Mechanism of Change in Cognitive Behavioral Therapy for Body Image and Self-Care on ART Adherence Among Sexual Minority Men Living with HIV

Protocol for a multisite, parallel-group, randomized clinical trial comparing a brief tele-cognitive behavioral therapy intervention (BRIGHT) with attention control for the reduction of body image-related distress among head and neck cancer survivors

One in four head and neck cancer (HNC) survivors experience clinically significant body image distress (BID), a devastating psychosocial morbidity that adversely affects quality of life. To date, effective interventions for these patients are lacking. BRIGHT (Building a Renewed ImaGe after Head and neck cancer Treatment), a brief cognitive behavioral treatment (CBT), has shown potential efficacy as a novel treatment paradigm for HNC survivors with BID. The primary objective of this randomized clinical trial (RCT) is to test the hypothesis that BRIGHT improves BID among HNC survivors relative to an Attention Control (AC) intervention. In this multisite RCT, N = 180 HNC survivors with BID will be randomized 1:1 to six weeks of BRIGHT or AC of dose and delivery-matched survivorship education. Outcomes are assessed at baseline and 2, 3, 6, and 9-months post-randomization. The primary endpoint is the IMAGE-HN (Inventory to Measure and Assess imaGe disturbancE-Head and Neck) score, a validated patient-reported outcome of HNC-related BID. Secondary endpoints include the HN Shame and Stigma Scale, the PROMIS SF v1.0-Depression 8a, Anxiety 8a, and Ability to Participate in Social Activities 8a, the Beck Scale for Suicidal Ideation, and the EORTC QLQ-HN35 Trouble with Social Eating and Trouble with Social Contact subscales. The trial will also evaluate whether the effect of BRIGHT on BID is mediated through improvements in automatic thinking and body image coping strategies. Findings from this multisite RCT will provide a rigorous test of the efficacy of BRIGHT as the first evidence-based strategy to manage BID among HNC survivors. TRIAL REGISTRATION ID: NCT05442957.

Body Image and Its Associated Factors among People Living with HIV: A Comprehensive Systematic Review and implications for integrated care

Objectives

People living with HIV (PLWH) face unique psychosocial challenges due to both infection and antiretroviral therapy (ART), one of which is body image disruption. Yet, a comprehensive synthesis of existing research on body image among PLWH is lacking. This study systematically reviewed relevant studies to explore body image issues, identify associated factors, and describe assessment methods and interventions targeting body image in this population.

Methods

Guided by the PRISMA, a thorough search of PsycINFO, PubMed, Embase, and Web of Science was conducted in January 2024, including empirical studies considering Body Image among PLWH published in peer-reviewed English journals, using search terms relevant to HIV and Body image. To include the latest articles, we conducted another round of searches in November 2024. NIH Study Quality Assessment Tools were used to assess the quality of the included studies, and a narrative synthesis was conducted to identify common themes, including definitions of body image, associated factors, measurement instruments, and interventions targeting body image among PLWH.

Results

From 2197 publications, 26 studies from 2004 to 2024 met the inclusion criteria, comprising a sample of 4095 PLWH aged 8 to 65 from different countries. Most of the studies were cross-sectional in design and varied in focus. Findings reveal that body image issues are prevalent among PLWH. The majority of studies demonstrated an association between negative body image and psychological comorbidities, including depression, anxiety, social withdrawal, and substance use. Body image dissatisfaction was also associated with physical health factors such as lipodystrophy. BMI measures reported in twelve studies indicated that BMI tends to increase with age in PLWH. Sixteen distinct body image measurement tools were used across studies. CBT-BISC was the only target intervention that showed effectiveness in mitigating body image disturbance and improving ART adherence among PLWH.

Conclusion

Body image issues represent a critical but often overlooked component of the biopsychosocial challenges faced by PLWH. This is the first comprehensive literature review to exclusively consider body image, associated factors, measurements, and target interventions among PLWH, which highlighted the need for comprehensive, culturally sensitive interventions that address both the physical and psychological dimensions of body image concerns.

Interventions, Barriers, and Facilitators to Address the Sexual Problems of Gay, Bisexual and Other Men Who Have Sex with Men Living with HIV: A Rapid Scoping Review

Sexual problems are common among gay, bisexual, and other men who have sex with men (GBM) after diagnosis with HIV. However, these are often overlooked in care and research, where sexual risk reduction and biomedical aspects of sexual health tend to dominate. We conducted a rapid scoping review to investigate which sexual problems of GBM living with HIV are addressed by interventions, and the barriers and facilitators to their implementation. Literature from high-income countries published in English since 2010 was reviewed. Medline, Embase, PsycInfo, and Scopus databases were searched on July 4, 2022. Targeted sexual problems were categorized according to the ten dimensions of Robinson's Sexual Health Model, and barriers and facilitators, according to the five domains of the Consolidated Framework for Implementation Research (CFIR). Interventions focused solely on the dimension of Sexual Health Care/Safer Sex were excluded. Relevant information was extracted from the qualifying documents with NVivo 12 software for content analysis. Fifty-two documents were included, referring to 37 interventions which mainly took place in the United States (n = 29/37; 78%), were group-based (n = 16; 41%), and used counselling techniques (n = 23; 62%; e.g., motivational interviewing, cognitive-behavioral therapy). Their settings were mostly primary care (n = 15; 40%) or community-based (n = 16; 43%). On average, interventions addressed three sexual health dimensions (SD = 2; range: 1-10). The most targeted dimension was Sexual Health Care/Safer Sex (n = 26; 70%), which concerned sexual risk reduction. Next, Challenges (n = 23; 62%), included substance use (n = 7; 19%), sexual compulsivity (n = 6; 16%), sexual abuse (n = 6; 16%), and intimate partner violence (n = 4; 11%). Third was Talking About Sex (n = 22; 59%) which mostly concerned HIV disclosure. About a third of interventions addressed Culture/Sexual identity (n = 14; 38%), Intimacy/Relationships (n = 12; 33%), and Positive sexuality (n = 11; 30%). Finally, few targeted Body Image (n = 4; 11%), Spirituality (n = 3; 8%), Sexual Anatomy Functioning (n = 2; 5%) or Masturbation/Fantasy (n = 1; 3%). Forty-one documents (79%) mentioned implementation barriers or facilitators, particularly about the characteristics of the interventions (41% and 78%, respectively; e.g., cost, excessive duration, acceptability, feasibility) and of the individuals involved (37% and 46%; e.g., perceived stigmatization, provider expertise). The other three CFIR dimensions were less common (5%-17%). The search strategy of this review may not have captured all eligible documents, due to its limit to English-language publications. Overall, most interventions incorporated a focus on Sexual Health Care/Safer Sex, at the expenses of other prevalent sexual problems among GBM living with HIV, such as intimate partner violence (Challenges), erectile dysfunction (Sexual Anatomy Functioning), and Body Image dissatisfaction. These findings suggest they could receive more attention within clinical care and at the community level. They also highlight the importance of cost-effective and acceptable interventions conducted in non-stigmatizing environments, where patients' needs can be met by providers who are adequately trained on sexuality-related topics.

Mechanism underlying a brief cognitive behavioral treatment for head and neck cancer survivors with body image distress

PURPOSE

Body image distress (BID) among head and neck cancer (HNC) survivors is a debilitating toxicity associated with depression, anxiety, stigma, and poor quality of life. BRIGHT (Building a Renewed ImaGe after Head & neck cancer Treatment) is a brief cognitive behavioral therapy (CBT) that reduces BID for these patients. This study examines the mechanism underlying BRIGHT.

METHODS

In this randomized clinical trial, HNC survivors with clinically significant BID were randomized to receive five weekly psychologist-led video tele-CBT sessions (BRIGHT) or dose-and delivery matched survivorship education (attention control [AC]). Body image coping strategies, the hypothesized mediators, were assessed using the Body Image Coping Skills Inventory (BICSI). HNC-related BID was measured with the Inventory to Measure and Assess imaGe disturbancE-Head and Neck (IMAGE-HN). Causal mediation analyses were used to estimate the mediated effects of changes in BICSI scores on changes in IMAGE-HN scores.

RESULTS

Among 44 HNC survivors with BID allocated to BRIGHT (n = 20) or AC (n = 24), mediation analyses showed that BRIGHT decreased avoidant body image coping (mean change in BICSI-Avoidance scale score) from baseline to 1-month post-intervention relative to AC (p = 0.039). Decreases in BICSI-Avoidance scores from baseline to 1-month resulted in decreases in IMAGE-HN scores from baseline to 3 months (p = 0.009). The effect of BRIGHT on IMAGE-HN scores at 3 months was partially mediated by a decrease in BICSI-Avoidance scores (p = 0.039).

CONCLUSIONS

This randomized trial provides preliminary evidence that BRIGHT reduces BID among HNC survivors by decreasing avoidant body image coping. Further research is necessary to confirm these results and enhance the development of interventions targeting relevant pathways to reduce BID among HNC survivors.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03831100 .

Mechanism Underlying a Brief Cognitive Behavioral Treatment for Head and Neck Cancer Survivors with Body Image Distress

Purpose

Body image distress (BID) among head and neck cancer (HNC) survivors is a debilitating toxicity associated with depression, anxiety, stigma, and poor quality of life. BRIGHT (Building a Renewed ImaGe after Head & neck cancer Treatment) is a brief cognitive behavioral therapy (CBT) that reduces BID for these patients. This study examines the mechanism underlying BRIGHT.

Methods

In this randomized clinical trial, HNC survivors with clinically significant BID were randomized to receive 5 weekly psychologist-led video tele-CBT sessions (BRIGHT) or dose-and delivery matched survivorship education (attention control [AC]). Body image coping strategies, the hypothesized mediators, were assessed using the Body Image Coping Skills Inventory (BICSI). HNC-related BID was measured with the IMAGE-HN. Causal mediation analyses were used to estimate the mediated effects of changes in BICSI scores on changes in IMAGE-HN scores.

Results

Among 44 HNC survivors with BID, mediation analyses showed that BRIGHT decreased avoidant body image coping (mean change in BICSI-Avoidance scale score) from baseline to 1-month post-intervention relative to AC (p = 0.039). Decreases in BICSI-Avoidance scores from baseline to 1-month decreased IMAGE-HN scores from baseline to 3-months (p = 0.009). The effect of BRIGHT on IMAGE-HN scores at 3-months was partially mediated by a decrease in BICSI-Avoidance scores (p = 0.039).

Conclusions

This randomized trial provides preliminary evidence that BRIGHT reduces BID among HNC survivors by decreasing avoidant body image coping. Further research is necessary to confirm these results and enhance the development of interventions targeting relevant pathways to reduce BID among HNC survivors.

Trial Registration

This trial was registered on ClinicalTrials.gov identifier NCT03831100 on February 5, 2019.

Cognitive Behavioral Therapy for AIDS Prevention among College Students in China: A Cluster Randomized Controlled Trial

BACKGROUND

Acquired immune deficiency syndrome (AIDS) is a serious worldwide public health problem and has become the focus of prevention and control in China, while the student population is the key population for AIDS prevention.

OBJECTIVE

The purpose of this study was to investigate the effects of cognitive behavioral therapy (CBT) on college students' AIDS-related cognitions, attitudes, and behaviors, and to find programmatic strategies for AIDS prevention in terms of changing college students' cognitions and behaviors.

METHODS

In a cluster randomized controlled trial, 233 undergraduate students were assigned to the CBT group (CBT-based intervention, n=92), the TAU group (treatment as usual, n=72), and the CON group (no intervention, n=59). AIDS-related knowledge, attitudes, and behaviors of participants were assessed at pre-intervention, post-intervention, and follow-up.

RESULTS

After one month of the study, AIDS-related knowledge, attitudes, and behaviors improved in both the TAU and CBT groups, while there were no significant changes in the CON group. The intervention effect was more significant and sustainable in the CBT group compared to the TAU group.

CONCLUSIONS

The application of CBT in AIDS prevention among college students is feasible, acceptable, and effective. CBT can increase the level of knowledge about AIDS, improve AIDS-related attitudes, and increase willingness to use condoms. CBT is expected to replace traditional health education as an innovative tool for AIDS prevention because of its long-lasting and efficacious nature.

HIV infection disclosure, treatment self-efficacy and quality of life in HIV-infected MSM receiving antiretroviral therapy

BACKGROUND

Research on the relationship between disclosure of HIV status to male sexual partners (HIV disclosure) and quality of life (QOL) revealed complex and even contradictory results. The impact of HIV disclosure on various domains of QOL and the mediation effect between them are unclear. The purposes of this study were to explore the impact of HIV disclosure on QOL among men who have sex with men (MSM), and whether HIV treatment self-efficacy mediated these relationships.

METHODS

The data came from a baseline survey on the design of a randomized control trial conducted in Shandong, China. A total of 579 MSM patients were included. SPSS 24.0 was used to conduct independent samples t test, one-way analysis of variance and nonparametric tests and the PROCESS macro was used to conduct mediation analysis.

RESULTS

Among 579 participants, 16.06% disclosed their HIV infection status to their male sexual partners. The effect of HIV disclosure on QOL was mediated by treatment self-efficacy. Self-efficacy played partial mediating role in social relationships, meaning that HIV disclosure had both direct and indirect effects on this factor. In the overall QOL and domains of physical, psychological, independence, and environment, HIV disclosure had an indirect effect only through self-efficacy and no significant effect on the spirituality domain.

CONCLUSIONS

The results emphasize the importance of HIV disclosure and self-efficacy on the QOL of MSM patients and suggest that health care providers should assist MSM patients in deciding whether to disclose their HIV status during daily medical services.

Self-esteem and antiretroviral therapy adherence among young people living with HIV: An exploratory serial mediation analysis

Capitalising further on the benefits of antiretroviral therapy (ART) for individual treatment requires an improved understanding of the psychological processes that may affect optimal ART adherence among people living with HIV. We examined internalised HIV/AIDS-related stigma and body appreciation as mediators of the association between self-esteem and ART adherence among young people living with HIV (YPLHIV). A sample of 76 YPLHIV (Mage = 19.36, s.d.age = 2.56; male 56.58%) residing in an HIV hyperendemic region of South Africa completed self-report measures of self-esteem, internalised HIV/AIDS-related stigma, body appreciation, and ART adherence. Path-analytic mediation modelling was performed to test for direct and indirect effects linking self-esteem with ART adherence. Results of serial mediation analyses indicated that self-esteem and ART adherence were indirectly associated through a two-step path of internalised HIV/AIDS-related stigma and then body appreciation, as well as a one-step path through internalised HIV/AIDS-related stigma. The results provide preliminary support for internalised HIV/AIDS-related stigma and body appreciation as mechanisms underlying the association between self-esteem and ART adherence. Implications of the findings for promoting ART adherence among YPLHIV are discussed.

Body image and antiretroviral therapy adherence among people living with HIV: a protocol for a systematic review and meta-analysis

INTRODUCTION

Adherence to antiretroviral therapy (ART) remains a key challenge to achieving the fast-track goal of ending the HIV epidemic by 2030. To provide a more comprehensive indication of whether interventions designed to promote ART adherence might benefit from targeting body image perceptions, we aim to conduct a systematic review to synthesise existing evidence on the association between body image and ART adherence.

METHODS AND ANALYSIS

A systematic review of peer-reviewed observational studies and randomised controlled trials that have investigated the association between body image and adherence to ART will be performed. JSTOR, PsycARTICLES, PsycINFO, PubMed, ScienceDirect and Web of Science databases will be searched from 1 January 2000 to 31 March 2021. Eligible records will consider body image as either an independent variable or a mediator, whereas ART adherence will be assessed as an outcome variable. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and study quality will be assessed using relevant tools developed by the National Institute of Health. If sufficient data are available, a meta-analysis will be conducted. Effect size estimates will be aggregated using a random effects meta-analysis approach. Publication bias and its impact will be evaluated through the use of a funnel plot and the trim-and-fill method. The Grading of Recommendations Assessment, Development and Evaluation approach will be used to report on the overall quality of evidence.

ETHICS AND DISSEMINATION

Ethical approval is not required for a systematic review protocol. Findings of the proposed systematic review will be disseminated through conference presentations and publication in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020212597.

Body perception treatment, a possible way to treat body image disturbance in eating disorders: a case-control efficacy study

BACKGROUND

The body image disturbance (BID) is a common symptom in eating disorders, often observed and described in anorexia nervosa (AN) and bulimia nervosa (BN). Recently, this symptom has also been observed in binge eating disorder (BED). The research underlines that the BID presents three different altered components: affective, cognitive, and perceptual one. Current treatments for BID have mainly focused on the affective and cognitive components. Nowadays, the need emerges for treatments focused also on the perceptual component of the BID. In this paper, we present the results of an efficacy study on the body perception treatment (BPT), a new treatment for BID focused on the perceptual component of the disorder.

OBJECTIVE

We looked for an additional treatment effect on a protocol for ED inpatients to evaluate the efficacy of BPT. We performed the study through statistical analysis of admission and discharge scores.

METHODS

We conducted a case-control study in a hospital ward specialized in eating disorders. Two groups were identified: the control group (TAU; N = 91) and the experimental group (TAU + BPT; N = 91). The experimental group performed BTP activities in addition to the treatment at usual. All patients in both groups had an eating disorder diagnosis (AN, BN, BED and EDNOS/OSFED). Sampling occurred on a time basis and not by randomization. Moreover, all patients admitted in the ED hospital ward in the time frame considered (from end-2009 to mid-2017) were included in the study. BPT activities were introduced in mid-2013 and three psychometric instruments upon entry and discharge were used: Symptom Check List-90 (SCL-90) to measure the general psychopathological state; the Eating Disorder Inventory-3 (EDI-3) to estimate the incidence of personality traits strongly correlated to eating disorders; the body uneasiness test (BUT) to measure the body uneasiness. We performed a pre/post analysis for both groups; we studied the additional effect of the treatment through deltas analysis of the three questionnaires (Δ = assessment at discharge - assessment at the entrance). Data were analyzed using the Student T and the Wilcoxon rank-sum test.

RESULTS

The pre/post analysis showed statistically significant improvement in both conditions (TAU and TAU + BPT) in the general psychopathological state (SCL-90) and in the incidence of personality traits (EDI-3). Improvements in body uneasiness (BUT) were observed only in the experimental group (TAU + BPT). Furthermore, the analysis of the deltas shows more significant improvements in TAU + BPT compared to TAU in all the variables considered.

CONCLUSION

We found an additional effect of the BPT on TAU. The usual ED protocol added with BPT activities showed significantly better clinical results. We have interpreted these results in light of recent developments in the neuroscientific field of body image.

LEVEL OF EVIDENCE

Level II: controlled trial without randomization.