The feeling of stigmatization that people living with HIV often experience doesn’t only exact a psychological toll new UCLA research suggests it can also lead to quantifiably negative health outcomes.

In a study published in the October issue of the Journal of General Internal Medicine, researchers from the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA found that a large number of HIV-positive individuals who reported feeling stigmatized also reported poor access to care or suboptimal adherence to antiretroviral therapy (ART).

In fact, individuals who experienced high levels of internalized stigma were four times as likely as those who didn’t to report poor access to medical care; they were three times as likely to report suboptimal adherence to HIV medications.

These findings were due, at least in part, to the poor mental health found among many of the participants. Researchers found that HIV stigma was one of the strongest predictors of poor access to medical care and that both HIV stigma and poor mental health predicted suboptimal adherence to medication. Adherence to HIV medications is already known to lead to better health outcomes, including survival, among people living with HIV.

“We were surprised to find that in our models, experiencing high levels of internalized HIV stigma was one of the strongest predictors of poor access to medical care, even after controlling for sociodemographics such as gender, race and ethnicity, income, insurance status, and clinical variables such as T-cell count and years since HIV diagnosis,” said the study’s lead investigator, Dr. Jennifer Sayles, an assistant professor of medicine at the David Geffen School of Medicine at UCLA and medical director of the Los Angeles County Department of Public Health’s Office of AIDS Programs and Policy.

The findings demonstrate the urgent need for more community dialogue, education and awareness about HIV and the stigma that surrounds the disease, according to Sayles.

“It also highlights the need to address some of the social and contextual aspects of HIV for those living with the disease and to develop interventions that reduce internalized HIV stigma as a barrier to care and treatment,” Sayles said.

The two-year study focused on 202 HIV-positive men and women in Los Angeles County, many of them minorities and many with limited incomes and limited education. Study participants completed anonymous surveys assessing internalized HIV stigma, self-reported access to medical care, their regular source of HIV care and ART adherence.

Overall, one-third of the participants reported experiencing high levels of stigma, and, on average, participants described experiencing or perceiving stigma slightly less frequently than “some of the time.” Additionally, 77 percent of participants said they had poor access to care, 42.5 percent reported suboptimal adherence to ART and 10.5 percent reported having no regular source of HIV care.

The researchers point to some limitations in the study. They could not establish causality between internalized HIV stigma and negative outcomes only a strong association between them. Also, the study did not directly measure social inequality, social support, self-efficacy and other similar covariates that may be related to HIV stigma. The study may also have missed people who do not access care or HIV services at all, given that study participants were recruited from community organizations providing outreach and social services to people living with HIV and from HIV clinical care sites. Finally, non-English speakers such as Latinos and Asian Americans were underrepresented in the sample.

Study co-authors include Mitchell D. Wong, Janni J. Kinsler and William Cunningham, all of UCLA, and David Martins of Charles R. Drew University of Medicine and Science.

Grants from the American Foundation for AIDS Research, the California HIV Research Program Network for AIDS Research in Los Angeles, the National Institute of Mental Health, the National Center on Minority Health and Health Disparities, and the National Institute on Aging supported this research.

The General Internal Medicine and Health Services Research Division in the department of medicine at the David Geffen School of Medicine at UCLA provides a unique interactive environment for collaborative efforts between health services researchers and clinical experts with experience in evidence-based work. The division’s 100-plus clinicians and researchers are engaged in a wide variety of projects that examine issues related to access to care, quality of care, health measurement, physician education, clinical ethics and doctor patient communication. Researchers in the division have close working relationships with economists, statisticians, social scientists and other specialists throughout UCLA and frequently collaborate with their counterparts at the RAND Corp. and the Charles Drew University of Medicine and Science.

Source: UCLA

The House on Wednesday voted 408-9 to approve legislation (S 1793) that would reauthorize the Ryan White Program, which provides health care services and other assistance to low-income people living with HIV/AIDS, CQ Today reports. The program is scheduled to expire on Oct. 30.

The measure — which the Senate passed by voice vote on Monday — would authorize $2.35 billion in funding for fiscal year 2010, with slight increases each year through FY 2013, capping at $2.7 billion. In a change from previous legislation, the bill does not include a sunset provision.

Under the legislation, states would have to track HIV cases by name rather than code by 2012. Some states currently track HIV/AIDS cases with codes or numbers for privacy reasons. In addition, the bill would set a goal of conducting five million annual HIV tests nationwide (McCarthy/Ethridge, CQ Today, 10/21). The bill also includes a provision to prevent funding decreases in communities that experience relative drops in the number of HIV/AIDS cases (Becker, “The Caucus,” New York Times, 10/21).

House Energy and Commerce Committee Chair Henry Waxman (D-Calif.) said that lawmakers “didn’t see eye to eye” on the details of the bill but that they “all agree that the HIV/AIDS epidemic isn’t a partisan issue and that the Ryan White program must continue.”

President Obama is expected to sign the bill (CQ Today, 10/21).

Reprinted with kind permission from http://www.nationalpartnership.org. You can view the entire Daily Women’s Health Policy Report, search the archives, or sign up for email delivery here. The Daily Women’s Health Policy Report is a free service of the National Partnership for Women & Families, published by The Advisory Board Company.

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Highly active antiretroviral therapy has increased the longevity and quality of life for people living with human immunodeficiency virus. But it requires strict adherence in taking the medicine, something that is extremely difficult for many individuals to do.

Two new University of Washington studies illustrate just how hard it is to make sure people take their HIV medication. One study looked at the effects of drinking alcohol on adherence and showed the risk for non-adherence was double among drinkers compared to abstainers. The second study evaluated interventions using peers, electronic pagers or both, and showed that these tools promoted no lasting improvements in adherence rates.

“HIV is unique in the adherence levels needed to be effective,” said Jane Simoni, a University of Washington psychology professor who specializes in studying adherence. She is the lead author of the pager-peer paper and a co-author of the alcohol study.

“Typical adherence for people taking medication is 50 percent. But 50 or 60 percent adherence isn’t going to work for HIV medications and will lead to resistance to the drugs. Taking drugs for HIV is a lifetime commitment; you are married to the pills,” she said.

The alcohol paper analyzed data from 40 previous studies involving more than 25,000 people and established that drinking does have a consistent effect on adherence across studies.

“Drinking quantity, more than frequency of drinking, is associated with non-adherence,” said Christian Hendershot, lead author of the alcohol study.

Hendershot is now a postdoctoral researcher at the University of New Mexico after earning his doctorate at the UW. Because the various studies had different criteria for drinking, the researchers used meta-analysis to examine three categories any drinking, moderate drinking and problem drinking. The latter was defined as meeting the National Institute on Alcohol Abuse and Alcoholism criteria for at-risk drinking 4 drinks a week or more than 4 in a day for men or meeting criteria for an alcohol use disorder.

“In general, people who drank alcohol had nearly twice the risk of non-adherence. But the risk of non-adherence went up as the level of drinking went up,” he said. “At problem levels of drinking we see a higher probability of non-adherence.”

However, Hendershot cautioned that these finding don’t necessarily hold for all people on HIV medication and who drink.

“Alcohol may have a causal effect, but there also may be other factors affecting both alcohol and adherence that partly explain the association. We need to treat people individually.”

For the peer-pager study, researchers recruited 224 patients being treated at a Seattle clinic. Patients were randomly assigned to one of four treatment groups pager, peer, combined peer-pager and treatment as usual for three months.

Patients with peer support attended twice-monthly meetings with other participants and trained HIV-positive peers who provided medication-related social support. Peers also called participants weekly to provide more one-on-one feedback. Participants in the pager group were asked to carry a customized device when they were awake. The two-way pagers came with messages that were timed to each participant’s daily medication schedule.

The pagers also sent educational, humorous and adherence assessment text messages. Participants in all four groups also received the usual care at the clinic including an educational program that provided information about the medication and adherence in a series of three meetings with a pharmacist, nutritionist and case manager.

The participants completed self reports on their adherence two weeks after the study began and again at three, six and nine months. An electronic pill cap and bottle also was used to monitor medication taking. Every three months they also had blood drawn to measure the levels of HIV and white blood cells in their system. For this study, adherence was defined as taking medication 100 percent of the time over the past seven days. The typical patient on the highly active antiretroviral therapy takes one or two pills once or twice a day.

Simoni said patients who had peer support initially showed some increased adherence levels, but this didn’t persist once the support ended. The pagers did not successfully promote adherence at any point.
“We can change adherence a little, but it disappears when the intervention is taken away,” Simoni said. “Even though you are capable of doing something that doesn’t mean you are motivated to do it all the time. Just ask anyone, ‘Did you exercise yesterday?’ ‘Floss your teeth?’ ‘Avoid sweets?’

“Add to this the complication that a person has to take these meds every day for a life-threatening disease. There is a lot of emotional baggage surrounding the disease and the pills, and the medications have severe side effects.”

So what is needed to promote better adherence?

“I wish I knew,” said Simoni. “We looked for less intensive solutions. But they didn’t work. What we need are very individualized comprehensive programs. And to sustain adherence, the intervention must be as dynamic as the changes in people’s lives.”

The studies also have broader societal implications and Simoni believes adherence will be a major problem in the years ahead as the nation’s aging baby-boom population takes its medications to stay healthy.

The studies, published in the Journal of Acquired Immune Deficiency Syndromes, were funded by the National Institute on Alcohol Abuse and Alcoholism, the National Institute of Mental Health and the UW Center for AIDS Research. Co-authors of the papers are David Huh, Cynthia Pearson, Michele Andrasik and Dr. Peter Dunbar of the UW; Susan Stoner of Talaria, Inc; David Pantalone of Suffolk University; Pamela Frick, formerly of the UW-affiliated Haborview Medical Center UW; and Dr. Thomas Hooton of the University of Miami.

Source: University of Washington