Adherence to Antiretroviral Therapy, Safer Sex, and Safer Injection Drug Use Among Persons Living with HIV (Apr 20-24, 2009)

Hi Alex,

Thank you for a very enlightening presentation.

The public health professionals around Saskatchewan have expressed concern regarding the rising level of HIV in the provinces at risk communities, mostly northern communities. Many of the people contracting HIV are IV drug users sharing needles.

Since safe sexual practice discussions are basic with all clinic presented STI cases. This makes me wonder how it is possible that safe sex discussions are not mandatory in HIV clinics in Canada.

Knowing how they contracted the disease, I am interested in discovering why HIV patients do not ask their health care provider questions regarding sexual transmission of HIV and preventing the transmission to future partners. I would also want to know based on your questionnaire how many of the HIV+ patients having sexual intercourse with HIV- or HIV unknown status inform their partner of their HIV+ status. I also wonder if there is a difference between those people who reported using a condom and those that reported never using a condom.

Dissemination of the information collected requires a different approach for each audience. For health care professionals the information must be presented showing why discussions regarding safe sexual practices are important to have with HIV+ patients. The information must also discuss what information the patient needs to know, how to get the information across to the patient in the most useful way. To disseminate the information to HIV+ patients and their partners discussion and pamphlets would be needed. These would both include topics on what exactly is safe sex and why it is so important. It would also be necessary to reiterate why it is important to adhere to the antiretroviral medications.

Hi Alex, how are you doing?? Thanks for sharing your work today!!I like it a lot.
Are you considering extending the work to other places beside the clinics? I know it's not easy to find them but maybe recruitment of patients with social workers that may visit them in their homes, they could be a good mean of also delivering information in a population of people that might not visit the doctor in a regular manner. High schools seem like another good place to study. I know that what I am asking could take a complete different protocol but it may be a good complement to icrease the variety of your population.
You mentioned that you would like to provide a profile of the sexual risk behaviours of HIV+ individuals and associated psychosocial characteristics. Which characteristics are you evaluating, how are you evaluating them?
The high number of people having intercourse without condom is scary. Did you discriminate between permanent or casual partners? Anyway, that is a sign that the education for prevention should be done not only at the HIV + population. I remember when the pandemic started there were strong prevention campaigns in TV and even on the streets with big posters promoting ways to prevent the dissemination of the disease. I wonder if because we don't see anymore the patient devastated by the disease thanks to the treatments, the general public have the impression that the infection is "not that bad after all". And they don't realize that there is no cure and the treatment is hard.
As for your questions: I guess from a basic point of view and without being familiar with the topic, things like development of resistance to the treatment and effect of a reinfection with a different strain on the effectiveness of a treatment would be interesting to study in those patients.
I think there is a big need for what you are doing and I hope you can reach the policy making people, show them your numbers and they start very soon aggressive prevention campaigns.
I hope you are doing well, kind regards, Pia

Hi Pia! So good to hear from you. I hope you are well and are enjoying the spring season (is it spring there in Newfoundland yet? :)

Thanks for your thoughts re: my project. I’ll try to address the main ones you raised:

1) I think using other samples could be important, particularly since HIV+ patients are a vulnerable population which may not want to seek out traditional medical services. That being said, I think having specialized HIV clinics makes it a little easier for patients to go there as the professionals who are working there are trained to work with HIV patients and are usually sensitive to their situation. The HIV clinics where are collecting data are also unmarked (i.e., there is no sign saying it is an HIV-clinic) which may make it less stigmatizing to go there as well. But I am sure it is not always the case. From a purely methodological point of view, patients who are on antiretroviral medications (which are the majority of patients) have to see their physicians every three months or so to have their prescriptions refilled and to have their blood-work monitored, therefore it is a good place to collect data in terms of trying to cast as large net as possible.

2) In terms of the psychosocial characteristics of patients, we plan to look at demographic characteristics such as age and health status of the patient, beliefs related to the transmission of HIV (e.g., “Someone who is willing to have unprotected sex with me is probably already HIV+”), and reasons for using or not using condoms (e.g., “in the heat of the moment, it is hard to remember to use a condom”, “it is not up to me to decide whether a condom is used during sex “). We are trying to understand what might be driving the use or lack of use of condoms and other risky behaviours, but as this is one of the first studies on this topic in Canada, the main purpose of the study is to survey the current risk behaviour patterns of HIV+ individuals to provide epidemiological data, before going on to test more specific causal hypotheses.

3) We did not distinguish between casual partners and regular sexual partners, but we do ask about the number of sexual partners in the past month, which gives you a sense of their sexual relationships. The range of number of partners who were also HIV+ was from 1-7 and the range was from 1-3 for partners who were HIV-.

4) I think you may be on to something when you talk about lack of public awareness about what it is like to live with HIV. I suspect many see HIV as a thing of the ‘80s and ‘90s and that it is now something that is a problem in places far, far away such as Africa or is a problem only for marginalized groups such as IV drug users or gay men. I think it is still hard for people to see it is a disease that could be transmitted among “people like you and me.”

Among college students – not necessarily HIV+, one of the main reasons people cite that they stop using condoms and switch to birth control is that their partner does not look like they have HIV, or it has been a long enough time that they could tell if their partner had HIV (this is typically after a 3-month period). They rarely go to get tested for HIV or STIs or even ask their partner about it. I suspect this is because they do not want their partner to think that they have HIV, that they think their partner is the “type of person” who could have HIV, etc. But we can see from the results of our study that HIV was transmitted primarily by sexual means and that not all HIV+ people use condoms. So it would be very important to have a conversation with a partner about this – and I agree with you that we should target prevention efforts to the broader community as well, and not just HIV+ people. That being said, research by my supervisor, Dr. Fisher, suggests that there have been a number of prevention efforts focused on uninfected, HIV- people without the same kind of efforts focused on HIV+ people.

Interesting thoughts Pia! Thank you for contribution :)
Alex.

Jo Watson RN, MScN, ACNP
Director, Obstetrics and Gynaecology
Sunnybrook Health Sciences Centre

Hi Alex, I appreciate the work you have been doing and I wanted to answer the following question that you posed for us.

How would you approach this research topic from your discipline’s perspective? What measures and/or research methodologies and/or theoretical questions would you want to pursue?

I think that now it is known that safe sex conversations are not happening, that an intervention focused on enabling clinic staff to have these conversations could be evaluated. I recall a strategy to support obstetrical staff to ask about intimate partner abuse during antenatal visits. The strategy included education for staff as well as support for their emotional response to the topic of intimate partner abuse. These sessions gave staff the tools, and even the phrases and questions to use to begin these sensitive discussions with women. I wonder if a similar strategy could be considered for HIV clinic staff to increase their comfort in discussing safe sex with HIV positive clients?
Jo

Hello Alex,

thank you for sharing your work. It made me sad for those who may have been infected due to negligence of HIV+ persons. People tend to stick to old habits if their health and other natural and socially imposed limitations allow them to. Did you make an analysis of social layers the participants came from (perhaps based on income/education/job)? Are there differences to US, South Africa and Asia?

>Questions for Trainees
>1) How would you approach this research topic from your discipline’s perspective? What measures and/or research methodologies and/or theoretical questions >would you want to pursue?

I wonder if something like cognitive behavioural therapy (CBT) has been attempted in individuals with HIV+ to help them cope and improve their social interaction.

From OBGYN stand point, did you look if any of the HIV+ participants was married and possibly had new children since the diagnosis? If not, was this because they decided not to, or for other reasons?

>2) If you were writing up this research for dissemination, how would you frame it for (a) a research audience, (b) health care professionals who work with >HIV+ patients, (c) HIV+ patients and/or their partners? Would your approach differ depending on who you were presenting this to? Why or why not?

I think the most immediate and acute result and impact of these findings is for the public health. Hence, I would gear the dissemination towards making research audience and health care professionals more aware of the lack of 'social compliance' by HIV+ individuals with suggestions for possible solutions: e.g. CBT designs; ethical framework for ensuring that HIV- people know - it works for epilepsy and other diseases which also used to be stigmatized that people wear a wristlet/necklace to be detected by others in case they need help; why can it not work the other way around provided that work is being made to decrease stigmatization?). I would address the latter issue from practical and ethical / moral perspective, i.e., less theoretical and policy making - oriented, with c) group.

All the best to finish recruiting and analyzing the study. I hope it will find attention by all groups involved.

Martin

Hi Martin,

I think you raise some interesting questions and approaches to dissemination and hope I can adequately address your questions.

1) In my preliminary analyses there were no differences between individuals who did and did not use condoms with HIV- or HIV-status unknown partners based on income or education. But at this point, we may not have enough power to detect such differences (data collection is on-going). I think looking at socio-economic status variables / social layers is an interesting avenue for investigation though, and is something that will be pursued when we have our full data set. In one of our samples we may have a sufficient number of people who are recently immigrated to examine whether there are any differences based on country of origin. Currently, William Fisher, my mentor, is part of a large-scale study in South Africa. The social and economic realities there are quite complex and they add additional barriers to engaging in safer sex. For example, some patients rely on their partners for economic support, transportation, to get them food, etc. So it certainly adds barriers to disclosing about their HIV status.

2) You mentioned CBT as a possible avenue to enhance preventive behaviours and I think that’s a good suggestion. As I was writing to Jo above, interventions teaching HIV-care physicians to use Motivational Interviewing with their HIV+ patients have been successful in the United States. I think a CBT or Motivational Interviewing approach could be implemented successfully in Canada as well. The trick is to make it easy for physicians to deliver at every visit, so it has to be short and sweet. I think that’s where Motivational Interviewing was emphasized over CBT (because CBT can take longer to implement), but some of the principles could definitely be used.

3) In this study we do not ask if HIV+ participants are married and/or have had new children. I think this, in of itself, is an interesting topic for study and as you mentioned, examining the decision-making process of HIV+ patients and their partners would be very interesting.
I believe that the first cohort of patients who were born with HIV are just reaching 18 years of age and so looking at their decision-making around childbearing could also be very interesting.

4) I think your take on dissemination is an interesting one. I get your point about moving away from approaches that are too theoretical and not practical. I think interventions such as the one I described from the United States would be ideal and could be implemented with HIV-care physicians in Canada. I would be interested in hearing more about what you are thinking re: ethical and moral approaches to dissemination – I think it is a lack of understanding of terminology on my part. I think you are meaning public health interventions that identify HIV+ patients to others so that HIV- people will be informed regardless of whether the HIV+ person discloses to them about their status. I think the reasoning is that this would help stem the spread of HIV. Is this correct?

Part of me can see where you are coming from – there is a sense of wanting to take action and do something to prevent the spread of HIV. It is a communicable disease that results in life-long impairment. I guess I am hesitant to take the approach you mentioned with the bracelet / necklace as it is used for epilepsy and other diseases for a couple of reasons:

a) HIV is a communicable disease and so others may avoid HIV+ people or refuse to treat them for fear of contamination whereas epilepsy and diabetes cannot be passed on to others.

b) I think the purpose of wearing the bracelets for epilepsy / diabetes is to help the person in case of a medical emergency and is for their own protection whereas in the case of HIV it would be to protect others from the person.

So, I think it is important to take some kind of action but I am concerned that making HIV+ patients is wear an identifying marker is too akin to ‘branding’ them in some kind of way. For me, it is a slippery slope that could then open to door to then possibly quarantining them (as they have done in Cuba and other places in the past) and other approaches that impinge on human rights. It may also serve to further marginalize HIV+ patients and push them underground – i.e., they would be even less likely to tell others because there would be even more ramifications.

I think particularly because counseling interventions have been shown to be successful , whether via physicians or a computerized system, it would be best to implement that kind of approach and to empower and encourage HIV+ patients to practice safer behaviours.

I appreciate you voicing your thoughts on this though and would like to hear if you have any reactions to my post if you have the time.

Thank you,
Alex.

Hello Alex,

Thanks for your very interesting research, which I am sure will generate a lot of impact from a public health perspective.

Concerning your questions, now that you have valuable information from a group of HIV+ participants, I think it would be interesting to complement this information with the point of health care professionals such as nurses, clinicians, psychologists, etc. This could be used also as a strategy to deliver the information obtained from your study to health care professionals who work with HIV+ patients. As an example, you could design a survey for health care professionals starting by the presentation of your results, followed by questions about their opinion of the problem found (HIV+ patients may not be receiving the counselling and support they need to adhere to safer sexual behaviour practices), possible causes and solutions to this situation.

With the results of both studies you will have extensive arguments for convincing decision-makers to implement strategies involving formation and surveillance of health care professionals to deliver better counselling and support to HIV + patients.

Thank you againg for sharing your research to us,

Maria

Hi Alex,

Thank you for sharing your work. It is very far for my area of expertise so I’ve learned a lot. I has quite surprised to learn that there is no comprehensive research on HIV transmission by HIV+ individuals or policies geared toward the prevention of HIV transmission by HIV+ patients in Canada. It seems to me that it should be the first line of defence in the prevention of the transmission of the disease.

Was there a correlation between lack of condom use and higher adherence to antiviral medication or low viral load? In other words does healthy HIV+ individuals with a low viral load do not use the condom with HIV- partners because they perceive that “don’t have to anymore”? Did you ask if their HIV status changed their sexual behaviour (regarding safe sex practises)? What is the perception of HIV+ individuals (or among the general population) regarding the health consequences of multiple strains infection? Could it contribute to low safe sex compliance amongst HIV+ individuals with HIV+ partners?

Thanks,

Eric

Hi Alex,
Thank you for the presentation.

Since you mentioned that there is data from the US regarding this topic, I wonder if your data is different and in what aspects.
Did anyone tested different strategies to educate HIV patients regarding there behavior?

Ori

Hi Ori,

So far, our results seem to be in line with what they are finding in the United States. Patients who receive little-to-no counseling about safer sex practices do engage in unprotected sexual activity with HIV+, HIV-, and HIV-status unknown partners. What we do not yet know in Canada is whether providing patients with safer-sex counseling would help to decrease their unsafe sexual behaviours. It would be great to run this kind of study at some point.

Thanks for your question,
Alex.

Jo Watson RN, MScN, ACNP
Director, Obstetrics and Gynaecology
Sunnybrook Health Sciences Centre

Hi Alex
I wondered if any participants in your study were pregnant at the time they completed the survey. I would imagine that we know just as little about behaviours during pregnancy as we do of behaviour in general.
Jo

Hi Jo,

We did not ask participants if they were pregnant at the time of the study, but this is an interesting line of thought. I'd imagine that it would take some time to amass enough pregnant HIV+ patients to conduct meaningful analyses but it would be interesting. Perhaps you are also suggesting looking at the general sexual behaviours of pregnant women and couples (regardless of HIV-status). I agree – that would be very interesting. A brief literature search using a psychology search engine (psychinfo) suggests that most work looking at sexual behaviour and pregnancy is focused on teens and high-risk groups. I believe would be quite valuable to study sexual behaviour during pregnancy among the general population as well.

Thanks for your comments this week Jo,
Alex.

Resume.

I wanted to thank everyone for their participation this week and for their thoughtful comments. I think the themes that most stuck out for me were:

1) Surprise over the lack of a specific policy on “prevention for positives”

2) Concern over the less than 100% use of condoms by patients

3) Trying to understand why HIV+ patients may end up not using condoms

a. ideas about low viral load meaning that they cannot infect others
b. lack of understanding about the possibility of transmitting or acquiring multiple- strain infections

There were also some great suggestions for how to get health care providers involved in prevention efforts and interesting ideas for research were also proposed (i.e., studies on sexual behaviour during pregnancy).

I think the ideas and questions that were raised reflect the challenges of working in this particular area: balancing the needs and rights of individual HIV+ patients with the needs for public safety and population public health goals. Thank you for raising your thoughts, questions and concerns with me – you have given me lots to think about.

Alex.