Journal Article Annotations
2018, 4th Quarter
Annotations by John Grimaldi, MD; and Mary Ann Cohen MD, FAPM
Also of interest:
The CDC has estimated that over a lifetime, 1 in 6 men who have sex with men (MSM) will be diagnosed with HIV disease. CDC 2016 surveillance data demonstrated that nearly half of new infections in the U.S. were in black and Latino MSM and over half occurred in the southeast U.S. These data, coupled with CDC estimates that HIV preexposure prophylaxis (PrEP) has not reached a large majority of the eligible population, suggest the need to target PrEP uptake in vulnerable populations. Expansion of PrEP will require confronting multiple barriers: cost, mistrust of the medical system, stigma against HIV in gay and bisexual men, and lack of knowledge and awareness among both providers as well as MSM. Serving as models for future programs, community involvement and collaboration among state and city public health agencies in New York City and San Francisco have successfully reduced rates of new infections. Fulton County, Georgia, Task Force on HIV/AIDS has expanded access to PrEP providers through community engagement and education. Rather than focus on “race and sexuality which can feel disrespectful and reductive,” a creative campaign in San Francisco focused on all aspects of an individual’s life including work, family and friends. These examples offer guidance and hope that increased access to PrEP can be achieved in vulnerable populations.
Type of study: Systematic review of qualitative studies published between 2010 and 2017 that focused on provider HIV-related stigma and its association with aspects of patient care
The finding: This systematic review identified 6 out of 619 survey-based and qualitative studies involving healthcare providers in the U.S. that met a prior inclusion criteria regarding provider HIV-related stigma and discrimination. Three important themes emerged: 1) provider attitudes, beliefs and behavior; 2) quality of patient care; and 3) education and training. Significant findings included the following: 1) limited HIV-related stigma training and holding negative beliefs about people living with HIV (PLWH) were associated with stigmatizing behaviors and attitudes; 2) providers with limited access to post-exposure prophylaxis (PEP) and fear of acquiring HIV through occupational exposure negatively affected patient care; and 3) limited training and education about HIV care facilitated provider HIV-related stigma.
Strength and weaknesses: Previous research has demonstrated the detrimental impact of provider-related bias and ideologies in non-HIV populations. This review complements this existing research and fills a significant gap in studies about ways in which provider HIV-related stigma may affect patient care and impede the patient-provider relationship. The studies also offer important guidance about potentially effective interventions to improve patient access, engagement and retention across the entire continuum of HIV care. Generalizability and interpretation of findings are limited by several factors. Several of the studies involved small sample sizes and collected data using focus groups and qualitative interviews. This method may have introduced social desirability and personal bias that computer-assisted quantitative surveys may mitigate. In considering the effect of racism and discrimination, geographic location should be accounted for. These factors may vary among U.S. geographic regions and thus have differing effects. The studies selected were limited to peer-reviewed articles published in the last 8 years and did not include studies conducted outside the U.S. Innovative interventions addressing provider HIV-related stigma in areas with limited resources may offer useful guidance for the U.S. and other resource-advantaged countries.
Relevance: Full implementation of preexposure prophylaxis and treatment as prevention are cornerstones of strategies to prevent HIV and fully engage PLWH across the entire continuum of care. Previous research has identified stigma as a significant barrier to achieving these goals. Further research in this area may lead to effective interventions that improve care by enhancing provider awareness of biases through education about HIV prevention and establishing clinical policies that address HIV-related stigma.
Type of study: Single-blinded, randomized, controlled trial conducted at six U.S. hospital-based HIV clinics from July 2011 to June 2014
The finding: This single-blinded, randomized controlled trial examined the effect of family-centered pediatric advanced care planning (FACE pACP) on HIV symptoms and suffering in 105 adolescent-family dyads. Intervention arms comprised FACE pACP and an active control. Measures of HIV symptoms and suffering and dyad treatment congruence (degree of family understanding of goals of care and end-of-life treatment preferences) were obtained at 3, 6, and 12 months post-intervention. Latent class analysis grouped patients by symptom patterns while path analysis assessed the role of dyad treatment congruence in mediating the effect of interventions on symptom patterns. Findings were as follows: 1) dyads receiving the FACE pACP intervention were more likely to agree about treatment goals and end-of-life care compared to controls (odds ratio 3.11, p=0.03); 2) based on 17 dichotomous measures of HIV symptoms and suffering, 27% of adolescents were classified into a higher symptom group and 73% fell into the lower symptom group; 3) the perceived threatened loss of desired others and objects by adolescents predicted the intervention effect on symptom classification; however, this variable did not mediate the effect on symptoms; 4) likewise, adolescents scoring higher on the religiousness scale were more likely to be in the higher symptom group. Religiousness did not moderate the FACE pACP intervention effect.
Strength and weaknesses: The study’s randomized, longitudinal, single-blinded, controlled design strengthened the validity of its findings. The protocol was culturally sensitive and the study’s positive results and high participation rate in an understudied and underserved population, suggest a role in improving health equity. FACE pACP’s manualized and structured design facilitate its use and replication in other settings. Generalizability is limited to African-Americans and Hispanic adolescents living with HIV who have an identified surrogate decision maker. The study’s one-year duration limits the applicability of its findings over the full life of adolescents living with HIV. It remains unknown whether pACP will result in goal-concordant care.
Relevance: This study targeted a vulnerable adolescent population, the majority of whom acquired HIV at birth. This group together with nonperinatally infected adolescents face the added challenges imposed by HIV of transitioning to adulthood. The study suggests the possible role of shared understanding of treatment goals and decision making in mitigating the stress of this time of transition and facilitating improved quality of care and outcomes. This study found that adolescents who experienced the perceived threat of loss of desired others or objects were more likely to experience HIV symptoms and suffering, thus suggesting a potential target for intervention. Another significant finding was a link between religiousness and HIV symptoms, especially pain, suggesting that some adolescents may benefit from a health and treatment framework that incorporates religious beliefs and interventions involving chaplaincy services. Further research may elucidate factors mediating the effect of FACE pACP and dyadic treatment agreement on HIV symptoms and suffering and examine their effect in other chronic illnesses.