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OBJECTIVES: Combination antiretroviral therapy (cART) for HIV is widely available in sub-Saharan Africa. Adherence is crucial to successful treatment. This study aimed to apply an extended theory of planned behaviour (TPB) model to predict objectively measured adherence to cART in Tanzania. DESIGN: Prospective observational study (n = 158) where patients completed questionnaires on demographics (Month 0), socio-cognitive variables including intentions (Month 1), and action planning and self-regulatory processes hypothesised to mediate the intention-behaviour relationship (Month 3), to predict adherence (Month 5). MAIN OUTCOME MEASURES: Taking adherence was measured objectively using the Medication Events Monitoring System (MEMS) caps. Model tests were conducted using regression and bootstrap mediation analyses. RESULTS: Perceived behavioural control (PBC) was positively (ß = .767, p < .001, R2 = 57.5%) associated with adherence intentions. Intentions only exercised an indirect effect on adherence (B = 1.29 [0.297-3.15]) through self-regulatory processes (B = 1.10 [0.131-2.87]). Self-regulatory processes (ß = .234, p = .010, R2 = 14.7%) predicted better adherence. CONCLUSION: This observational study using an objective behavioural measure, identified PBC as the main driver of adherence intentions. The effect of intentions on adherence was only indirect through self-regulatory processes, which were the main predictor of objectively assessed adherence.

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This study examines a proposed theoretical model examining the interrelationships between stigma, disclosure, coping, and medication adherence among 158 HIV-infected patients on antiretroviral therapy (ART) in northern Tanzania. Perceived and self-stigma, voluntary and involuntary disclosure, positive and negative coping, and demographics were assessed by trained interviewers, and self-reported adherence was collected during 5 months follow-up. Data were examined using correlation and regression analyses. The analyses showed that perceived stigma is primarily related to involuntary disclosure, whereas self-stigma is related to voluntary disclosure. Religious coping positively relates to acceptance, whereas perceived stigma explains higher levels of denial of HIV status. Lastly, adherence was negatively affected by alcohol use, self-stigma, and denial. We conclude that adherence is predominantly predicted by negative rather than positive coping mechanisms. Therefore, substituting maladaptive coping mechanisms like denial and alcohol use with a more adaptive coping style may be an important strategy to improve long-term ART adherence and well-being of patients. Moreover, this study showed that it is useful to examine both involuntary and voluntary disclosure when studying its relation with stigma.

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OBJECTIVES: Internalised homonegativity (IH) is hypothesised to be associated with HIV risk behaviour and HIV testing in men who have sex with men (MSM). We sought to determine the social and individual variables associated with IH and the associations between IH and HIV-related behaviours. DESIGN AND SETTING: We examined IH and its predictors as part of a larger Internet-delivered, cross-sectional study on HIV and health in MSM in 38 European countries. PARTICIPANTS: 181 495 MSM, IH data analysis subsample 144 177. All participants were male, over the age of consent for homosexual activity in their country of domicile, and have had at least one homosexual contact in the past 6 months. METHODOLOGY: An anonymous Internet-based questionnaire was disseminated in 25 languages through MSM social media, websites and organisations and responses saved to a UK-based server. IH was measured using a standardised, cross-culturally appropriate scale. RESULTS: Three clusters of European countries based on the level of experienced discrimination emerged. IH was predicted by country LGB (lesbian, gay and bisexual) legal climate, Gini coefficient and size of place of settlement. Lower IH was associated with degree the respondent was 'out' as gay to others and older age. 'Outness' was associated with ever having an HIV test and age, education and number of gay friends, while IH (controlling for the number of non-steady unprotected sex partners and perceived lack of control over safe sex) was associated with condom use for anal intercourse. CONCLUSIONS: IH is associated with LGB legal climate, economic development indices and urbanisation. It is also associated with 'outness' and with HIV risk and preventive behaviours including HIV testing, perceived control over sexual risk and condom use. Homonegative climate is associated with IH and higher levels of HIV-associated risk in MSM. Reducing IH through attention to LGB human rights may be appropriate HIV reduction intervention for MSM.

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PURPOSE: Prison officers have a vital role in running a secure and healthy living environment for the inmates. The purpose of this article is to examine the relationship between HIV/AIDS-related knowledge and attitude towards inmates living with HIV among the officers in an Indonesian narcotics prison. DESIGN/METHODOLOGY/APPROACH: A total of 93 officers from a narcotics prison in Bandung, Indonesia voluntarily participated in this cross-sectional study by completing a self-reported questionnaire. A Prior focus group discussion was also held among selected participants. FINDINGS: Statistical data analyses indicate that all domains of HIV/AIDS-related knowledge, i.e. knowledge of HIV-transmission, general HIV/AIDS knowledge and knowledge of HIV-prevention, have substantial positive correlations with the prison officers' attitude towards inmates living with HIV. These results show that the more knowledgeable the officers are, the less likely they are to respond in an unfavourable manner to inmates living with HIV and vice versa. RESEARCH LIMITATIONS/IMPLICATIONS: Despite the limited participants involved in this study, the knowledge gaps that are identified in this study should be the starting point for the development of educational interventions for prison officers. PRACTICAL IMPLICATIONS: Sufficient educational programs and the latest materials need to be made available within the prison. SOCIAL IMPLICATIONS: Commitment from prison authorities as well as a proper policy are also needed. ORIGINALITY/VALUE: This study helped prison authorities to identify areas for knowledge development of the officers. Hopefully the positive attitude towards inmates living with HIV will be developed.

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BACKGROUND: To design effective, tailored interventions to support antiretroviral therapy (ART) adherence, a thorough understanding of the barriers and facilitators of ART adherence is required. Factors at the individual and interpersonal level, ART treatment characteristics and health care factors have been proposed as important adherence determinants. METHODS: To identify the most relevant determinants of adherence in northern Tanzania, in-depth interviews were carried out with 61 treatment-experienced patients from four different clinics. The interviews were ad-verbatim transcribed and recurrent themes were coded. RESULTS: Coding results showed that the majority of patients had basic understanding of adherence, but also revealed misconceptions about taking medication after alcohol use. Adherence motivating beliefs were the perception of improved health and the desire to live like others, as well as the desire to be a good parent. A de-motivating belief was that stopping ART after being prayed for was an act of faith. Facilitators of adherence were support from friends and family, and assistance of home based care (HBC) providers. Important barriers to ART adherence were the use of alcohol, unavailability of food, stigma and disclosure concerns, and the clinics dispensing too few pills. Strategies recommended by the patients to improve adherence included better Care and Treatment Centre (CTC) services, recruitment of patients to become Home Based Care ( HBC) providers, and addressing the problem of stigma through education. CONCLUSION: This study underscores the importance of designing tailored, patient-centered adherence interventions to address challenges at the patient, family, community and health care level.

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OBJECTIVES: Understanding the gap between people's intentions and actual health behavior is an important issue in health psychology. Our aim in this study was to investigate whether self-regulatory processes (monitoring goal progress and responding to discrepancies) mediate the intention-behavior relation in relation to HIV medication adherence (Study 1) and intensive exercise behavior (Study 2). METHOD: In Study 1, questionnaire and electronically monitored adherence data were collected at baseline and 3 months later from patients in the control arm of an HIV-adherence intervention study. In Study 2, questionnaire data was collected at 3 time points 6-weeks apart in a cohort study of physical activity. RESULTS: Complete data at all time points were obtained from 51 HIV-infected patients and 499 intensive exercise participants. Intentions were good predictors of behavior and explained 25 to 30% of the variance. Self-regulatory processes explained an additional 11% (Study 1) and 6% (Study 2) of variance in behavior on top of intentions. Regression and bootstrap analyses revealed at least partial, and possibly full, mediation of the intention-behavior relation by self-regulatory processes. CONCLUSIONS: The present studies indicate that self-regulatory processes may explain how intentions drive behavior. Future tests, using different health behaviors and experimental designs, could firmly establish whether self-regulatory processes complement current health behavior theories and should become routine targets for intervention. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

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BACKGROUND: An often-used tool to measure adherence to antiretroviral therapy (ART) is the Medication Event Monitoring System (MEMS), an electronic pill-cap that registers date and time of pill-bottle openings. Despite its strengths, MEMS-data can be compromised by inaccurate use and acceptability problems due to its design. These barriers remain, however, to be investigated in resource-limited settings. We evaluated the feasibility and acceptability of using MEMS-caps to monitor adherence among HIV-infected patients attending a rural clinic in Tanzania's Kilimanjaro Region. METHODS: Eligible patients were approached and asked to use the MEMS-caps for three consecutive months. Thereafter, qualitative, in-depth interviews about the use of MEMS were conducted with the patients. MEMS-data were used to corroborate the interview results. RESULTS: Twenty-three of the 24 patients approached agreed to participate. Apart from MEMS-use on travel occasions, patients reported no barriers regarding MEMS-use. Unexpectedly, the MEMS-bottle design reduced the patients' fear for HIV-status disclosure. Patients indicated that having their behavior monitored motivated them to adhere better. MEMS-data showed that most patients had high levels of adherence and there were no bottle-openings that could not be accounted for by medication intake. Non-adherence in the days prior to clinic visits was common and due to the clinic dispensing too few pills. CONCLUSION: MEMS-bottle use was readily accepted by patients. Although the MEMS-bottle was used accurately by most patients, patients need to be more explicitly instructed to continue MEMS-use when travelling. Even HIV-clinics with sufficient staff and free medication may impose structural adherence barriers by supplying an insufficient amount of pills.

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OBJECTIVE: To investigated the effectiveness of an adherence intervention (AIMS) designed to fit HIV-clinics' routine care procedures. DESIGN: Through block randomization, patients were allocated to the intervention or control group. The study included 2 months baseline measurement, 3 months intervention, and 4 months follow-up. HIV-nurses delivered a minimal intervention ("adherence sustaining") to patients scoring >95% adherence at baseline, and an intensive intervention ("adherence improving") to patients with <95% adherence. Control participants received high-quality usual care. MAIN OUTCOME MEASURES: Electronically monitored adherence and viral load. RESULTS: 133 patients were included (67 control, 66 intervention), 60% had <95% adherence at baseline, and 87% (116/133) completed the trial. Intent-to-treat analyses showed that adherence improved significantly in the complete intervention sample. Subgroup analyses showed that this effect was caused by participants scoring <95% at baseline (mean difference = 15.20%; p < .001). These effects remained stable during follow-up. The number of patients with an undetectable viral load increased in the intervention group compared to the control group (OR = 2.96, p < .05). Treatments effects on viral load were mediated by the improvements in adherence. CONCLUSIONS: The AIMS-intervention was effective and can be integrated in routine clinical care for HIV-infected patients. Future research should study its (cost)effectiveness among more heterogeneous samples and in settings with variable levels of standard care.

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The present study examined the first episode of anal intercourse of young gay and bisexual men (YGBM) who were in the midst of their coming-out. Cross-sectional data regarding the first episode of anal intercourse were extracted from Outcomes, a longitudinal study on coming-out and sexual behavior of YGBM in the Netherlands. Overall, 45% of respondents reported unprotected anal intercourse (UAI) with their first same-sex partner. Rates of UAI did not significantly differ between meeting place (offline vs. online) and partner status (steady, regular or casual).

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BACKGROUND: Poor adherence to medication limits the effectiveness of treatment for human immunodeficiency virus. Systematic reviews can identify practical and effective interventions. Meta-analyses that control for variability in standard care provided to control groups may produce more accurate estimates of intervention effects. METHODS: To examine whether viral load and adherence success rates could be accurately explained by the active content of highly active antiretroviral therapy (HAART) adherence interventions when controlling for variability in care delivered to controls, databases were searched for randomized controlled trials of HAART adherence interventions published from 1996 to January 2009. A total of 1342 records were retrieved, and 52 articles were examined in detail. Directly observed therapy and interventions targeting specific patient groups (ie, psychiatric or addicted patients, patients <18 years) were excluded, yielding a final sample of 31 trials. Two coders independently retrieved study details. Authors were contacted to complete missing data. RESULTS: Twenty studies were included in the analyses. The content of adherence care provided to control and intervention groups predicted viral load and adherence success rates in both conditions (P < .001 for all comparisons), with an estimated impact of optimal adherence care of 55 percentage points. After controlling for variability in care provided to controls, the capacity of the interventions accurately predicted viral load and adherence effect sizes (R(2) = 0.78, P = .02; R(2) = 0.28, P < .01). Although interventions were generally beneficial, their effectiveness reduced noticeably with increasing levels of standard care. CONCLUSIONS: Intervention and control patients were exposed to effective adherence care. Future meta-analyses of (behavior change) interventions should control for variability in care delivered to active controls. Clinical practice may be best served by implementing current best practice.

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The aim of this prospective study was to identify relevant determinants of young gay and bisexual men's (YGBM) condom use when having anal sex with casual partners. Respondents (185 YGBM in the midst of their coming-out; mean age 18.9 years) completed an online questionnaire on social-cognitive determinants of condoms use derived from the theory of planned behavior (Ajzen, 1991) at Wave 1. At six months follow-up (Wave 2) sexual behavior with casual partners was assessed. A total of 63 YGBM reported sex with a casual partner in the six months between Waves 1 and 2, of whom 49% (N=31) had anal sex. Of the YGBM who had anal sex, 42% (N=13) had unprotected anal sex. Condom use with casual partners was best predicted by the intention to always use condoms. Furthermore, attitude, descriptive and personal norms, and perceived control significantly predicted intention to always use condoms. Interventions, targeting YGBM, aiming to promote condom use with casual partners should focus on increasing attitudes and strengthening skills to negotiate and use condoms.

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AIM: to explore the teacher perspective on needs (in terms of knowledge, skills and curriculum content), attitudes, beliefs and self-efficacy related to teaching and implementation of a reproductive health (RH)/drug education (DE) program at their own junior high school. METHODS: one hundred and thirty-three teachers participated in a survey, from February to April 2009, measuring: socio demographic, behavioral intention, perceived behavior control, content knowledge, school climate, reproductive health knowledge and school drug education. RESULTS: all teachers had a high intention to teach RH and DE, especially the younger RH teachers had a high intention to teach about teenage pregnancy and sexually transmitted infections. DE teachers had a high intention facts/effects of drugs, first-time drug use dealing with peer pressure. Perceived beliefs of teachers, parents, school management and perceived self-efficacy were strong predictors for the intention of RH teaching and DE. CONCLUSION: the high intention of the RH and DE teacher offers a great opportunity to build and implement a DE and RH curriculum in junior high school. Before a curriculum is developed and implemented there is a need to assess and strengthen the teacher's skills and effectiveness in teaching RH and DE.

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AIM: to identification the predictors of HIV-seropositivity and level of immunosuppression. METHODS: in a cross-sectional study, we examined HIV-testing practice, HIV-knowledge, perceived risk of being HIV-positive, and health status among out-patients enrolled in voluntary counseling and testing (VCT), and in-patients who underwent provider-initiated testing (PITC) in the largest teaching hospital in West Java, Indonesia. RESULTS: among 202 respondents, 47% were HIV+, and the median CD4 of HIV+ was 193/mm³ among VCT (n=124) and 11/mm³ among PITC (n=78). HIV/AIDS related knowledge among those entering VCT was significantly higher than among those in PITC, but perceived risk of being HIV-infected was lower. Logistic regression analysis predicting HIV status revealed a significant main effect for oral thrush and chronic diarrhea and for Hepatitis C status (p<.01). For those who are HIV positive, weight loss was strongly predictive of a low CD4 cell count (p<.01). CONCLUSION: in this setting, the HIV-seroprevalence is high and many HIV-infected subjects are symptomatic. Increasing HIV knowledge may lead to earlier HIV-detection. Health care workers play an important role in referral for VCT and PITC, and several symptoms, alone or in combination, can help identify those who are at highest risk for HIV.

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Projections estimate 1,000,000 HIV infected by 2015 in Indonesia. Key behaviors to HIV prevention and care are determined by a complex set of individual/ environmental factors. This paper presents empirical data, local evidence and theoretical concepts to determine the role of social sciences in HIV prevention/care. Injecting Drug Use (IDU) is a social and very risky activity: 95% injected in the presence of peers and 49% reported needles sharing. 82% of IDUs do not use condoms consistently. Poor adherence to ARV treatment is related to a complex set of, mostly behavioral, factors beyond effective influence by standard professional skills of medical staff. Meta-analysis indicated that about 1/3 of the variance in behaviour can be explained by the combined effect of intention and perceived behavioral control, the two cornerstones of the Theory of Planned Behavior (TPB). It is advisable to adapt TPB in the light of the Indonesian context. Current theories of behavior and behavior change give professionals of all disciplines, working in HIV prevention and care, effective tools to change behavior and to improve HIV prevention and access and quality of HIV care.

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OBJECTIVE: Clinical trials of behavioral interventions seek to enhance evidence-based health care. However, in case the quality of standard care provided to control conditions varies between studies and affects outcomes, intervention effects cannot be directly interpreted or compared. The objective of the present study was to examine whether standard care quality (SCQ) could be reliably assessed, varies between studies of highly active antiretroviral HIV-adherence interventions, and is related to the proportion of patients achieving an undetectable viral load ("success rate"). DESIGN: Databases were searched for relevant articles. Authors of selected studies retrospectively completed a checklist with standard care activities, which were coded to compute SCQ scores. The relationship between SCQ and the success rates was examined using meta-regression. MAIN OUTCOME MEASURES: Cronbach's alpha, variability in SCQ, and relation between SCQ and success rate. RESULTS: Reliability of the SCQ instrument was high (Cronbach's alpha = .91). SCQ scores ranged from 3.7 to 27.8 (total range = 0-30) and were highly predictive of success rate (p = .002). CONCLUSIONS: Variation in SCQ provided to control groups may substantially influence effect sizes of behavior change interventions. Future trials should therefore assess and report SCQ, and meta-analyses should control for variability in SCQ, thereby producing more accurate estimates of the effectiveness of behavior change interventions.

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OBJECTIVE: The treatment of obesity is universally disappointing; although usually some weight loss is reported directly after treatment, eventual relapse to, or even above, former body weight is common. In this study it is tested whether the addition of cognitive therapy to a standard dietetic treatment for obesity might prevent relapse. It is argued that the addition of cognitive therapy might not only be effective in reducing weight and related concerns, depressed mood, and low self-esteem, but also has an enduring effect that lasts beyond the end of treatment. METHODS: Non-eating-disordered overweight and obese participants in a community health center (N=204) were randomly assigned to a group dietetic treatment+cognitive therapy or a group dietetic treatment+physical exercise. RESULTS: Both treatments were quite successful and led to significant decreases in BMI, specific eating psychopathology (binge eating, weight-, shape-, and eating concerns) and general psychopathology (depression, low self-esteem). In the long run, however, the cognitive dietetic treatment was significantly better than the exercise dietetic treatment; participants in the cognitive dietetic treatment maintained all their weight loss, whereas participants in the physical exercise dietetic treatment regained part (25%) of their lost weight. CONCLUSION: Cognitive therapy had enduring effects that lasted beyond the end of treatment. This potential prophylactic effect of cognitive therapy is promising; it might be a new strategy to combat the global epidemic of obesity.

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BACKGROUND: There is currently a trend towards unsafe unprotected anal intercourse (UAI) among men who have sex with men. We evaluated a short individual counselling session on reducing UAI among gay and bisexual men. METHODS: A quasi-experimental design was used to evaluate the counselling session. This session was conducted during consulting hours at four municipal health clinics during a Hepatitis B vaccination campaign. These clinics offered free vaccination to high-risk groups, such as gay and bisexual men.All gay and bisexual men attending health clinics in four cities in the Netherlands were asked to participate. Each participant in the intervention group received a fifteen-minute individual counselling based on the Theory of Planned Behaviour and Motivational Interviewing. Changes in UAI were measured over a 5-months period, using self-administered questionnaires. UAI was measured separately for receptive and insertive intercourse in steady and casual partners. These measures were combined in an index-score (range 0-8). RESULTS: While UAI in the counselling group remained stable, it increased in the controls by 66% from 0.41 to 0.68. The results show that the intervention had a protective effect on sexual behaviour with steady partners. Intervention effects were strongest within steady relationships, especially for men whose steady-relationship status changed during the study. The intervention was well accepted among the target group. CONCLUSION: The fifteen-minute individually tailored counselling session was not only well accepted but also had a protective effect on risk behaviour after a follow-up of six months.

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Obese people prefer and overconsume high-fat foods. At the same time they often attempt to lose weight. In two studies we investigated relations between palatable high-fat food words and disinhibition related concepts (study 1) and palatable high-fat food words and restraint related concepts (study 2) within the semantic priming paradigm. In study 1, 24 overweight/obese and 19 healthy weight women participated. There was no association between palatable high-fat food words and disinhibition. In study 2, 27 obese and 29 healthy weight women participated. The presentation of palatable high-fat food words facilitated the accessibility of restraint related concepts as hypothesized, but independent of weight status. Clearly, early associations with palatable high-fat food words are restraint related in both healthy weight and obese people.

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Determinants of intended condom use with steady and casual sex partners were examined among Dutch HIV-positive men who have sex with men (MSM) (N = 296). Given the proposition that safer sex behavior among HIV-positive people is a form of prosocial behavior, the present study extended the general framework of the Theory of Planned Behavior with Schwartz's norm-activation theory and tested the assumption that personal norms would mediate the effects of other psychosocial factors on intended condom use for anal sex. In addition, it was hypothesized that, depending on the context in which sex occurs, specific motives for unprotected anal sex may have a negative influence on intended condom use and, as such, undermine a prosocial tendency to practice safer sex. Therefore, we also investigated the influence of sexual motives for unprotected anal sex on intended condom use with steady and casual sex partners. Results indicated that the Theory of Planned Behavior adequately predicted condom use intentions (for casual sex partners and steady sex partners, the explained variance was 52% and 53%, respectively). However, our proposed model of sexual decision-making significantly improved the prediction of behavioral intentions. For steady and casual sex partners, the assumption of the mediating role of personal norms on condom use intention was confirmed empirically. Additionally, sexual motives for unprotected anal sex exerted, as expected, a direct, negative effect on condom use intention with casual sex partners. The implications of the findings for future research and the development of HIV-prevention programs for HIV-positive MSM are discussed.

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OBJECTIVE: To review research on sexual risk behavior among HIV-positive men who have sex with men (MSM) after the year 2000. METHOD: The review included 53 published studies that reported on unprotected anal intercourse (UAI) in cross-sectional and longitudinal surveys of HIV-positive MSM and MSM of mixed HIV status. RESULTS: The findings indicate high levels of UAI among HIV-positive MSM, particularly with HIV-negative or HIV status unknown partners. In studies of MSM of mixed HIV status, we found that the rate of UAI among HIV-positive MSM was much higher than that of HIV-negative MSM. Furthermore, the prevalence of UAI among HIV-positive MSM has increased in recent years. CONCLUSION: Although studies indicate that HIV-positive MSM have adopted risk reduction strategies, roughly two in five HIV-positive MSM continue to engage in UAI, which represents a risk for continued HIV and STI (sexually transmitted infection) transmission. PRACTICE IMPLICATIONS: Prevention efforts targeting HIV-positive MSM to assist them in adopting and maintaining safer sexual behaviors need to be intensified.

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