Overview and implementation of an intervention to prevent adherence failure among HIV-infected adults initiating antiretroviral therapy: lessons learned from Project HEART

Project HEART, an acronym for Helping Enhance Adherence to Retroviral Therapy, was a prospective, controlled study to develop, implement, and evaluate a clinic-based behavioural intervention to prevent adherence failure among HIV-infected adults beginning their first highly active antiretroviral therapy (HAART) regimen (N = 227). In this paper, we describe the conceptualisation of the Project HEART adherence intervention, characteristics of the participants, and lessons learned implementing HEART in an inner-city clinic setting. A multi-component intervention, HEART combined enhanced education, reminders, adherence feedback, social support and adherence-focused problem solving in an integrated manner to address common cognitive, motivational, and social barriers to adherence. Unique components of the intervention included use of participant-identified adherence support partners and a standardized adherence barriers assessment to develop and implement individualised adherence plans. Lessons learned regarding the feasibility of using participant-identified support partners were as follows. Few participants eligible for the study had trouble identifying a support partner. Over 90% of support partners attended at least one intervention visit. Support partners were most available and amenable to participate early in the initiation of therapy. Participants' experiences as the 'supported' partner were generally positive. Though many participants faced barriers not easily addressed by this intervention (for example, housing instability), formally integrating support partners into the intervention helped to address many other common adherence barriers. Family and friends are an under-utilised resource in HIV medication adherence. Enlisting the help of support partners is a practical and economical approach to adherence counselling.

Highway cowboys, old hands, and Christian truckers: risk behavior for human immunodeficiency virus infection among long-haul truckers in Florida

This paper reports the results of ethnographic research to describe risk for human immunodeficiency virus (HIV) infection among long-haul truck drivers and the contexts and factors that influence risk and protective behaviors. Drivers were selected using purposive and snowball sampling at trucking-related businesses along major truck routes in Florida. Interview information was used to categorize truckers' levels of potential risk, describe behavioral characteristics of each group, identify sex partners, and assess perceptions of the risk of HIV infection. One-third of the 71 men interviewed had frequent sexual intercourse on the road with multiple partners, but few ever used condoms. Commercial sex workers were their most frequent partners for on-the-road sex. The risk was compounded by occupational conditions, which motivated truckers to drive long hours, often using drugs to stay alert. Sex, alcohol, and drugs were perceived as quick, effective stress relievers during downtime on long, lonely trips. Despite their high-risk behaviors, truckers tended to consider themselves at low risk for HIV infection and expressed a number of misconceptions regarding HIV transmission. For example, many truckers did not associate HIV risk with heterosexual contact or think that condoms were effective in preventing HIV transmission. In addition, many truckers maintained strong homophobic and anti-government opinions that reinforced their suspicion of safe-sex messages. These findings suggest that high-risk sexual behavior is common among long-haul truckers in the US, who may be at risk for HIV infection primarily because of unprotected sexual intercourse with multiple sex partners. Also, drug use may be associated with HIV risk behavior. The authors recommend establishing prevention programs that are developed by and for truckers, determining HIV seroprevalence rates of truckers, addressing drug and alcohol abuse among truckers, and altering industry policy that keeps truckers on the road too long for their own and others' safety.