Injecting drug users' adherence to HIV antiretroviral treatments: physicians' beliefs

Do I care for you more when you really need help? An experimental test of the effect of clinical urgency on compassion in health care

OBJECTIVES

To experimentally investigate whether more urgent patient presentations elicit greater compassion from health care professionals than less urgent, facilitating future research and thinking to address systemic barriers to compassion in health care.

DESIGN

This is a pre-registered online study with an experimental, within-subjects repeated-measure study design. Two clinical vignettes that systematically varied the urgency of patient presentation were utilized. Both vignettes depicted a patient with difficult behaviours typically associated with lower compassion.

METHODS

Health care professionals (doctors, nurses and allied health practitioners) recruited from all 20 District Health Boards across Aotearoa/New Zealand completed two vignettes in a counterbalanced order. Paired-sample t-tests were used to test the effect of the presentation urgency on indices of compassion.

RESULTS

A total of 939 participants completed the vignettes (20% doctors, 47%, nurses and 33% allied health professionals). As expected, participants reported greater care and motivation to help the more urgent patient. However, the more urgent patient was also perceived as less difficult, and exploratory analyses showed that perceived patient difficulty was associated with lower caring and motivation to help, particularly in the less urgent patient.

CONCLUSIONS

This is the first work to experimentally test the relationship between the urgency of patient presentation and compassion in health care. Although the association between urgency and difficulty is complex, our findings are consonant with evolutionary views in which urgent distress elicits greater compassion. A system-wide orientation towards efficiency and urgency may exacerbate this 'bias' which must be addressed to ensure more equitable compassion in health care.

Human Immunodeficiency Virus Infection-Associated Cardiomyopathy and Heart Failure

The landscape of human immunodeficiency virus (HIV) epidemiology and treatment is ever-changing, with the widespread and evolving use of antiretroviral therapy (ART). With timely ART, people living with HIV (PLWH) are nearing the life expectancies and the functionality of the general population; nevertheless, the effects of HIV and ART on cardiovascular health remain under investigation. The pathophysiology of HIV-related cardiomyopathy and heart failure (HF) have historically been attributed to systemic inflammation and changes in cardiometabolic function and cardiovascular architecture. Importantly, newer evidence suggests that ART also plays a role in modulating the process of HIV-related cardiomyopathy and HF. In the short term, newer highly active ART (HAART) seems to have cardioprotective effects; however, emerging data on the long-term cardiovascular outcomes of certain HAART medications, i.e., protease inhibitors, raise concerns about the potential adverse effects of these drugs in the clinical course of HIV-related HF. As such, the traditional phenotypes of dilated cardiomyopathy and left ventricular systolic failure that are associated with HIV-related heart disease are incrementally being replaced with increasing rates of diastolic dysfunction and ischemic heart disease. Moreover, recent studies have found important links between HIV-related HF and other clinical and biochemical entities, including depression, which further complicate cardiac care for PLWH. Considering these trends in the era of ART, the traditional paradigms of HIV-related cardiomyopathy and HF are being called into question, as is the therapeutic role of interventions such as ventricular assist devices and heart transplantation. In all, the mechanisms of HIV-related myocardial damage and the optimal approaches to the prevention and the treatment of cardiomyopathy and HF in PLWH remain under investigation.

Incidence, Predictors, and Outcomes of Implantable Cardioverter-Defibrillator Discharge Among People Living With HIV

Background

People living with HIV (PHIV) are at an increased risk for sudden cardiac death, and implantable cardioverter‐defibrillators (ICDs) prevent SCD. There are no data on the incidence, predictors, and effects of ICD therapies among PHIV.

Methods and Results

We compared ICD discharge rates between 59 PHIV and 267 uninfected controls. For PHIV, we tested the association of traditional cardiovascular risk factors and HIV‐specific parameters with an ICD discharge and then tested whether an ICD discharge among PHIV was associated with cardiovascular mortality or an admission for heart failure. The indication for ICD insertion was similar among groups. Compared with controls, PHIV with an ICD were more likely to have coronary artery disease and to use cocaine. In follow‐up, PHIV had a higher ICD discharge rate (39% versus 20%; P=0.001; median follow‐up period, 19 months). Among PHIV, cocaine use, coronary artery disease, QRS duration, and higher New York Heart Association class were associated with an ICD discharge. An ICD discharge had a prognostic effect, with a subsequent 1.7‐fold increase in heart failure admission and a 2‐fold increase in cardiovascular mortality, an effect consistent across racial/ethnic and sex categories.

Conclusions

ICD discharge rates are higher among PHIV compared with uninfected controls. Among PHIV, cocaine use and New York Heart Association class are associated with increased ICD discharge, and an ICD discharge is associated with a subsequent increase in admission for heart failure and cardiovascular mortality.

Cardiomyopathy and Heart Failure in Patients With HIV Infection

With the advent and widespread use of antiretroviral therapy (ART), the epidemiology of cardiomyopathy and heart failure (HF) associated with HIV infection is changing. Near-normal life expectancy in contemporary HIV-infected populations has been associated with prolonged exposure to increased cardiometabolic burden and chronic immune activation and systemic inflammation. Therefore, the pre-ART phenotype of HIV-associated cardiomyopathy with overt left ventricular systolic dysfunction and poor prognosis has been replaced over time by cardiomyopathy with a more insidious course, more frequent ischemic background, and highly prevalent left ventricular diastolic dysfunction. Patients with HIV are more prone to development of coronary artery disease and development of HF after myocardial infarction. The role of ongoing immune activation and systemic inflammation, despite highly active ART (HAART), appears to be central in this process. The role of HAART toxicity is controversial, as HAART itself appears to be protective for the development of HF, but recent data suggest that protease inhibitors might adversely affect the course of HIV-associated HF. Because of these unique features, the optimal therapeutic approach for HIV-associated cardiomyopathy remains unknown. The current therapeutic approaches are an extrapolation from noninfected populations. Importantly, the significance of the highly prevalent diastolic abnormalities among HIV-infected patients is not known. Therefore, further research is needed to identify its prognostic implications. Considering the prevalence of structural and functional cardiac abnormalities in HIV-infected persons and the lack of evidence on how to best screen and treat these patients, systematic research on this topic is a public health priority.

What makes decision-making difficult for oncologists faced with critical situations? The socio-affective side of the physician-patient relationship

The aim of this qualitative study based on a Social Representations approach was to explore experienced oncologists' representations of difficult decision-making situations. In total, 22 semi-structured interviews with oncologists were conducted and analysed by performing a thematic content analysis. The thematic content analysis brought to light the main medical problem involved such as uncertainty, the lethal nature of cancer and physicians' specialties, as well as the psychosocial ones, such as patients' non-medical characteristics and the patient-physician relationships. This analysis also showed the painful tensions experienced by specialists in the context of decision-making situations when the medical arguments conflict with the psychosocial ones. These findings suggest that in order to understand more clearly the complex processes involved in difficult medical decision-making situations, studies on physicians' expertise should include the socio-affective climate involved in each patient-physician relationship.

Plasma HIV-1 RNA viral load rebound among people who inject drugs receiving antiretroviral therapy (ART) in a Canadian setting: an ethno-epidemiological study

Background

People who inject drugs (PWID) living with HIV often experience sub-optimal antiretroviral therapy (ART) treatment outcomes, including HIV plasma viral load (PVL) rebound. While previous studies have identified risk factors for PVL rebound among PWID, no study has examined the perspectives of PWID who have experienced PVL rebound episodes. We conducted an ethno-epidemiological study to investigate the circumstances surrounding the emergence of rebound episodes among PWID in Vancouver, BC, Canada.

Methods

Comprehensive clinical records linked to a community-based prospective observational cohort of HIV-positive drug users were used to identify PWID who had recently experienced viral rebound. In-depth qualitative interviews with 16 male and 11 female participants explored participant perspectives regarding the emergence of viral rebound. A timeline depicting each participant’s HIV viral load and adherence to ART was used to elicit discussion of circumstances surrounding viral rebound.

Findings

Viral rebound episodes were shaped by interplay between various individual, social, and environmental factors that disrupted routines facilitating adherence. Structural-environmental influences resulting in non-adherence included housing transitions, changes in drug use patterns and intense drug scene involvement, and inadequate care for co-morbid health conditions. Social-environmental influences on ART adherence included poor interactions between care providers and patients producing non-adherence, and understandings of HIV treatment that fostered intentional treatment discontinuation.

Conclusions

This study describes key pathways which led to rebound episodes among PWID receiving ART and illustrates how environmental forces may increase vulnerability for non-adherence leading to treatment failure. Our findings have potential to help inform interventions and supports that address social-structural forces that foster non-adherence among PWID.

Unmet needs among men with human immunodeficiency virus in community mental health care: a cross-sectional study

While community-based mental health services play an important role in caring for persons with HIV (human immunodeficiency virus) and co-existing mental health disorders, the extent to which their support needs are addressed in this setting is unknown. Accordingly, we examined if HIV infection was associated with unmet support needs among men living with and without HIV receiving community mental health care. This cross-sectional study examined 215 men (135 living with HIV and 80 without HIV) receiving case management services in urban Ontario. Using the Camberwell Assessment of Need, we ascertained the prevalence of support needs in 13 domains grouped into three clusters: Basic needs (accommodation, food, benefits, and money management); self-care/functional needs (daytime activities, self-care, and looking after the home); and health/safety needs (physical, psychological distress, psychotic symptoms, safety to self, and safety to others). We used generalized estimating equations with a logit link to examine the association between HIV and unmet need in each domain. Compared to HIV-negative men, men with HIV were more likely to have mood and concurrent disorders, and intellectual and developmental disabilities. Following multivariable analyses, men with HIV had greater unmet needs related to food (odds ratio + 95% confidence interval: 9.36 (4.03, 21.75), p < 0.001); money (OR: 1.90 (1.04, 3.47), p = 0.036) [basic need domains]; psychological distress (OR: 2.39 (1.68, 3.41), p < 0.001); drug use (OR: 5.10 (2.16, 12.08) p < 0.001); and safety to self (OR: 3.35 (1.51, 7.52), p < 0.003) [health and safety domains]. Despite living in a setting with universal health insurance, men with HIV receiving community mental health support had greater unmet need in basic and health domains than HIV-negative men receiving such support. Further research is required to develop and evaluate interventions to best support community-dwelling persons with HIV and mental health disorders.

Barriers to antiretroviral treatment access for injecting drug users living with HIV in Chennai, South India

India's National AIDS Control Organization provides free antiretroviral treatment (ART) to people living with HIV (PLHIV), including members of marginalized groups such as injecting drug users (IDUs). To help inform development of interventions to enhance ART access, we explored barriers to free ART access at government ART centers for IDUs living with HIV in Chennai by conducting three focus groups (n = 19 IDUs) and four key informant interviews. Data were explored using framework analysis to identify categories and derive themes. We found interrelated barriers at the family and social, health-care system, and individual levels. Family and social level barriers included lack of family support and fear of societal discrimination, as well as unmet basic needs, including food and shelter. Health-care system barriers included actual or perceived unfriendly hospital environment and procedures such as requiring proof of address and identity from PLHIV, including homeless IDUs; provider perception that IDUs will not adhere to ART, resulting in ART not being initiated; actual or perceived inadequate counseling services and lack of confidentiality; and lack of effective linkages between ART centers, needle/syringe programs, and drug dependence treatment centers. Individual-level barriers included active drug use, lack of self-efficacy in ART adherence, low motivation to initiate ART stemming from a fatalistic attitude, and inadequate knowledge about ART. These findings indicate that to facilitate IDUs gaining access to ART, systemic changes are needed, including steps to make the environment and procedures at government ART centers more IDU-friendly and steps to decrease HIV- and drug use-related stigma and discrimination faced by IDUs from the general public and health-care providers. Housing support for homeless IDUs and linkage of IDUs with drug dependence treatment are also essential.

Task shifting redefined: removing social and structural barriers to improve delivery of HIV services for people who inject drugs

HIV infection among people who inject drugs (IDU) remains a major global public health challenge. However, among IDU, access to essential HIV-related services remains unacceptably low, especially in settings where stigma, discrimination, and criminalization exist. These ongoing problems account for a significant amount of preventable morbidity and mortality within this population, and indicate the need for novel approaches to HIV program delivery for IDU. Task shifting is a concept that has been applied successfully in African settings as a way to address health worker shortages. However, to date, this concept has not been applied as a means of addressing the social and structural barriers to HIV prevention and treatment experienced by IDU. Given the growing evidence demonstrating the effectiveness of IDU-run programs in increasing access to healthcare, the time has come to extend the notion of task shifting and apply it in settings where stigma, discrimination, and criminalization continue to pose significant barriers to HIV program access for IDU. By involving IDU more directly in the delivery of HIV programs, task shifting may serve to foster a new era in the response to HIV/AIDS among IDU.

Physician experience and rates of plasma HIV-1 RNA suppression among illicit drug users: an observational study

Background

Despite the availability of antiretroviral therapy (ART), suboptimal treatment outcomes have been observed among HIV-seropositive illicit drug users. As there is an urgent need to improve responses to antiretroviral therapy among this population, we undertook this study to evaluate the role of physician experience on rates of plasma HIV-1 RNA suppression following initiation of ART.

Methods

Using data from a community-recruited cohort of HIV-positive illicit drug users, we used Cox proportional hazards regression to model the time to plasma viral HIV RNA < 500 copies/mL among antiretroviral-naïve subjects initiating ART. Physician experience was defined as a continuous variable measured per 100 HIV-infected patients previously enrolled in the province-wide HIV treatment registry by that physician at the time a patient was enrolled.

Results

Between May 1996 and December 2008, 267 individuals initiated ART among whom 227 (85%) achieved a plasma HIV RNA < 500 copies/mL during the study period. In a multivariate analysis, greater physician experience was independently associated with higher rates of plasma HIV RNA suppression (adjusted hazard ratio [AHR] = 1.17, 95% confidence interval [CI]: 1.03-1.34) after adjustment for adherence to ART. Other factors associated with viral suppression included engagement in methadone maintenance therapy (AHR = 1.61, 95% CI: 1.23-2.09), ≥ 95% adherence to ART (AHR = 2.42, 95% CI: 1.80-3.26), baseline CD4 count (AHR = 0.89, 95% CI: 0.83-0.96) and baseline plasma HIV-1 RNA (AHR = 0.65, 95% CI: 0.53-0.81).

Conclusions

In this setting of universal HIV/AIDS care, illicit drug users with more experienced physicians exhibited faster rates of plasma viral load suppression. These findings argue for specialized services to help optimize HIV treatment outcomes among this population.

Human rights and HIV prevention, treatment, and care for people who inject drugs: key principles and research needs

Efforts to provide HIV prevention, treatment, and care to injecting drug users (IDU) are shaped by tensions between approaches that regard IDU as criminals and those regarding drug-dependent individuals as patients deserving treatment and human rights. Advocates for IDU health and human rights find common cause in urging greater attention to legal frameworks, the effects of police abuses, and the need for protections for particularly vulnerable populations including women and those in state custody. Arbitrary detention of drug users, and conditions of pretrial detention, offer examples of how HIV prevention and treatment are adversely impacted by human rights abuse. National commitments to universal access to prevention and treatment for injecting drug users, and the recognition that users of illicit substances do not forfeit their entitlement to health services or human dignity, offer a clear point of convergence for advocates for health and rights, and suggest directions for reform to increase availability of sterile injection equipment, opiate substitution treatment, and antiretroviral therapy. For IDU, protection of rights has particular urgency if universal access to HIV prevention and treatment is to become an achievable reality.

Treatment and care for injecting drug users with HIV infection: a review of barriers and ways forward

We review evidence for effectiveness, cost-effectiveness, and coverage of antiretroviral therapy (ART) for injecting drug users (IDUs) infected with HIV, with particular attention to low-income and middle-income countries. In these countries, nearly half (47%) of all IDUs infected with HIV are in five nations--China, Vietnam, Russia, Ukraine, and Malaysia. In all five countries, IDU access to ART is disproportionately low, and systemic and structural obstacles restrict treatment access. IDUs are 67% of cumulative HIV cases in these countries, but only 25% of those receiving ART. Integration of ART with opioid substitution and tuberculosis treatment, increased peer engagement in treatment delivery, and reform of harmful policies--including police use of drug-user registries, detention of drug users in centres offering no evidence-based treatment, and imprisonment for possession of drugs for personal use--are needed to improve ART coverage of IDUs.

No variability across centers in adherence and response to HAART in French hospitals: results from the ANRS-EN12-VESPA study

OBJECTIVE

Because a centre effect can sometimes exist in HIV treatment, we sought to measure the heterogeneity of French hospital departments delivering HIV care and to test the presence of such an effect on adherence and response to highly active antiretroviral therapy.

METHODS

The ANRS-EN12-VESPA study is a nationally representative 2-stage cross-sectional survey conducted in France in 2003 and covering 102 hospital departments providing HIV care. Each department described its HIV care activities and care provision. Analyses of adherence and 4 indicators of treatment outcome were restricted to the 699 patients diagnosed from 1996 onwards and treated with highly active antiretroviral therapy for at least 6 months. The variability between departments was assessed with random-effect models for binary outcomes.

RESULTS

The departments delivering HIV care proved to be somewhat heterogeneous in numerous respects, including their size and their onsite provision of consultancies and other services, and the characteristics of their patient population. Mean observed adherence was 63.3%, and the means of the different treatment failure indicators ranged from 6.1% to 59.8%. The departments showed some variability for these outcomes, but no significant centre effect was detected.

CONCLUSIONS

Despite the heterogeneity of the specific types of medical services offered by the hospitals providing HIV care, the nationwide treatment results seem homogeneous. This homogeneity could be attributed to the widespread and consistent application of therapeutic guidelines, which are regularly updated by consensus.

A review of barriers and facilitators of HIV treatment among injection drug users

Globally, injection drug use continues to account for a substantial proportion of HIV infections. There have not, however, been any evidence-based reviews of the barriers and facilitators of HIV treatment among injection drug users. For this review, published studies were extracted from nine academic databases, with no language or date specified in the search criteria. Existing evidence demonstrates that, although injection drug users often have worse outcomes from HIV treatment than non-injection drug users, major antiretroviral-associated survival gains still have been observed among this population. Inferior outcomes are explained by a range of barriers to antiretroviral access and adherence, which often stem from the negative influences of illicit drug policies, as well as issues within medical systems, including lack of physician education about substance abuse. Evidence demonstrates that several under-utilized interventions and novel antiretroviral delivery modalities have helped to greatly address these barriers in several settings, and there is sufficient evidence to support immediate scale-up of these programmes. These interventions include coupling antiretroviral therapy with opioid substitution therapies as well as directly administered antiretroviral therapy programmes. Of particular interest for future evaluation is the coupling of HIV treatment programmes within comprehensive services, which also provide low-threshold (harm reduction) HIV prevention programmes. Scale-up of evidence-based HIV treatment and prevention to injection drug users, however, will require increasing political will among both national policy-makers and international public health agencies.

Factors associated with antiretroviral therapy adherence and medication errors among HIV-infected injection drug users

BACKGROUND

Active drug use is often associated with poor adherence, but few studies have determined psychosocial correlates of adherence in injection drug users (IDUs).

METHODS

Of 1161 Intervention for Seropositive Injectors-Research and Evaluation study enrollees, 636 were taking antiretrovirals. We assessed self-reported adherence to self-reported antiretroviral regimens and medication errors, which we defined as daily doses that were inconsistent with standard or alternative antiretroviral prescriptions.

RESULTS

Most subjects (75%, n=477) self-reported good (>or=90%) adherence, which was strongly associated with an undetectable viral load. Good adherence was independently associated with being a high school graduate, not sharing injection equipment, fewer depressive symptoms, positive attitudes toward antiretrovirals, higher self-efficacy for taking antiretrovirals as prescribed, and greater sense of responsibility to protect others from HIV. Medication errors were made by 54% (n=346) and were strongly associated with a detectable viral load and fewer CD4 cells. Errors were independently associated with nonwhite race and with depressive symptoms, poorer self-efficacy for safer drug use, and worse attitudes toward HIV medications.

CONCLUSIONS

Modifiable factors associated with poor adherence, including depressive symptoms and poor self-efficacy, should be targeted for intervention. Because medication errors are prevalent and associated with a detectable viral load and fewer CD4 cells, interventions should include particular efforts to identify medication taking inconsistent with antiretroviral prescriptions.

Adherence among women with HIV infection in Puerto Rico: the potential use of modified directly observed therapy (MDOT) among pregnant and postpartum women

Women are the fastest growing segment of the adult population acquiring HIV, and most women infected with HIV are in their reproductive years. The success of HAART is highly dependent upon the ability and willingness of the individual to adhere to complex antiretroviral regimens. Improved adherence among HIV-infected pregnant women will delay disease progression in the mother and should also reduce HIV transmission to the baby. Modified directly observed therapy (MDOT), may benefit this population. MDOT has been shown to be an acceptable and feasible intervention among HIV substance users; however, no-one has yet evaluated the use of MDOT in pregnant and postpartum women. Based on semi-structured interviews with 17 Latina women with HIV infection, we explored women's adherence patterns and barriers to adherence and their perceptions of a hypothetical MDOT program. The vast majority of women positively appraised the MDOT program as an effective means to increase and reinforce adherence to demanding drug regimens. Respondents cited the face-to-face contact, the supportive nature of the relationship, and the practical approach of the program as the primary reasons for the effectiveness of MDOT. Results indicate that MDOT could be an acceptable intervention for pregnant and postpartum Latina women to improve adherence to HAART.

Paradoxes in antiretroviral treatment for injecting drug users: access, adherence and structural barriers in Asia and the former Soviet Union

Offered proper support, injection drug users (IDUs) can achieve the same levels of adherence to and clinical benefit from antiretroviral treatment (ARV) as other patients with HIV. Nonetheless, in countries of Asia and the former Soviet Union where IDUs represent the largest share of HIV cases, IDUs have been disproportionately less likely to receive ARV. While analysis of adherence amongst IDUs has focused on individual patient ability to adhere to medical regimens, HIV treatment systems themselves are in need of examination. Structural impediments to provision of ARV for IDUs include competing, vertical systems of care; compulsory drug treatment and rehabilitation services that often offer neither ARV nor effective treatment for chemical dependence; lack of opiate substitution treatments demonstrated to increase adherence to ARV; and policies that explicitly or implicitly discourage ARV delivery to active IDUs. Labeling active drug users as socially untrustworthy or unproductive, health systems can create a series of paradoxes that ensure confirmation of these stereotypes. Needed reforms include professional education and public campaigns that emphasize IDU capacity for health protection and responsible choice; recognition that the chronic nature of injecting drug use and its links to HIV infection require development of ARV treatment delivery that includes active drug users; and integrated treatment that strengthens links between health providers and builds on, rather than seeks to bypass, IDU social networks and organizations.

Delivering Care to Injection Drug Users Coinfected with HIV and Hepatitis C Virus

Injection drug use has fueled the epidemic of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection in the United States. Nevertheless, drug dependence is among the main reasons that coinfected persons are not being treated for HCV infection. This report describes the development and progress of an HIV clinic program (funded by the Ryan White Comprehensive AIDS Resources Emergency Act) to deliver care for HCV infection to HIV-seropositive injection drug users. To optimize safety and adherence, pegylated interferon is directly administered to patients in the context of integrated addiction, psychiatric, and HIV and HCV therapy. Ribavirin is packed weekly in pill boxes for patients to take at home. Thus far, adherence to weekly visits for treatment with interferon has been 99%. No one has had to stop treatment for HCV infection because of ongoing drug use, addiction relapse or exacerbation, or psychiatric complications. Presented here is a work in progress, rather than a finished research project or definitive model of care.

Adherence, stereotyping and unequal HIV treatment for active users of illegal drugs

Adherence to antiretroviral therapy promotes viral suppression and extends the lives of individuals with HIV, yet illegal drug users are underrepresented among eligible persons receiving HIV treatment. One explanation for this is the assumption that drug users are less capable than others of adhering to complicated medication regimens. This paper investigates this assumption by making explicit a number of its underlying propositions and examining them in light of data collected from 52 active drug users living in and around Boston, USA, who were taking highly active antiretroviral therapy for HIV (HAART). The propositions are: (1) drug users lead "chaotic" lives; (2) active drug users are always using drugs; (3) being under the influence of drugs precludes taking medications as prescribed; and (4) drug users are intrinsically different from non-users in the lives they lead and the problems they face. Data collection consisted of a series of qualitative interviews with each participant. An analytic approach informed by grounded theory was used to construct thematic content categories from the data. Results revealed stability and control as well as "chaos" in the lives of study participants. Frequency of drug use varied considerably. Using did interfere with adherence, but not in every circumstance or all cases. Not "carrying" medications, competing priorities, and re-defining regimens were the most salient of a number of non-drug-use-related obstacles observed. Documentation of patterns of variation in corresponding data highlights the stereotypical quality of the propositions. Stereotyping risks overemphasis on drug use as a barrier to adherence for active users, and underemphasis on non-drug-use-related obstacles. Adherence capabilities of users, in contrast to inadequacies, are also obscured through stereotyping. As a medium for stigmatization, stereotyping may contribute to unequal treatment for drug users and other populations living with HIV.

Patient-reported and physician-estimated adherence to HAART: social and clinic center-related factors are associated with discordance

OBJECTIVES

To evaluate the rate of discordance between patients and physicians on adherence to highly active antiretroviral therapy (HAART) and identify factors related to discordance in these two assessments.

DESIGN

Prospective, multicenter, cohort study (AdICONA) nested within the Italian Cohort Naive Antiretrovirals (ICONA) study.

SETTING

Tertiary clinical centers.

PARTICIPANTS

The patients filled out a 16-item self-administered questionnaire on adherence to HAART. At the same time, physicians estimated the current HAART adherence of their patient.

MAIN OUTCOME MEASURE

Discordance between patient and physician on adherence to antiretroviral therapy.

RESULTS

From May 1999 to March 2000, 320 paired patient-physician assessments were obtained. Patients had a mean plasma HIV RNA of 315 copies/ml (64% had undetectable HIV RNA) and a mean CD4+ cell count of 577 cells x 10(6)/L. Nonadherence was reported by 30.9% of patients and estimated by physicians in 45.0% cases. In 111 cases (34.7%), patients and physicians were discordant on adherence to HAART. Kappa statistics was 0.27. Using patient-assessed adherence as reference, sensitivity, specificity, positive predictive value, and negative predictive value of physician-estimated adherence were 64.7%, 66.6%, 81.2%, and 45.8%, respectively. On multivariable analysis, low education level, unemployment, absence of a social worker in the clinical center, and unavailability of afternoon visits were significantly correlated with patient-physician discordance on adherence to antiretrovirals.

CONCLUSIONS

Physicians did not correctly estimate patient-reported adherence to HAART in more than one third of patients. Both social variables and factors related to the clinical center were important predictors of discordance between patients and physicians. Interventions to enhance adherence should include strategies addressed to improve patient-physician relationship.

Disparities in HIV treatment and physician attitudes about delaying protease inhibitors for nonadherent patients

BACKGROUND

Current HIV treatment guidelines recommend delaying antiretroviral therapy for nonadherent patients, which some fear may disproportionately affect certain populations and contribute to disparities in care.

OBJECTIVES

To examine the relationship of physician's attitude toward prescribing protease inhibitors (PIs) to nonadherent patients with disparities in PI use and with health outcomes.

DESIGN

Prospective cohort study.

PATIENTS AND SETTING

A national probability sample of HIV-infected adults in the United States and their health care providers was surveyed between January 1996 and January 1998. We analyzed data on 1717 patients eligible for PI treatment and the 367 providers who cared for them.

MEASUREMENTS

Providers' attitude toward prescribing PIs to nonadherent patients, time until patients' first receipt of PIs, mortality, and physical health status.

MAIN RESULTS

Eighty-nine percent of providers agreed that patient adherence is important in their decision to prescribe PIs (Selective) while 11% disagreed (Nonselective). Patients who had a Selective provider received PIs later than those with a Nonselective provider (P =.05). Adjusting for patient demographics and health characteristics and provider demographics, HIV knowledge, and experience, Latinos, women, and poor patients received PIs later if their provider had a Selective attitude but as soon as others if their provider had a Nonselective attitude. African-American patients received PIs later than whites, irrespective of their providers' prescribing attitude. Patients with Selective providers had similar odds of mortality than those with Nonselective providers (odds ratio, 1.1; 95% confidence interval, 0.6 to 2.0), but had slightly worse adjusted physical health status at follow-up (49.1 vs 50.4, respectively; P =.04), after controlling for baseline physical health status and other patient and provider covariates.

CONCLUSIONS

Most providers consider patient adherence an important factor in their decision to prescribe PIs. This attitude appears to account for the relatively later use of PI treatment among Latinos, women, and the poor. Given the rising HIV infection rates among minorities, women, and the poor, further investigation of this treatment strategy and its impact on HIV resistance and outcomes is warranted.

Case management of human immunodeficiency virus-infected injection drug users: a case study in Rio de Janeiro, Brazil

The provision of care and support to persons living with human immunodeficiency virus (HIV) in Brazil who also use drugs and/or alcohol represents special challenges because of the combined effects of addiction, poverty, stigma, and discrimination. This paper presents details on a program providing both clinic- and field-based care to HIV-infected injection drug users, highlighting the use of a specialized case management approach to address the clinical and psychosocial needs of this population. This program includes both a mobile case management team that fosters group discussions and provides individual counseling, and provision of medical consultations at 2 major drug treatment centers in Rio de Janeiro. The article also describes the experience of working with injection drug users who regularly attend an outpatient clinic serving marginalized communities through the use of mutual self-help groups and specialized support groups to address to issue of adherence to antiretroviral therapies for the treatment of HIV/acquired immunodeficiency syndrome.

Psychiatric and social barriers to HIV medication adherence in a triply diagnosed methadone population

Although antiretrovirals can prolong life, medication adherence also poses a constant challenge for HIV-infected individuals because the success of antiretroviral regimens demands nearly perfect adherence to medications. This paper describes the psychiatric and social barriers to adherence in a convenience sample of HIV-positive clients in methadone treatment in the Bronx, New York. The study sample was part of a national study of HIV treatment adherence and health care utilization among triply diagnosed populations, the HIV/AIDS Treatment Adherence Health Outcomes and Cost Study. The triply diagnosed study sample is defined here as HIV-infected individuals who screened into the study with at least one psychiatric diagnosis in addition to opioid dependence on agonist therapy (methadone treatment) and at least one substance use diagnosis. Interviewers utilized modified versions of the Structured Clinical Interview for DSM-IV Disorders (SCID-I), the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), and the Addiction Severity Index (ASI-Lite), among a battery of Cost Study instruments. Results showed that within this sample, borderline personality disorder was significantly associated with nonadherence to HIV medications. A related finding showed a significant relationship between serious social/family problems and nonadherence. These findings build on previous research on the impact of psychiatric illness on HIV medication adherence and suggest that psychiatric assessment and treatment options be linked to adherence interventions.

Attitudes toward HIV protease inhibitors and medication adherence in an inner city HIV population

The objective of this pilot study was to examine attitudes toward protease inhibitors (PIs) among HIV-infected individuals and to assess the relationship between PI attitudes and adherence to PIs. Respondents were recruited from four AIDS service organizations in New York City; the total sample consisted of 97 HIV-infected individuals who were taking a PI. The sample consisted largely of African Americans and Latinos from inner city areas, and most had a low level of education. Adherence was suboptimal, with more than 50% of respondents failing to take their PI medications exactly as prescribed within the previous month. Individuals who had recently used illegal drugs within the past 6 months were more likely to be nonadherent to PIs. Those who were not adherent to PI medications reported greater concern about the side effects of PIs and were more likely to believe that it was acceptable to skip doses of PIs.