Faculty Bibliography

For about 30 years, soon after the onset of the AIDS epidemic, sexual-health messaging has emphasized personal responsibility for using condoms to protect from acquiring or transmitting HIV or other sexually transmitted infections. Those who did not use condoms during casual sexual encounters may therefore feel compelled to offer to others aware of their behavior what sociologists have called "accounts," an impression-management strategy to avoid unfavorable judgment. We analyzed accounts-excuses and justifications-from qualitative interviews with 150 adults who had unprotected sex in the past 3 months with at least two different partners met online (ages 18-50, mean: 33.7, equally divided among black, Hispanic, and white men and women, over half were college educated and the median yearly household income range was $50-$75,000). Many participants made excuses that aimed to defer responsibility for unprotected sex: they claimed that consistently practicing safer sex was impossible, that they got carried away by sexual passion, that they were inebriated, that they were influenced by emotional or psychological problems, or they put fault on their partners. Participants also provided justifications, claiming that unsafe sex had been acceptable because the risks taken were likely minimal or negotiated with their partner. Understanding the accounts heterosexual adults offer to excuse and justify condomless sex with partners met online can be helpful in developing prevention messages that debunk these explanations for their behavior.

Heterosexuals' use of the Internet for meeting romantic or sexual partners is rapidly increasing, raising concerns about the Internet's potential to facilitate encounters that place individuals at risk for acquiring HIV or other sexually transmitted infections (STIs). For example, online sharing of personal information and self-revelations can foster virtual intimacy, promoting a false sense of familiarity that might accelerate progression to unprotected sex. Therefore, it is critical to understand how those who meet sexual partners online attempt to assess the possible risk of acquiring HIV or STIs posed by having unprotected sex with a new partner and decide whether to use a condom. To investigate this issue, in-depth interviews were conducted with a diverse sample of heterosexual male and female participants from large metropolitan cities who had had unprotected vaginal or anal sex with at least two partners met online in the past 3 months. With few exceptions, participants relied on faulty strategies and heuristics to estimate these risks; yet, most engaged in unprotected sex at their first meeting or very soon afterward. While some seemed to try to make a genuine effort to arrive at a reliable assessment of the HIV risk posed, most appeared to be looking for a way to justify their desire and intention to have unprotected sex. The findings suggest the need for more HIV and sexual health education targeted at heterosexuals, especially for those who go online to meet partners.

Nurses are often first to identify and manage a patient leaving against medical advice (AMA), and so they are critical contributors to the development of strategies to address this problem. We studied AMA discharge in order to help develop useful interventions. We performed a cross-sectional analysis of 55,938 discharges from a single urban hospital for the years 2002-2003 and 2012-2013. AMA discharge rates were higher for HIV-infected patients than for patients with alcohol-related disorders or sickle cell anemia in both time periods, even after adjustment for age, race, sex, insurance status, and household income. For HIV infection, 25% of AMA discharges occurred in patients with multiple AMA discharges and 30-day readmission rates were higher after an AMA discharge: odds ratio 1.57 (95% confidence interval 1.01 to 2.43, p = .046). Team-based and nursing interventions that incorporate the treatment-based values and preferences of HIV-infected patients with prior AMA discharges may improve linkage to care and reduce readmissions.

The phenomenon of leaving the hospital against medical advice (AMA) despite being quite common and associated with significant deleterious health outcomes remains inadequately understood and addressed. Researchers have identified certain patient characteristics as predictors of AMA discharges, but the patients' reasons for these events have not been comprehensively explored. Moreover, because the medical authority model dominates this research area, providers' experiences of AMA discharges remain unstudied. We examined the AMA discharge from a patient-centered perspective by analyzing the content of notes providers generate to record such events. We analyzed providers' notes for all inpatients with a primary HIV diagnosis (N = 33) that, in 2012, left an urban hospital AMA. Applying the Scott and Lyman accounts framework, we identified that the notes constituted records of providers' and patients' excuses and justifications for failing to meet the expectations of a provider offering patient-centered care and a compliant patient receiving care. Alongside the patients' reasons for leaving AMA, the notes also revealed the providers' reasons for honoring or discrediting the patients' accounts. The style of the accounts and the professional status of the notes' authors enabled us to contextualize the production and sharing of AMA notes in the hospital hierarchy. Conceptualizing AMA notes as dyadic accounts elicited specific factors that challenge the patient-provider relationship, and generated insights on how to strengthen it, and thus decrease the rates of AMA discharges and their associated health effects.

BACKGROUND: Patients retained in HIV care but not on antiretroviral therapy (ART) represent an important part of the HIV care cascade in the United States. Even in an era of more tolerable and efficacious ART, decision making in regards to ART offer and uptake remains complex and calls for exploration of both patient and provider perspectives. We sought to understand reasons for lack of ART usage in patients meeting the Health Resources Services Administration definition of retention as well as what motivated HIV primary care appointment attendance in the absence of ART. METHODS AND FINDINGS: We conducted a qualitative study consisting of 70 in-depth interviews with ART-naive and ART-experienced patients off ART and their primary care providers in two urban safety-net HIV clinics in San Francisco and New York. Twenty patients and their providers were interviewed separately at baseline, and 15 dyads were interviewed again after at least 3 mo and another clinic visit in order to understand any ART use in the interim. We applied dyadic analysis to our data. Nearly all patients were willing to consider ART, and 40% of the sample went on ART, citing education on newer antiretroviral drugs, acceptance of HIV diagnosis, social support, and increased confidence in their ability to adhere as facilitators. However, the strength of the provider recommendation of ART played an important role. Many patients had internalized messages from providers that their health was too good to warrant ART. In addition, providers, while demonstrating patient-centered care through sensitivity to patients experiencing psychosocial instability, frequently muted the offer of ART, at times unintentionally. In the absence of ART, lab monitoring, provider relationships, access to social services, opiate pain medications, and acute symptoms motivated care. The main limitations of this study were that treatment as prevention was not explored in depth and that participants were recruited from academic HIV clinics in the US, making the findings most generalizable to this setting. CONCLUSIONS: Provider communication with regard to ART is a key focus for further exploration and intervention in order to increase ART uptake for those retained in HIV care.

Adolescents may come from family settings that heighten their vulnerability to early sexual initiation, promiscuity and sexual exploitation. Using qualitative data, we illustrated how early life and family circumstances including neglectful or dysfunctional parenting, sexual abuse, and unstable housing placed young women on a risk trajectory for HIV infection. Five representative cases from a sample of 26 adolescent and young adult HIV-infected females (ages 16-24) who participated in a study about the disease-related adaptive challenges they faced are discussed. Study participants were recruited from five New York City adolescent HIV clinics that provided comprehensive specialty medical and ancillary social services to adolescents and young adults with the disease. The findings revealed that these young women's unmet need for love, protection, and feeling valued left them vulnerable to exploitive relationships with men who were often significantly older and resulted in their HIV infection.

CONTEXT: Fatigue is a prevalent, debilitating, and often disruptive symptom for cancer patients. Yet, it remains inadequately understood and managed, especially among late middle-aged and older patients with advanced disease. Few studies have explored fatigue qualitatively, and almost none have focused on patients' attributions for this subjective and multidimensional symptom. OBJECTIVES: Our objectives were to 1) examine the attributions patients aged 55 years or older with advanced cancer made for their fatigue and how they arrived at these attributions and 2) understand how patients' attributions affect how they contend with fatigue, including communication with health care providers. METHODS: We conducted qualitative in-depth interviews with 35 patients aged 55 years or older on their experiences with fatigue. Patients had a variety of cancers and were at stages IV or late III of the disease. Interviews were thematically coded and analyzed. RESULTS: Two main themes emerged: 1) Cancer-related treatment was the master and often the sole attribution patients made for their fatigue. Patients making this attribution expressed certainty about its accuracy and seemed less distressed about the symptom. 2) Multiple causes of fatigue, typically a combination of cancer, treatment, and nonthreatening causes (e.g., older age, overexertion, or anemia), also were offered by some. Patients seemed to resist identifying disease severity as a cause and appeared motivated to normalize and minimize the symptom, thus decreasing its threatening impact. CONCLUSION: Patients' causal attributions for fatigue had a profound effect on their physical and psychological well-being, their communication with providers, and their integration of the symptom into their lives.

Despite the high prevalence of hepatitis C virus (HCV) infection among injection drug users also infected with human immunodeficiency virus (HIV), and the synergistic adverse effect of the two diseases on patients' health and survival, research on the clinical management of these patients and particularly the low uptake of HCV therapy is limited. We conducted qualitative interviews with 17 HIV providers from two urban public hospitals. We discovered that the limitations of the current state of medical knowledge, the severe side effects of HIV and HCV therapies, and the psychosocial vulnerability of HIV/HCV-coinfected patients combined with their resistance to becoming informed about HCV posed significant challenges for providers. To contend with these challenges, providers incorporated key dimensions of patient-centered medicine in their practice, such as considering their patients' psychosocial profiles and the meaning patients assign to being coinfected, and finding ways to engage their patients in a therapeutic alliance.

The realization that many persons with HIV/AIDS are subjected to multiple layers of stigmatization because they belong to socially deviant and disenfranchised groups (e.g., injection drug users, racial/ethnic and sexual minorities) accounts for an increasing interest in the phenomenon of stigma layering. The stigma associated with hepatitis C virus (HCV) has also been conceptualized as layered. However, researchers have overlooked the fact that HCV adds a layer to the HIV stigma and vice versa. Qualitative interviews with 132 HIV/HCV-coinfected patients were analyzed to explore how they experience the two layers of stigma. Most participants hierarchically ordered the stigmas associated with each disease and regarded HIV as the more stigmatizing of the two. A small number perceived HIV and HCV as equally stigmatizing. The impact of the hierarchical and nonhierarchical ordering of the two stigmas on coinfected patients' felt and enacted stigmatization is explored and implications for interventions are discussed.