Healthy Living Project Team. Effects of a behavioral intervention to reduce risk of transmission among people living with HIV: the healthy living project randomized controlled study

Behavioral health risks in perinatally HIV-exposed youth: co-occurrence of sexual and drug use behavior, mental health problems, and nonadherence to antiretroviral treatment

In a sample of perinatally HIV-infected (PHIV+) and perinatally HIV-exposed, uninfected (PHEU) adolescents, we examined the co-occurrence of behavioral health risks including mental health problems, onset of sexual and drug use behaviors, and (in PHIV+ youth) nonadherence to antiretroviral therapy (ART). Participants, recruited from 2007 to 2010, included 349 youth, ages 10-16 years, enrolled in a cohort study examining the impact of HIV infection and ART. Measures of the above behavioral health risks were administered to participants and primary caregivers. Nearly half the participants met study criteria for at least one behavioral health risk, most frequently, mental health problems (28%), with the onset of sexual activity and substance use each reported by an average of 16%. Among the sexually active, 65% of PHIV+ and 50% of PHEU youth reported unprotected sex. For PHIV +youth, 34% reported recent ART nonadherence, of whom 45% had detectable HIV RNA levels. Between 16% (PHIV+) and 11% (PHEU) of youth reported at least two behavioral health risks. Older age, but not HIV status, was associated with having two or more behavioral health risks versus none. Among PHIV+ youth, living with a birth mother (versus other caregivers) and detectable viral load were associated with co-occurrence of behavioral health risks. In conclusion, this study suggests that for both PHIV+ and PHEU youth, there are multiple behavioral health risks, particularly mental health problems, which should be targeted by service systems that can integrate prevention and treatment efforts.

Project REACH: a provider-delivered dual protection intervention for women using family planning services in New York City

High rates of unintended pregnancies and sexually transmitted infection (STI), including HIV, highlight the importance of promoting dual protection (DP) - i.e., methods that offer concurrent protection against unintended pregnancies and STI - during contraceptive counseling. Using a Phase II quasi-experimental design, this study compared an individualized, clinic-based, nurse-delivered intervention designed to increase DP against standard of care among 101 HIV negative women accessing contraceptive services in medically under-served areas of New York City. Participants were evaluated at baseline, post-counseling, and six months later. Findings indicated that the intervention has possible benefit. At six-month follow-up, there was greater perceived susceptibility to STI and fewer condom-unprotected vaginal sex occasions in the intervention arm. Women in the intervention also had five times the odds of reporting female condom use. Results suggest that this intervention has the potential for a larger population impact and should be more rigorously evaluated in a Phase III trial.

The Treatment Advocacy Program: a randomized controlled trial of a peer-led safer sex intervention for HIV-infected men who have sex with men

OBJECTIVE

Primary care may be an effective venue for delivering behavioral interventions for sexual safety among HIV-positive men who have sex with men (MSM); however, few studies show efficacy for such an approach. We tested the efficacy of the Treatment Advocacy Program (TAP), a 4-session, primary-care-based, individual counseling intervention led by HIV-positive MSM "peer advocates" in reducing unprotected sex with HIV-negative or unknown partners (HIV transmission risk).

METHOD

We randomized 313 HIV-positive MSM to TAP or standard care. HIV transmission risk was assessed at baseline, 6 months, and 12 months (251 participants completed all study waves). We conducted intent-to-treat analyses using general estimating equations to test the interaction of group (TAP vs. standard care) by follow-up period.

RESULTS

At study completion, TAP participants reported greater transmission risk reduction than did those receiving standard care, χ2(2, N = 249) = 6.6, p = .04. Transmission risk among TAP participants decreased from 34% at baseline to about 20% at both 6 and 12 months: Transmission risk ranged from 23% to 25% among comparison participants.

CONCLUSIONS

TAP reduced transmission risk among HIV-positive MSM, although results are modest. Many participants and peer advocates commented favorably on the computer structure of the program. We feel that the key elements of TAP-computer-based and individually tailored session content, delivered by peers, in the primary care setting-warrant further exploration.

Psychiatric risk factors for HIV disease progression: the role of inconsistent patterns of antiretroviral therapy utilization

BACKGROUND

In the era of antiretroviral therapy (ART), depression and substance use predict hastened HIV disease progression, but the underlying biological or behavioral mechanisms that explain these effects are not fully understood.

METHODS

Using outcome data from 603 participants enrolled in a randomized controlled trial of a behavioral intervention, binary logistic and linear regression were employed to examine whether inconsistent patterns of ART utilization partially mediated the effects of depression and substance use on higher HIV viral load over a 25-month follow-up.

RESULTS

Elevated affective symptoms of depression independently predicted ART discontinuation [adjusted odds ratio = 1.39, 95% confidence interval (CI) = 1.08 to 1.78], and use of stimulants at least weekly independently predicted intermittent ART utilization (adjusted odds ratio = 2.62, 95% CI = 1.45 to 4.73). After controlling for the average self-reported percentage of ART doses taken and baseline T-helper (CD4) count, elevated depressive symptoms predicted a 50% higher mean viral load, and weekly stimulant use predicted a 137% higher mean viral load. These effects became nonsignificant after accounting for inconsistent patterns of ART utilization, providing evidence of partial mediation.

CONCLUSIONS

Inconsistent patterns of ART utilization may partially explain the effects of depression and stimulant use on hastened HIV disease progression.

Integrated behavioral intervention to improve HIV/AIDS treatment adherence and reduce HIV transmission

OBJECTIVES

We conducted a randomized clinical trial to test an integrated behavioral intervention designed to enhance using HIV treatment as prevention by improving medication adherence, reducing risks for other sexually transmitted infections, and minimizing risk compensation beliefs.

METHODS

Individuals living with HIV/AIDS (n = 436) participated in a randomized clinical trial testing an intensive behavioral intervention aimed at reducing HIV transmission risks compared with an attention control condition. We used unannounced pill counts to monitor antiretroviral therapy adherence and computerized interviews to measure risk behaviors.

RESULTS

The integrated transmission risk reduction intervention demonstrated increased antiretroviral therapy adherence and less unprotected intercourse with nonseroconcordant partners at 3- and 6-month follow-ups as well as fewer new sexually transmitted infections diagnosed over the 9-month follow-up period (adjusted odds ratio = 3.0; P < .05; 95% confidence interval = 1.01, 9.04). The integrated intervention also reduced behavioral risk compensation beliefs.

CONCLUSIONS

A theory-based integrated behavioral intervention can improve HIV treatment adherence and reduce HIV transmission risks. HIV treatment as prevention should be bundled with behavioral interventions to maximize effectiveness.

Secondary prevention of HIV in the United States: past, current, and future perspectives

To provide a synopsis of past, current, and potential next-generation approaches to prevention for positives (PfP) interventions in the United States. For a variety of reasons, PfP interventions, with the goals of limiting HIV transmission from people living with HIV/AIDS (PLWHA) to others and protecting the health of PLWHA, did not appear with any frequency in the United States until about 2000. Even today, the number and breadth of evidence-based PfP interventions is very limited. Nevertheless, meta-analytic evidence demonstrates that such interventions can be effective, perhaps even more so than interventions targeting HIV-uninfected individuals. We review early and more recent PfP interventions and suggest that next-generation PfP interventions must involve behavioral and biologic components and target any element that affects HIV risk behavior and/or infectivity. Next-generation PfP interventions should include increased HIV testing to identify additional PLWHA, components to initiate and maintain HIV care, to initiate antiretroviral therapy and promote adherence, and to reduce sexual and injection drug use risk behavior, as well as ancillary treatments and referrals to services. Comprehensive next-generation PfP interventions, including all of these elements and effective linkages among them, are discussed.

Treatment of medical, psychiatric, and substance-use comorbidities in people infected with HIV who use drugs

HIV-infected drug users have increased age-matched morbidity and mortality compared with HIV-infected people who do not use drugs. Substance-use disorders negatively affect the health of HIV-infected drug users, who also have frequent medical and psychiatric comorbidities that complicate HIV treatment and prevention. Evidence-based treatments are available for the management of substance-use disorders, mental illness, HIV and other infectious complications such as viral hepatitis and tuberculosis, and many non-HIV-associated comorbidities. Tuberculosis co-infection in HIV-infected drug users, including disease caused by drug-resistant strains, is acquired and transmitted as a consequence of inadequate prescription of antiretroviral therapy, poor adherence, and repeated interfaces with congregate settings such as prisons. Medication-assisted therapies provide the strongest evidence for HIV treatment and prevention efforts, yet are often not available where they are needed most. Antiretroviral therapy, when prescribed and adherence is at an optimum, improves health-related outcomes for HIV infection and many of its comorbidities, including tuberculosis, viral hepatitis, and renal and cardiovascular disease. Simultaneous clinical management of multiple comorbidities in HIV-infected drug users might result in complex pharmacokinetic drug interactions that must be adequately addressed. Moreover, interventions to improve adherence to treatment, including integration of health services delivery, are needed. Multifaceted, interdisciplinary approaches are urgently needed to achieve parity in health outcomes in HIV-infected drug users.

Adapting positive prevention interventions for international settings: applying U.S. evidence to epidemics in developing countries

HIV prevention efforts with people living with HIV are critical, and Positive Prevention (PP) interventions have expanded globally to address this growing need. This article provides an overview of U.S. PP literature addressing evidence-based interventions. It continues by looking at the prevention needs and care issues of people living with HIV in Mozambique and the larger African context, and then discusses which U.S. PP models may be best suited for adaptation and use in Mozambique. The research suggests that the lessons learned from these U.S.-developed interventions can be modified to develop theoretically sound interventions. These interventions must be culturally specific and include a collaborative approach for best results.

A mixed methods evaluation of the effect of the protect and respect intervention on the condom use and disclosure practices of women living with HIV/AIDS

This mixed methods study evaluated the efficacy of an intervention to increase HIV status disclosure and condom use among 184 women living with HIV/AIDS (WLH/A). Participants were recruited from an HIV clinic and randomly assigned to: (1) a comparison group, who received brief messages from their health care providers (HCPs), or; (2) an intervention group, who received messages from HCPs, a group-level intervention, and peer-led support groups. Participants completed risk surveys at baseline, 6-, 12-, and 18-months. Quantitative analyses using hierarchical generalized linear models within a repeated measures framework indicated that intervention participants had significantly higher odds of reporting condom use with sexual partners in months 6 and 18. Grounded Theory-based qualitative analyses suggested that the opportunity to discuss the social context of their lives in addition to HIV/AIDS, including continued stigma and fear related to disclosure, are also essential components of a prevention strategy for WLH/A.

Interventions delivered in clinical settings are effective in reducing risk of HIV transmission among people living with HIV: results from the Health Resources and Services Administration (HRSA)'s Special Projects of National Significance initiative

To support expanded prevention services for people living with HIV, the US Health Resources and Services Administration (HRSA) sponsored a 5-year initiative to test whether interventions delivered in clinical settings were effective in reducing HIV transmission risk among HIV-infected patients. Across 13 demonstration sites, patients were randomized to one of four conditions. All interventions were associated with reduced unprotected vaginal and/or anal intercourse with persons of HIV-uninfected or unknown status among the 3,556 participating patients. Compared to the standard of care, patients assigned to receive interventions from medical care providers reported a significant decrease in risk after 12 months of participation. Patients receiving prevention services from health educators, social workers or paraprofessional HIV-infected peers reported significant reduction in risk at 6 months, but not at 12 months. While clinics have a choice of effective models for implementing prevention programs for their HIV-infected patients, medical provider-delivered methods are comparatively robust.

Decrease of initial CD4+ T-cell counts at the time of diagnosis of HIV infection in Korea; 1988-2006

The aim of the study was to evaluate the trends of initial CD4+ T-cell counts (CD4+) at HIV diagnoses and to identify the factors influencing the annual changes of CD4+ cell counts in Korea during 1988-2006. As a retrospective study, 2613 individuals (>/=15 years at diagnosis, their CD4+ counts were measured within six months) were selected from all 4580 HIV-infected Koreans diagnosed between 1985 and 2006. The mean CD4+ cell counts in all the selected individuals was 312 cells/mm(3), and this value decreased significantly by 20.3 cells/mm(3)/year over the 19 year study period. Men had lower CD4+ cell count than women by 22.7 cells/mm(3), and age at HIV diagnosis had an inverse relationship with CD4+ cell counts of 23.5 cells/mm(3) lower per 10 years advancing age. Cases diagnosed in hospitals showed CD4+ cell count levels 33.9 cells/mm(3) lower than public institutions by 33.9 cells/mm(3). Gender and age seemed to affect trends of CD4+ count; however the institution where cases were diagnosed had the strongest effect on decreasing CD4+ cell counts. The results suggest that HIV diagnoses in recent years are being made in later stages of HIV infection and that it is imperative to develop more efficient programmes for early HIV diagnosis to prevent transmission.

Trends in sexually transmitted diseases and risky behaviors among HIV-infected patients at an outpatient clinic in southern Taiwan

BACKGROUND

Little is known about the prevalence of concurrent sexually transmitted diseases (STDs) and associated risky behaviors among patients living with HIV in Taiwan.

METHODS

A cross-sectional study was conducted using HIV-infected patients who attended the outpatient clinic of an AIDS referral center in Taiwan between August 2005 and December 2005. Participants received physical examinations, serological tests for syphilis, and urine tests for both Neisseria gonorrhoea and Chlamydia trachomatis by the polymerase chain reaction method. A self-administered questionnaire concerning sexual behaviors and history of STDs was collected. The history of repeat STDs since the diagnosis of HIV was retrieved by chart review.

RESULTS

A total of 123 HIV-infected patients were enrolled. Among these, 43.1% reported a history of STDs before the diagnosis of HIV infection. A total of 36.1% had concurrent STDs at the time of HIV diagnosis, and 8.9% were diagnosed with STDs at enrollment. Syphilis was the most common STD. The rate of condom usage for the last sexual intercourse was 68.3%, and the use of illicit/recreational drugs was 7.9%. HIV diagnosis within 3 months (odds ratio [OR], 46.5; 95% confidence interval [CI], 3.9-552.0; P = 0.002) and repeated infection with STDs since HIV diagnosis (OR, 18.7; 95% CI, 1.7-201.6; P = 0.016) were 2 independent predictors of participants with active STDs at enrollment.

CONCLUSION

HIV-infected individuals had a high rate of concurrent STDs before and after diagnosis of HIV infection. Our study findings highlight the importance of secondary prevention strategies for patients living with HIV.

Mental health treatment to reduce HIV transmission risk behavior: a positive prevention model

Secondary HIV prevention, or "positive prevention," is concerned with reducing HIV transmission risk behavior and optimizing the health and quality of life of people living with HIV/AIDS (PLWHA). The association between mental health and HIV transmission risk (i.e., sexual risk and poor medication adherence) is well established, although most of this evidence is observational. Further, a number of efficacious mental health treatments are available for PLWHA yet few positive prevention interventions integrate mental health treatment. We propose that mental health treatment, including behavioral and pharmacologic interventions, can lead to reductions in HIV transmission risk behavior and should be a core component of secondary HIV prevention. We present a conceptual model and recommendations to guide future research on the effect of mental health treatment on HIV transmission risk behavior among PLWHA.

Relationships over time between mental health symptoms and transmission risk among persons living with HIV

Relationships between mental health symptoms (anxiety and depression) or a positive state of mind and behavior associated with HIV transmission (substance use and risky sexual behavior) were explored in a longitudinal study of persons living with HIV (PLH; N = 936) who were participants in a transmission-prevention trial. Bivariate longitudinal regressions were used to estimate the correlations between mental health symptoms and HIV-related transmission acts for 3 time frames: at the baseline interview, over 25 months, and from assessment to assessment. At baseline, mental health symptoms were associated with transmission acts. Elevated levels of mental health symptoms at baseline were associated with decreasing alcohol or marijuana use over 25 months. Over 25 months, an increasingly positive state of mind was associated with decreasing alcohol or marijuana use; an increasingly positive state of mind in the immediate intervention condition and increasing depressive symptoms in the lagged condition were related to increasing risky sexual behavior. Our findings suggest that mental health symptoms precede a decrease in substance use and challenge self-medication theories. Changes in mental health symptoms and sexual behavior occur more in tandem.

Lack of understanding of acute HIV infection among newly-infected persons-implications for prevention and public health: The NIMH Multisite Acute HIV Infection Study: II

Acute/early HIV infection is a period of high HIV transmission. Consequently, early detection of HIV infection and targeted HIV prevention could prevent a significant proportion of new transmissions. As part of an NIMH-funded multisite study, we used in-depth interviews to explore understandings of acute HIV infection (AHI) among 34 individuals diagnosed with acute/early HIV infection in six US cities. We found a marked lack of awareness of AHI-related acute retroviral symptoms and a lack of clarity about AHI testing methods. Most participants knew little about the meaning and/or consequences of AHI, particularly that it is a period of elevated infectiousness. Over time and after the acute stage of infection, many participants acquired understanding of AHI from varied sources, including the Internet, HIV-infected friends, and health clinic employees. There is a need to promote targeted education about AHI to reduce the rapid spread of HIV associated with acute/early infection within communities at risk for HIV.

Psychiatric context of acute/early HIV infection. The NIMH Multisite Acute HIV Infection Study: IV

Acute/early HIV infection is a period of high risk for HIV transmission. Better understanding of behavioral aspects during this period could improve interventions to limit further transmission. Thirty-four participants with acute/early HIV infection from six US cities were assessed with the Mini International Diagnostic Interview, Beck Depression Inventory II, State-Trait Anxiety Inventory, Brief COPE, and an in-depth interview. Most had a pre-HIV history of alcohol or substance use disorder (85%); a majority (53%) had a history of major depressive or bipolar disorder. However, post-diagnosis coping was predominantly adaptive, with only mild to moderate elevations of anxious or depressive mood. Respondents described challenges managing HIV in tandem with pre-existing substance abuse problems, depression, and anxiety. Integration into medical and community services was associated with adaptive coping. The psychiatric context of acute/early HIV infection may be a precursor to infection, but not necessarily a barrier to intervention to reduce forward transmission of HIV among persons newly infected.

Lessons learned about behavioral science and acute/early HIV infection. The NIMH Multisite Acute HIV Infection Study: V

Acute/early HIV infection is a period of heightened HIV transmission and a window of opportunity for intervention to prevent onward disease transmission. The NIMH Multisite Acute HIV Infection (AHI) Study was an exploratory initiative aimed at determining the feasibility of recruiting persons with AHI into research, assessing their psychosocial and behavioral characteristics, and examining short-term changes in these characteristics. This paper reports on lessons learned in the study, including: (1) the need to establish the cost-effectiveness of AHI testing; (2) challenges to identifying persons with AHI; (3) the need to increase awareness of acute-phase HIV transmission risks; (4) determining the goals of behavioral interventions following AHI diagnosis; and (5) the need for "rapid response" public health systems that can move quickly enough to intervene while persons are still in the AHI stage. There are untapped opportunities for behavioral and medical science collaborations in these areas that could reduce the incidence of HIV infection.

Sociocultural dimensions of HIV/AIDS among Middle Eastern immigrants in the US: bridging culture with HIV/AIDS programmes

The population of Middle Eastern immigrants in the US has been increasing dramatically over the past 30 years, growing from 200,000 in 1970 to 1.5 million in 2000. These immigrants and their descendants constitute an important new population of interest for public health and other social programmes. With this addition to the cultural diversity of American society, it is important for healthcare programmes to be responsive to the unique cultural needs of those of Middle Eastern origin and to include them in healthcare curricula. This need is particularly imperative for human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) intervention programmes, where the reduction of risky behaviours is essential to controlling the epidemic. When Middle Easterners emigrate to the US they must adjust to the American culture, which leads to preservation of some aspects of their culture and adjustment of behaviors to match American customs. This article aims to present sociocultural factors of HIV risk behaviours that are specific to Middle Eastern culture. The article also provides recommendations for HIV/AIDS-culturally appropriate intervention programmes.

Lessons Learned from "integrating" intensive family-based interventions into medical care settings for mothers living with HIV/AIDS and their adolescent children

Centers for Disease Control and Prevention (CDC) has recommended integrating behavioral interventions into medical care settings for persons living with HIV. Delivering an intensive, family-based intervention for mothers living with HIV (MLH) (n = 173) and their adolescent children (n = 116) integrated into medical care was problematic. Despite the fact that nearly half of MLH were recruited at HIV/AIDS clinics, community centers and children's hospitals were the most popular and most successful sites for the delivery of the intervention. We provide recommendations for how to integrate intensive interventions into medical care, given the needs of MLH, their adolescents, and the organizations serving them.

Sexual risk reduction among Zambian couples

Zambia has over 1 million HIV infections nationwide and an urban prevalence rate of 23%. This study compared the impact of male involvement in multiple and single session risk reduction interventions among inconsistent condom users in Zambia and the role of serostatus among HIV-seropositive and serodiscordant couples. Couples (N=392) were randomised into intervention arms. Among inconsistent condom users at baseline (N=83), condom use increased in both conditions and this increase was maintained over a 12- month period. At 12 months, seronegative men in the multiple session condition increased sexual barrier (male and female condoms) use in comparison with those in the single session condition (F=16.13, =0.001) while seropositive individuals increased sexual barrier use regardless of condition. Results illustrate the importance of both single and multiple session risk reduction counseling among seronegative men in serodiscordant couples in Zambia, and highlight the differing perception of risk between seropositive and serodiscordant persons.

Understanding differences in HIV sexual transmission among Latino and black men who have sex with men: The Brothers y Hermanos Study

HIV sexual transmission risk behaviors were examined among 1,065 Latino and 1,140 black men who have sex with men (MSM). Participants completed a computer-administered questionnaire and were tested for HIV infection. Of men who reported that their last HIV test was negative or that they had never been tested or did not get the result of their last test, 17% of black and 5% of Latino MSM tested HIV-positive in our study. In both ethnic groups, the three-month prevalence of unprotected anal intercourse (UAI) with HIV-negative or unknown serostatus partners was twice as high among men unaware of their HIV infection than men who knew they were HIV seropositive at the time of enrollment. UAI exclusively with HIV-positive partners was more prevalent among HIV-positive/aware than HIV-positive/unaware men. The findings advance understanding of the high incidence of HIV infection among black MSM in the U.S.

The development and validation of a tool to assess nurse performance in dual protection counseling

OBJECTIVE

To present preliminary evidence for the reliability and validity of the Dual Protection Counseling Checklist (DPCC), an instrument designed to evaluate nurses' fidelity to high quality dual protection counseling in a family planning setting.

METHODS

During a trial comparing a dual protection (DP) nurse counseling intervention to standard of care (SOC), client-counselor sessions were audiotaped. Following good inter-rater reliability, 78 audiotaped interviews were coded from the two conditions using the DPCC. We constructed indices from a subset of codes to capture three domains: Promotion of DP (PDP), Relapse prevention counseling (RPC), and Quality of Nurse-Client Interaction (QNCI). The association between scores on these indices and client outcomes was evaluated using logistic regression.

RESULTS

The DPCC and indices were reliable. Construct validity of indices was supported by greater frequency of target behaviors by the DP nurse. Validity of the QNCI was further supported by its association with clients' sexual risk reduction 6 months post-counseling.

CONCLUSION

The DPCC and indices hold practical utility for evaluation, monitoring, and supervision of nurse-client counseling sessions.

PRACTICE IMPLICATIONS

The Dual Protection Counseling Checklist provides a user-friendly tool for assessing nurses' and other providers' counseling behaviors in dual protection.

Prevention with positives: a review of published research, 1998-2008

HIV prevention education and counseling efforts have historically been directed toward those individuals considered at risk for exposure to HIV and assumed to be uninfected with HIV. In the late 1990s, prevention efforts began to include individuals who were HIV-infected. In 2003, the Centers for Disease Control and Prevention recommended that HIV prevention be incorporated into the medical care of persons living with HIV. This domain of HIV prevention work is known as prevention with positives or positive prevention, and research within this domain has been ongoing for a decade. This article provides a review of the scientific evidence within the prevention with positives domain from 1998 to 2008. A discussion is provided regarding early descriptive and formative studies as well as more recent and ongoing intervention trials specifically designed for persons living with HIV. A summary of current knowledge, a description of ongoing research, and gaps in knowledge are identified. Topics for future research are suggested.

Secondary prevention of HIV infection: the current state of prevention for positives

PURPOSE OF REVIEW

To provide a state-of-the-science review of the literature on secondary prevention of HIV infection or 'prevention for positives' (PfP) interventions.

RECENT FINDINGS

Early work on PfP focused on understanding the dynamics of risky behavior among People Living with HIV/AIDS (PLWH) and on designing, implementing, and evaluating a limited number of interventions to promote safer sexual and drug use behavior in this population (i.e., PfP interventions). Previous meta-analyses demonstrated that PfP interventions can effectively promote safer behavior. However, the understanding of risk dynamics among PLWH and the extant number and breadth of effective PfP interventions were scant. Recent work has addressed some of these problems, yielding greater understanding of risk dynamics and providing additional, effective interventions. Still, only a modest number of recent, rigorously evaluated, effective interventions have been identified. New ideas for creating stronger, more integrated, and effective PfP interventions have emerged that will guide future intervention research and practice.

SUMMARY

There remains much to be done to understand why, when, and under what conditions PLWH practice risk. Substantial work also needs to be performed to design, implement, rigorously evaluate, and when effective, to disseminate widely, additional, evidence-based PfP interventions targeting diverse populations. Directing such interventions to populations of PLWH at greatest risk for transmission of HIV has the potential to yield significant impact on the pandemic.

Randomized controlled trial of a cognitive-behavioral intervention for HIV-positive persons: an investigation of treatment effects on psychosocial adjustment

Questions remain regarding the clinical utility of psychological interventions for HIV-positive persons because randomized controlled trials have utilized stringent inclusion criteria and focused extensively on gay men. The present randomized controlled trial examined the efficacy of a 15-session, individually delivered cognitive-behavioral intervention (n = 467) compared to a wait-list control (n = 469) in a diverse sample of HIV-positive persons who reported HIV transmission risk behavior. Five intervention sessions that dealt with executing effective coping responses were delivered between baseline and the 5 months post-randomization. Additional assessments were completed through 25 months post-randomization. Despite previously documented reductions in HIV transmission risk, no intervention-related changes in psychosocial adjustment were observed across the 25-month investigation period. In addition, there were no intervention effects on psychosocial adjustment among individuals who presented with mild to moderate depressive symptoms. More intensive mental health interventions may be necessary to improve psychosocial adjustment among HIV-positive individuals.

Reducing risky sexual behavior and substance use among currently and formerly homeless adults living with HIV

OBJECTIVES

We examined the efficacy of the Healthy Living Program in reducing risky sexual behavior and substance use among adults with HIV infection who were marginally housed (i.e., homeless at some point over a 37-month period).

METHODS

We had previously conducted a randomized controlled trial with 936 adults living with HIV infection. In that study, 3 intervention modules of 5 sessions each addressed different goals: reducing risky sexual acts and drug use, improving the quality of life, and adhering to healthful behaviors. Participants were interviewed at baseline and at 5, 10, 15, 20, and 25 months; 746 completed 4 or more assessments. In this study, we analyzed sexual behavior and drug use outcomes for the 35% (n = 270 of 767) of participants who were considered marginally housed.

RESULTS

Among the marginally housed participants, there were significantly greater reductions in unprotected risky sexual acts, the number of sexual partners of HIV negative or unknown serostatus, alcohol or marijuana use, and hard drug use among the intervention group than among the control group.

CONCLUSIONS

Intensive, skill-focused intervention programs may improve the lives of marginally housed adults living with HIV infection.

A qualitative analysis of partner selection, HIV serostatus disclosure, and sexual behaviors among HIV-positive urban men

Using grounded theory, 18 interviews with HIV-positive urban men were conducted to understand their sexual relationships. Analysis of the verbatim transcripts revealed that regardless of age, sexual orientation or race/ethnicity, the participants were "making choices" related to their sexual relationships. Some men were "avoiding sex" whereas others were engaging in "just sex" or having sex in a relationship that was "going somewhere." However, dependent upon the type of sexual relationship, these HIV-positive urban men struggled with issues associated with "disclosure" of serostatus, the sexual "behaviors" in which they engaged, and selecting sexual "partners." Health care providers can facilitate sexual health and well-being among HIV-positive urban men by recognizing that men may be seeking sexual intimacy for different purposes, in different types of relationships, or avoiding it entirely. By exploring these decision-making processes, it is possible to facilitate sexual relationships that prevent new infections as well as manage the dissonance associated with this decision-making associated with disclosure, behaviors and their sexual partners.

Persistence of virological benefits following directly administered antiretroviral therapy among drug users: results from a randomized controlled trial

BACKGROUND

Although directly administered antiretroviral therapy (DAART) has demonstrated impressive biological benefits compared with self-administered therapy (SAT) among drug users, the persistence of DAART after transition to SAT has not been examined.

METHODS

We conducted a community-based, prospective, randomized controlled trial of 6 months of DAART compared with SAT. The primary outcome was the proportion of subjects who achieved virological success at 6 months postintervention, defined as either a 1.0 log10 reduction from baseline or HIV-1 RNA <400 copies per milliliter. Secondary outcomes included the change from baseline in HIV-1 RNA and CD4 lymphocyte count.

RESULTS

Of the 53 subjects in the SAT arm and 88 subjects in the DAART arm, 52 and 82, respectively, provided blood samples at 6 months postintervention. The DAART (n = 88) and SAT (n = 53) arms did not differ on virological success (DAART 58.0% vs. SAT 56.6%, P = 0.64), mean reduction in log10 HIV-1 RNA (-0.79 vs. -0.31 log10 copies/mL, P = 0.53), or mean change in CD4 lymphocyte count (+60.2 vs. -15.4 cells/mL, P = 0.12). In the multivariate analysis, only high levels of social support significantly predicted virological success.

CONCLUSIONS

This analysis, from the first randomized controlled trial of DAART among active drug users, failed to show the persistence of the DAART intervention at improving virological outcomes. Additional strategies are needed to ensure the on-treatment benefits persist following the cessation of DAART.

Substance use and high risk sexual behaviors among women in psychosocial outpatient and methadone maintenance treatment programs

OBJECTIVES

The purpose of the present study was to assess the association between substance use/diagnosis and sexual risk behaviors among women enrolled in both psychosocial outpatient (PS) and methadone maintenance (MM) treatment and involved in a HIV prevention intervention study within the National Institute for Drug Abuse Clinical Trials Network.

METHODS

515 sexually active women reported on unprotected sexual occasions (USO), anal sex, sex trading, sex with drug occasions, and multiple male sex partners at the baseline assessment.

RESULTS

Within the PS sample, cocaine use diagnosis was associated with more than twice the risk of having multiple partners, trading sex for drugs, having anal sex, or having sex with drugs; alcohol or opioid use diagnosis was associated with fewer risk behaviors. Within the MM sample, cocaine use, alcohol use and opiate use diagnoses were each associated with one to two risk behaviors. Associations between sexual risk and substance using days were less frequent in both samples.

CONCLUSIONS

These findings highlight the need for integration of HIV sexual prevention interventions that address the relationship between sexual risk behavior and substance use diagnoses into substance abuse treatment programs.

A behavioral intervention reduces HIV transmission risk by promoting sustained serosorting practices among HIV-infected men who have sex with men

OBJECTIVE

To examine factors that explain the effect of a cognitive-behavioral intervention on reductions in HIV transmission risk among HIV-infected men who have sex with men (MSM).

METHOD

Of the 1910 HIV-infected MSM screened, 616 participants considered to be at risk of transmitting HIV were randomized to a 15-session, individually delivered cognitive-behavioral intervention (n=301) or a wait-list control (n=315).

RESULTS

Consistent with previous intent-to-treat findings, there was an overall reduction in transmission risk acts among MSM in both intervention and control arms, with significant intervention effects observed at the 5-, 10-, 15-, and 20-month assessments (risk ratios=0.78, 0.62, 0.48, and 0.38, respectively). These intervention-related decreases in HIV transmission risk acts seemed to be partially due to sustained serosorting practices. MSM in the intervention condition reported a significantly greater proportion of sexual partners who were HIV infected at the 5- and 10-month assessments (risk ratios=1.14 and 1.18).

CONCLUSIONS

The Healthy Living Project, a cognitive-behavioral intervention, is efficacious in reducing transmission risk acts among MSM. This seems to have been due in large part to the fact that MSM in the intervention condition reported sustained serosorting practices.

Stimulant use is associated with immune activation and depleted tryptophan among HIV-positive persons on anti-retroviral therapy

Cocaine, crack, and methamphetamine are stimulants that promote autonomic nervous system activation. Although these stimulants may have immunomodulatory effects, relatively few studies have examined this possibility. The present cross-sectional investigation utilized baseline data from 127 HIV-positive individuals on anti-retroviral therapy (ART) that were enrolled in a randomized controlled trial. The goal of this study was to examine whether stimulant use is independently associated with immune activation and indices of tryptophan degradation. Forty-four participants reported using stimulants 2-3 times a month or more (i.e., monthly stimulant use) and a sub-set of these (n=27) reported using stimulants once a week or more (i.e., weekly stimulant use) during the past three months. These stimulant-using groups were compared to a group of participants who reported no stimulant use (n=83) during the past three months. Results indicated that individuals who reported either monthly or weekly stimulant use displayed elevated neopterin, a measure of immune activation. Those who reported weekly stimulant use also displayed a markedly elevated HIV viral load and lower tryptophan levels. Even after controlling for self-reported ART non-adherence, weekly stimulant use was independently associated with higher neopterin, elevated HIV viral load, and lower tryptophan. To our knowledge, this is the first study to observe that stimulant use may independently promote immune activation and tryptophan degradation among HIV-positive persons on ART. Further research is needed to replicate these findings and examine the plausible bio-behavioral pathways that may account for the effects of stimulant use on HIV disease markers and depleted tryptophan.

Predictors of attrition among high risk HIV-infected participants enrolled in a multi-site prevention trial

Retaining high-risk individuals is critical for HIV prevention trials. The current analyses examined predictors of trial dropout among HIV-infected men and women in a multi-site HIV prevention trial. Results indicated that dropouts (n = 74) were more likely to be younger, depressed, and not taking antiretroviral therapy (ART) than those who continued (n = 815). No other background, substance use, or transmission risk differences were found, suggesting no direct evidence of dropout bias on key outcomes. Efforts may be warranted for early detection and treatment of depression and for improving retention of younger participants and those not on ART.

Internalized heterosexism among HIV-positive, gay-identified men: implications for HIV prevention and care

Internalized heterosexism (IH), or the internalization of societal antihomosexual attitudes, has been consistently linked to depression and low self-esteem among gay men, and it has been inconclusively associated with substance use and sexual risk in gay and bisexual men. Using structural equation modeling, the authors tested a model framed in social action theory (C. K. Ewart, 1991, 2004) in which IH is associated with HIV transmission risk and poor adherence to HIV antiretroviral therapy (ART) through the mechanisms of negative affect and stimulant use. Data from a sample of 465 gay-identified men interviewed as part of an HIV risk reduction behavioral trial were used to test the fit of the model. Results support the hypothesized model in which IH was associated with unprotected receptive (but not insertive) anal intercourse with HIV-negative or unknown HIV status partners, and with ART nonadherence indirectly via increased negative affect and more regular stimulant use. The model accounted for 15% of the variance in unprotected receptive anal intercourse and 17% of the variance in ART nonadherence. Findings support the potential utility of addressing IH in HIV prevention and treatment with HIV-positive gay men.

Effectiveness of HIV/STD sexual risk reduction groups for women in substance abuse treatment programs: results of NIDA Clinical Trials Network Trial

CONTEXT

Because drug-involved women are among the fastest growing groups with AIDS, sexual risk reduction intervention for them is a public health imperative.

OBJECTIVE

To test effectiveness of HIV/STD safer sex skills building (SSB) groups for women in community drug treatment.

DESIGN

Randomized trial of SSB versus standard HIV/STD Education (HE); assessments at baseline, 3 and 6 months.

PARTICIPANTS

Women recruited from 12 methadone or psychosocial treatment programs in Clinical Trials Network of National Institute on Drug Abuse. Five hundred fifteen women with >or=1 unprotected vaginal or anal sex occasion (USO) with a male partner in the past 6 months were randomized.

INTERVENTIONS

In SSB, five 90-minute groups used problem solving and skills rehearsal to increase HIV/STD risk awareness, condom use, and partner negotiation skills. In HE, one 60-minute group covered HIV/STD disease, testing, treatment, and prevention information.

MAIN OUTCOME

Number of USOs at follow-up.

RESULTS

A significant difference in mean USOs was obtained between SSB and HE over time (F = 67.2, P < 0.0001). At 3 months, significant decrements were observed in both conditions. At 6 months, SSB maintained the decrease and HE returned to baseline (P < 0.0377). Women in SSB had 29% fewer USOs than those in HE.

CONCLUSIONS

Skills building interventions can produce ongoing sexual risk reduction in women in community drug treatment.

Integrating HIV care and HIV prevention: legal, policy and programmatic recommendations

Since the start of the HIV epidemic we have witnessed significant advances in our understanding of the impact of HIV disease worldwide. Furthermore, breakthroughs in treatment and the rapid expansion of HIV care and treatment programmes in heavily impacted countries over the past 5 years are potentially critical assets in a comprehensive approach to controlling the continued spread of HIV globally. A strategic approach to controlling the epidemic requires continued and comparable expansion and integration of care, treatment and prevention programmes. As every new infection involves transmission, whether vertically or horizontally, from a person living with HIV/AIDS (PLWHA), the integration of HIV prevention into HIV care settings has the potential to prevent thousands of new infections, as well as to improve the lives of PLWHA. In this paper, we highlight how to better utilize opportunities created by the antiretroviral roll-out to achieve more effective prevention, particularly in sub-Saharan Africa. We offer specific recommendations for action in the domains of healthcare policy and practice in order better to utilize the advances in HIV treatment to advance HIV prevention.

Behavioral interventions to reduce risk for sexual transmission of HIV among men who have sex with men

BACKGROUND

Men who have sex with men (MSM) remain at great risk for HIV infection. Program planners and policy makers need descriptions of interventions and quantitative estimates of intervention effects to make informed decisions concerning prevention funding and research. The number of intervention strategies for MSM that have been examined with strong research designs has increased substantially in the past few years.

OBJECTIVES

1. To locate and describe outcome studies evaluating the effects of behavioral HIV prevention interventions for MSM.2. To summarize the effectiveness of these interventions in reducing unprotected anal sex.3. To identify study characteristics associated with effectiveness.4. To identify gaps and indicate future research, policy, and practice needs.

SEARCH STRATEGY

We searched electronic databases, current journals, manuscripts submitted by researchers, bibliographies of relevant articles, conference proceedings, and other reviews for published and unpublished reports from 1988 through December 2007. We also asked researchers working in HIV prevention about new and ongoing studies.

SELECTION CRITERIA

Studies were considered in scope if they examined the effects of behavioral interventions aimed at reducing risk for HIV or STD transmission among MSM. We reviewed studies in scope for criteria of outcome relevance (measurement of at least one of a list of behavioral or biologic outcomes, e.g., unprotected sex or incidence of HIV infections) and methodologic rigor (randomized controlled trials or certain strong quasi-experimental designs with comparison groups).

DATA COLLECTION AND ANALYSIS

We used fixed and random effects models to summarize rate ratios (RR) comparing intervention and control groups with respect to count outcomes (number of occasions of or partners for unprotected anal sex), and corresponding prevalence ratios (PR) for dichotomous outcomes (any unprotected anal sex vs. none). We used published formulas to convert effect sizes and their variances for count and dichotomous outcomes where necessary. We accounted for intraclass correlation (ICC) in community-level studies and adjusted for baseline conditions in all studies. We present separate results by intervention format (small group, individual, or community-level) and by type of intervention delivered to the comparison group (minimal or no HIV prevention in the comparison condition versus standard or other HIV prevention in the comparison condition). We examine rate ratios stratified according to characteristics of participants, design, implementation, and intervention content. For small group and individual-level interventions we used a stepwise selection process to identify a multivariable model of predictors of reduction in occasions of or partners for unprotected anal sex. We used funnel plots to examine publication bias, and Q (a chi-squared statistic with degrees of freedom = number of interventions minus 1) to test for heterogeneity.

MAIN RESULTS

We found 44 studies evaluating 58 interventions with 18,585 participants. Formats included 26 small group interventions, 21 individual-level interventions, and 11 community-level interventions. Sixteen of the 58 interventions focused on HIV-positives. The 40 interventions that were measured against minimal to no HIV prevention intervention reduced occasions of or partners for unprotected anal sex by 27% (95% confidence interval [CI] = 15% to 37%). The other 18 interventions reduced unprotected anal sex by 17% beyond changes observed in standard or other interventions (CI = 5% to 27%). Intervention effects were statistically homogeneous, and no independent variable was statistically significantly associated with intervention effects at alpha=.05. However, a multivariable model selected by backward stepwise elimination identified four study characteristics associated with reduction in occasions of or partners for unprotected anal sex among small group and individual-level interventions at alpha=.10. The most favorable reductions in episodes of or partners for unprotected anal sex (33% to 35% decreases) were observed among studies with count outcomes, those with shorter intervention spans (<=1 month), those with better retention in the intervention condition than in the comparison condition, and those with minimal to no HIV prevention intervention delivered to the comparison condition. Because there were only 11 community-level studies we did not search for a multivariable model for community-level interventions. In stratified analyses including only one variable at a time, the greatest reductions (40% to 54% decreases) in number of episodes of or partners for unprotected anal sex among community-level interventions were observed among studies where groups were assigned randomly rather than by convenience, studies with shorter recall periods and longer follow-up, studies with more than 25% non-gay identifying MSM, studies in which at least 90% of participants were white, and studies in which the intervention addressed development of personal skills.

AUTHORS' CONCLUSIONS

Behavioral interventions reduce self-reported unprotected anal sex among MSM. These results indicate that HIV prevention for this population can work and should be supported. Results of previous studies provide a benchmark for expectations in new studies. Meta-analysis can inform future design and implementation in terms of sample size, target populations, settings, goals for process measures, and intervention content. When effects differ by design variables, which are deliberately selected and planned, awareness of these characteristics may be beneficial to future designs. Researchers designing future small group and individual-level studies should keep in mind that to date, effects of the greatest magnitude have been observed in studies that used count outcomes and a shorter intervention span (up to 1 month). Among small group and individual-level studies, effects were also greatest when the comparison condition included minimal to no HIV prevention content. Nevertheless, statistically significant favorable effects were also seen when the comparison condition included standard or other HIV prevention content. Researchers choosing the latter option for new studies should plan for larger sample sizes based on the smaller expected net intervention effect noted above. When effects differ by implementation variables, which become evident as the study is conducted but are not usually selected or planned, caution may be advised so that future studies can reduce bias. Because intervention effects were somewhat stronger (though not statistically significantly so) in studies with a greater attrition in the comparison condition, differential retention may be a threat to validity. Extra effort should be given to retaining participants in comparison conditions. Among community-level interventions, intervention effects were strongest among studies with random assignment of groups or communities. Therefore the inclusion of studies where assignment of groups or communities was by convenience did not exaggerate the summary effect. The greater effectiveness of interventions including more than 25% non-gay identifying MSM suggests that when they can be reached, these men may be more responsive than gay-identified men to risk reduction efforts. Non-gay identified MSM may have had less exposure to previous prevention messages, so their initial exposure may have a greater impact. The greater effectiveness of interventions that include efforts to promote personal skills such as keeping condoms available and behavioral self-management indicates that such content merits strong consideration in development and delivery of new interventions for MSM. And the finding that interventions were most effective for majority white populations underscores the critical need for effective interventions for MSM of African and Latino descent. Further research measuring the incidence of HIV and other STDs is needed. Because most studies were conducted among mostly white men in the US and Europe, more evaluations of interventions are needed for African American and Hispanic MSM as well as MSM in the developing world. More research is also needed to further clarify which behavioral strategies (e.g., reducing unprotected anal sex, having oral sex instead of anal sex, reducing number of partners, avoiding serodiscordant partners, strategic positioning, or reducing anal sex even with condom use) are most effective in reducing transmission among MSM, the messages most effective in promoting these behaviors, and the methods and settings in which these messages can be most effectively delivered.

Effects of behavioral intervention on substance use among people living with HIV: the Healthy Living Project randomized controlled study

AIM

Reductions in substance use were examined in response to an intensive intervention with people living with human immunodeficiency virus (HIV) (PLH).

DESIGN, SETTING AND PARTICIPANTS

A randomized controlled trial was conducted with 936 PLH who had recently engaged in unprotected sexual risk acts recruited from four US cities: Milwaukee, San Francisco, New York and Los Angeles. Substance use was assessed as the number of days of use of 19 substances recently (over the last 90 days), evaluated at 5-month intervals over 25 months.

INTERVENTION

A 15-session case management intervention was delivered to PLH in the intervention condition; the control condition received usual care.

MEASUREMENTS

An intention-to-treat analysis was conducted examining reductions on multiple indices of recent substance use calculated as the number of days of use.

FINDINGS

Reductions in recent substance use were significantly greater for intervention PLH compared to control PLH: alcohol and/or marijuana use, any substance use, hard drug use and a weighted index adjusting for seriousness of the drug. While the intervention-related reductions in substance use were larger among women than men, men also reduced their use. Compared to controls, gay and heterosexual men in the intervention reduced significantly their use of alcohol and marijuana, any substance, stimulants and the drug severity-weighted frequency of use index. Gay men also reduced their hard drug use significantly in the intervention compared to the control condition.

CONCLUSIONS

A case management intervention model, delivered individually, is likely to result in significant and sustained reductions in substance use among PLH.

Co-occurrence of treatment nonadherence and continued HIV transmission risk behaviors: implications for positive prevention interventions

Effective treatment regimens for HIV infection demand very high levels of adherence and people infected with HIV are expected to adhere to safer sex and drug use practices throughout their lives. Treatment nonadherence overlaps with continued unsafe sexual practices for some people living with HIV/AIDS. The co-occurrence of nonadherence and HIV transmission risk behavior poses particular risk for the spread of drug-resistant variants of HIV. There are common correlates of both nonadherence and risk behavior, particularly substance use and depression. Interventions designed to address treatment nonadherence and those designed to reduce risk behavior also share common elements, particularly self-efficacy enhancement and behavioral skills training. The common correlates and shared intervention elements suggest that integrated intervention approaches that simultaneously address adherence and risk reduction may be feasible. Research is currently testing interventions that simultaneously increase HIV treatment adherence and reduce behaviors that risk HIV transmission.

Receipt of prevention services among HIV-infected men who have sex with men

Unprotected sexual intercourse remains a primary mode of HIV transmission in the United States. We found that receipt of services to reduce HIV transmission-risk behaviors was low among 3787 HIV-infected individuals and that men who have sex with men were especially unlikely to receive these services even though they were more likely to report unprotected sexual intercourse with seronegative and unknown serostatus casual partners. Greater efforts should be made to ensure that prevention counseling is delivered to all HIV-infected persons, especially men who have sex with men.

Interactive "Video Doctor" counseling reduces drug and sexual risk behaviors among HIV-positive patients in diverse outpatient settings

BACKGROUND

Reducing substance use and unprotected sex by HIV-positive persons improves individual health status while decreasing the risk of HIV transmission. Despite recommendations that health care providers screen and counsel their HIV-positive patients for ongoing behavioral risks, it is unknown how to best provide "prevention with positives" in clinical settings. Positive Choice, an interactive, patient-tailored computer program, was developed in the United States to improve clinic-based assessment and counseling for risky behaviors.

METHODOLOGY AND FINDINGS

We conducted a parallel groups randomized controlled trial (December 2003-September 2006) at 5 San Francisco area outpatient HIV clinics. Eligible patients (HIV-positive English-speaking adults) completed an in-depth computerized risk assessment. Participants reporting substance use or sexual risks (n = 476) were randomized in stratified blocks. The intervention group 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. Compared with control, fewer intervention participants reported continuing illicit drug use (RR 0.81, 95% CI: 0.689, 0.957, p = 0.014 at 3 months; and RR 0.65, 95% CI: 0.540, 0.785, p<0.001 at 6 months) and unprotected sex (RR 0.88, 95% CI: 0.773, 0.993, p = 0.039 at 3 months; and RR 0.80, 95% CI: 0.686, 0.941, p = 0.007 at 6 months). Intervention participants reported fewer mean days of ongoing illicit drug use (-4.0 days vs. -1.3 days, p = 0.346, at 3 months; and -4.7 days vs. -0.7 days, p = 0.130, at 6 months) than did controls, and had fewer casual sex partners at (-2.3 vs. -1.4, p = 0.461, at 3 months; and -2.7 vs. -0.6, p = 0.042, at 6 months).

CONCLUSIONS

The Positive Choice intervention achieved significant cessation of illicit drug use and unprotected sex at the group-level, and modest individual-level reductions in days of ongoing drug use and number of casual sex partners compared with the control group. Positive Choice, including Video Doctor counseling, is an efficacious and appropriate adjunct to risk-reduction efforts in outpatient settings, and holds promise as a public health HIV intervention.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00447707.

Effects of a behavioral intervention on antiretroviral medication adherence among people living with HIV: the healthy living project randomized controlled study

OBJECTIVE

To examine the effect of a 15-session individually delivered cognitive behavioral intervention on antiretroviral (ART) medication adherence.

DESIGN

A multisite, 2-group, randomized controlled trial.

PARTICIPANTS

Two hundred four HIV-infected participants with self-reported ART adherence <85% from a total of 3818 participants screened were randomized into the trial. Potential participants were recruited for the main trial based on sexual risk criteria in Los Angeles, Milwaukee, New York, and San Francisco.

INTERVENTION

The primary outcome of the intervention was a reduction in HIV transmission risk behaviors. Fifteen 90-minute individually delivered sessions were divided into 3 modules: Stress, Coping, and Adjustment; Safer Behaviors; and Health Behaviors, including an emphasis on ART adherence. Controls received no intervention until trial completion. Both groups completed follow-up assessments at 5, 10, 15, 20, and 25 months after randomization.

MAIN OUTCOME MEASURE

Self-reported ART adherence as measured by 3-day computerized assessment.

RESULTS

A significance difference in rates of reported adherence was observed between intervention and control participants at months 5 and 15, corresponding to the assessments after the Stress, Coping, and Adjustment module (5-month time point) and after the Health Behaviors module (15-month time point). The relative improvements among the intervention group compared with the control group dissipated at follow-up.

CONCLUSIONS

Cognitive behavioral intervention programs may effectively improve ART adherence, but the effects of intervention may be short-lived.

Affect regulation, stimulant use, and viral load among HIV-positive persons on anti-retroviral therapy

OBJECTIVE

A substantial minority of HIV-positive individuals have comorbid affective or substance use disorders, which can interfere with effective medical management. The present study examined the associations among affect regulation, substance use, non-adherence to anti-retroviral therapy (ART), and immune status in a diverse sample of HIV-positive persons.

METHODS

A total of 858 HIV-positive participants self-reporting risk of transmitting HIV were enrolled in a randomized behavioral prevention trial and provided baseline blood samples to measure T-helper (CD4+) counts and HIV viral load.

RESULTS

Among individuals on ART, regular stimulant users had a five-fold (0.70 log10) higher HIV viral load than those who denied regular stimulant use. The association between regular stimulant use and elevated HIV viral load remained after accounting for demographics, differences in CD4+ counts, and polysubstance use. In the final model, 1 unit increase in affect regulation (decreased severity of depressive symptoms as well as enhanced positive states of mind) was associated with a 23% decrease in the likelihood of reporting regular stimulant use and 15% decrease in the likelihood of being classified as nonadherent to ART. Regular stimulant users, in turn, were more than twice as likely to be nonadherent to ART. Even after accounting for the effects of nonadherence and CD4+ counts, regular stimulant use was independently associated with 50% higher HIV viral load.

CONCLUSIONS

Increased mental health treatment as well as more intensive referrals to substance abuse treatment or 12-step self-help groups may be crucial to assist stimulant users with more effectively managing treatment for HIV/AIDS.

The role of self-efficacy in HIV treatment adherence: validation of the HIV Treatment Adherence Self-Efficacy Scale (HIV-ASES)

Adherence to HIV treatment, including adherence to antiretroviral (ART) medication regimens, is paramount in the management of HIV. Self-efficacy for treatment adherence has been identified as an important correlate of medication adherence in the treatment of HIV and other medical conditions. This paper describes the validation of the HIV Treatment Adherence Self-Efficacy Scale (HIV-ASES) with two samples of HIV+ adults on ART. Factor analyses support subscales measuring Adherence Integration (eigenvalue=6.12) and Adherence Perseverance (eigenvalue=1.16), accounting for 61% of the variance in scale items. The HIV-ASES demonstrates robust internal consistency (rhos>.90) and 3-month (rs>.70) and 15-month (rs>.40) test-retest reliability. Concurrent validity analyses revealed relationships with psychosocial measures, ART adherence, clinical status, and healthcare utilization. Findings support the use of the HIV-ASES and provide guidance for further investigation of adherence self-efficacy in the context of treatment for HIV and other diseases.

Long-term psychosocial challenges for people living with HIV: let's not forget the individual in our global response to the pandemic

Since the beginning of the HIV epidemic, people living with HIV have faced numerous psychological and behavioral challenges. With the advent of antiretroviral therapy (ART) there have been dramatic shifts in some of these key challenges and new ones have come to the forefront. This paper highlights several critical psychological and behavioral aspects of HIV disease, a few of which require focused attention, including mental health, stigma and disclosure, adherence, and sexual behavior. Although the focus is primarily on adults living with HIV, we also comment on some of the additional challenges for children and young people. Our critical examination in these areas draws upon the lessons learned in contexts in which ART has been available for a decade, and we explore what is currently happening in settings with more recent treatment access. In the end we offer our insights into what we may expect in the future, and provide recommendations for ongoing prevention and care initiatives with adults, children, and young people affected by this disease.

Predicting HIV transmission risk among HIV-infected patients seen in clinical settings

We assessed risk of transmission among 4,016 HIV-infected patients in primary care, including men who have sex with men (MSM, n = 2,109), women (n = 1,104) and men who had sex with women (MSW, n = 803) in clinics in 15 cities across the U.S. A transmission risk act, assessed by computer assisted interviews, was defined as unprotected vaginal or anal sex with a partner who was HIV-uninfected or of unknown HIV status. MSM were more than twice as likely to report transmission risk acts than MSW (Odds Ratio [OR] = 2.35; 95% Confidence Interval [CI] = 1.84, 3.00; P < or = .001). Women were also more likely to report transmission risk acts than MSW (OR = 1.56; 95% CI = 1.19, 2.05; P < or = .001). Stimulant use was associated with transmission risk in all three groups (P < or = .05). MSM were more likely to use methamphetamines (8% versus 2% and 3% respectively), while MSW (17%) and women (12%, compared to 11% for MSM) were more likely to use cocaine. Clinical settings offer opportunities for preventing HIV transmission, particularly if interventions are tailored to sub-populations of HIV-infected patients.