Effectiveness of HIV-Aids Prevention and Intervention Policies - Research Paper Example

EFFECTIVENESS OF HIV/AIDS PREVENTION AND INTERVENTION POLICIES: AN ASSESSMENT USING THE COCHRANE METHODOLOGY Background The numbers of HIV-infected persons and those that develop AIDS steadily rise worldwide, and the US is no exemption. While the government is able to provide funds through the Ryan White CARE Act by allocating $2.1 billion dollars annually for the care and support of HIV-positive and AIDS patients, and the availability of antiretroviral therapy has already increased, there is still an observed increase in the number of patients that become infected of the virus. Policies may be lacking certain initiatives or may be demoralizing HIV-positive persons, which means that revamps in the existing law and policies needed to be looked into. This review aims to show some policies that were implemented regarding HIV/AIDS intervention and prevention methods, along with the published results and expected outcome of the implementations. Methods and Findings Due to the limited number of journals that discuss both policies and the direct results of the implementation of these policies, the review is only able to provide three studies that studied qualitative and quantitative data both from interviews and anonymous surveys completed by HIV seropositive patients, as well as assessment of policy amendments in all 50 states and the District of Columbia in complying with the recommendations by the CDC regarding increase in patient autonomy pertaining to HIV testing, opting out from mandatory tests, and their consent before undergoing such tests. Seven journals discuss possible policy changes with regards to amending existing policies on HIV care and treatment, surveillance of patients and assessing whether they entered treatment after identifying their HIV serotype or not, strengthening goals and strategies in the efforts of preventing and intervening the increase in the number of HIV cases each year, and by reaching out to high-risk populations and initiating early HIV testing, treatment and management so as to further decrease the risk of transferring the virus to others. It is presumed that the studies for these papers were not finished as of date due to the lack of statistically-processed data and results. Nevertheless, the policy amendments that were presented in these seven papers were derived from some scientific and behavioral studies, which show that some policy and lawmakers were already exerting efforts in integrating scientific and behavioral studies’ recommendations to increase the effectiveness of future HIV intervention and prevention methods. Conclusions Based on this review, aside from relying solely from feasibility studies and studying the economic aspects of HIV and AIDS prevention methods and interventions, there must also be utilization of both medical and behavioral methods of treatment. Some studies were supported by scientific data from national health institutions and local or state-funded researches, however the need to address the behavioral aspect of treatment such as awareness campaigns, support groups, uplifting the morale and reducing the effects of social stigma among HIV-positive persons must also be given emphasis, since doing risky sexual behaviors along with a lack of a positive perspective and sense of responsibility in living with the infection causes the spread of the virus to HIV-negative persons. It is recommended that the impact of existing or amended HIV and AIDS policies be looked into for future studies to assess the effectiveness, or to see whether better and much more humanitarian policies may be made to further encourage HIV-seropositive persons to enter treatment and be even more responsible with their sexual behaviors, as well as educating the rest of the public as to what HIV and AIDS really are, to help them become supportive of disease prevention with respect for the human rights of HIV and AIDS patients. Effectiveness of HIV/AIDS Prevention and Intervention Policies: An Assessment Using the Cochrane Methodology Thirty years after the first outbreak of the disease, Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) is still an ever-rising global epidemic. As of 2008, it has been estimated that there has been an occurrence of nearly 3 million new cases worldwide (Kurth, et al., 2011). In the United States, as many as 1.2 million individuals are living with the disease, with around 30% living with HIV, 30% already suffering from AIDS, and the rest either having HIV or AIDS but unaware of their serotype status (Lubinski, et al., 2009). The numbers steadily rise annually, despite the implementation of policies which aim to prevent further spread of the disease. While the availability of treatment options such antiretroviral therapy (ART) have increased due to technological advances, and that governmental support have been possible by allocating as much as $2.1 billion dollars annually through the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act for the treatment of patients with HIV and those suffering from AIDS, there is still a perceived need to revise policies such as the criminalization of non-disclosure of HIV-seropositive status as necessary, the improvement of state statues in order to prevent stigmatization, demoralization, and discrimination of and against HIV-positive persons, improve coordination between funding agencies and agencies that provide HIV support services such as treatment and counseling, and to improve the programs in order to respond to the increasing needs to address the HIV epidemic, among others (Fagan, et al., 2010; Mahajan, et al., 2009; Millet, et al., 2010; Mugavero, et al., 2011; Rotheram-Borus, et al., 2008). The lack of improvement in these areas were seen as hindrances in strengthening of the country’s fight against the spread of HIV, especially with regards to the affected person’s possibility of being discriminated against due to the condition. While there are numerous researches with regards to the effectiveness of HIV behavioral interventions and health-awareness methods, these results are rarely used as bases for the creation of policies that empower HIV-positive persons and AIDS-patients (Rotheram-Borus, et al., 2009). This aspect of treatment has been neglected, despite the rapid advancements in antiretroviral treatments and improvement of care methods. The lack of support for the positive behavior of patients, as well as failing to sustain the patients’ follow-up visits due to lack of motivation prevents HIV-positive patients from continuing their ART, as well as the lack of continuous behavioral conditioning not only keeps them from getting treated properly for their infection, but also these keeps them from doing risky behaviors, which in turn puts their sexual partners at even higher risks of contracting the virus (Fisher, et al., 2010; Mugavero, et al., 2011; Rotheram-Borus, et al., 2008). It is necessary that aside from focusing on advancing the treatment of the virus, other methods such as behavioral modification for the patients, and revision of policies to reflect humanitarian values in the treatment of HIV and AIDS must also be considered. Objectives This review aims to show some policies in the US regarding HIV/AIDS and whether or not these policies were able to address the concerns regarding the education of all members of the population, whether HIV-seropositive or not about the importance of preventing further transmissions of the virus, as well as assessing whether the policies are discriminatory or not against patients that tested positive for HIV or already developed AIDS. However, much more focus will be given to the strategies used, and less for the assessment of the economics and feasibility of such methods, in order to narrow down the subjects for this review. Future implications of new amendments may help lawmakers in decision-making, and comparing the levels of effectiveness of existing policies make for a possible eye-opener on how policies can be made or modified to be both anti-discriminatory against and supportive of HIV-positive and AIDS-suffering patients. The Cochrane Review Methodology shall be used for this review. Methods Selection Criteria The following criteria were used for the selection of papers to be included in this review: Policies. Papers that include past or present policies implemented in the US within the past two decades were selected for this review. Due to the relatively few publications that publish both policy implementations and studies that measure the successes of these policies, most papers in this review only focus on the call for policy amendments and future implications. Study Types. Papers which study the effects of present policies and propose amendments in order to reach out to more HIV-seropositive patients, and possibly those which may unknowingly harbor the virus were selected. For papers with results, interviews were the chosen method of obtaining qualitative and quantitative data. For papers without results as of date, the studies mostly focused on the implications of old policies to the provision of care to HIV-positive serotypes, as well as proposed amendments for these policies and the expected outcome of the said amendments. The call for policy changes were defined due to the steady rise of HIV cases despite the existence of intervention and prevention methods, and this rise in cases were attributed to the alarming number of HIV-positive patients that choose not to get treatment or engage in risky sexual behaviors, as well as their reasons why they do not take follow-up treatments. Participant Types. The papers that targeted policies which were either empowering or otherwise for HIV-positive individuals were selected for this review. So as to provide results that could influence future HIV and AIDS policies, researches conducted in the US were selected. Types of Interventions. For papers with proposed amendments, interventions such as changing of policies to reflect humanitarian values in identifying, counseling, and treating HIV-positive patients were included in the review. As for papers with published results, risk-assessment and behavioral management of HIV-positive patients sexual behaviors serotype disclosure to sexual partners, being educated of some laws and policies with regards to HIV-transmission and management, as well as provision of care were included for intervention methods to patients who already tested positive for HIV. Types of Outcome Measures. The main outcome measures for intervention methods for papers which only propose amendments for policies is the standardization of policies across the country, as well as the number of institutions and states that implement the policy changes. For papers with published results, the increase in awareness among HIV-positive patients of being responsible for not transmitting the virus to others by notifying sexual partners of their HIV-serotype, use of barriers such as condoms or abstinence, and the increase in patients that undergo ART and their compliance to existing policies and laws were used as outcome measures. Study Identification The papers used for this review were searched using search engines in the PubMed and Google Scholar website, and studies with full text readily available were selected. Abstracts-only or researches with broken links were excluded from the study. The following keywords used for searches were: HIV AIDS policies; HIV AIDS intervention policies; HIV AIDS prevention policies; United States HIV AIDS intervention policies; United States HIV AIDS prevention policies; HIV AIDS care policies; HIV AIDS policy recommendations; and HIV AIDS disclosure policies. Study Descriptions Ten papers which tackle both ongoing policies and the results of implementing these in certain areas within certain aspects were selected for this review. Three studies have published the results of policy implementation, with two involving interviews and surveys of identified HIV-positive persons, and one involving the review of statutes and laws across all 50 states and the District of Columbia and assessing whether some recommendations by the CDC were included in the policies or not. The remaining seven have only mentioned the policy, statements or guidelines as well as the potential impact of the policies once implemented. It is assumed that the studies without results were still ongoing, and have yet to publish the outcomes. The implementing bodies in the papers range from researchers in medical schools at the state level, to national groups such as the CDC and IDSA. All of the papers focused on HIV risk reductions and early treatment, as well as implementation of policies that may be applied across a national scale, thus needing for a standardized set of guidelines, rules, and methods. The lists of included papers and their corresponding focus and policies are shown in Table 1. Methodological Quality of Included Studies For two of the three papers with published results, the main limitations which were mentioned were the selection of the interview and survey participants, particularly the HIV-positive patients that participated in the survey. The randomization of participants decreased since only those that fit inclusion criteria and completed the surveys and interviews were included in the two studies. The study which assessed whether the recommendations given out by the CDC were included in the policy changes or not had lesser limitations since the statutes and laws of each state can be easily accessed. It was thus easy to identify which states complied with the CDC recommendations, which states were unable to fully comply, and which states were unable to comply at all. For the papers without published results as of date, because methodology contents were mostly proposed amendments for existing policies, the exact ways of implementing these changes were not fully disclosed, and only expected outcomes were included in the studies. Thus it would be harder to gauge the possibility of these proposed amendments to be successful after a certain period of implementation. Table 1. Reference list along with the focus for each paper and policy Author State/Agency Focus Policy/Statement With results from research as of date Mahajan, et al., 2009 Centers for Disease Control and Prevention (CDC) Improvement of statutes by following CDC guidelines and recommendations Recommendations from CDC shall be used to unify laws and statues across all states Rutledge, 2009 Seattle, WA Risk-reduction through serostatus disclosure Formation of Personal HIV Disclosure Policy Galletly, et al., 2012 New Jersey Risk-reduction through serostatus disclosure, belief systems New Jersey’s HIV Exposure Law Without definitive results as of date Lubinski, et al., 2009 Infectious Diseases Society of America (IDSA) & American College of Physicians (ACP) Early detection and treatment of HIV, routine screening for HIV Guidance statement for screening HIV Fagan, et al., 2010 CDC, other local institutions Surveillance system for HIV-seropositive patients that did not enter HIV treatment Creation of Never-in-Care (NIC), a national surveillance of HIV patients that did not enter treatment Millet, et al., 2010 CDC Identification of strategy goals and targets for HIV intervention and prevention National HIV/AIDS Strategy for the United States Vermund, et al., 2010 Tennessee/HIV Prevention Trials Network Outreach, testing, and early treatment of infected persons BROTHERS study, ISIS study implementations Gallant, et al., 2011 Maryland Identification of essential components of an effective HIV care model National HIV/AIDS Strategy Liebowitz, et al., 2011 California Implementation of biomedical HIV prevention strategies Policy regarding cost-effectiveness of strategies Mugavero, et al., 2011 Alabama Successful HIV care programs and limitations of current health care systems Policy for an integrated and coordinated HIV care system Results The data in the three studies were of different types, some were qualitative and some were quantitative. It was thus hard to create a generalized outcome through meta-analyses of the collected data. However, there were similarities between the measurable outcomes such as an increased sense of responsibility and awareness of one’s HIV seropositive status. On the other hand, because the seven papers without statistically-derived results only had future implications of policy changes, only the similarities between their expected outcomes that were reported and mentioned were used for this review. Papers with Published Results The two studies that utilized interviews and anonymous surveys from HIV-positive persons were concerned with their confidence in disclosing their serotype status to their sexual partners. Rutledge mentioned that the survey participants formed their own disclosure policies based on their personal experiences with the disease, as well as a sense of growth of their sense of responsibility in preventing the spread of the virus to others (Rutledge, 2009). Galletly and colleagues showed that awareness of HIV disclosure laws or the lack of it does not directly affect the abstinence patterns or sexual intercourse frequencies of HIV-seropositive patients, and thus criminalizing nondisclosure of seropositive HIV persons would not decrease their risky sexual behaviors (Galletly, et al., 2012). However, their choices of disclosure to their sexual partners as or perceived stigma in living with HIV were attributed to the levels of their understanding and knowledge of the HIV disclosure policy. Thus, the more unaware an HIV-positive person is of the HIV disclosure policy, the more that this person would feel stigmatized, while being knowledgeable of the policy reduces feelings of stigma and increases comfort levels of HIV-serotype status disclosure. Mahajan et al. reported that after the release of CDC recommendations on policy amendments with regards to existing HIV testing policies, while some states were able to comply during the first year of implementation, some states were unable to do so due to some existing laws that prevent or block the implementation of the recommendations (Mahajan, et al., 2009). Inconsistent compliance in statutes of some states were due to partial implementations, however after two years of being released, more states were able to comply fully to CDC recommendations, bringing the original number of compliant states from 15 to 35. The researchers expected that there would be an increasing trend towards compliance with regards to HIV testing policies, opting out of tests and consent from patients (Mahajan, et al., 2009). Papers with Policy Amendments Only Four papers discuss the importance of identifying goals as to how existing or amended policies can be strengthened among HIV-positive serotype persons and their provision of care. These includes the creation of a surveillance system for HIV-positive patients that discontinued treatment or did not undergo treatment after identifying serotype status, identification of goals and strategy for HIV prevention and intervention as well as the components of successful care methods, and implementation of HIV prevention strategies through biomedical means (Fagan, et al., 2010; Millet, et al., 2010; Gallant, et al.2011; Liebowitz, et al., 2011). Two studies mentioned the importance of early detection and treatment of HIV, as well as routine testing to screen out the disease especially to high-risk members of the population (Lubinski, et al., 2009; Vermund, et al., 2010). One study discussed possible limitations of the current health care programs and what possible amendments can be done to improve the scope of policies that cater to the needs of HIV-seropositive persons (Mugavero, et al., 2011). All seven studies were presumed to be unfinished and still in the stages of implementation and effectiveness assessment since there were no concrete or statistically-derived results mentioned in the discussions and conclusions. Discussion After reviewing all ten studies, regardless of whether there were results or not, some similarities between the findings of the three studies with results and the seven papers with policy changes can be seen. One is that there is a need to assess whether policies are effective in changing the attitudes of HIV-positive persons with regards to perception of social stigma in accepting and disclosing their serotype status to sexual partners as well as in seeking treatment continuously. Also, it is important that these people are treated as humanely as possible and without discrimination, as well as providing them with behavioral and social support in order for them to become confident and accepting of their condition, as well as to increase their volition in complying with policies in relation to HIV treatment and care. It is a recognized fact that their acknowledgement of their social responsibility in preventing the spread of infection to others is a very important factor in the success of intervention and prevention methods, since more often than not the spread of the infection is caused by risky sexual behaviors, aside from being unaware of harboring the virus or being socially stigmatized and in fear of being discriminated against or becoming targets of violent acts (Kurth, et al., 2011). Other than the intentional transmission of HIV to others, there must also be clear regulations with regards to criminalizing of transferring the virus to others due to lack of knowing one’s HIV-serotype status. It is thus important that the community, the state, and the government be able to address the needs of HIV-seropositive patients not just with the provision of evidence-based treatment or care, but also of being treated humanely and without any prejudice against, both inside the medical facility and within the community and society (Rotheram-Borus, et al., 2008). Conclusions Implications for Practice The papers used and synthesized in this review can be helpful for medical practitioners in further improving their patient-based care for patients, especially for those that give care for HIV-positive patients and AIDS-sufferers. It would also give additional insights as to why some patients are receptive to treatment while some are adamant to do it, and this should help them decide on positively-reinforcing actions that would help those which are newly or already diagnosed with HIV make responsible and positive actions, as well as to provide them with support to continue or proceed getting treatment. Implications for Research While there are numerous researches that address the advancement of ART drugs for HIV and AIDS, there have been few researches that focus on the behavioral aspects of disease treatment. It is relevant that along with selecting participants that would undergo clinical trials of drugs, they must also have proper behavioral and cognitive follow-ups as well as initiatives on group and society support, so that even after they have finished the drug trials they are still able to be fully confident of their serotype status, as well as remaining responsible for preventing disease transfer through their actions and behavior. Implications for Policy and Lawmakers Aside from putting efforts in studying the economics and feasibility of HIV policies, intervention and prevention programs, evidence-based results as well as the impact of behavioral studies must also be taken into consideration before creating or amending policies related to HIV-serotype status and its disclosure. Law and policymakers must also remember that any person, whether HIV-positive or not have rights that needed to be respected because they are also living members of the society, and that just as other people, they also deserve to be treated with dignity despite their health condition. The call for policy changes were initiated not because of the failure of treatments to cure and prevent the spread of HIV and AIDS, but due to the lack of the policies’ sensitivity to the needs of HIV-positive persons and AIDS patients, especially with regards to their fears of discrimination, social stigma, and possibility of being targeted by violence. Being able to create policies that would make these people become more engaged with treatment and behavior-modification methods would not only assist in increasing awareness in people with or without HIV, but also could help in the prevention of the disease from infecting a greater number of people, as well as to help improve the quality of life among people with HIV or AIDS. References Fagan, J., Bertolli, J., & McNaghten, A. (2010). Understanding people who have never received hiv medical care: a population-based approach. Public Health Reports, 125(4):520-527. Fisher, J., Smith, L., & Lenz, E. (2010). Secondary prevention of hiv in the united states: past, current, and future perspectives. Journal of Acquired Immune Deficiency Syndrome, 55(2):106-115. Gallant, J., Adimora, A., Carmichael, J., Horberg, M., Kitahara, M., Quinlivan, E., . . . et al.. (2011). Essential components of effective hiv care: a policy paper of the hiv medicine association of the infectious diseases society of america and the ryan white medical providers coalition . Clinical Infectious Diseases, 53(11):1043-1050. Galletly, C., Glasman, L., Pinkerton, S., & DiFranceisco, W. (2012). New Jerseys HIV exposure law and the HIV-related attitudes, beliefs, and sexual and seropositive status disclosure behaviors of persons living with HIV. American Journal of Public Health, doi:10.2105/AJPH.2012.300664. Kurth, A., Celum, C., Baeten, J., Vermund, S., & Wasserheit, J. (2011). Combination HIV prevention: significance, challenges, and opportunities. Current HIV/AIDS Reports, 8(1):62-72. Leibowitz, A., Byrnes, K., & Rotheram-Borus, M. (2011). A US policy perspective on oral preexposure prophylaxis for HIV. American Journal of Public Health, doi: 10.2105/AJPH.2010.300066. Lubinski, C., Aberg, J., Bardeguez, A., Elion, R., Emmanuel, P., Kuritzkes, D., . . .et al.. (2009). HIV Policy: The path forward—a joint position paper of the hiv medicine association of the infectious diseases society of america and the american college of physicians. Clinical Infectious Diseases, 48(10):1335-1344. Mahajan, A., Stemple, L., Shapiro, M., King, J., & Cunningham, W. (2009). Consistency of state statutes with the centers for disease control & prevention hiv testing recommendations for health care settings. Annals of Internal Medicine, 150(4):263-269. Millet, G., Crowley, J., Koh, H., Valdiserri, R., Frieden, T., Dieffenbach, C., ....et al.. (2010). A way forward: the national HIV/AIDS strategy and reducing HIV incidence in the United States. Journal of Acquired Immune Deficiency Syndrome, 55:144-147. Mugavero, M., Norton, W., & Saag, M. (2011). Health care system and policy factors influencing engagement in hiv medical care: piecing together the fragments of a fractured health care delivery system. Clinical Infectious Diseases, 52(2):238-246. Rotheram-Borus, M., Swendeman, D., Flannery, D., Rice, E., Adamson, D., & Ingram, B. (2008). Common factors in effective hiv prevention programs. AIDS Behavior, doi: 10.1007/s10461-008-9464-3. Rotheram-Borus, M., Swendemann, D., & Chovnick, G. (2009). The past, present, and future of HIV prevention: integrating behavioral, biomedical, and structural intervention strategies for the next generation of HIV prevention. Annual Review of Clinical Psychology, 5:143-167. Rutledge, S. (2009). Formation of personal hiv disclosure policies among hiv-positive men who have sex with men. AIDS Patient Care and STDS, 23(7):531-543. Vermund, S., Hodder, S., Justman, J., Koblin, B., Mastro, T., Mayer, K., ...et al.. (2010). Addressing research priorities for prevention of hiv infection in the united states. Clinical Infectious Diseases, 50(3):149-155. Read More