Browsing by Subject "HIV/AIDS"

Introduction: In the fourth decade of the HIV epidemic, African American women continue to be disproportionately affected by HIV across all age ranges in the U.S. African American women make up only 13% of the female population in the U.S. yet account for 64% of HIV infections among women (Aitcheson et al., 2014). African American women face multiple challenges that intersect to influence how they effectively age into older adulthood and manage their health. Due to the increased challenges experienced by older African American women across the life course, it is imperative to identify factors that may mitigate the challenges of aging with the disease. Scant research exists focusing specifically on older African American women with HIV and thus our understanding of their experiences is still quite limited. Examining the personal strengths and social resources utilized to curb the deleterious effects of aging is necessary to improve health and well-being in this population.

Purpose and Methods: The purpose of this dissertation was to advance our understanding of the experiences of African American women with HIV aging across the life course with particular attention paid to the influence of the role of social relationships on health and well-being. The purpose was achieved through exploring the challenges of aging with HIV as an African American woman and the importance of utilizing the life course perspective (Elder & Giele, 2009) to explore their experiences over time; examining the literature on the relationship between social relationships and health; and presenting two papers from the findings of a qualitative descriptive study conducted with older African American women that explored their experiences over the life course. Eighteen African American women over the age of 50 participated in this qualitative study that utilized in-depth life history interviews and timelines as the primary means of data elicitation. In the first paper, we analyzed the data for experiences with social relationships across the life course. In the second paper, we analyzed trajectories and turning points across the life course.

Results: Findings from the first paper highlight that developing and maintaining relationships over time was influenced by a variety of life course themes at the personal, relational, and structural level presented over three developmental time periods (childhood/adolescence, young/middle adulthood, and older adulthood). Women described tremendous barriers to relationship development and maintenance in both childhood/adolescence and young/middle adulthood including child sexual abuse, crack cocaine addiction, intimate partner violence, and HIV-related stigma. Women also reported having large social networks in younger years but not many important relationships. In contrast, older adulthood was described as a time with more positive social relationships, especially for those who were addicted to crack cocaine in their youth. As women aged, they built supportive networks with people they valued.

Findings from the trajectories and turning points paper show that while trajectories across participants were diverse, they were categorized into three main patterns: anchored; early struggling and upward progression; and continuously struggling. Life experiences were most dissimilar between women who experienced crack cocaine addiction compared to women who never used to drugs. The syndemic impact of substance abuse, violence, and HIV (Singer, 2009) was also important as was the cyclical nature of these co-occurring epidemics over time. Our study provides evidence that a traumatic event in early life may be the first step in the syndemic cycle.

Background: Adolescents and young people (AYP) living in Zimbabwe face an exceptionally high burden of HIV. Even with increased health intervention focusing on young people, engagement with sexual, reproductive healthcare remains low. AYP need increased attention to achieve the UNAIDS’ 95-95-95 goal for 2030. This study aims to assess the barriers and facilitators to sexual, reproductive healthcare access for adolescents and young people aged 16-24 in three districts in Zimbabwe. Methods: Seventy-five stakeholders, including AYP living with HIV, AYP with unknown or negative HIV status, family members of AYP, community gatekeepers, community- and facility-based healthcare workers, and community-based organization representatives contributed to in-depth interviews. We conducted thematic analysis on the interview summaries to assess knowledge and perceptions of sexual, reproductive health (SRH), barriers and facilitators to accessing SRH services, and challenges maintaining ART. Results: The stakeholder analysis revealed varied levels of knowledge and perceptions of SRH, and consensus about barriers and facilitators to accessing SRH services and challenges to maintaining ART. The most frequent challenges mentioned included stigma and logistical barriers, while the most frequent facilitators included a private and a youth-friendly environment. Conclusions: Based on the consensus among all stakeholders, findings from this study indicate an urgent need for youth-friendly sexual health interventions that offer a private and welcoming environment for AYP living in Zimbabwe. Additionally, this study contributes to existing literature supporting community-based sexual, reproductive healthcare interventions. This formative research can inform targeted future interventions addressing sexual, reproductive healthcare access for adolescents and young people in Zimbabwe.

Background: AIDS is the leading killer of adolescents in Africa, the continent most impacted by the AIDS pandemic. The East African nation of Tanzania is one of the top five countries with the highest burden of HIV in the world. Despite these challenges, scale up of anti-retroviral therapy (ART) has enabled millions of children infected with HIV to survive into adolescence and adulthood. These children attend family-centered and adolescent clinics where they not only receive HIV care, but also form close knit bonds with their healthcare providers and peers. As patients age into adulthood, they require to transition to the adult HIV clinic. Failure to transition results in an adolescent treatment bulge and strain on capacity in the family centered and adolescent clinics. This adolescent to adult transition period is a point of frequent loss to follow-up in the HIV care continuum, which may be partially due to fear and anxiety about the change. As clinics seek guidance on how best to manage the transition, few established protocols exist, and those available were primarily written for well-resourced settings. This study examined challenges and facilitators of the transition of care among youth living with HIV in Moshi, Tanzania.

Methods: Purposive sampling methods were used to recruit youth living with HIV who attended an adolescent specific clinic, Teen Club, and the adult HIV clinic at Kilimanjaro Christian Medical Centre. Two native Swahili speaking research assistants trained in qualitative research conducted in-depth interviews. Medical records were reviewed retrospectively to collect data on factors associated with HIV outcomes. Preliminary results were presented to key stakeholders. Youth and key stakeholders separately suggested solutions to identified challenges associated with transition of care. Results: 19 youth participated in the study. A slight majority were female (53%) and on first-line ART. Participants’ age of HIV diagnosis ranged from 5 to 18 years with a mean ART duration of 9.8 years. Barriers and facilitators of transition were categorized into four domains based on the Health Care Transition Research Consortium (HCTRC) framework. Individual domain: Barriers included long ART duration and financial constrains due to low socio-economic status. Facilitators to care were a positive perspective on living with HIV, high sense of maturity and responsibility, and good health maintenance. Family/Social Support Domain: Barriers were stigma and lack of social events in the adult clinic. Facilitators were family and peer support. Health care system domain: Barriers were lack of preparation for transition and concern about the quality of care in the adult clinic which entailed payment for services, few physicians, long waiting times and poor patient-provider communication. Environment domain: Barriers were lack of national guidelines for transition and inadequate investment in adolescent health and education by the government.

Conclusion: Transition is a complex, dynamic process influenced by many factors. With projections indicating that the number of youth living with HIV in Tanzania is likely to increase in the coming years, it is vital to develop a transition protocol that addresses the challenges identified and is feasible to implement in low resource settings. A strong protocol may influence the use of health system resources, facilitate continuity of care, and improve long term disease outcomes.

Chronic pain is a common problem among HIV-infected persons and yet data on the prevalence, character, severity and management of HIV-related pain is lacking. No studies have evaluated cross-cultural differences in perceptions of pain and its impact on the quality of life of affected patients. The goals of this study were to examine the differences in pain intensity reports and impairment in quality of life determinants attributed to pain among American, Ethiopian and Ghanaian HIV patients. We performed a multi-center cross-sectional study in 20 American, 50 Ethiopian and 51 Ghanaian HIV patients in outpatient clinics within three tertiary referral health care facilities. Pain intensity and quality of life impairment levels were measured on a 0 to 10 Likert scale. Additionally, we also assessed demographic and socioeconomic variables and clinical characteristics of HIV disease. Clinical characteristics of HIV disease, such as CD4 cell count and presence and length of ARV therapy were not significantly different among the three cohorts. However, American patients were more likely to report higher levels of pain and more quality of life impairment, despite receiving higher levels of opioid analgesics. This study confirms the role of cultural influence on pain intensity and impact of pain on quality of life among American, Ethiopian and Ghanaian patients. Further research is warranted to better understand the present findings and future studies should attempt to explore the underling mechanisms that may explain cultural differences in pain reports.

As countries transition from low income to middle income countries, they gradually lose donor aid. Donor aid for HIV in Ghana is slowly declining and more commitment from the government is expected for funding HIV/AIDS programs. Vulnerable populations are disproportionally affected by HIV and might be at greater risk as donors exit Ghana. This research used semi-structured interviews with 26 key informants to understand how vulnerable populations could be affected by the transition away from donor aid for HIV. This study found that vulnerable populations in Ghana mostly receive support from civil society organizations (CSOs) that are funded by donors. As funding transitions to government, CSOs are likely to reduce the scope of their work, and populations will lose access to some key preventative activities. In addition, HIV programs will be focused on the general population as opposed to the most vulnerable. Finally, if the transition is managed properly, involving key stakeholders at early stages of the process and ensuring partnerships between government and CSOs, it could in fact empower vulnerable populations to have increased decision-making power.

This dissertation explores strategies for reducing HIV-virion transport to mucosal surfaces to prevent HIV infection. Infection requires contact between HIV and an infectable cell, so any means of inhibiting this step could contribute to HIV prevention. Our goals were to quantify the effects of strategies that reduce transport of HIV virions and to evaluate them in the context of HIV prevention. We used fundamental transport theory to design two basic strategies: (1) modifying the effective radius of virions; and (2) modifying the native medium through which virions diffuse. We proposed to implement these strategies using (1) anti-HIV antibodies that would bind and aggregate virions and (2) topically-applied semi-solid gels that coat vaginal epithelial surfaces.

We measured diffusion coefficients of HIV virions and HIV-like particles in the presence of antibodies and within semi-solid gels. In experiments with antibodies, we did not observe reductions in the diffusion coefficients. In experiments using particle tracking to measure the diffusion coefficients of virions in vaginal gels, we found that the diffusion coefficients in gels were approximately 10,000 times lower than those in water.

We proceeded to evaluate the potential for semi-solid gels to prevent HIV transmission at mucosal surfaces. From previous experiments in our lab that characterized the topical deployment of vaginal gels in vivo, we know that vaginal gels form an uneven coating on the epithelium with gel layer thicknesses of the order of hundreds of microns. Thus, we determined whether semi-solid gels could function as physical barriers to HIV when deployed as thin, incomplete layers on the epithelium.

We developed an experimental system to test the barrier functioning of thin gel layers. We applied thin gel layers to the porous membrane of a Transwell system, and added a solution of HIV to the top compartment. After incubation, samples were assayed for levels of HIV. We found that thin gel layers reduced levels of HIV in the bottom compartment compared to controls where no gel had been applied: There was a log reduction in levels of HIV in conditions where gel layers of approximately 150 μm thickness had been applied to the membrane after 0-, 4-, and 8-hour incubation. Thus, it appears possible for gel layers of thicknesses found in vivo to function as physical barriers to HIV over biologically-relevant time scales.

We studied how nonuniform deployment of semi-solid gels affects accumulation of virions in tissue using a mathematical model. We used transport theory to develop a model of HIV diffusing from semen, through gel layers where present, to tissue. Our findings suggest that comprehensive coating of over 80% of the tissue surface area and gel layer thicknesses over 100 μm are crucial to the barrier functioning of topical gels. Under these conditions, the level of viral restriction makes a significant contribution to increasing the time required for virions to reach tissue.

Overall, the work presented here applies transport theory in the context of HIV transmission and prevention. Results contribute to theoretical and experimental frameworks that can help understand events in HIV transmission and to design and evaluate new technologies for HIV prevention.

Background: Over one million people have HIV infection in the United States (U.S.), where HIV has permeated all regions of the nation and all ethnic and racial groups. HIV transmission occurs through a number of mechanisms, many of which can be exacerbated by substance use. In 2008, nearly one in four of the HIV-positive population was in need of substance use treatment. The lives of HIV-positive substance users can be further complicated by histories of sexual and physical abuse which is related to worse overall health, health behaviors, and health outcomes.

Objective: This study explores the relationship between the age of initiation of abuse, the type of abuse, psychological symptoms that may result from abusive events, and the confidence in one's ability to communicate with a health care provider, get support from family and friends, and manage his or her mood.

Methods: In the current study, 206 HIV-positive patients were recruited from three infectious disease clinics. The participants screened positive for alcohol or substance use and, as part of a larger study, consented to twelve months of integrated HIV-substance use treatment. Using pre-intervention, baseline data, multiple regression analysis was used to examine the relationship between sexual and physical abuse during childhood and adolescence and current self-efficacy among HIV-positive substance users. Mediational analysis was used to test whether psychological symptoms mediated the relationship between abuse and self-efficacy.

Results: Because of the small sample size, individual categories of abuse were reported but interpretations of these results could not be justified. The primary focus of the discussion focused on individuals who experienced any abuse before the age of 19. Any abuse was not directly associated with one's confidence to communicate (p=0.78). In the relationship between any abuse, psychological symptoms, and communication self-efficacy, anxiety and depression trended towards significance (Banxiety=-0.03, p=0.06; Bdepression=-0.02, p=0.10), but was not a mediator of the relationship. Any abuse was not directly associated with one's confidence to seek support from others (p=0.35). When accounting for psychological symptoms, depression was associated with one's confidence to seek support (B=-0.06, p=0.01). Results were inconclusive for determining a mediation relationship. Any abuse trended toward significance of being negatively associated with one's confidence to manage one's mood (B=-0.34, p=0.11). In the relationship between any abuse, psychological symptoms, and mood management self-efficacy, anxiety and depression were associated with one's confidence to manage one's mood (Banxiety=-0.08, p=0.01; Bdepression=-0.06, p=0.01), but were not mediators of the relationship.

Conclusion: The findings suggest that one's confidence to apply positive health behaviors are tied to psychological symptoms and may be tied to histories of abuse. This study suggests that efforts to improve health behaviors should focus on one's self-efficacy in communicating with health care providers, seeking support from others, and managing one's mood. Additional efforts should be made to address symptoms of depression and anxiety and particularly the correlation that abuse may have in aggravating these symptoms.

Abstract

Background

Significant delay occurs in initiating cancer treatment worldwide. In Uganda, there has been an increase in HIV/AIDS related malignancies due to the large number of people with HIV/AIDS. One particular cancer that has had a very large increase in prevalence is Kaposi Sarcoma. Despite the availability of chemotherapy for Kaposi Sarcoma at the Uganda Cancer Institute, many patients will present with advanced disease. Most studies on delay in cancer have been done in developed countries and very few have been done in Africa. Even fewer studies have been done in the context of HIV/AIDS and KS where patients are under continuous care. This study sought to establish the causes of treatment delay and describe the pathway to care in KS patients in Uganda.

Methods

The study was a cross sectional study carried out at the Uganda Cancer Institute. The study enrolled adult consenting patients that presented to the Uganda Cancer Institute with histologically diagnosed Kaposi Sarcoma. The study used an interviewer-administered survey that comprised questions on demography, socio-economic status as well as different aspects of HIV/AIDS and KS care. The study lasted from July to August 2011.

Findings

180 patients were enrolled in the study, and 27% experienced delays in treatment initiation lasting more than 3 months. 44% of the study participants used traditional healers and of these, 33% experienced delays greater than 3 months (P value=0.05) compared to 23% in those that did not use traditional healers. The odds of delay in those who visited traditional healers was 2 times the odds of delay in those who did not use traditional healers (P Value= 0.07). Other factors that were correlated with delay were education status, attendance of HIV care clinics, use of HAART and marriage.

Discussion

Treatment delay still remains a significant problem in cancer patients in Uganda despite the increasing knowledge about cancer, and in HIV/AIDS related malignancies, despite the availability of evaluation in HIV care clinics. Some of the factors responsible for treatment delay use of traditional healers, and knowledge of cancer and the potential care, which is available. It is important that we address the lack of knowledge about cancer symptoms in the patients if we are to address treatment delay sufficiently. It is also imperative that we address the challenges in the health care systems that contribute to delay in order to ensure access to diagnostic and treatment services.

Lao People's Democratic Republic (Laos) faces a unique set of supply chain challenges for HIV and malaria control. Although the HIV and malaria prevalence rates are relatively low, the country has struggled to maintain an adequate supply of HIV and malaria commodities throughout the country, resulting in delays or stock outs of key commodities for both diseases. Supply chains in developing countries are often strained and weak, but creating sustainable procurement and supply chain management (PSM) processes is vital to the overall success of a county's health system. Poor PSM practices are reflective of and reinforced by a weak health system, and Laos, like other low-income countries, is confronting many PSM challenges. The Global Fund to Fight AIDS, Tuberculosis, and Malaria heavily supports both the HIV and malaria programs in Laos and is now placing increased emphasis on improving PSM processes in grant recipient countries. Research on supply chains in developing countries is scarce and in-depth, country-level analysis of challenges and barriers to successful PSM is essential to improving the long-term sustainability of health systems. The aim of this research is to improve supply chain management for HIV and malaria control programs. The specific objectives are:

1. To identify barriers and bottlenecks through a situation analysis of Laos' supply chains for national HIV/AIDS and malaria control programs.

2. To analyze factors affecting HIV/AIDS and malaria supply chains in Laos.

3. To suggest policy recommendations for the WHO, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Lao Ministry of Health, and other institutional or organizational stakeholders for improved supply chain management and function.

Qualitative research was conducted in Vientiane Capital and Savannakhet Province in May-July 2012 and included 41 key-informant interviews, document review, and informal observations. Data collection and analysis were primarily guided by the USAID