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HIV+ persons
What are HIV+ persons’ HIV prevention needs?
revised 9/05
do HIV+ persons need prevention?
Yes. Over 1 million persons in the US are living with HIV/AIDS.1 Advances in the early diagnosis, treatment and care of HIV+ persons have helped many people enjoy increased health and longer life. Some HIV+ persons have experienced a renewed interest in sexual or drug-using activity. This can place them at risk for acquiring additional STD infections and for transmitting HIV to their uninfected partners.2 Many HIV+ persons, therefore, require programs to help them stay safe. Most HIV+ persons are concerned about not infecting others and make efforts to prevent transmission.3 However, a significant percentage of HIV+ persons struggle with prevention: from 20-50% of HIV+ persons report unprotected sex with partners who are HIV- or whose HIV status they do not know. For many HIV+ persons, the same structural, inter-personal and behavioral challenges that put them at risk for HIV persist beyond their HIV diagnosis and play a role in their inability to prevent HIV transmission.4 Prevention with HIV+ persons may include education and skills building interventions, efforts to test more persons who are HIV+ but do not know their status, support and testing for partners of HIV+ persons and integrating prevention into routine medical care.5
how is it different?
HIV prevention programs with HIV+ persons are different than programs with HIV- persons in that they must address clinical, mental and social support needs as well as build skills to prevent HIV transmission to current and future partners. Stigma. Pre-existing stigma towards gay men, women, drug users, sex workers and persons of color has helped fuel the HIV epidemic in this country by creating social conditions that foster HIV transmission.6 Added to this is the additional stigma of living with HIV. Previous experience of stigma (coming out as gay or as a drug user) may lead to trauma that impacts the ability to cope with HIV transmission.7 It is important to address these structural factors to build strength and resiliency in HIV+ communities. Disclosure. One of the foremost concerns for HIV+ persons is how, when, where and to whom to disclose their HIV status.8 The traditional message has been that HIV+ persons should always disclose their HIV status to partners. In reality, disclosure is complex and difficult. Some HIV+ persons decide not to disclose and not engage in risk behavior. HIV+ persons often fear that disclosure may bring partner or familial rejection, limit sexual opportunities or increase risk for physical and sexual violence. A survey of HIV+ persons found that 42% of gay men, 19% of heterosexual men and 17% of women had sex without disclosing their HIV status.9 HIV+ persons may disclose differently with doctors, family, friends, work colleagues and sexual and injecting partners. Responsibility. Persons with HIV live with both the experience of being infected (sometimes by someone they love and trust) and the tremendous responsibility of knowing that they can infect other people. Although the subject of responsibility is complex, prevention programs can provide support to HIV+ persons to explore and understand what it means for them individually.10
what can HIV+ persons do?
Many HIV+ persons are using strategies that limit HIV transmission. One strategy is having sex mainly with other known HIV+ persons.11 Knowing that your sexual partner is also HIV+ avoids the risk of transmission and allows for sex without consistent condom use. There have been recent concerns about superinfection among HIV+ couples, where one HIV+ person might acquire another strain of HIV from their HIV+ partner. However, superinfection among such couples appears to be rare.12 Another strategy is switching from high-risk to lower risk activities. HIV+ persons can avoid high-risk activities such as being an insertive partner (top) during anal and vaginal sex, having sex while menstruating, breastfeeding and sharing syringes. Lower risk activities can be having oral sex and being a receptive partner (bottom).11
what can my agency/clinic do?
HIV+ persons are a diverse group and require prevention programs that fit their specific needs. Programs need to see the whole person, not just sex and drug use. Relationships, employment, healthcare, housing, stigma and discrimination should be addressed as needed. Listening to HIV+ persons and involving them in the design, delivery and evaluation of programs ensures that programs are relevant and useful.13 Prevention programs with HIV+ persons can require institutional change and adjustment for agencies and clinics that may be integrating care and prevention services for the first time. Healthcare clinics may train providers and staff to deliver prevention counseling, link with prevention and social service agencies or provide referrals to agencies. Prevention programs may train staff in treatment and care issues, forge relationships with clinics and service agencies or provide referrals. It is critical for healthcare providers to maintain a non-judgmental tone about situations and behaviors with HIV+ clients.14 It is equally important to work in collaboration with HIV+ persons to develop a concrete risk reduction plan based on the client’s needs and abilities.14 Providers should be supportive, empathic, goal-oriented and focus on a client’s strengths and resiliencies. Prevention programs need to provide clients with the knowledge, skills and resources (such as condoms, clean needles and a plan to decrease alcohol and drug use) to put the risk reduction plan in place.
what’s being done?
There are currently many programs and interventions addressing prevention with HIV+ persons in service agency and clinical settings across the US. The following programs are part of the CDC’s Replicating Effective Programs initiative.15 Healthy Relationships is a five-session risk-reduction group intervention for men and women. The program focuses on developing decision-making and problem-solving skills for making informed and safe decisions about disclosure and behavior. The groups allow HIV+ persons to interact, examine their risks, develop skills to reduce their risks and receive feedback from others. Participants reported significantly less unprotected intercourse and greater condom use at six-month follow-up.16 Choosing Life: Empowerment, Action, Results (CLEAR) offers HIV+ youth 18 one-on-one 90-minute sessions with a counselor. CLEAR seeks to build motivation and enhance self-esteem so that youth can learn to choose healthy activities over self destructive behaviors. CLEAR is divided into three modules: substance use, sexual decision-making and self care. Youth also can choose telephone sessions instead of in person sessions. Youth participating reported having fewer sexual partners, using fewer drugs and feeling less emotional distress.17 CLEAR is now known as Street Smart. Partnership for Health trained staff in HIV medical clinics to provide brief, safer-sex counseling supplemented by written information and clinic posters. The program found that counseling emphasizing the negative consequences of unsafe sex helped reduce risky behaviors with patients who reported 2 or more partners.18
what needs to be done?
Prevention programs with HIV+ persons need to pay attention to structural barriers to safer sexual and drug use behavior. For some HIV+ persons, barriers may include housing instability, lack of access to HIV care and repeated incarceration. The challenges of sexual and drug risk behavior, disclosure and responsibility need to be placed in social and structural contexts that are meaningful to HIV+ persons. There is a need to further examine how early childhood and adult trauma, sexual abuse, coming out, racism and homophobia affect an HIV+ person’s ability to maintain safer behaviors. More emphasis should be placed on couples and sexual partners, both in research and in prevention programs, because sexual risk behavior among HIV+ persons is often a shared risk decision within couples/partners.19 Prevention with positives programs present the opportunity and challenge of forging relationships and integrating services in areas that have not traditionally worked together. Treatment, prevention and social services need to work in tandem, helping clients deal with the multiple issues they may face. Involving HIV+ persons is key. Prepared by Kelly Knight MEd and Carol Dawson-Rose RN PhD, CAPS
Says who?
1. Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #595. 2. Janssen RS, Valdiserri RO. HIV prevention in the Unites States: increasing emphasis on working with those living with HIV. Journal of AIDS. 2004;37:S119-S121. 3. Marks G, Crepaz N, Senterfitt JW, et al. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States. Journal of AIDS. 2005;39:446-453. 4. Crepaz N, Marks G. Towards an understanding of sexual risk behavior in people living with HIV: a review of social, psychological and medical findings. AIDS. 2002;16:135-149. 5. Centers for Disease Control and Prevention. Advancing HIV prevention: new strategies for a changing epidemic – United States, 2003. Morbidity and Mortality Weekly Report. 2003;52:329-332. 6. Herek GM, Capitanio JP, Widaman KF. Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness. Health Psychology. 2003;22:533-540. 7. Knight KR. With a little help from my friends: community affiliation and perceived social support. In HIV+ Sex. PN Halkitis, CA Gómez, RJ Wolitsky, eds. American Psychological Association; Washington DC. 2005. 8. Parsons JT, Missildine W, Van Ora J, et al. HIV serostatus disclosure to sexual partners among HIV-positive injection drug users. AIDS Patient Care and STDs. 2004;18:457-469. 9. Ciccarone DH, Kanouse DE, Collins RL, et al. Sex without disclosure of positive HIV serostatus in a US probability sample of persons receiving medical care for HIV infection. American Journal of Public Health. 2003;93:949-954. 10. Wolitski RJ, Bailey CJ, O’Leary A, et al. Self-perceived responsibility of HIV-seropositive men who have sex with men for preventing HIV transmission. AIDS and Behavior. 2003;7:363-372. 11. Parsons JT, Schrimshaw EW, Wolitski RJ, et al. Sexual harm reduction practices of HIV-seropositive gay and bisexual men: serosorting, strategic positioning, and withdrawal before ejaculation. AIDS. 2005;19:S13-S25. 12. Grant RM, McConnell JJ, Herring B, et al. No superinfection among seroconcordant couples after well-defined exposure. Presented at the International Conference on AIDS. 2004. Abst #ThPeA6949. 13. National Association of People with AIDS. Principles of HIV prevention with positives. www.napwa.org/pdf/PWPPrinciples.pdf (Accessed 4/20/06) 14. Dawson-Rose C, Shade SB, Lum P, et al. The healthcare experience of HIV positive injection drug users. Journal of Multicultural Nursing and Health. 2005;11:23-30. 15. https://www.cdc.gov/hiv/effective-interventions/index.html (Accessed 4/20/06) 16. Kalichman SC, Rompa D, Cage M, et al. Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people. American Journal of Preventive Medicine. 2001;21:84-92. 17. Rotheram-Borus MJ, Swendeman D, Comulada WS, et al. Prevention for substance-using HIV-Positive young people: telephone and in-person delivery. Journal of AIDS. 2004;37:S68-S77. 18. Richardson JL, Milam J, McCutchan A, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: A multi-clinic assessment. AIDS.2004;18:1179-1186. 19. Remien RH, Wagner G, Dolezal C, et al. Factors associated with HIV sexual risk behavior in male couples of mixed HIV status. Journal of Psychology and Human Sexuality. 2001;13:31-48.
September 2005. Fact Sheet #37ER Special thanks to the following reviewers of this Fact Sheet: Latoya Conner, Keith Folger, Mari Gasiorowicz, Trevor Hart, Gregory Herek, Jessica Merron-Brainerd, Katie Mosack, Judith Moskowitz, Lisa Orban, Robert Remien, Kurt Schroeder, Stephen Trujillo, Tim Vincent.
Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. ©Sepetmber 2005, University of California
Informal caregivers
Are Informal Caregivers Important in AIDS Care?
What do caregivers do?
Informal caregivers of people with AIDS (PWAs) provide practical help and nursing care at home. They are often the lovers, spouses, friends, or family of someone with AIDS and are not professional care providers. The service they provide is essential to the scope of AIDS care services and saves society great expense. AIDS care services in the US have shifted from hospital-based care to community-based and in-home care. Rising health care costs and many people’s preference to receive health care, and, when possible, to die at home, have driven this trend. The percentage of AIDS deaths in hospitals decreased from 92% in 1983 to 57% in 1991.1 Informal caregivers have helped make this shift possible. Caregivers provide practical support such as shopping, housekeeping, and transportation to clinics, as well as more basic assistance such as help with bathing, going to the bathroom, and feeding. As symptoms worsen, caregivers are also likely to take on more clinical roles such as keeping track of medications, giving injections, inserting catheters, and cleaning wounds.2 Caregivers often provide front-line medical and mental assessment, being the first to note changes in health and to decide when to go for help. One study found the value of personal care tasks and housework performed by caregivers equaled a per capita value of over $25,000 a year for caregiving.3
Who are AIDS caregivers?
A national survey found that 3.2% of the entire US adult population have provided care to a friend, spouse, relative, or lover with AIDS. Almost three-fourths of caregivers were under 40 years old. Caregiving was equally distributed across gender, race and ethnic groups among the general population.4 Traditionally, parents, spouses and adult daughters have been the caregivers of people with terminal illnesses. With AIDS, family members still provide care in many cases. However, with gay men, it is more often the partners and friends who provide care. A study of 265 British men with AIDS found that 87% had a close friend or partner as primary caregiver.5 What are caregiver burdens? AIDS is prevalent in young and middle-aged people; one in every four new HIV infections occurs in young people under the age of 22.6 Caregivers, also, are often in their 20s, 30s and 40s. At that age most people are traditionally building relationships and developing careers, not caring for sick people or preparing for the loss of their partner. The stress involved in this “off-time” caregiving can be enormous.2 Unlike professional care providers, informal caregivers are often on call 24-hours a day and are not protected by a limited work day or professional distance. Many informal caregivers have never cared for a seriously ill person, nor have they seen someone die. Also, caregivers must learn skills such as how to give shots or insert catheters, often under extremely stressful circumstances.2 Many caregivers of AIDS patients are also their sexual partners. This puts them at risk for HIV infection. For HIV-positive caregivers, disease progression symbolizes the loss of their partner as well as their own changing health status. Caregiving also raises the question of who will care for them when they become ill. Informal caregivers may experience numbness, compassion fatigue, or burnout from losing multiple friends and loved ones to AIDS, or from caring for someone who has been ill for a very long time. In some communities there is still fear and stigma surrounding HIV disease. In addition, people greatly affected by AIDS are often already stigmatized populations: gay men, injection drug users, African-Americans and Latinos. Caregivers may fear social rejection, loss of job and/or housing and may thus conceal their caregiving status from family, friends, and co-workers.7 For women with HIV, having responsibility for children at home may pose a barrier to obtaining caregiving support for themselves. A study of HIV-infected mothers across the US found 46% were the sole caretakers of children. Only 30% knew about child care assistance services, and only 8% had contacted those services.8 Caregiving for mothers with HIV must include the children as well as the sick mother, and address the welfare of the children after a parent dies. According to one estimate, there could be over 80,000 AIDS orphans in the US by the year 2000.9
What can be done to help?
Helping caregivers benefits both the caregiver and the patient. Professional clinicians can include the caregiver in the “triad of care”-doctor, patient, caregiver-and train them in simple medical procedures to help improve patient care.10 Caregivers can benefit from psychological help (like support groups) to help them cope with the emotional roller coaster involved in caring for a terminally ill person. Caregivers may also need support in grieving the death of a loved one. Some people may be unsure how to act around a person with AIDS, or confused about the best way to show love and support. A study of PWAs identified what they see as helpful and unhelpful actions in caregiving. Helpful actions included expressing love or concern, acting naturally, providing an opportunity for reciprocity and providing encouragement. Unhelpful actions included avoiding interaction, acting embarrassed or ashamed, breaking confidentiality, and criticizing their medical care decisions.11 Doctors and clinical staff have an excellent opportunity for primary and secondary prevention with caregivers during medical appointments or home visits.12 Informal caregivers may benefit from prevention education and assistance in staying HIV-negative. HIV-positive caregivers need information on early treatment of HIV in order to stay healthier longer. Many organizations have emerged to provide care for AIDS caregivers. Kairos Support for Caregivers and Home Care Companions Inc. in San Francisco, CA, and Gay Men’s Health Crisis in New York City, NY, provide training, educational and emotional support to caregivers with support groups, workshops, and classes. Some religious organizations, such as the HIV/AIDS Ministries Network and the National Episcopal AIDS Coalition, also provide support to caregivers.13 In Africa, many different community responses have helped AIDS caregivers. In Rwanda, a Red Cross project trains volunteers to train family caregivers in nursing skills, and to give emotional support. In Kamwokya, Uganda, where 20-30% of people 20-45 years old are HIV-positive, the religious community provides medical and material support to caregivers and also helps break down social tensions and unfounded fears in the community.14 The UCSF Coping Project, in San Francisco, CA, has been studying the physical and psychological well-being of gay male caregivers for over five years. The project found that while caregivers experience stress and depression, they also experience positive feelings associated with loving, caring and comforting. To sustain this positive well-being, the Coping Project suggests three techniques: define what is personally meaningful and valued by the caregiver; facilitate intimacy and conversation between caregivers and their partners; and help caregivers tune in to “brief human moments” that create positive feelings.2 The UCSF Care Study has also been following the caregiving experiences of over 600 friends, partners and family members.15 Prepared by Pamela DeCarlo and Susan Folkman, PhD
********** Says Who?
1. Kelly JJ, Chu SY, Buehler JW. AIDS deaths shift from hospital to home . American Journal of Public Health. 1993;83:1433-1437. 2. Folkman S, Chesney MA, Christopher-Richards A. Stress and coping in caregiving partners of men with AIDS . Psychiatric Manifestations of HIV Disease. 1994;17:35-53. Contact: Susan Folkman 415/597-9156. 3. Ward D, Brown MA. Labor and cost in AIDS family caregiving . Western Journal of Nursing Research. 1994;16:10-22. 4. Turner HA, Catania JA, Gagnon J. The prevalence of informal caregiving to persons with AIDS in the United States: caregiver characteristics and their implications . Social Science and Medicine. 1994;38:1543-1552. 5. McCann K, Wadsworth E. The role of informal carers in supporting gay men who have HIV related illness. What do they do and what are their needs? AIDS Care. 1992;4:25-34. 6. Rosenberg PS, Biggar RJ, Goedert JJ. Declining age at HIV infection in the United States . New England Journal of Medicine. 1994;330:789-790. 7. Raveis VH, Siegel K. The impact of care giving on informal or familial care givers. AIDS Patient Care. 1991;39-43. 8. Schable B, Diaz T, Chu SY, et al. Who are the primary caretakers of children born to HIV-infected mothers? Results from a multi-state surveillance project . Pediatrics. 1995;95:511-515. 9. Michaels D, Levine C. Estimates of the number of motherless youth orphaned by AIDS in the United Sates. Journal of the American Medical Association. 1992;268:3456-3461. 10. Rabkin J, Remien R, Wilson C. Good Doctors, Good Patients: Partners in HIV Treatment. New York: NCM Publishers, Inc.;1994. Contact: Robert Remien 212/966-2375. 11. Hays RB, Magee RH, Chauncey S. Identifying helpful and unhelpful behaviours of loved ones: the PWA’s perspective . AIDS Care. 1994;6:379-392. 12. D’Arrigo,T. When the caregiver has HIV: early intervention through home care . Caring. 1994;13:4,7,80. Contact: Caring Magazine 202/547-5277. 13. Contacts: Kairos Support for Caregivers 415/861-0877; Home Care Companions, Inc 415/824-3269; Gay Men’s Health Crisis 212/337-3524; HIV/AIDS Ministries Network 212/870-3909; National Episcopal AIDS Coalition 202/628-6628. 14. Anderson S. Community responses to AIDS . International Nursing Review. 1994;41:57-60. Contact: UCSF Care Study, Joe Mullan 800/350-8660. Other caregiver resources: Shelby D. If A Partner Has AIDS: Guide to Clinical Intervention for Relationships in Crisis. Binghamton, NY: Harrington Park Press;1992. Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. ©1996, University of California
Prevention in health care settings
How can HIV prevention be integrated into health care settings?
Prepared by Carol Dawson-Rose RN PhD, Janet Myers PhD MPH, and Karen McCready MA; CAPS Fact Sheet 68, July 2010Why is HIV prevention important in health care settings?
HIV prevention is an important part of health care for all individuals. It is particularly key for those at risk of becoming infected, as well as for those who are already infected, who can then avoid transmitting HIV to others and stay healthy themselves. Many strategies can be used in health care settings to optimize HIV prevention, including: assessing HIV risk; enhancing access to HIV testing; providing HIV-infected patients with disclosure and partner services; screening and treating patients for problem drinking, drug use and sexually transmitted infections (STIs); and providing the best possible care to HIV-infected individuals including access to anti-retroviral therapy (ARVs) and adherence counseling.Do health care settings have a role in finding new infections?
Health care settings are important sites for providing access to HIV testing and prevention messages, for finding new infections and for linking infected individuals into HIV care. In 2006, the CDC issued guidelines for primary health care providers suggesting expanded access to HIV testing for all patients 13 to 64 years old.1 Providing HIV testing as a routine part of care has been most productive in emergency room and labor and delivery settings,2,3 although community health centers have also provided important new access.4 Testing programs have also proven effective in helping pregnant women to not transmit HIV to their babies.3 One key strategy for expanding testing is rapid test technology.5 Rapid tests allow providers to perform a test and deliver the results in under an hour, although a confirmatory test is required for positive rapid test results. Appropriate follow-up care can be planned before the patient leaves the health care facility. Especially when HIV testing is newly introduced, providers in health care settings need to learn how to integrate HIV testing into regular care, and to refer patients for additional support services if needed. Providers should also be trained in documenting test results to ensure they are shared with other health care providers and to maintain the confidentiality of client information. Providers must ensure that HIV-infected persons get the care and support they need. Linkage to care is an important and often overlooked piece of integrating HIV testing into health care. Individuals who are just finding out they are infected often need a great deal of help and support to find an HIV provider, to make an appointment and to show up at that appointment. Intensive case management models show promise in enhancing linkages to care for newly-diagnosed individuals.6What other HIV prevention strategies work in health care settings?
Risk assessment. Assessing HIV risk behaviors should be a standard part of new patient intake, regardless of HIV status. In-depth HIV prevention education is not necessary for every patient. However, health care providers should ask all patients about their sexual behavior, condom use, number of sexual partners, and alcohol and illicit drug use to assess a patient’s risk for acquiring or transmitting HIV. These quick questions may lead to longer discussions and counseling about safer sex or alcohol and drug use practices.7 Drug treatment. Helping patients get into alcohol or drug treatment can be an effective HIV prevention tool and can help HIV-infected persons stay healthy. Health care providers can have a profound effect on patients’ lives by showing an interest in drug-using patients and encouraging willing patients to enter drug or alcohol treatment programs. Because relapse is common in treating addictions, health care providers should use a non-judgmental approach. Screening and treating for STIs. Providers should encourage screening for STIs. They should also provide STI education, emphasize the link between HIV and STIs, and encourage screening for partners.9How does positive prevention work in health care settings?
Prevention counseling. Brief prevention counseling delivered in health care settings at every visit has been shown to decrease the likelihood that HIV-infected individuals transmit HIV to others, particularly if interventions are tailored to sub-populations of HIV-infected patients.10 Important messages include: helping people understand the relative risks of their actions and the effectiveness of different prevention strategies such as using condoms; disclosing HIV status to sex and drug using partners; and understanding their responsibility with regard to prevention. Formal provider training is important to facilitate these approaches.11,12 Viral suppression. A unique component that health care settings play in HIV prevention is helping HIV-infected persons find and adhere to an effective ARV regimen to help keep their viral load low. Some research has demonstrated that keeping the viral load below a threshold that is detectable with lab tests can help prevent up to 60% of new STIs.13 New research suggests that effective detection of HIV and treatment to reduce the viral load could reduce the overall community viral load and have a population-level impact on HIV transmission.14How can HIV prevention capacity be increased in health care settings?
Risk assessment. Knowing how to assess risk among patients is key to HIV prevention of any kind. Having risk assessment tools and training providers to use them is critical. Written protocols. It is important to make sure that procedures are in place to guide testing efforts in health care settings.15 Having a “prevention plan” tailored to the clinic size, the service delivery model, the types of providers and the patient population is critical. Leadership. Successful clinic programs often have identified staff leaders who function as counselors or team leaders for positive prevention.16 Training. Underlying all of these important components is training. Training can facilitate buy-in from clinic providers and can address provider attitudes and beliefs about risk reduction and counseling.17 Training should outline staff responsibilities and anticipate changes to clinic flow.16What are effective models for use in health care settings?
Positive STEPs17 is a training intervention to help HIV care providers deliver prevention counseling to their patients. The model was effective in improving provider attitudes, comfort, self-efficacy and frequency of delivering prevention counseling. Partnership for Health18 is an EBI (CDC’s Effective Behavioral Intervention) for providers in HIV clinics. Medical providers are trained to deliver brief risk-reduction counseling to their patients. All clinic staff are trained to integrate prevention messages into the clinic setting, and counseling is supplemented with written information for all patients. The intervention was effective in reducing unprotected intercourse by 38% among patients who had two or more sexual partners. Positive Choice19 is an interactive “Video Doctor.” Patients at HIV clinics completed an in-depth computerized risk assessment and received tailored risk-reduction counseling from a “Video Doctor” via laptop computer and a printed educational worksheet. Providers received a Cueing Sheet on reported risks for discussion during the clinical encounter. Provider-Delivered Counseling.10,16 In a large federal demonstration project, brief counseling messages delivered by primary care providers in clinic settings were most effective in reducing risk among HIV-infected patients, although there were also benefits in programs delivered by prevention specialists and HIV-infected peers.What needs to be done?
Health care providers need more and repeated training on how HIV prevention can be integrated into the care they deliver. There are still significant misperceptions among health care providers about who should be tested for HIV and when to implement rapid testing. Provider attitudes, beliefs and self-efficacy can affect whether or not they address prevention through HIV testing or by providing risk-reduction counseling. Methods that enhance provider uptake of HIV prevention in health care delivery settings need attention and further research. Leaders in health care settings can establish written protocols that guide HIV prevention practices, including HIV testing in their clinics. Establishing protocols, documentation and quality assurance practices can enhance testing and prevention practices in all types of health care settings.Says who?
1. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.Morbidity and Mortality Weekly Report. 2006;55:1-17. 2. Haukoos JS, Hopkins E, Byyny RL, et al. Patient acceptance of rapid HIV testing practices in an urban emergency department: assessment of the 2006 CDC recommendations for HIV screening in health care settings. Annals of Emergency Medicine. 2008;51:303-309. 3. Tepper NK, Farr SL, Danner SP, et al. Rapid human immunodeficiency virus testing in obstetric outpatient settings: the MIRIAD study. American Journal of Obstetrics and Gynecology. 2009;201:31-36. 4. Myers JJ, Modica C, Bernstein C, Kang M, McNamara K. Routine rapid HIV screening in six Community Health Centers serving populations at risk. Journal of General Internal Medicine. 2009;24:1269–1274. 5. Branson BM. State of the art for diagnosis of HIV infection. Clinical Infectious Diseases. 2007;15:S221-225. 6. Christopoulos K, Koester K, Weiser S, et al. A comparative evaluation of the development and implementation of three emergency department HIV testing programs (forthcoming) 7. Schechtel J, Coates T, Mayer K, et al. HIV risk assessment: physician and patient communication. Journal of General Internal Med. 1997;12:722-723. 8. Bruce RD. Methadone as HIV prevention: High volume methadone sites to decrease HIV incidence rates in resource limited settings. International Journal of Drug Policy. 2010;21:122-124. 9. McClelland RS, Baeten JM. Reducing HIV-1 transmission through prevention strategies targeting HIV-1-seropositive individuals. Journal of Antimicrobial Chemotherapy. 2006;57:163-166. 10. Myers JJ, Shade S, Dawson Rose C, et al. Interventions delivered in clinical settings are effective in reducing risk of HIV transmission among people living with HIV. AIDS and Behavior. 2010;14:483-492. 11. Gilliam PP, Straub DM. Prevention with positives: A review of published research, 1998-2008. Journal of the Association of Nurses in AIDS Care. 2009;20:92-109. 12. Harder & Co. Community Research. Prevention with positives: Best practices Guide. Prevention with Positives Workgroup. 2009. 13. Porco TC, Martin JN, Page-Shafer KA, et al. Decline in HIV infectivity following the introduction of highly active antiretroviral therapy. AIDS. 2004;18:81-88. 14. Das M, Chu PL, Santos G-M, et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS ONE. 2010;5:e11068. 15. Myers JJ, Steward, WT, Koester KA, et al. Written procedures enhance delivery of HIV “prevention with positives” counseling in primary health care settings. Journal of AIDS. 2004;37:S95-S100. 16. Koester KA, Maiorana A, Vernon K, et al. Implementation of HIV prevention interventions with people living with HIV/AIDS in clinical settings: Challenges and lessons learned. AIDS and Behavior. 2007;1:S17-S29. 17. Thrun M, Cook PF, Bradley-Springer LA, et al. Improved prevention counseling by HIV care providers in a multisite, clinic-based intervention: Positive STEPs. AIDS Education and Prevention. 2009;21:55-66. 18. Richardson J, Milam J, McCutchan A, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: A multi-clinic assessment. AIDS. 2004;18:1179-1186. 19. Gilbert P, Ciccarone D, Gansky SA, et al. Interactive “Video Doctor” counseling reduces drug and sexual risk behaviors among HIV+ patients in diverse outpatient settings. PLoS One. 2008;3.Special thanks to the following reviewers of this Fact Sheet: Lucy Bradley-Springer, Kimberly Carbaugh, Mark Cichocki, Renata Dennis, Josh Ferrer, Mark Molnar, Quentin O’Brien, Jim Sacco. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©July 2010, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].
Superinfection
What do we know about HIV superinfection?
revised 5/06
what is dual infection, co-infection, superinfection?
Dual infection is when a person is infected with two or more strains of HIV. That person may have acquired both strains simultaneously from a dually infected partner or from multiple partners. A different strain of the virus is one that can be genetically distinguished from the first in a “family” or phylogenetic tree. Acquisition of different HIV strains from multiple partners is often called co-infection if all the virus strains were acquired prior to seroconversion, that is, very early before any HIV infection is recognized. Acquisition of different HIV strains from multiple partners is called superinfection if the second virus is acquired after seroconversion when the first virus strain already has been established.1 Superinfection and re-infection mean the same thing. Dual infections can be sequentially expressed, which can make co-infection look like superinfection. Sequentially Expressed Dual Infections (SEDI) may occur because immune responses against the predominant virus may allow other virus strains in the body to be expressed. Random shifts in evolving virus populations can also occur, which could look like superinfection even though dual infection was present from the beginning.
why does superinfection matter?
Superinfection is a concern because it may be a way for someone who is HIV+ to acquire drug resistance, and it may lead to more rapid disease progression.2,3 Research on when superinfection may or may not occur could identify types of immune responses that may protect against infection. This could guide the development of HIV vaccines. People who are HIV+ and have HIV+ partners often ask about superinfection. Public health officials need information about superinfection in order to craft messages that help people understand the possible risks of unprotected sexual intercourse among HIV+ persons, without creating undue anxiety that could undermine rewarding relationships between HIV+ persons and disclosure of HIV status with prospective new partners.
does superinfection occur?
Many scientists believe that superinfection can occur. Research in monkeys has indicated that superinfection with viruses like HIV can occur.4,5 Sixteen people with SEDI (apparent superinfection) have been reported in the scientific literature, including injection drug users in Asia, women in Africa, and men in Europe and the US. Laboratory analysis in some of these reports suggested that the second virus that appeared in these individuals was not present earlier in the course of infection, which suggests superinfection. The sensitivity of these laboratory assays is limited, and source partners have not been identified, so there is no way to know for sure when the second virus was acquired.
who is at highest risk?
Ninety-five percent of apparent superinfection cases have occurred during the first three years of infection.6-9 Studies have found evidence of superinfection in 2 to 5% of persons in the first year of infection. Intermittent treatment in acute or recent HIV infection may prolong superinfection susceptibility.10-11 In contrast, studies in persons with longer term infection have found no evidence of superinfection. One study found no cases after 1,072 person-years of observation.12 Another found none after 215 person-years of observation among intravenous drug users.13 A third found none after 233 person-years and 20,859 exposures through unprotected sex.14 It is possible that people with very low viral load in their blood may be more susceptible to superinfection. Low viral load in the blood can occur during combination antiretroviral therapy or in “healthy non-progressors.” Antiviral immune responses and viral interference is lower in persons with low viral load, so superinfection may occur more frequently.15 More research is needed to know for sure.
is it bad to have more than one virus?
Dual infection can have a harmful effect on the health of HIV+ persons. Superinfected individuals may have higher viral loads and lower CD4 counts, which causes more rapid disease progression.2,3 Disease progression can accelerate after a second virus appears.1 Superinfection may also affect treatment of HIV, as it increases the likelihood of drug resistance.16 HIV+ persons with dual infection may not respond as well to available antiretroviral medication due to resistant strains.
what don’t we know?
There is a lot we still do not know about superinfection. First of all, we need to be more sure whether superinfection actually occurs between HIV+ persons. A definitive case of superinfection has not been documented, which would require that the timing of the second infection be traced to initiation of a relationship with a new sexual partner. Second, we need to understand how and when superinfection occurs. Among researchers some consensus is developing about the idea that HIV+ persons in early infection–and particularly the first year of infection–may be at higher risk for superinfection than HIV+ persons with chronic infection.17 We also should determine whether persons with suppressed viral load on treatment are susceptible to superinfection. Third, we need to know how to protect against superinfection. If superinfection is rare, or if it only happens in recent infection, it is important to determine what mechanisms make an HIV+ person immune to acquiring a second virus. It would be important to know if exposure to different viral strains may provide protective immunity against superinfection.18 Lastly, we must continue to provide up-to-date scientific data on superinfection, its causes and consequences to HIV+ persons and healthcare professionals who work with them.
what can we recommend right now?
Counseling about superinfection should be based on understanding the individual’s sexual relationships. Before providing advice about superinfection, the counselor should know whether the individual is in a continuing relationship with another HIV+ partner, whether the person routinely seeks out other HIV+ partners for unprotected sex, and whether there is disclosure of HIV status with prospective partners. This background should inform the discussion about the risks and benefits of sex among HIV+ partners. If the counselor does not have time to consider these personal issues, it would probably be best to simply say that “There is not enough information available about superinfection. If superinfection occurs at all, it probably occurs in the first few years after infection. After that, it may be rare.” Even less is known about superinfection as a result of sharing needles, although it is reasonable to expect that the same pattern of initial high risk followed by low risk during chronic infection may occur. However, because intravenous drug users are at high risk of hepatitis C infections from sharing needles, efforts to obtain clean needles through needle exchange should always be emphasized. Interested persons should be referred to on-going research studies so that important gaps in information can be filled.19 People with multiple sexual partners, or partners with multiple partners, should be counseled regarding the risks of other sexually transmitted infections. Vaccination for hepatitis B and periodic testing for syphilis is warranted.
Says who?
1. Smith DM, Richman DD, Little SJ. HIV superinfection . Journal of Infectious Diseases. 2005;192:438-444. 2. Gottlieb GS, Nickle DC, Jensen MA, et al. Dual HIV-1 infection associated with rapid disease progression . The Lancet. 2004;363:610-622. 3. Grobler J, Gray CM, Rademeyer C, et al. Incidence of HIV-1 dual infection and its association with increased viral load set point in a cohort of HIV-1 subtype c-infected female sex workers . Journal of Infectious Diseases. 2004;190:1355-9. 4. Otten RA, Ellenberger DL, Adams DR, et al. Identification of a window period for susceptibility to dual infection with two distinct human immunodeficiency virus type 2 isolates in a Macaca nemestrina model . Journal of Infectious Diseases. 1999;180:673-84. 5. Fultz PN, Srinivasan A, Greene CR, et al. Superinfection of a chimpanzee with a second strain of human immunodeficiency virus . Journal of Virology. 1987;61:4026-4029. 6. Angel JB, Hu YW, Kravcik S, et al. Virological evaluation of the ‘Ottawa case’ indicates no evidence for HIV-1 superinfection . AIDS. 2004;18:331-334. 7. Smith DM, Wong JK, Hightower GK, et al. Incidence of HIV superinfection following primary infection . Journal of the American Medical Association. 2004;292:1177-1178. 8. Hu DJ, Subbarao S, Vanichseni S, et al. Frequency of HIV-1 dual subtype infections, including intersubtype superinfections, among injection drug users in Bangkok, Thailand . AIDS. 2005;19:303-308. 9. Grant R, McConnell J, Marcus J, et al. High frequency of apparent HIV-1 superinfection in a seroconverter cohort. 12th Conference on Retroviruses and Opportunistic Infections. 2005. Abst #287. 10. Altfeld M, Allen TM, Yu XG, et al. HIV-1 superinfection despite broad CD8+ T-cell responses containing replication of the primary virus . Nature. 2002;420:434-439. 11. Jost S, Bernard M, Kaiser L, et al. A patient with HIV-1 super-infection . New England Journal of Medicine. 2002;347:731-736. 12. Gonzales MJ, Delwart E, Rhee SY, et al. Lack of detectable human immunodeficiency virus type 1 superinfection during 1072 person-years of observation . Journal of Infectious Diseases. 2003;188:397-405. 13. Tsui R, Herring BL, Barbour JD, et al. Human immunodeficiency virus type 1 superinfection was not detected following 215 years of injection drug user exposure . Journal of Virology. 2004;78:94-103. 14. Grant R, McConnell J, Herring B, et al. No superinfection among seroconcordant couples after well-defined exposure. International Conference on AIDS, Bangkok, Thailand, 2004. Abst #ThPeA6949. 15. Marcus J, McConnell J, Liegler T, et al. Highly divergent viral lineages in blood DNA appear frequently during suppressive therapy in persons exposed to superinfection. 13th Conference on Retroviruses and Opportunistic Infections. 2006. Abst #297. 16. Smith DM, Wong JK, High-tower GK, et al. HIV drug resistance acquired through superinfection . AIDS. 2005;19:1251-1256.16. Gross KL, Porco TC, Grant RM. HIV-1 superinfection and viral diversity. AIDS. 2004;18:1513-1520. 17. Gross KL, Porco TC, Grant RM. HIV-1 superinfection and viral diversity . AIDS. 2004;18:1513-1520. 18. McConnell J, Liu Y, Kreis C, et al. Broad neutralization of HIV-1 variants in couples without evidence of systemic superinfection. 13th Conference on Retroviruses and Opportunistic Infections. 2006. Abst #92. 19. HIV+ persons who have HIV+ partners residing or visiting San Francisco can call the Positive Partners Study 1-415-734-4878.
Prepared by Robert M. Grant MD, J. Jeff McConnell MA Gladstone Institute of Virology and Immunology, UCSF May 2006 . Fact Sheet #56ER Special thanks to the following reviewers of this Fact Sheet: Jonathan Angel, Michael Carter, Mark Cichocki, Eric Delwart, Keith Folger, Geoffrey Gottlieb, Luc Perrin, Travis Porco, Peter Shalit, David Spach, Carolyn Williamson, Zenda Woodman. Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © May 2006, University of California
Apego a tratamientos
¿Cuál es el papel del apego en el tratamiento del VIH?
¿por qué es importante el apego?
La introducción de la terapia antirretroviral sumamente activa o altamente activa, TARSA o TARAA respectivamente (HAART, siglas en inglés) ha extendido y mejorado la calidad de vida de las personas con VIH al disminuir la carga viral, hasta niveles muchas veces imperceptibles. Sin embargo, tras descubrir que estos medicamentos requieren un apego (o adherencia) casi perfecto para evitar la replicación y mutación del virus, el entusiasmo inicial se ha menguado en cierto grado. Estudios han demostrado que la TARSA requiere un apego del 95% para lograr la supresión viral, y que incluso una disminución mínima del apego puede aumentar enormemente la carga viral.1 Si se permite la mutación del virus en cepas resistentes a medicamentos, el régimen de tratamiento puede perder su eficacia, lo cual limita las opciones de tratamiento tanto para los individuos con poco apego como para las parejas a quienes les transmitan estas cepas.2¿cómo se mide el apego?
Por lo general, el apego se mide mediante el autoinforme del paciente, el recuento de pastillas, el uso de dispositivos electrónicos en la tapa del frasco de medicamentos (tapas MEMS, siglas en inglés) y los análisis de laboratorio.3 El autoinforme que el paciente provee en visitas médicas, en cuestionarios, en entrevistas o en registros diarios de medicamentos es una manera sencilla y práctica de determinar autopercepción del apego.4 Pero muchos individuos no recuerdan si tomaron todas las pastillas, o se les olvida anotarlo en el registro todos los días. Otros pueden fingir un mayor apego para quedar bien con el entrevistador o con el proveedor médico. Asimismo, los registros podrían tener poca utilidad entre personas analfabetas. El recuento de pastillas, especialmente si se hace sin aviso previo, puede ofrecer una evaluación más exacta del nivel de apego que el autoinforme. Sin embargo, este método demanda mucho tiempo y puede percibirse como una intromisión, especialmente si se realiza durante una visita no programada a la casa del paciente. En estos casos, podría ser mejor contar las pastillas en la clínica. Las tapas MEMS registran cada ocasión en la que el paciente quita la tapa al frasco. Se ha demostrado una correlación estrecha entre la carga viral concurrente y el número de veces que se abre la tapa. Sin embargo, son costosas y pueden subestimar el apego en pacientes que saquen más de una dosis a la vez para guardarlas en organizadores de pastillas (Medi-sets).6 Todos estos métodos suponen que los pacientes de hecho se han tomado todas las pastillas extraídas del frasco. Los análisis de laboratorio miden el apego indirectamente y pueden incluir la carga viral, el recuento de las células CD4 y los niveles sanguíneos de metabolitos de los medicamentos. Estas mediciones son menos frecuentes y muy costosas. Los resultados no indican concretamente el número de dosis omitidas ni el apego al horario de los medicamentos, y pueden ser afectadas por otros factores tales como la presencia de un virus resistente a medicamentos. No obstante, muchas veces los análisis de laboratorio se consideran útiles para medir el apego cuando se usan en combinación con el autoinforme del paciente o el recuento de pastillas.¿cuáles son los obstáculos?
Es difícil seguir estrictamente un régimen de medicamentos. La mayoría de las personas tienen problemas hasta para terminar una dosis de antibióticos de 5 días. El apego se dificulta aun más cuando se toman varios medicamentos con dosis diferentes y efectos secundarios intensos y molestos como la diarrea, los daños nerviosos y los cambios en la composición corporal. La vida de muchas personas con VIH se complica por otros factores que les impiden dar prioridad al apego, tales como los trastornos de la salud mental, los problemas económicos y el uso de alcohol o drogas. Se destacan comúnmente tres tipos de obstáculos al apego: los que son específicos del régimen, los sociales/psicológicos y los institucionales.7 Las dificultades debidas al régimen, como la complejidad del tratamiento y la necesidad de tomar numerosas pastillas en diferentes horarios, así como los efectos secundarios de los medicamentos, pueden causar que se pierdan algunas dosis.8 Las exigencias del tiempo, tales como el trabajo, los viajes y el horario de las comidas también pueden ser barreras. El apego se ve afectado por factores sociales y psicológicos. Los trastornos de la salud mental (como la depresión o la angustia); las actitudes hacia el tratamiento y hacia el VIH; y el apoyo de los trabajadores de salud, familiares y amigos juegan un papel clave.9 Las reacciones positivas fomentan el apego mientras que las negativas (la falta de apoyo, el pesimismo) pueden impedirlo. Los factores institucionales como el encarcelamiento, el ambiente de la clínica y el acceso a servicios médicos y medicamentos confiables afectan al apego. Los factores que promueven el apego son un ambiente clínico agradable, un horario conveniente de citas, la confidencialidad, y la disponibilidad del transporte y del cuidado infantil.10¿qué se está haciendo al respecto?
Action Point, un centro de servicios sin cita previa en San Francisco, CA, promueve el apego en personas pobres con adicción activa a las drogas o al alcohol. Ubicado en un local que da a la calle en una zona donde los arrestos y muertes relacionadas con las drogas son muy frecuentes, Action Point opera 6 días por semana empleando un principio de reducción de daños que alienta cualquier cambio que mejore la salud. El programa ofrece manejo de casos de apego, surtido de recetas médicas, servicios de enfermería, acupuntura y recomendaciones a servicios de salud mental y del abuso de drogas o alcohol. Un mes después de la inscripción, los clientes reciben un localizador (pager) con correo electrónico para recordarles de tomar sus medicamentos. Después de seis meses, el 61% de los participantes de Action Point tomaban la terapia TARSA y el 81% de éstos reportaron un apego superior al 90%.11 En Nueva York, pacientes que nunca habían tomado TARSA participaron en un programa de tres módulos: conocimientos básicos del VIH, apego y opciones de tratamiento. Los consejeros hablaron a fondo con cada paciente sobre los posibles obstáculos al apego, las toxicidades esperadas, el trabajo de tomar las pastillas, los intervalos de las dosis y las preferencias de medicamentos. Luego de evaluar esta información, la reportaron al proveedor médico quien la aprovechó para formular un régimen individualizado. Los pacientes recibieron herramientas tales como pastilleros, tarjetas de dosificación y localizadores (bípers), según la necesidad. Tuvieron seguimiento intensivo y una línea telefónica para consultas. El programa incrementó el apego y mejoró la respuesta virológica.12 Una estrategia prometedora para promover el apego es la terapia de observación directa o TOD (DOT, siglas en inglés) que para los antirretrovirales sería TODARSA (DAART, siglas en inglés). Basada en la TOD para la tuberculosis, la TODARSA se ha usado con pacientes que tienen contacto frecuente con los trabajadores de salud, como por ejemplo en las prisiones y clínicas de metadona. Una de las complicaciones del uso de la TODARSA es la necesidad de tomar los medicamentos de por vida y por lo general más de una vez al día.13¿qué podemos hacer?
El apego a la TARSA es un proceso complicado, por lo que las intervenciones que logren aumentarlo tendrán un diseño multifacético. Se deben considerar, entre otros factores, la complejidad del régimen, los efectos secundarios, los factores asociados al paciente y hasta la relación paciente-trabajador médico, ya que todos juegan un papel en el apego al tratamiento. En general, cuanto más el régimen “se ajuste” al estilo de vida del paciente, mayor será el apego.14 Los trabajadores de salud pueden ayudar a incrementar el apego haciendo lo siguiente: involucrar al paciente en la selección de un régimen con horarios tolerables de dosificación; anticipar y manejar los efectos secundarios, identificar y tratar los problemas de salud mental y uso de drogas; responder a obstáculos concretos tales como la falta de transporte o vivienda; proporcionar recursos que estimulen la memoria y anticipar la fatiga debido al tratamiento prolongado.15 Los pacientes pueden ayudar aprendiendo más sobre el VIH, los medicamentos para tratarlo, y cómo funcionan éstos; fijándose metas no relacionadas con el VIH (ver crecer a sus hijos, mantenerse sanos y luciendo bien, etc.); reclutando amigos o familiares que vigilen su apego y anticipando los cambios de rutina, como por ejemplo los viajes.15¿qué queda por hacer?
Con el apoyo adecuado, toda persona VIH+ puede apegarse al tratamiento. Muchas personas VIH+ no sólo combaten el VIH, sino también la drogadicción, la falta de vivienda o el encarcelamiento. Con el tratamiento y las herramientas adecuadas, muchos de los obstáculos al apego se pueden superar. Por ejemplo, la depresión y otros trastornos mentales que impiden el apego óptimo deben ser diagnosticados y tratados, lo cual es posible en muchos casos. La complejidad del apego muchas veces requiere “un equipo de apego”. La colaboración entre pacientes, médicos, manejadores de casos, trabajadores sociales, farmacéuticos, consejeros y familiares o amigos es esencial.¿quién lo dice?
1. Paterson DL, Swindells S, Mohr J, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Annals of Internal Medicine. 2000;133:21-30. 2. Bangsberg DR, Deeks SD. Is average adherence to HIV antiretroviral therapy enough? Journal of General Internal Medicine. 2002;17:812-813. 3. Fogarty L, Roter D, Larson S et al. Patient adherence to HIV medication regimens: a review of published and abstract reports. Patient Education and Counseling. 2002;46:93-108. 4. Chesney MA, Ickovics JR, Chambers DB, et al. Self-reported adherence to antiretroviral medications among participants in HIV clinical trials: The AACTG Adherence Instruments. AIDS Care. 2000;12:255-266. 5. Samet JH, Sullivan LM, Traphagen ET, et al. Measuring adherence among HIV-infected persons: is MEMS consummate technology? AIDS and Behavior. 2001;5:21-30. 6. Wendel CS, Mohler MJ, Kroesen K, et al. Barriers to use of electronic adherence monitoring in an HIV clinic. The Annals of Pharmacotherapy. 2001;35:1010-1015. 7. Ickovics JR, Meade CS. Adherence to HAART among patients with HIV: breakthroughs and barriers. AIDS Care. 2002;14:309-318. 8. Altice FL, Mostashari F, Friedland GH. Trust and the acceptance of and adherence to antiretroviral therapy. Journal of Acquired Immune Deficiency Syndromes. 2001;28:47-58. 9. Gordillo V, Del Amo J, Soriano V, et al. Sociodemographic and psychological variables influencing adherence to antiretroviral therapy. AIDS. 1999;13:1763-1769. 10. Ciccarone D, Bangsberg D. , Bamberger J, et al. HIV-Related hospitalization before and during participation in ‘Action Point’ an adherence case management program. Presented at the American Public Health Association Conference. 2003. 11. Bamberger JD, Unick J, Klein P et al. Helping the urban poor stay with antiretroviral HIV drug therapy. American Journal of Public Health. 2000;90:699-701. 12. Esch L, Hardy H, Wynn H, et al. Intensive adherence interventions improve virologic response to antiretroviral therapy (ART) in naive patients. Presented at the 8th Conference on Retroviruses and Opportunistic Infections, Chicago, IL. 2001. Abst #481. 13. Lucas GM, Flexner CW, Moore RD. Directly administered antiretroviral therapy in the treatment of HIV infection: benefit or burden? AIDS Patient Care and STDs. 2002;16:527-535. 14. Chesney MA, Malow RM. Adherence in Chronic Diseases: Lessons learned from HIV/AIDS. World Health Organization volume on Adherence in Chronic Diseases. in press 15. Bartlett JA. Addressing the challenges of adherence. Journal of Acquired Immune Deficiency Syndromes. 2002;29:S2-S10. Información sobre cómo el apego afecta en la prevención en la Hoja Informativa #27 “¿Las nuevas medicinas afectan la prevención del VIH?”Preparado por Maria Ekstrand, Michael Crosby y Pamela DeCarlo, CAPS Traducción Rocky Schnaath Abril 2003. Hoja Informativa 47S