status, treatment optimism, social support, rationalizing, social comparison, spirituality/religiosity, avoidance, and distraction. Age and gender differences also emerged: younger participants generally lacked specific coping strategies; compared to females, male adolescents reported greater use of avoidance/distraction techniques. Findings underscore the need to address stigma within homes and schools, and to equip adolescents with the comprehensive knowledge and skills to address their varied challenges.

"It is all about the fear of being discriminated [against]…the person suffering from HIV will not be accepted": a qualitative study exploring the reasons for loss to follow-up among HIV-positive youth in Kisumu, Kenya

BACKGROUND

Youth represent 40% of all new HIV infections in the world, 80% of which live in sub-Saharan Africa. Youth living with HIV (YLWH) are more likely to become lost to follow-up (LTFU) from care compared to all other age groups. This study explored the reasons for LTFU among YLWH in Kenya.

METHODS

Data was collected from: (1) Focus group Discussions (n = 18) with community health workers who work with LTFU youth. (2) Semi-structured interviews (n = 27) with HIV + youth (15-21 years old) that had not received HIV care for at least four months. (3) Semi-structured interviews (n = 10) with educators selected from schools attended by LTFU interview participants. Transcripts were coded and analyzed employing grounded theory.

RESULTS

HIV-related stigma was the overarching factor that led to LTFU among HIV + youth. Stigma operated on multiple levels to influence LTFU, including in the home/family, at school, and at the clinic. In all three settings, participants' fear of stigma due to disclosure of their HIV status contributed to LTFU. Likewise, in the three settings, the dependent relationships between youth and the key adult figures in their lives were also adversely impacted by stigma and resultant lack of disclosure. Thus, at all three settings stigma influenced fear of disclosure, which in turn impacted negatively on dependent relationships with adults on whom they rely (i.e. parents, teachers and clinicians) leading to LTFU.

CONCLUSIONS

Interventions focusing on reduction of stigma, increasing safe disclosure of HIV status, and improved dependent relationships may improve retention in care of YLWH.

Using online social media for recruitment of human immunodeficiency virus-positive participants: a cross-sectional survey

Background

There are many challenges in recruiting and engaging participants when conducting research, especially with HIV-positive individuals. Some of these challenges include geographical barriers, insufficient time and financial resources, and perceived HIV-related stigma.

Objective

This paper describes the methodology of a recruitment approach that capitalized on existing online social media venues and other Internet resources in an attempt to overcome some of these barriers to research recruitment and retention.

Methods

From May through August 2013, a campaign approach using a combination of online social media, non-financial incentives, and Web-based survey software was implemented to advertise, recruit, and retain participants, and collect data for a survey study with a limited budget.

Results

Approximately US $5,000 was spent with a research staff designated at 20% of full-time effort, yielding 2034 survey clicks, 1404 of which met the inclusion criteria and initiated the survey, for an average cost of US $3.56 per survey initiation. A total of 1221 individuals completed the survey, yielding 86.97% retention.

Conclusions

These data indicate that online recruitment is a feasible and efficient tool that can be further enhanced by sophisticated online data collection software and the addition of non-financial incentives.

Predictors of highly active antiretroviral therapy utilization for behaviorally HIV-1-infected youth: impact of adult versus pediatric clinical care site

OBJECTIVES

We evaluated highly active antiretroviral therapy (HAART) utilization in youth infected with HIV through risk behaviors who met treatment criteria for HAART. We assessed the impact of receiving care at an adult or pediatric HIV clinical site on initiation and discontinuation of the first HAART regimen in behaviorally infected youth (BIY).

METHODS

This was a retrospective analysis of treatment-naive BIY, aged 12-24 years, who enrolled in the HIV Research Network between 2002 and 2008 and who met criteria for HAART. The outcomes were time from meeting criteria to initiation of HAART and time to discontinuation of the first HAART regimen. Analyses were conducted using Cox proportional hazards regression.

RESULTS

Of 287 treatment-eligible youth, 198 (69%) received HAART; of these 198 youth, 58 (29.3%) subsequently discontinued HAART. In multivariable analyses, there was no significant difference in the time between meeting treatment criteria and initiating HAART for BIY followed at adult or pediatric HIV clinical sites. However, BIY followed at adult sites discontinued HAART sooner than BIY followed at pediatric HIV clinical sites (adjusted hazard ratio [AHR]: 3.19 [1.26-8.06]).

CONCLUSIONS

Two-thirds of treatment-eligible BIY in the HIV Research Network cohort initiated HAART; however, one-third who initiated HAART discontinued it during the study period. Identifying factors associated with earlier HAART initiation and sustainability can inform interventions to enhance HAART utilization among treatment-eligible youth. The finding of earlier HAART discontinuation for youth at adult care sites deserves further study.

[The sexuality of HIV-positive adolescents: rights and challenges for healthcare]

Sexuality and reproductive healthcare represent relevant issues for comprehensive care of HIV-positive adolescents. However, public policies and health services give this issue insufficient attention. The scope of this article is to assess how HIV-positive young people and teenagers cope with their sexuality, dating and the urge to have children and start a family. In a qualitative study, in-depth interviews were staged with 21 HIV-positive (contracted by vertical, sexual or intravenous transmission) teenagers and 13 caregivers of children and youths living in Sao Paulo and Santos. The interviews revealed the different ways teenagers cope with their sexuality and with the anxiety of HIV disclosure in this context. Lack of information about HIV prevention, lack of support and skills to cope with their sexuality were revealed in the reports. Furthermore, stigma and discrimination were the most frequently reported difficulties. The main challenges to be faced in Brazil in regard to this issue are discussed, especially the need to consider HIV-positive youth as entitled to sexual rights. Recommendations are also made for incorporating the issue into a humanized and comprehensive care approach for HIV-positive children and young people.

Strategies for promoting adherence to antiretroviral therapy: a review of the literature

The success of antiretroviral therapy (ART) for HIV infection, though widespread and resounding, has been limited by inadequate adherence to its unforgiving regimens, especially over the long term. This article summarizes the literature on behavioral interventions to promote ART adherence and highlights some of the most recent and innovative research on patient education and case management, modified directly observed therapy, contingency management, interventions emphasizing social support, and novel technologies to promote awareness. Research in the area of adherence in pediatric HIV infection and in resource-constrained international settings also is considered. Although adherence interventions have been successful in experimental trials, they may not be feasible or adaptable given the constraints of real-world clinics and community-based settings. Implementation and dissemination of adherence interventions needs increased attention as ART adherence research moves beyond its first decade. We conclude with suggestions for incorporating research findings into clinical practice.

We never thought this would happen: transitioning care of adolescents with perinatally acquired HIV infection from pediatrics to internal medicine

PURPOSE

Transitioning the medical care of children with perinatally acquired HIV from pediatric care to internal medicine practices has become increasingly important as newer therapies prolong survival. The study aims to describe challenges to caring for these adolescents and the potential barriers to transitioning them to internal medicine-based care.

METHODS

Qualitative study in which data were gathered from open-ended interviews conducted from November 2005 to April 2006 with 18 adolescents with HIV, 15 of their parents, and 9 pediatric health care providers from the Yale Pediatric AIDS Care Program, New Haven, Connecticut.

RESULTS

Issues of stigma played a prominent role in both the challenges to care and barriers to transitioning care. Challenges to care were: (1) poor adherence to medication regimens; (2) adolescent sexuality; and (3) disorganized social environments. Potential barriers to transitioning care were: (1) families' negative perceptions of and experiences with stigma of HIV disease - which undermined the desire to meet new providers; (2) perceived and actual lack of autonomy - pediatric providers feared that staff in adult clinics would demand a level of independence that adolescents did not have; and (3) difficulty letting go of relationships - adolescents, guardians, and providers described a familial relationship and expressed anxiety about terminating their relationships.

CONCLUSION

Understanding these challenges and barriers can inform both pediatric and adult HIV care providers and enable them to create successful transition programs, with the goal of improving retention and follow-up to care.

Case study: multisystemic therapy for adolescents who engage in HIV transmission risk behaviors

OBJECTIVE

To present a case study using multisystemic therapy (MST), an intensive family focused psychotherapy. For the clinical trial from which this case was drawn, MST was adapted to address multiple human immunodeficiency virus (HIV) transmission risk behaviors in HIV-infected youth. Targeted behaviors included medication nonadherence, risky sexual behaviors, and substance use.

METHOD

One young woman's transmission risk behaviors are described, followed by a description of the MST procedures used to identify and treat the primary drivers of these risk behaviors. Outcome measures were self-report, urine screens, and blood draws.

RESULTS

At discharge, the young woman showed significant improvements in medication adherence and related health status (e.g., reduced HIV viral load), healthier sexual behaviors, and reduced substance use. Importantly, neither her boyfriend nor her newborn tested positive for HIV.

CONCLUSIONS

Findings from this case study suggest that MST has the potential to reduce transmission risk behaviors among teens with HIV.

Predictors of attrition among high risk HIV-infected participants enrolled in a multi-site prevention trial

Retaining high-risk individuals is critical for HIV prevention trials. The current analyses examined predictors of trial dropout among HIV-infected men and women in a multi-site HIV prevention trial. Results indicated that dropouts (n = 74) were more likely to be younger, depressed, and not taking antiretroviral therapy (ART) than those who continued (n = 815). No other background, substance use, or transmission risk differences were found, suggesting no direct evidence of dropout bias on key outcomes. Efforts may be warranted for early detection and treatment of depression and for improving retention of younger participants and those not on ART.

Adherence to antiretroviral therapy for pediatric HIV infection: a qualitative systematic review with recommendations for research and clinical management

Although nonadherence to prescribed therapies is widespread, it is particularly problematic with highly active antiretroviral therapy for HIV infection. This review of >50 studies in the area of pediatric HIV infection revealed varying methods for assessing antiretroviral adherence with a wide range of estimates of adherence. Correlates of adherence could be grouped as those relating to the medication, the patient, and the caregiver/family, with many conflicting findings and a lack of theory guiding the research. Only 8 studies, mainly small feasibility or pilot investigations, evaluated highly active antiretroviral therapy adherence interventions in pediatric populations. We conclude with specific recommendations for assessment and clinical management of adherence and discuss directions for future research in this area.

How qualitative methods contribute to understanding combination antiretroviral therapy adherence

Strict adherence to medication regimens is generally required to obtain optimal response to combination antiretroviral therapy (ART). Yet, we have made limited progress in developing strategies to decrease the prevalence of nonadherence. As we work to understand adherence in developed countries, the introduction of ART in resource-poor settings raises novel challenges. Qualitative research is a scientific approach that uses methods such as observation, interviews, and verbal interactions to gather rich in-depth information about how something is experienced. It seeks to understand the beliefs, values, and processes underlying behavioral patterns. Qualitative methods provide powerful tools for understanding adherence. Culture-specific influences, medication beliefs, access, stigma, reasons for nonadherence, patterns of medication taking, and intervention fidelity and measurement development are areas ripe for qualitative inquiry. A disregard for the social and cultural context of adherence or the imposition of adherence models inconsistent with local values and practices is likely to produce irrelevant or ineffective interventions. Qualitative methods remain underused in adherence research. We review appropriate qualitative methods for and provide an overview of the qualitative research on ART nonadherence. We discuss the rationales for using qualitative methods, present 2 case examples illustrating their use, and discuss possible institutional barriers to their acceptance.

Social stigma concerns and HIV medication adherence

The threat of social stigma may prevent people living with HIV from revealing their status to others and serve as a barrier to HIV treatment adherence. We evaluated the effect of such concerns on self-reported treatment adherence using a short, three-item measure among 204 people living with HIV. Overall, the mean age of participants was 40.1 years, 45% were African American, and 80% were male. People with high HIV stigma concerns were 2.5 times less likely to define and interpret the meaning of CD4 count correctly and 3.3 times more likely to be nonadherent to their medication regimen than those with low concerns. Concern over revealing HIV status was the only statistically significant, independent predictor of adherence in multivariate analysis. Clinical care directed to individuals living with HIV should therefore include considerations for patient sensitivity to social stigma, such as modifications to medication schedules and referrals for counseling prior to enrollment in antiretroviral therapies.

Pediatric HIV adherence: an ever-evolving challenge

Providers working with children living with HIV strive to achieve "good adherence," often viewed only as consistent pill taking by the infected child. This goal, while important, needs to be expanded with a thorough examination of the many biopsychosocial factors impacting the HIV affected family. The complexity of the issues affecting adherence to a pediatric HIV medical regimen can overwhelm both the practitioner and the patient. By utilizing a developmental framework and emphasizing the critical importance of the relationship between provider, patient and family, the authors (both of whom are social workers who have worked over a period of many years with children and families living with terminal and serious chronic illnesses) describe a developmental approach that includes comprehensive assessment to address the multiple challenges faced by individuals and families they have worked with.

HIV in adolescents

Adolescence is a time of dramatic physical, emotional, cognitive, and social change that brings new vulnerabilities. Youth represent half of all new HIV infections in the United States and the rest of the world. The number of newly infected adolescents who acquire the disease behaviorally and the number of perinatally infected children surviving into adolescence have both contributed to this growth. This article reviews the most recent epidemiology of HIV/AIDS in adolescents, gives guidance on clinical practice, including medical and psychosocial care, and examines prevention issues, including counseling and testing, which are needed to make programs effective for youth.

Youths and HIV/AIDS: psychiatry's role in a changing epidemic

OBJECTIVE

To review the past 10 years of published research on human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in the United States, including psychosocial and psychiatric risk factors, epidemiology, biology, neurocognitive and psychiatric sequelae, disclosure issues, prevention strategies, and biological and behavioral treatments.

METHOD

Researchers reviewed the English-language literature with a focus on child and adolescent risk factors associated with HIV/AIDS, prevention, and treatment.

RESULTS

Substantial scientific advances have occurred over the past two decades leading to decreased morbidity and mortality in the United States from AIDS-related opportunistic infections. At the same time, rates of HIV infection are increasing in teenagers, young women, and minorities, and growing numbers of youths are living with an infected family member. Understanding HIV risk behavior requires a broad theoretical framework. Comprehensive HIV prevention programs have led to reduced risk behavior among HIV-affected youths and teens at risk of infection. Biological and behavioral treatments of HIV infection continue to evolve and have led to longer life span, improved quality of life, and fewer psychiatric problems.

CONCLUSIONS

HIV/AIDS has significant mental health implications, and psychiatry can play a critical role in curbing the epidemic. With minimal effort, mental health professionals can adapt and apply the strategies that they use to treat psychiatric symptoms to prevent HIV transmission behaviors.