"It's a hidden issue": exploring the experiences of women with HIV-associated neurocognitive challenges using a disability framework

"A fog that impacts everything": a qualitative study of health-related quality of life in people living with HIV who have cognitive impairment

Background

Cognitive impairment (CI) in people living with HIV (PLWH) is an important health concern in the context of an ageing HIV population. Impacting 14–28% of PLWH, CI is associated with lower health-related quality of life (HRQoL), however, evaluation of the illness-specific factors comprising HRQoL in PLWH with CI have not been assessed.

Objective

We sought to contribute evidence toward an understanding of HRQoL and identify domains of HRQoL in PLWH with CI.

Methods

Qualitative interviews with 25 PLWH with objective CI related to HIV disease were conducted with participants attending HIV clinics in the UK. Clinically significant CI was defined based on The European AIDS Clinical Society guidelines, requiring: (i) subjective reporting of cognitive symptoms; (ii) symptoms to be related to HIV (e.g. potentially confounding non-HIV related conditions have been excluded or are being optimally managed) and; (iii) formal neuropsychological assessment confirming CI. Median age was 56 years (range 35–80); 18 participants were men (72%); 11 (44%) were white British and 8 (32%) were Black African; 14 (56%) were men that have sex with men and 10 (40%) were heterosexual; median number of years living with HIV was 17 (range 1–34); and all participants were on combination antiretroviral therapy. Analyses employed techniques from grounded theory, underpinned by an inductive, collaborative team-based approach.

Results

Findings revealed seven interrelated domains comprising HRQoL experiences were identified: Physical function, Cognition, Social connectedness, Physical and mental health, Stigma, Self-concept, and Control and acceptance, and each was defined by specific descriptive components.

Conclusion

This study provides valuable insights on the factors that drive HRQoL in PLWH with CI and contribute to a body of evidence which provides targets for the development of targeted interventions to maintain or improve quality of life.

Strategies Employed by Community-Based Service Providers to Address HIV-Associated Neurocognitive Challenges: A Qualitative Study

Background:

HIV-associated neurocognitive disorders and other causes of neurocognitive challenges experienced by people living with HIV (PLWH) persist as public health concerns in developed countries. Consequently, PLWH who experience neurocognitive challenges increasingly require social support and mental health services from community-based providers in the HIV sector.

Methods:

Thirty-three providers from 22 AIDS service organizations across Ontario, Canada, were interviewed to determine the strategies they used to support PLWH experiencing neurocognitive difficulties. Thematic analysis was conducted to determine key themes from the interview data.

Results:

Three types of strategies were identified: (a) intrapersonal, (b) interpersonal, and (c) organizational. Intrapersonal strategies involved learning and staying informed about causes of neurocognitive challenges. Interpersonal strategies included providing practical assistance, information, counseling, and/or referrals to PLWH. Organizational strategies included creating dedicated support groups for PLWH experiencing neurocognitive challenges, partnering with other organizations with services not available within their own organization, and advocating for greater access to services with expertise and experience working with PLWH.

Conclusion:

Through concerted efforts in the future, it is likely that empirically investigating, developing, and customizing these strategies specifically to address HIV-associated neurocognitive challenges will yield improved social support and mental health outcomes for PLWH.

The relationship between stigma and a rehabilitation framework [international classification of functioning, disability and health (ICF)]: three case studies of women living with HIV in Lusaka, Zambia

PURPOSE

To explore how the International Classification of Functioning, Disability and Health, a rehabilitation framework, can provide a holistic understanding of stigma experiences of three women living with human immunodeficiency virus in Lusaka, Zambia.

METHODS

A secondary analysis of three cases by drawing on interview transcripts collected as part of a larger longitudinal study with eighteen women living with the virus. The interview tool used the rehabilitation framework to ask questions about the impact of the virus on the body, daily activities, social participation and the future. Vignettes were produced for each of the eighteen women including information on stigma and the rehabilitation framework. Three case studies were developed from women who provided comprehensive accounts of stigma and the International Classification of Functioning, Disability and Health.

RESULTS

Stigma experiences aligned well with three dimensions of the International Classification of Functioning, Disability and Health: participation restrictions, environmental and personal factors. These domains were used to understand stigma in three forms (i.e. enacted, self and structural stigma) as experienced by these women.

CONCLUSIONS

More research is needed to ascertain how stigma and rehabilitation are related in other environments and populations and to explore how to mitigate stigma within the rehabilitation context.IMPLICATIONS FOR REHABILITATIONRehabilitation professionals deal with aspects of stigma and discrimination in their clinical work and this analysis offers a way to consider HIV-related stigma within rehabilitation in an organized and theoretically-informed way.The insights from this study are important for the field of HIV and for advancing understanding of the complexities of stigma in the context of rehabilitation more broadly.This analysis offers guidance to rehabilitation providers about the nuanced and multi-faceted ways that stigma can occur in the context of rehabilitation, including within their own clinical practice.

Use of Living Strategies among Adults Aging with HIV in Canada: Comparison by Age-Group Using Data from the HIV, Health and Rehabilitation Survey

Objective:

To examine the type and frequency of living strategies used by adults living with HIV.

Methods:

We conducted a cross-sectional web-based survey that included 51 living strategies: maintaining sense of control, attitudes and beliefs, blocking HIV out of the mind, and social interaction. We examined the frequency of use and compared the proportion of respondents who engaged in strategies across 3 age-groups (<40 years, 40-49 years, and ≥50 years).

Results:

Of the 935 participants, the majority were men (79%) and most (≥60%) engaged “most” or “all of the time” in healthy lifestyle strategies and maintained a positive outlook living with HIV. Compared to younger participants, a higher proportion of older adults (≥50 years) engaged “most” or “all the time” in strategies that involved maintaining control over health and adopting positive attitudes and outlook living with HIV.

Conclusions:

Findings can help to inform the role of self-management to enhance successful aging with HIV.

Disability Among Middle-Aged and Older Persons With Human Immunodeficiency Virus Infection

Background

Older human immunodeficiency virus (HIV)-infected adults may experience higher rates of frailty and disability than the general population. Improved understanding of the prevalence, risk factors, and types of impairment can better inform providers and the healthcare system.

Methods

HIV-infected participants within the AIDS Clinical Trials Group A5322 HAILO study self-reported disability by the Lawton-Brody Instrumental Activities of Daily Living (IADL) Questionnaire. Frailty was measured by 4-m walk time, grip strength, self-reported weight loss, exhaustion, and low activity. Logistic regression models identified characteristics associated with any IADL impairment. Agreement between IADL impairment and frailty was assessed using the weighted kappa statistic.

Results

Of 1015 participants, the median age was 51 years, 15% were aged ≥60 years, 19% were female, 29% black, and 20% Hispanic. At least 1 IADL impairment was reported in 18% of participants, most commonly with housekeeping (48%) and transportation (36%) and least commonly with medication management (5%). In multivariable models, greater disability was significantly associated with neurocognitive impairment, lower education, Medicare/Medicaid insurance (vs private/other coverage), smoking, and low physical activity. Although a greater proportion of frail participants had IADL impairment (52%) compared to non-frail (11%) persons, agreement was poor (weighted kappa <0.18, 95% confidence interval, 0.13, 0.23).

Conclusion

IADL disability occurs frequently among middle-aged and older HIV-infected adults on effective antiretroviral therapy. Potentially modifiable risk factors (smoking, physical activity) provide targets for interventions to maintain independent living. Systematic recognition of persons at greater risk for disability can facilitate connection to resources that may help preserve independence.

"I'm Just Forgetting and I Don't Know Why": Exploring How People Living With HIV-Associated Neurocognitive Disorder View, Manage, and Obtain Support for Their Cognitive Difficulties

HIV-associated neurocognitive disorder (HAND) is common, but the lived experience of HAND is not well-understood. In this descriptive qualitative study, we explored how adults with HAND view, manage, and obtain support for cognitive difficulties. We interviewed 25 participants (20% female; median age = 51 years) who were diagnosed with HAND using neuropsychological assessment and a clinical interview. Semistructured interviews, co-developed with community members living with HIV, focused on how cognitive difficulties manifested and progressed, impacted well-being, and were discussed with others. We analyzed interview transcripts using a team-based, thematic approach. Participants described concentration, memory, and multitasking difficulties that fluctuated over time, as well as potential risk factors, management strategies, and psychosocial consequences. They reported they seldom discussed cognitive impairment with health care professionals, and that receiving a HAND diagnosis was validating, informative, yet somewhat disconcerting. Conversations between health care professionals and people living with HIV about HAND may provide opportunities for education, assessment, and support.

Sustaining people with dementia or mild cognitive impairment in employment: A systematic review of qualitative evidence

Introduction

The World Health Organization estimates that 10% of the 35.6 million people worldwide with dementia are aged under 65 years. In an ageing workforce this has implications for employers, employees, and statutory and third sector services. Limited research has been conducted into this emerging global issue.

Method

This systematic review, employing the methodology of the Joanna Briggs Institute, aimed to identify and synthesise the best available qualitative evidence regarding the needs, experiences and perspectives of people with early onset dementia or mild cognitive impairment who were either in employment or wished to gain employment.

Results

Of 69 studies identified, eight met the inclusion criteria. From these, four themes emerged: disease progression and recognition; the emotional impact of change; the employer’s management of the worker; and changes to the worker role.

Conclusion

There are health benefits to the individual with dementia or mild cognitive impairment of continuing to engage in meaningful occupation. Retirement policy changes have resulted in an ageing workforce with concurrent risk factors for dementia. A lack of understanding of reasonable adjustments and sheltered employment opportunities was evident from the literature. This review highlights the potential for occupational therapists to engage this client group in vocational rehabilitation.

The DEPICT model for participatory qualitative health promotion research analysis piloted in Canada, Zambia and South Africa

Health promotion researchers are increasingly conducting Community-Based Participatory Research in an effort to reduce health disparities. Despite efforts towards greater inclusion, research teams continue to regularly exclude diverse representation from data analysis efforts. The DEPICT model for collaborative qualitative analysis is a democratic approach to enhancing rigour through inclusion of diverse stakeholders. It is broken down into six sequential steps. Strong leadership, coordination and facilitation skills are needed; however, the process is flexible enough to adapt to most environments and varying levels of expertise. Including diverse stakeholders on an analysis team can enrich data analysis and provide more nuanced understandings of complicated health problems.

"My body's a 50 year-old but my brain is definitely an 85 year-old": exploring the experiences of men ageing with HIV-associated neurocognitive challenges

INTRODUCTION

Research investigating HIV, neurocognition and ageing is well developed using neuropsychometric or other quantitative approaches; however, little is known about individuals' subjective experiences. The purpose of this article is to explore the experiences of men aged 50 and older who self-identify as having HIV-associated neurocognitive challenges. In particular, this study uses the Episodic Disability Framework (EDF) to explore participants' perceptions regarding: 1) symptoms/impairments, difficulties with day-to-day activities, challenges with social inclusion and uncertainty; 2) ageing as related to their HIV-associated neurocognitive challenges, and 3) the episodic nature of their HIV-associated neurocognitive challenges.

METHODS

This qualitative, interpretive study involved in-depth, semi-structured interviews with 12 men aged 50 years and older who self-identified as having HIV-associated neurocognitive challenges. Participants were recruited from a neurobehavioural research unit (NBRU) at a large hospital in Toronto, Canada. Data were analyzed thematically and with reference to the EDF.

RESULTS

Participants' experiences reflected all concepts within the EDF to some extent. Difficulties with daily activities were diverse but were addressed using similar living strategies. Participants described challenges with work and social relationships resulting from neurocognitive challenges. Participants downplayed the significance of uncertainty in their lives, which they attributed to effective living strategies. Most men reported confusion regarding the link between their neurocognitive challenges and ageing. Others discussed ageing as an asset that helped with coping.

CONCLUSIONS

This is the first study to use a disability framework to examine the subjective experiences of men ageing with HIV-associated neurocognitive challenges. Findings reframe the episodic disability experienced by these individuals as being predictably linked to certain triggers. As such, support for managing neurocognitive challenges could focus on triggers that exacerbate the condition in addition to the impairments themselves. The study also describes ageing as not only a source of problems but also as an asset among men growing older with HIV.