High Concordance between Self-Reported Adherence, Treatment Outcome and Satisfaction with Care Using a Nine-Item Health Questionnaire in InfCareHIV

Infant feeding knowledge among women living with HIV and their interaction with healthcare providers in a high-income setting: a longitudinal mixed methods study

BACKGROUND

Recent changes in the infant feeding guidelines for women living with HIV from high-income countries recommend a more supportive approach focusing on shared decision-making. Limited information is available on the infant feeding knowledge of women living with HIV and how healthcare providers engage with them in this context. This multicenter, longitudinal, mixed methods study aims to get a comprehensive and nuanced understanding of infant feeding knowledge among women living with HIV of Nordic and non-Nordic origin living in Nordic countries, and their interaction with healthcare providers regarding infant feeding planning.

METHODS

Pregnant women living with HIV in Denmark, Finland, and Sweden were recruited in 2019-2020. The Positive Attitudes Concerning Infant Feeding (PACIFY) questionnaire was completed in the 3rd trimester (T1), three (T2), and six (T3) months postpartum. Women who completed the quantitative survey were also invited to participate in qualitative semi-structured interviews at T1 and T3. Results from the survey and interviews were brought together through merging to assess for concordance, complementarity, expansion, or discordance between the datasets and to draw meta-inferences.

RESULTS

In total, 44 women living with HIV completed the survey, of whom 31 also participated in the interviews. The merged analyses identified two overarching domains: Knowledge about breastfeeding in the U = U era and Communications with healthcare providers. The women expressed confusion about breastfeeding in the context of undetectable equals untransmittable (U = U). Women of Nordic origin were more unsure about whether breastfeeding was possible in the context of U = U than women of non-Nordic origin. Increased postpartum monitoring with monthly testing of the mother was not seen as a barrier to breastfeeding, but concerns were found regarding infant testing and infant ART exposure. Infant feeding discussions with healthcare providers were welcome but could also question whether breastfeeding was feasible, and many participants highlighted a need for more information.

CONCLUSIONS

Healthcare providers caring for women living with HIV must have up-to-date knowledge of HIV transmission risks during breastfeeding and engage in shared decision-making to optimally support infant feeding choices.

Patient-reported outcome measures in adult HIV care: A rapid scoping review of targeted outcomes and instruments used

OBJECTIVE

There is international interest in the integration of patient-reported outcome measures (PROMs) into routine HIV care, but little work has synthesized the content of published initiatives. We conducted a rapid scoping review primarily to identify their selected patient-reported outcomes and respective instruments.

METHODS

Four databases were searched on 4 May 2022 (Medline, Embase, CINAHL and PsychINFO) for relevant English language documents published from 2005 onwards. Dual review of at least 20% of records, full texts and data extraction was performed. Outcomes and instruments were classified with an adapted 14-domain taxonomy. Instruments with evidence of validation were described.

RESULTS

Of 13 062 records generated for review, we retained a final sample of 94 documents, referring to 60 distinct initiatives led mostly in the USA (n = 29; 48% of initiatives), Europe (n = 16; 27%) and Africa (n = 9; 15%). The measured patient-reported outcome domains were: mental health (n = 42; 70%), substance use (n = 23; 38%), self-management (n = 16; 27%), symptoms (n = 12; 20%), sexual/reproductive health (n = 12; 20%), physical health (n = 9; 15%), treatment (n= 8; 13%), cognition (n = 7; 12%), quality of life (n = 7; 12%), violence/abuse (n = 6; 10%), stigma (n = 6; 10%), socioeconomic issues (n = 5; 8%), social support (n = 3; 5%) and body/facial appearance (n = 1; 2%). Initiatives measured 2.6 outcome domains, on average (range = 1-11). In total, 62 distinct validated PROMs were identified, with 53 initiatives (88%) employing at least one (M = 2.2). Overwhelmingly, the most used instrument was any version of the Patient Health Questionnaire to measure symptoms of depression, employed by over a third (26; 43%) of initiatives.

CONCLUSION

Published PROM initiatives in HIV care have spanned 19 countries and disproportionately target mental health and substance use.

Factors associated with sex differences in viral non-suppression in the Swedish InfCareHIV cohort: An observational real-world study

OBJECTIVES

Women living with HIV are underrepresented in clinical trials assessing outcomes of antiretroviral treatment (ART), justifying the need for observational studies. We investigated differences in viral non-suppression between women and men in the Swedish InfCareHIV cohort and analysed results in relation to biological and socio-demographic variables and patient-reported outcome measures (PROMs).

METHODS

The study included people living with HIV (PLWH) aged ≥18 years, who initiated ART at least 6 months prior to inclusion. Data from the InfCareHIV registry 2011-2018 were collected. Associations between variables and HIV RNA ≥50 copies/mL were investigated in uni- and multivariable analyses using generalized estimating equations, providing relative risks (RRs) as effect size.

RESULTS

The study included 38% (n = 2981) women. Women were more likely to have HIV RNA ≥50 copies/mL than were men [RR = 1.20, 95% confidence interval (CI): 1.10-1.31]. After adjusting for origin and route of transmission, sex at birth was no longer associated with viral non-suppression. PROMs were available in 52.4% of PLWH, and items associated with viral non-suppression were impaired adherence in women (RR = 2.38, 95% CI: 1.79-3.17) and men (RR 1.84, 95% CI: 1.40-2.42), and experience of side effects in women (RR = 1.49, 95% CI: 1.10-2.02).

CONCLUSIONS

This observational study found a 20% higher relative risk of viral non-suppression in women than in men and the difference was associated with socio-demographic factors. The associations between PROMs and viral non-suppression varied between women and men. PROMs are important health outcomes that may identify PLWH in need of support to achieve viral non-suppression.

Difficult-to-treat HIV in Sweden: a cross-sectional study

BACKGROUND

Our aim was to examine the prevalence and characteristics of difficult-to-treat HIV in the current Swedish HIV cohort and to compare treatment outcomes between people with difficult and non-difficult-to-treat HIV.

METHODS

In this cross-sectional analysis of the Swedish HIV cohort, we identified all people with HIV currently in active care in 2023 from the national register InfCareHIV. We defined five categories of difficult-to-treat HIV: 1) advanced resistance, 2) four-drug regimen, 3) salvage therapy, 4) virologic failure within the past 12 months, and 5) ≥ 2 regimen switches following virologic failure since 2008. People classified as having difficult-to-treat HIV were compared with non-difficult for background characteristics as well as treatment outcomes (viral suppression and self-reported physical and psychological health).

RESULTS

Nine percent of the Swedish HIV cohort in 2023 (n = 8531) met at least one criterion for difficult-to-treat HIV. Most of them had ≥ 2 regimen switches (6%), and the other categories of difficult-to-treat HIV were rare (1-2% of the entire cohort). Compared with non-difficult, people with difficult-to-treat HIV were older, had an earlier first year of positive HIV test and lower CD4 counts, and were more often female. The viral suppression rate among people with difficult-to-treat HIV was 84% compared with 95% for non-difficult (p = 0.001). People with difficult-to-treat HIV reported worse physical (but not psychological) health, and this remained statistically significant after adjustment for age, sex, and transmission group.

CONCLUSIONS

Although 9% of the HIV cohort in Sweden in 2023 were classified as having difficult-to-treat HIV, a large proportion of these were virally suppressed, and challenges such as advanced resistance and need for salvage therapy are rare in the current Swedish cohort.

Perception and Emotional Experiences of Infant Feeding Among Women Living With HIV in a High-Income Setting: A Longitudinal Mixed Methods Study

BACKGROUND

The recommendation of breastfeeding avoidance for women living with HIV in high-income settings may be influenced by cultural beliefs and come at an emotional cost. This multicenter, longitudinal, convergent mixed methods study aimed to compare differences in attitudes, concerns, and experiences surrounding breastfeeding in women living with HIV of Nordic and non-Nordic origin.

SETTING

High-income setting.

METHODS

Pregnant women living with HIV in the Nordic countries Denmark, Finland, and Sweden were recruited in 2019-2020. Quantitative data on attitudes surrounding infant feeding were assessed using the Positive Attitudes Concerning Infant Feeding questionnaire completed in the third trimester (T1), and 3 (T2) and 6 (T3) months postpartum. Women who completed the survey were also invited to participate in semistructured interviews at T1 and T3. The findings from the quantitative survey and qualitative interviews were brought together through merging to assess for concordance, complementarity, expansion, or discordance between the data sets and to draw metainferences.

RESULTS

In total, 44 women completed the survey, of whom 31 also participated in qualitative interviews. The merged analyses identified three overarching domains representing commonalities across the quantitative and qualitative data: emotional impact, justifying not breastfeeding, and coping strategies. Not being able to breastfeed was emotionally challenging. Cultural expectations influenced the women's experiences and the strategies they used to justify their infant feeding choice.

CONCLUSIONS

For women living with HIV in Nordic countries not breastfeeding was a complex, multilayered process substantially influenced by social and cultural expectations.

Cohort profile: InfCareHIV, a prospective registry-based cohort study of people with diagnosed HIV in Sweden

PURPOSE

The Swedish InfCareHIV cohort was established in 2003 to ensure equal and effective care of people living with HIV (PLHIV) and enable long-term follow-up. InfCareHIV functions equally as a decision support system as a quality registry, ensuring up-to-date data reported in real time.

PARTICIPANTS

InfCareHIV includes data on >99% of all people with diagnosed HIV in Sweden and up to now 13 029 have been included in the cohort. InfCareHIV includes data on HIV-related biomarkers and antiretroviral therapies (ART) and also on demographics, patient-reported outcome measures and patient-reported experience measures.

FINDINGS TO DATE

Sweden was in 2015 the first country to reach the UNAIDS (United Nations Programme on HIV/AIDS)/WHO's 90-90-90 goals. Late diagnosis of HIV infection was identified as a key problem in the Swedish HIV-epidemic, and low-level HIV viraemia while on ART associated with all-cause mortality. Increased HIV RNA load in the cerebrospinal fluid (CSF) despite suppression of the plasma viral load was found in 5% of PLHIV, a phenomenon referred to as 'CSF viral escape'. Dolutegravir-based treatment in PLHIV with pre-existing nucleoside reverse transcriptase inhibitor-mutations was non-inferior to protease inhibitor-based regimens. An increase of transmitted drug resistance was observed in the InfCareHIV cohort. Lower efficacy for protease inhibitors was not due to lower adherence to treatment. Incidence of type 2 diabetes and insulin resistance was high in the ageing HIV population. Despite ART, the risk of infection-related cancer as well as lung cancer was increased in PLHIV compared with HIV-negative. PLHIV were less likely successfully treated for cervical precancer and more likely to have human papillomavirus types not included in current HPV vaccines. Self-reported sexual satisfaction in PLHIV is improving and is higher in women than men.

FUTURE PLANS

InfCareHIV provides a unique base to study and further improve long-term treatment outcomes, comorbidity management and health-related quality of life in people with HIV in Sweden.

Sexual satisfaction and its associations with patient-reported outcomes in a cohort of women living with human immunodeficiency virus in Sweden

Background: Sexual satisfaction is an important dimension of health-related quality of life that needs to be addressed. Various factors may influence sexual satisfaction in women living with HIV (WLHIV); however, research in this area is limited. The aim of this study was to investigate patients' self-reported sexual satisfaction and its associations with patient-reported outcomes in WLHIV in Sweden. Methods: Data was retrieved from the InfCareHIV registry for the years 2011-2016. The registry includes a self-reported validated 9-item health questionnaire to assess patient-reported outcomes, side effects and adherence. In total, 1292 WLHIV aged ≥18 years were included, corresponding to 42.8% of the female Swedish InfCareHIV cohort 2011-2016. A total of 2444 questionnaires were included in the study. The patient-reported outcomes used were satisfaction with physical health and psychological health, sexual satisfaction, and experiencing side effects from HIV-medication. Associations were tested in univariable and multivariable models. Results: The study shows that there was a significant association between sexual satisfaction and satisfaction with psychological health (p ≤ 0.0001). There was a lower probability of reporting sexual satisfaction in women who were of an older age when they received an HIV-diagnosis (p = 0.033), who had lived for more years with HIV (p = 0.0004), or who had experienced side effects (p = 0.028). Conclusions: This national register-based study identified that sexual satisfaction in WLHIV is associated with psychological health and with having experienced side-effects. Patient-reported outcomes can provide valuable information so that the care of WLHIV covers all aspects of health and supports sexual satisfaction, which is an important part of quality of life.

HIV-positive women have higher prevalence of comorbidities and anticholinergic burden: assessment of the HIV-positive population from Menorca (Balearic Islands)

Currently, the management of comorbidities and polypharmacy in HIV-infected patients requires a coordinated action, with special focus on gender differences. Observational, cross-sectional study was conducted to study the HIV population from Menorca (Illes Balears). Adult HIV-positive individuals on antiretroviral treatment attending the pharmacy service from Hospital Mateu Orfila (Menorca) were included. In a single visit, demographical and clinical characteristics, comorbidities and cotreatments were collected. Anticholinergic burden (Drug Burden Index, DBI), drug-to-drug interactions (BOT PLUS database) and symptoms associated with HIV treatment (HIV-SI index) were assessed. A total of 223 patients were included, 68.2% men, with a median age of 53.00 (44.50-58.00) years, median BMI of 24.07, 47.73% smokers and 9.90% drug consumers. Women had more advanced stages of the disease and significantly more symptoms (cough and anxiety) versus men (p = .033 and p = .048, respectively). Moreover higher exposures to anticholinergic drugs (DBI 0.51 vs. 0.27) were reported, together with more frequency of drug-to-drug interactions (57.7% vs. 37.5%; p = .005) that increased with age. Red interactions were more frequently reported in PI (2.69%), NNRTIs (1.92%) and booster drugs (1.92%). These results support the need to implement specific measures for the management of HIV-infected women and tools to assess polypharmacy and risk of drug-to-drug interactions.

Time difference in retrieving clinical information in Patient-overview Prostate Cancer compared to electronic health records

BACKGROUND

Patients with advanced prostate cancer (PCa) typically undergo numerous lines of treatment leading to large amounts of information in Electronic Health Records (EHRs). The Patient-overview Prostate Cancer (PPC) presents clinical information in a graphical overview. The aim of this study was to measure time spent on retrieving clinical information in PPC compared to EHRs, to assess if retrieved data was correct and to explore usability of PPC.

MATERIAL AND METHODS

Oncologists, urologists and nurses in three hospitals in Sweden were timed when filling out questionnaires about patients using PPC and two different EHRs; Melior and COSMIC. Time and number of errors were analysed using linear mixed models (LMMs). Usability of PPC was measured with the System Usability Scale.

RESULTS

The LMM showed a significantly shorter time to retrieve information in PPC compared to EHRs. The estimated time to complete one questionnaire was 8 minutes (95% CI = 6-10, p < 0.001) in PPC compared to 25 minutes in Melior and 21 minutes in COSMIC. Compared to PPC, the estimated time difference was 17 minutes longer in Melior (95% CI = 14-20, p < 0.001) and 13 minutes longer in COSMIC (95% CI = 10-17, p < 0.001). The LMM showed significantly fewer errors in PPC compared to Melior. No significant difference in the number of errors was found between PPC and COSMIC. The usability of PPC was rated as excellent by oncologists, urologists and nurses.

CONCLUSION

A graphical overview of a patient's medical history, as in PPC, gives health staff rapid access to relevant information with a high degree of usability.

Finnish HIV Quality of Care Register (FINHIV)

PURPOSE

The Finnish HIV Quality of Care Register (FINHIV) was created to: (1) estimate the number of people living with HIV (PLWH) in Finland, (2) evaluate the national level of antiretroviral medication use and viral suppression, (3) examine the change in the HIV epidemic in Finland to pinpoint issues to address and (4) enable evaluation of the health of the PLWH by combining the FINHIV data with other national healthcare data.

PARTICIPANTS

The FINHIV includes all people diagnosed or being treated for HIV infection in Finland since 1984. The register was formed in 2020 by combining data from the National Infectious Diseases Register (information from time of diagnosis, data from 1984) and from the 21 HIV Clinics that treat HIV-positive patients in Finland (earliest data from 1998). The register population forms a nationwide, open cohort with yearly updates; currently it consists of 4218 PLWH (including 718 deceased) with HIV diagnosed or treated in Finland 1984-2019. Current rate of new cases is 150 cases/year.

FINDINGS TO DATE

From the FINHIV data, we can confirm that Finland has reached the Joint United Nations Programme for HIV/AIDS (UNAIDS) 90-90-90 targets set for 2020, and that the proportion of virally suppressed is constant between all 21 HIV Clinics in Finland, despite their varying size. Linkage to care is estimated at 94.3% of those diagnosed. In contrast to the treatment results, more than half of the PLWH have been diagnosed at a late stage, and the proportion has increased since 2000.

FUTURE PLANS

Combinations of FINHIV data with other national healthcare register data in Finland will provide further information on other aspects of the health of the PLWH in a high-resource setting (eg, comorbidities, sexual health and use of healthcare resources). Additionally, implementation of patient-reported experience and outcome measures within the FINHIV is ongoing.

Psychosocial health in pregnancy and postpartum among women living with - and without HIV and non-pregnant women living with HIV living in the Nordic countries - Results from a longitudinal survey study

BACKGROUND

The success of antiretroviral therapy has normalized pregnancy among women living with HIV (WWH) with a very low risk of perinatal transmission of HIV. Despite these advances, WWH still face complex medical and psychosocial issues during pregnancy and postpartum. The aim of this study was to assess differences in psychosocial health outcomes between pregnant WWH, non-pregnant WWH, and pregnant women without HIV, and further identify factors associated with probable depression in the third trimester and postpartum.

METHODS

In a longitudinal survey study, participants were included from sites in Denmark, Finland, and Sweden during 2019-2020. Data was collected in the 3rd trimester, 3 and 6 months postpartum using standardized questionnaires assessing depression, perceived stress, loneliness, and social support. Mixed regression models were used to assess changes over time within and between groups. Logistic regression models were used to identify factors associated with depression in pregnancy and postpartum.

RESULTS

A total of 47 pregnant WWH, 75 non-pregnant WWH, and 147 pregnant women without HIV were included. The prevalence of depression was high among both pregnant and non-pregnant WWH. There was no significant difference between pregnant and non-pregnant WWH in depression scores, perceived stress scores, or social support scores at any time point. Compared to pregnant women without HIV, pregnant WWH reported worse outcomes on all psychosocial scales. Social support and loneliness were associated with an increased odds of depressive symptoms in the adjusted analysis.

CONCLUSIONS

A high burden of adverse psychosocial outcomes was observed in both pregnant and non-pregnant women living with HIV compared to pregnant women without HIV. Loneliness and inadequate social support were associated with increased odds of depression in pregnancy and should be a focus in future support interventions.

The experience of pregnancy among women living with HIV in Nordic countries: A qualitative narrative enquiry

Objective:

The success of antiretroviral therapy has resulted in the normalization of pregnancy among women living with HIV and a very low risk of perinatal transmission of HIV. Despite these advances, women living with HIV still face complex medical and psychosocial issues during pregnancy. The purpose of this study is to describe experiences of pregnancy and the relevance of social support among women living with HIV in Nordic countries.

Methods:

This qualitative study examined data from pregnant women living with HIV from sites in Denmark, Sweden and Finland from 2019 to 2020. Data were collected in the third trimester via individual interviews using a hybrid, narrative/semistructured format. The transcribed interviews were analyzed using narrative thematic analysis.

Results:

In total, 31 women living with HIV were enrolled, of whom 61% originated from an African country and 29% from a Nordic country. The analysis generated four primary narrative themes: just a normal pregnancy, unique considerations and concerns, interactions with healthcare, and social support. Women living with HIV have a strong desire to have normal pregnancies and to be treated like any other pregnant woman. However, this normality is fragile, and being pregnant and living with HIV does come with unique considerations and concerns, such as fear of transmission, antiretroviral therapy, and the need for specialized care, which are fundamental to the women’s experiences. Interactions with healthcare providers and social support influence their experiences in both positive and negative ways.

Conclusion:

The findings emphasize a sense of normality in pregnancy among women living with HIV. However, pregnancy does come with unique considerations and concerns, which highly influence the women’s experience of pregnancy. Healthcare providers should focus on person-centered care, ensuring continuity and that women living with HIV do not feel discriminated against throughout their pregnancy.

Men and sexual and reproductive healthcare in the Nordic countries: a scoping review

CONTEXT

Men generally seek healthcare less often than women and, other than traditional gender norms, less is known about the explanation. The aim was to identify knowledge gaps and factors influencing men regarding sexual and reproductive healthcare (SRHC) in the Nordic countries.

METHODS

We searched PubMed and SveMed+ for peer-reviewed articles published between January 2010 and May 2020. The analyses identified factors influencing men's experiences of and access to SRHC.

RESULTS

The majority of the 68 articles included focused on pregnancy, birth, infertility and sexually transmitted infections including HIV. During pregnancy and childbirth, men were treated as accompanying partners rather than individuals with their own needs. The knowledge and attitudes of healthcare providers were crucial for their ability to provide SRHC and for the experiences of men. Organisational obstacles, such as women-centred SRHC and no assigned healthcare profession for men's sexual and reproductive health issues, hindered men's access to SRHC. Lastly, the literature rarely discussed the impact of health policies on men's access to SRHC.

CONCLUSIONS

The literature lacked the perspectives of specific groups of men such as migrants, men who have sex with men and transmen, as well as the experiences of men in SRHC related to sexual function, contraceptive use and gender-based violence. These knowledge gaps, taken together with the lack of a clear entry point for men into SRHC, indicate the necessity of an improved health and medical education of healthcare providers, as well as of health system interventions.

Patients' Satisfaction by SmileInTM Totems in Radiotherapy: A Two-Year Mono-Institutional Experience

Background: Patient’s satisfaction is recognized as an indicator to monitor quality in healthcare services. Patient-reported experience measures (PREMs) may contribute to create a benchmark of hospital performance by assessing quality and safety in cancer care. Methods: The areas of interest assessed were: patient-centric welcome perception (PCWP), punctuality, professionalism and comfort using the Lean Six Sigma (LSS) methodology. The RAMSI (Radioterapia Amica Mia SmileIN^{TM (SI)} My Friend Radiotherapy^SI), project provided for the placement of SI totems with four push buttons using HappyOrNot technology in a high-volume radiation oncology (RO) department. The SI technology was implemented in the RO department of the Fondazione Policlinico Universitario A. Gemelli IRCCS. SI totems were installed in different areas of the department. The SI Experience Index was collected, analyzed and compared. Weekly and monthly reports were created showing hourly, daily and overall trends. Results: From October 2017 to November 2019, a total of 42,755 votes were recorded: 8687, 10,431, 18,628 and 5009 feedback items were obtained for PCWP, professionalism, punctuality, and comfort, respectively. All areas obtained a SI-approved rate ≥ 8.0. Conclusions: The implementation of the RAMSI system proved to be doable according to the large amount of feedback items collected in a high-volume clinical department. The application of the LSS methodology led to specific corrective actions such as modification of the call-in-clinic system during operations planning. In order to provide healthcare optimization, a multicentric and multispecialty network should be defined in order to set up a benchmark.

Supportive conditions for sexual and perinatal wellbeing in women living with HIV in Sweden: A phenomenological study

OBJECTIVES

Women living with HIV have specific needs regarding sexuality, pregnancy, and childbirth. However, there is lack of knowledge about how these needs can be met. The aim of this study was to identify supportive conditions for sexual and perinatal wellbeing in women living with HIV in Sweden.

METHODS

A phenomenological reflective lifeworld research approach was used. Transcribed interviews with 18 women living with HIV in Sweden were analyzed focusing on the meanings of the study phenomenon.

RESULTS

When living with HIV, "feeling safe with oneself and in relationships with others" is essential for sexual and perinatal wellbeing. This is constituted by having good overall health, being in a caring context, having access to high quality information about HIV, and being ensured the same rights as other women.

CONCLUSIONS

The study shows that women living with HIV have specific needs for the support of their sexual and perinatal wellbeing. This knowledge can be used by all those engaged in HIV care and HIV prevention in order to improve and implement supportive conditions for women living with HIV. It is important that all those involved in the care of women living with HIV constantly update their knowledge about HIV and women's experiences of living with HIV in order to provide safe arenas and caring contexts that support the wellbeing of these women.

People living with HIV in Sweden report high levels of sexual satisfaction in a registry-based cohort study

Sexual satisfaction can be challenging for people living with HIV (PLWH). To investigate self-reported sexual satisfaction in PLWH and its association with HIV-related biomarkers, a retrospective observational cohort study with data on sociodemographic characteristics and changes in PLWH's assessment of their sexual satisfaction over time were retrieved from the Swedish National Quality Assurance Registry (InfCareHIV) where patient-related outcomes are reported annually. PLWH who had assessed self-reported sexual satisfaction 2011-2016 were included. Sexual satisfaction was dichotomized into sexual "satisfaction and dissatisfaction" and associations were analysed. In total, 3798 patients (66% men) answered 8202 questionnaires. Overall, 67% reported sexual satisfaction, with women more satisfied than men (72% vs 64%, p < 0.0001). Sexual satisfaction did not differ between patients on antiretroviral treatment (ART) >6 months whether the viral load was suppressed or not. Overall, the probability of reporting sexual satisfaction increased by 4% annually (p < 0.001). This increase may be explained by evolving knowledge about the minimal risks of sexual HIV transmission when on ART together with Sweden's concomitant revision of legal restrictions. The use of patient-related outcomes in clinical practice is an important tool for facilitating conversations about sexuality in order to promote the health and well-being of PLWH.

Employment by HIV status, mode of HIV transmission and migrant status: a nation-wide population-based study

OBJECTIVE

To compare employment in people by HIV status, mode of HIV transmission and migrant status.

DESIGN

Nation-wide population-based register data from 1996 to 2016.

METHODS

All people born between 1940 and 2000 (n = 8587 629) were identified from the Swedish Total Population Register and linked to the Swedish National HIV Register (n = 9492) and Longitudinal Integration Database for Health Insurance and Labour Market Studies. Adjusted prevalence ratios (adjPR) of employment were calculated using Poisson regression. Trends in employment were illustrated in scatterplots with overlaid prediction plots.

RESULTS

People with HIV were less likely employed than HIV-negative but with decreasing difference over time [adjPR 0.57, 95% confidence interval (CI) 0.54-0.60 in 1996, adjPR 0.84, 95% CI 0.83-0.86 in 2016]. Female migrants with HIV had the highest increase of employment over time and were more likely employed than HIV-negative female migrants by end of follow-up (adjPR 1.12, 95% CI 1.08-1.16). Swedish-born with present/former intravenous drug use had the lowest employment rates. Individuals with undetectable HIV-RNA viral levels showed higher employment rates (adjPR 1.29, 95% CI 1.20-1.38) compared with those with detectable viral levels.

CONCLUSION

Employment in people living with HIV (PLWH) increased over time but remained lower than for HIV-negative people. HIV was not associated with lower employment in migrants by end of follow-up, indicating that HIV is not a barrier for employment among migrants in Sweden. The heterogeneity of PLWH needs to be taken into account in interventions, and future studies, focusing on access to the labour market in PLWH.

Longitudinal trends and determinants of patient-reported side effects on ART-a Swedish national registry study

Introduction

The use of patient-reported outcomes (PROs) to systematically quantify adverse events (AE) will assist in the improvement of medical care and the QoL of patients living with HIV (PLWH). The aim of this study was to investigate the associations between self-reported side effects and other PROs, demographics and laboratory data, and further evaluate the Health Questionnaire (HQ) as a tool for following trends in patient-reported side effects over time in relation to trends in prescribed third agent in ART.

Materials and methods

The Swedish National Registry InfCareHiv includes an annual self-reported nine-item HQwhich is used in patient-centered HIV care in all Swedish HIV units. In this study, the experience of side effects was addressed. We analyzed 9,476 HQs completed by 4,186 PLWH together with details about their prescribed ART and relevant biomarkers collected during 2011–2017. Data were analyzed using descriptive statistics, Pearson’s correlation coefficient and mixed logistic regression.

Results

The cross-sectional analysis of the HQs showed that the frequency of reported side effects decreased from 32% (2011) to 15% (2017). During the same period, there was a shift in ART prescription from efavirenz (EFV) to dolutegravir (DTG) (positive correlation coefficient r = 0.94, p = 0.0016). Further, PLWH who reported being satisfied with their physical health (OR: 0.47, p = <0.001) or psychological health (OR: 0.70, p = 0.001) were less likely to report side effects than those less satisfied.

Conclusions

Self-reported side effects were found to have a close relationship with the patient’s ratings of their overall health situation and demonstrated a strong correlation with the sharp decline in use of EFV and rise in use of DTG, with reported side effects being halved. This study supports the feasibility of using the HQ as a tool for longitudinal follow up of trends in PROs.

Study protocol: becoming and being a mother living with HIV - a multicentre longitudinal mixed methods study among pregnant women living with HIV, non-pregnant women living with HIV and pregnant women not living with HIV in a high-income setting (the 2B MOM study)

INTRODUCTION

The success of combination antiretroviral therapy has decreased the risk of perinatal HIV transmission and normalised pregnancy in women living with HIV (WLWH). Despite these advances, WLWH still face complex medical and psychosocial issues during pregnancy and postpartum, and there is a gap of knowledge on the experiences of becoming and being a mother living with HIV in today's context. The overall aim of this study is to investigate psychosocial outcomes and experiences of WLWH in Scandinavia during pregnancy and early motherhood.

METHODS AND ANALYSIS

This is a multicentre longitudinal convergent mixed methods study consisting of a quantitative survey study, a qualitative interview study and a mixed methods analysis. The survey study aims to examine psychosocial outcomes of WLWH across the pregnancy - postpartum trajectory. Participants are pregnant WLWH living in Scandinavia. Two control groups of HIV-negative pregnant women and non-pregnant WLWH are also included. Data is collected in the third trimester, 3 and 6 months postpartum using standardised questionnaires. Statistical analysis will assess changes over time and identify predictors of adverse outcomes. The interview study seeks to understand experiences of pregnancy and becoming a mother while living with HIV. Pregnant WLWH who are enrolled in the survey study will be asked to participate in individual interviews in the third trimester and 6 months postpartum. Data will be analysed using narrative analysis. The survey and interview results will be merged in a mixed methods analysis to assess confirmation, expansion or discordance between the data sets.

ETHICS AND DISSEMINATION

Approval from the Danish Data Protection Agency (VD-2018-253), and the Finnish and Swedish Ethics Committees have been obtained (HUS/1330/2019 and Dnr: 2019-04451, respectively). Study results will be disseminated to patient organisations, through publications in peer-reviewed journals and at scientific conferences.

Sexuality and childbearing as it is experienced by women living with HIV in Sweden: a lifeworld phenomenological study

The effectiveness of antiretroviral treatment has reduced sexual HIV transmission and mother-to-child-transmission. To optimally support women living with HIV, health care providers need deepened knowledge about HIV, sexuality and childbearing. The aim of this study was to describe the phenomenon sexuality and childbearing as experienced by women living with HIV in Sweden. Data were collected by phenomenon-oriented interviews with 18 HIV-positive women. A reflective lifeworld analysis based on phenomenological philosophy was conducted, describing the meaning structure of the phenomenon. The essence of the phenomenon is that perceptions about HIV and its contagiousness profoundly influence sexual habits and considerations in relation to pregnancy and childbearing. These perceptions are formed in combination with knowledge and interpretations about HIV by the women themselves and by their environments. The essence is further described by its constituents: Risk of transmission imposes demands on responsibility; The contagiousness of HIV limits sexuality and childbearing; Knowledge about HIV transmission provides confident choices and decisions; and To re-create sexuality and childbearing. Although HIV has a low risk of transmission if being well treated, our study shows that HIV-positive women feel more or less contagious, which influences sexuality and decision-making in relation to become pregnant and give birth.

The Relationship Between Stigma and Health-Related Quality of Life in People Living with HIV Who Have Full Access to Antiretroviral Treatment: An Assessment of Earnshaw and Chaudoir's HIV Stigma Framework Using Empirical Data

The aim was to empirically test the tenets of Earnshaw and Chaudoir's HIV stigma framework and its potential covariates for persons living with HIV in Sweden. Partial least squares structural equation modelling was used on survey data from 173 persons living with HIV in Sweden. Experiencing stigma was reported to a higher extent by younger persons and by women who had migrated to Sweden. As expected, anticipated stigma was related to lower Physical functioning, and internalized stigma to lower Emotional wellbeing. In contrast to that hypothesized by the HIV stigma framework, enacted stigma was not related to Physical functioning and no relationships were found between HIV-related stigma and antiretroviral adherence. These results indicate that the HIV stigma framework may need to be revised for contexts where a very high proportion of persons living with HIV are diagnosed and under efficient treatment.

Therapy Adherence and Emotional Awareness and Regulation in Persons With Human Immunodeficiency Virus

Adherence to antiretroviral therapy (ART) is a key issue for people with human immunodeficiency virus. Optimal adherence leads to benefits in terms of survival and quality of life, which do not occur with incomplete adherence. One factor that may influence adherence to ART is emotional unawareness deficits. To explore this possibility, we assessed emotional deficits and measured adherence in 100 adults using both self-report and viral load testing. Results showed that people classified as adherent in both measurements were more likely to have a greater awareness of their own emotions. Participants classified as nonadherent were more likely to have a reduced ability to recognize the emotions of others. Difficulty in recognizing one's own emotions, otherwise known as alexithymia, and impairment of the ability to recognize other's emotions may contribute to nonadherence to ART. Consequently, after repeated studies to confirm the findings, it can be considered a target for psychological therapies aimed at increasing adherence.

Patient-reported outcomes in daily clinical practise in HIV outpatient care

INTRODUCTION

The use of patient-reported outcomes (PROs) in outpatient care holds promise as a tool to enhance the quality of care. The management of chronic HIV infection is multidimensional, and clinical assessment includes broad screening to identify complications. With growing constraints on time and resources, the use of PROs may provide a much-needed tool to ensure optimal HIV care. The aim of this study was to evaluate the clinical implementation and use of a Web-based tool to collect PROs in a cohort of HIV-infected individuals.

METHODS

In December 2015, the PRO system AmbuFlex, a Web-based tool for self-reporting of clinical symptoms, was implemented in HIV outpatient care at Aarhus University Hospital. The HIV-specific questionnaire was designed to cover items in the European AIDS Clinical Society guidelines. Patients responded through a Web-based system from home. Based on an HIV-specific algorithm, responses were automatically assigned a green, yellow, or red colour code reflecting the severity of the symptom. HIV-related data from the electronic hospital management system were used to compare respondents and non-respondents. For cognitive and red symptoms, patient records were accessed to address whether PRO provided new information. Furthermore, it was sought to determine whether implementing PROs in clinical care can help focus the consultation on current needs. This was done by checking if a flagged symptom was assessed clinically at the following consultation.

RESULTS

Five hundred and five HIV patients were invited to participate and 277 (55%) accepted the invitation. Compared to respondents, non-respondents were significantly younger and more often female, born outside Denmark, newly diagnosed, and with a plasma viral load >50 copies/ml. Among the 262 correctly received PRO questionnaires, 104 (39%) had solely green colour-coded responses, whereas 59 (23%) had one or more red colour-coded responses. Of 69 red symptoms, 28 (41%) led to a specific clinical assessment. In many cases, PROs appeared to provide new information on cognitive (76%) and red-coded symptoms (42%).

CONCLUSIONS

The use of PROs identified several cases where physical or cognitive symptoms appeared to have been unnoticed. A substantial proportion of patients reported no symptoms requiring medical attention, suggesting a potential to individualize outpatient care and redistribute resource utilization.

Effect of dolutegravir in combination with Nucleoside Reverse Transcriptase Inhibitors (NRTIs) on people living with HIV who have pre-existing NRTI mutations

Until the introduction of dolutegravir (DTG), people living with HIV (PLWH) who have developed nucleoside reverse transcriptase inhibitor (NRTI) mutations have had few other treatment options outside of regimens based on ritonavir-boosted protease inhibitors (PI/r). Here we report treatment results among PLWH in Sweden with pre-existing NRTI mutations on antiretroviral treatment (ART) with DTG and one to two NRTIs. All PLWH on ART with DTG and one to two NRTIs with pre-existing NRTI mutations were retrospectively identified from the National InfCare HIV database. As controls, PLWH on PI/r and one to two NRTIs, matched according to Genotypic Susceptibility Score and observation time, were included. Data were collected as long as the study population was on treatment with DTG; controls were monitored for the same interval. Outcome was classified as either treatment success or failure. In total, 244 participants (122 individuals treated with DTG and 122 individuals treated with PI/r) were included. Median observation time was 78 weeks (interquartile range 50-98 weeks) for participants on DTG and 75 weeks (50-101 weeks) for individuals on PI/r. Viral failure was detected in four individuals treated with DTG and three individuals treated with PI/r, resulting in similar success rates of 96.7% and 97.5%, respectively. No new mutations were found among participants with treatment failure. DTG in combination with one to two NRTIs was as efficient as PI/r in individuals with pre-existing NRTI mutations in this setting. It may be considered an alternative to PI/r-based ART even in the presence of NRTI resistance.

Delivery of HIV Antiretroviral Therapy Adherence Support Services by HIV Care Providers in the United States, 2013 to 2014

BACKGROUND

Little is known about clinicians' adoption of recommendations of the International Association of Providers of AIDS Care and others for supporting adherence to antiretroviral therapy (ART).

METHODS

We surveyed a probability sample of US HIV care providers to estimate the percentage offering 3 ART adherence support services to most or all patients and assessed the characteristics of providers offering all 3 services (comprehensive support) to most or all patients.

RESULTS

Almost all providers (95.5%) discussed ART adherence at every visit, 60.1% offered advice about tools to increase adherence, 53.5% referred nonadherent patients for supportive services, and 42.8% provided comprehensive support. Nurse practitioners were more likely to offer comprehensive support as were providers who practiced at Ryan White HIV/AIDS Program-funded facilities, provided primary care, or started caring for HIV-infected patients within 10 years.

CONCLUSION

Less than half of HIV care providers offered comprehensive ART adherence support. Certain subgroups may benefit from interventions to increase delivery of adherence support.

HIV drug therapy duration; a Swedish real world nationwide cohort study on InfCareHIV 2009-2014

Background

As HIV infection needs a lifelong treatment, studying drug therapy duration and factors influencing treatment durability is crucial. The Swedish database InfCareHIV includes high quality data from more than 99% of all patients diagnosed with HIV infection in Sweden and provides a unique opportunity to examine outcomes in a nationwide real world cohort.

Methods

Adult patients who started a new therapy defined as a new 3^rd agent (all antiretrovirals that are not N[t]RTIs) 2009–2014 with more than 100 observations in treatment-naive or treatment-experienced patients were included. Dolutegravir was excluded due to short follow up period. Multivariate Cox proportional hazards models were used to estimate hazard ratios for treatment discontinuation.

Results

In treatment-naïve 2541 patients started 2583 episodes of treatments with a 3^rd agent. Efavirenz was most commonly used (n = 1096) followed by darunavir (n = 504), atazanavir (n = 386), lopinavir (n = 292), rilpivirine (n = 156) and raltegravir (n = 149). In comparison with efavirenz, patients on rilpivirine were least likely to discontinue treatment (adjusted HR 0.33; 95% CI 0.20–0.54, p<0.001), while patients on lopinavir were most likely to discontinue treatment (adjusted HR 2.80; 95% CI 2.30–3.40, p<0.001). Also raltegravir was associated with early treatment discontinuation (adjusted HR 1.47; 95% CI 1.12–1.92, p = 0.005). The adjusted HR for atazanavir and darunavir were not significantly different from efavirenz. In treatment-experienced 2991 patients started 4552 episodes of treatments with a 3^rd agent. Darunavir was most commonly used (n = 1285), followed by atazanavir (n = 806), efavirenz (n = 694), raltegravir (n = 622), rilpivirine (n = 592), lopinavir (n = 291) and etravirine (n = 262). Compared to darunavir all other drugs except for rilpivirine (HR 0.66; 95% CI 0.52–0.83, p<0.001) had higher risk for discontinuation in the multivariate adjusted analyses; atazanavir (HR 1.71; 95% CI 1.48–1.97, p<0.001), efavirenz (HR 1.86; 95% CI 1.59–2.17, p<0.001), raltegravir (HR 1.35; 95% CI 1.15–1.58, p<0.001), lopinavir (HR 3.58; 95% CI 3.02–4.25, p<0.001) and etravirine (HR 1.61; 95% CI 1.31–1.98, p<0.001).Besides the 3^rd agent chosen also certain baseline characteristics of patients were independently associated with differences in treatment duration. In naive patients, presence of an AIDS-defining diagnosis and the use of other backbone than TDF/FTC or ABC/3TC increased the risk for early treatment discontinuation. In treatment-experienced patients, detectable plasma viral load at the time of switch or being highly treatment experienced increased the risk for early treatment discontinuation.

Conclusions

Treatment durability is dependent on several factors among others patient characteristics and ART guidelines. The choice of 3^rd agent has a strong impact and significant differences between different drugs on treatment duration exist.

Validation of the Italian version of the Patient Reported Experience Measures for intermediate care services

BACKGROUND

Intermediate care (IC) services are a key component of integrated care for elderly people, providing a link between hospital and home through provision of rehabilitation and health and social care. The Patient Reported Experience Measures (PREMs) are designed to measure user experience of care in IC settings.

OBJECTIVE

To examine the feasibility and the scaling properties of the Italian version of PREMs questionnaires for use in IC services.

METHODS

A cross-sectional survey was conducted on consecutive users of 1 home-based and 4 bed-based IC services in Emilia-Romagna (Italy). The main outcome measure was the PREMs questionnaire results. PREMs for each home- and bed-based IC services were translated, back-translated, and adapted through consensus among the members of the advisory board and pilot testing of face validity in 15 patients. A total of 199 questionnaires were returned from users of bed-based services and 185 were returned by mail from users of home-based services. The return rates and responses were examined. Mokken analysis was used to examine the scaling properties of the PREMs.

RESULTS

Analysis performed on the bed-based PREMs (N=154) revealed that 13 items measured the same construct and formed a moderate-strength scale (Loevinger H=0.488) with good reliability (Cronbach's alpha =0.843). Analysis of home-based PREMs (N=134 records) revealed that 15 items constituted a strong scale (Loevinger H=0.543) with good reliability (Cronbach's alpha =0.875).

CONCLUSION

The Italian versions of the bed- and home-based IC-PREMs questionnaires proved to be valid and reliable tools to assess patients' experience of care. Future plans include monitoring user experience over time in the same facilities and in other Italian IC settings for between-service benchmarking.