Trauma exposure, PTSD, and suboptimal HIV medication adherence among marginalized individuals connected to public HIV care in Miami

Preventing medication nonadherence: a framework for interventions to support early engagement with treatment

ABSTRACTMedication nonadherence is common and results in avoidable morbidity, mortality, and burdens on healthcare systems. This paper proposes a preventative approach to medication nonadherence. We consider existing evidence on the prevalence and determinants of nonadherence early in a patient's medication-taking journey, and map these to potential opportunities for intervention. Many patients stop taking a new medication soon after they are prescribed it, often not collecting the medication. Early patterns of nonadherence are linked to later nonadherence via processes such as habit formation and symptom experiences. Known predictors of nonadherence may be present before someone starts a new treatment, when patients experience disruption to their lives and identity due to illness. Healthcare professionals typically have contact with patients around this time. We argue that it may be possible to prevent medication nonadherence: at the population level; by optimising the prescription process; and through low- and high-intensity interventions for patients with identified early barriers. We give examples of specific interventions and tools that might be needed to operationalise this approach in practice and propose new directions for research to promote early engagement with medication to prevent nonadherence.

Positive PTSD Screening and Its Health Correlates in Patients With HIV in Urban Primary Care Settings

Posttraumatic stress disorder (PTSD) is underdiagnosed and undertreated in primary care, especially among African American individuals. The current study assessed documentation rates of PTSD and clinical health correlates among 135 predominantly African American patients with HIV and positive PTSD screens in a primary care unit. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) and a retrospective chart review of 135 patients with HIV were conducted. On the PCPTSD-5 (cut point of 3), approximately one half of patients (49.6%; n = 67) had probable PTSD; however, only 11.9% of patients (n = 16) had a chart diagnosis of PTSD. A positive PTSD screen was associated with higher rates of depression and insomnia, but not anxiety, alcohol use, drug use, or pain in patients with HIV. Multi-morbidity of HIV, major depression, and positive PTSD screens was associated with increased risk for asthma, number of medical diagnoses, depression, insomnia, and anxiety. Findings highlight the need for trauma-informed care in primary care settings for people with PTSD and HIV. Larger samples are warranted to further explore health correlates of PTSD. [Journal of Psychosocial Nursing and Mental Health Services, 62(8), 25-36.].

Post-traumatic stress disorder symptoms and PrEP intentions among Black American young adults at high-risk for HIV

OBJECTIVES

Black Americans bear the greatest burden of HIV, accounting for 43% of new diagnoses. Yet Black Americans also evidence the lowest utilization rates of Pre-Exposure Prophylaxis (PrEP), a highly effective biomedical strategy for preventing HIV infection. Predictors of PrEP acceptance vary; however, little is known about psychological distress, such as post-traumatic stress disorder (PTSD) symptoms, as a predictor.

DESIGN

In this cross-sectional study, n = 195 Black Americans, evidencing behaviors found in the research literature to heighten risk for contracting HIV (e.g. sex work, injection drug use) ages 18-29, 55% cisgender women, 39.5% cisgender men, 3% transgender/non-binary, completed audio-computer-assisted self-interviews.

RESULTS

Bivariate analyses indicated significant positive associations between PTSD symptoms and PrEP acceptance and self-confidence. In multinomial logistic regression analyses, after controlling for Perceived HIV Risk, participants had a higher likelihood of responding they 'probably would' take PrEP (as opposed to 'definitely would not' take PrEP) if they reported higher levels of PTSD symptoms. Post-hoc analyses revealed a curvilinear relationship between PTSD symptoms and PrEP acceptance with those reporting the highest level of PTSD in the sample having slightly lower PrEP acceptance than those reporting moderately high levels of PTSD.

CONCLUSION

Findings are discussed in the context of the negative impacts of high levels of PTSD and potential positive adaptations subsequent to moderate levels of PTSD that could be relevant to advances in HIV prevention efforts.

Trauma Across the Life Span and Multisystem Morbidity in Women With HIV

OBJECTIVE

Sexual and physical abuse are highly prevalent among women living with HIV (WLWH) and are risk factors for the development of mental health and substance use disorders (MHDs, SUDs), and cognitive and medical comorbidities. We examined empirically derived patterns of trauma, MHD, and SUD, and associations with later cognitive and health outcomes.

METHODS

A total of 1027 WLWH (average age = 48.6 years) in the Women's Interagency HIV Study completed the World Mental Health Composite International Diagnostic Interview from 2010 to 2013 to identify MHDs, SUDs, and age at onset of sexual and physical abuse. Then, cognitive impairment, cardiovascular/metabolic conditions, and HIV disease outcomes were assessed for up to 8.8 years. Latent class analysis identified patterns of co-occurring trauma, MHDs, and/or SUDs. Generalized estimating equations determined associations between these patterns and midlife cognitive and medical outcomes.

RESULTS

Six distinct profiles emerged: no/negligible sexual/physical trauma, MHD, or SUD (39%); preadolescent/adolescent sexual trauma with anxiety and SUD (22%); SUD only (16%); MHD + SUD only (12%); early childhood sexual/physical trauma only (6%); and early childhood sexual/physical trauma with later MHD + SUD (4%). Profiles including early childhood trauma had the largest number of midlife conditions (i.e., cognitive, cardiovascular, HIV-related). Preadolescent/adolescent sexual trauma with anxiety and SUD predicted both global and domain-specific cognitive declines. Only SUD without trauma predicted lower CD4, whereas childhood trauma with MHD + SUD predicted increased CD8.

CONCLUSIONS

WLWH have complex multisystem profiles of abuse, MHD, and/or SUD that predict midlife cognitive, metabolic/cardiovascular, and HIV outcomes. Understanding the interplay between these factors over time can identify risks and personalize preventative and treatment interventions.

Prevalence of potentially traumatic events and symptoms of depression, anxiety, hazardous alcohol use, and post-traumatic stress disorder among people with HIV initiating HIV care in Cameroon

BACKGROUND

This study explored the relationship between specific types of potentially traumatic events (PTEs) and symptoms of mental health disorders among people with HIV (PWH) in Cameroon.

METHODS

We conducted a cross-sectional study with 426 PWH in Cameroon between 2019-2020. Multivariable log binominal regression was used to estimate the association between exposure (yes/no) to six distinct types of PTE and symptoms of depression (Patient Health Questionnaire-9 score > 9), PTSD (PTSD Checklist for DSM-5 score > 30), anxiety (Generalized Anxiety Disorder-7 scale score > 9), and hazardous alcohol use (Alcohol Use Disorders Identification Test score > 7 for men; > 6 for women).

RESULTS

A majority of study participants (96%) reported exposure to at least one PTE, with a median of 4 PTEs (interquartile range: 2-5). The most commonly reported PTEs were seeing someone seriously injured or killed (45%), family members hitting or harming one another as a child (43%), physical assault or abuse from an intimate partner (42%) and witnessing physical assault or abuse (41%). In multivariable analyses, the prevalence of PTSD symptoms was significantly higher among those who reported experiencing PTEs during childhood, violent PTEs during adulthood, and the death of a child. The prevalence of anxiety symptoms was significantly higher among those who reported experiencing both PTEs during childhood and violent PTEs during adulthood. No significant positive associations were observed between specific PTEs explored and symptoms of depression or hazardous alcohol use after adjustment.

CONCLUSIONS

PTEs were common among this sample of PWH in Cameroon and associated with PTSD and anxiety symptoms. Research is needed to foster primary prevention of PTEs and to address the mental health sequelae of PTEs among PWH.

The landscape of trauma informed care in community-based HIV service organizations in the United States south

Among people living with HIV, trauma is associated with increased viral loads and obstructed access to HIV care. Trauma-Informed Care (TIC), a SAMHSA Evidence Based Practice, responds to the impact of trauma for service users by focusing on all aspects of service delivery systems and structures. TIC could be potentially lifesaving in regions where HIV rates continue to rise, like the U.S. South. Thus, the purpose of this study is to (1) understand the extent to which HIV service organizations in the U.S. South provide mental health and substance use services and referrals; (2) the extent to which they employ trauma informed care and (3) the barriers of employing trauma informed care. Analyzing quantitative data of 207 organizations, we found that less than a third of organizations provided a trauma informed intervention. Only 44% of organizations had participated in TIC training but 84% expressed interest in TIC training. Organizations who completed TIC training were 10 times more likely than those who did not to report that they implemented at least one trauma informed care strategies. Barriers to TIC implementation included lack of training, capacity, and resources. Building the capacity of organizations to implement TIC will be a key to ending the HIV epidemic.

Intimate partner violence and HIV treatment adherence in urban South Africa: Mediating role of perinatal common mental disorders

Background

Antiretroviral therapy (ART) has potential to eliminate perinatal HIV infections, but adherence to ART in late pregnancy and postpartum is often suboptimal. Intimate partner violence (IPV) may influence non-adherence among perinatal women living with HIV (WWH), but few quantitative studies have examined this over time or explored mechanisms for this association.

Methods

We used secondary data from a parent trial in Johannesburg comprising WWH from the control arm (n=63) and WWH ineligible for the trial (n=133). Trained nurse researchers administered questionnaires at first antenatal visit on past-year psychological, physical, and/or sexual IPV (WHO instrument), socio-demographics (age, food security, education), and perinatal common mental symptoms of depression (Hospital Anxiety and Depression Screener-d); anxiety (HADS-a); post-traumatic stress disorder (PTSD; Harvard Trauma Questionnaire). At endline visit 2-4 months postpartum, nurse researchers assessed self-reported ART adherence using a visual analog scale (with ≥95% considered "good"). We fitted structural equation models (SEM) in MPlus to explore direct and indirect effects of IPV on ART adherence.

Results

Of 196 perinatal WWH, 53.1% reported IPV exposure at baseline. The majority of participants (85.7%) had good perinatal ART adherence. In adjusted models, IPV at baseline was associated with halved odds of good adherence (aOR=0.51, 95%CI=0.20-0.96). IPV was associated with higher adjusted odds of probable depression (aOR=4.64), anxiety (aOR=2.85), and PTSD (aOR=3.42). In SEM, IPV had a direct (standardized coef=-0.22) and indirect effect (coef=-0.05) on ART via common mental disorders. The total effect of IPV on perinatal adherence was of moderate size (coef= -0.27) and the model had good fit (CFI=0.972; TLI=0.969; RMSEA=0.045; SRMR=0.076).

Conclusion

IPV was longitudinally associated with perinatal ART non-adherence in part due to its relationship with mental health symptomology. Addressing IPV within clinical care has potential to improve perinatal mental health, maternal HIV outcomes, and HIV-free infant survival.

Anterior Insula Activation During Cardiac Interoception Relates to Depressive Symptom Severity in HIV-Positive and HIV-Negative Postmenopausal Women

OBJECTIVE

This study aimed to determine whether subclinical symptoms of depression in postmenopausal women are associated with blood oxygen level-dependent (BOLD) activity within the anterior insula during cardiac interoceptive awareness and whether this association differs for persons living with the human immunodeficiency virus (PWH).

METHOD

Twenty-three postmenopausal (mean [standard deviation] age = 56.5 [4.8] years) and 27 HIV-negative women (mean [standard deviation] age = 56.4 [8.0]) underwent functional magnetic resonance imaging while performing a heartbeat detection task. BOLD activation within the bilateral anterior insula based on the contrast of a heartbeat detection condition with and without a distracting tone was entered along with age, HIV status, and psychological stress into two multivariate regression models with self-reported depressive symptom severity as the outcome.

RESULTS

Depressive symptoms did not vary by HIV status, nor was there a main effect or interaction for PWH on insula BOLD activation. Depressive symptoms were positively associated with psychological stress for the left ( β = 0.310, t (49) = 2.352, p = .023) and right brain models ( β = 0.296, t (49) = 2.265, p = .028) as well as the magnitude of BOLD activation in the left insula ( β = 0.290, t (49) = 2.218, p = .032) and right insula ( β = 0.318, t (49) = 2.453, p = .018), respectively. Exploratory analyses revealed that greater magnitude of BOLD activation attributed to exteroceptive noise (tone) was also correlated with self-reported distrust and preoccupation with interoceptive sensations.

CONCLUSIONS

Results support an active interference model for interoceptive awareness wherein greater BOLD signal in the anterior insula in the presence of distracting exteroceptive stimuli may reflect greater prediction error, a feature of depression.

Burden and Correlates of Mental Health Symptoms Among Young Black Gay, Bisexual, and Other Men Who Have Sex with Men Engaged in HIV Care in Atlanta

Mental health comorbidities are prevalent among young Black gay, bisexual, and other men who have sex with men (YB-GBMSM) living with HIV and can adversely impact HIV-related outcomes. We conducted a cross-sectional survey study with 100 YB-GBMSM recruited from two HIV care centers in Atlanta, and constructed multivariable logistic and linear regression models to examine correlates of depression, anxiety, trauma symptoms, and general well-being. In adjusted models, full-time employment was associated with fewer depressive symptoms, while HIV stigma and substance use were associated with higher levels of depressive symptoms. Younger age and full-time employment were negatively associated with severe anxiety, while HIV stigma was positively associated with severe anxiety and trauma symptoms. Trust in physicians, lower HIV stigma, full-time employment, and lack of substance use were associated with higher average general well-being scores. In conclusion, we found high frequency of depressive, anxiety, and trauma-related symptoms among this sample of YB-GBMSM living with HIV. Unemployment, substance use, and HIV stigma emerged as particularly salient correlates of psychological morbidity, suggesting a need for structural and community-level interventions to address mental health in this population.

"The role of case management in HIV treatment adherence: HPTN 078"

Adherence to care and antiretroviral therapy is challenging, especially for people living with HIV (PLWH) with additional co-occurring risk factors. Case management interventions, including motivational interviewing (MI), show promise to improve HIV treatment adherence, but few studies have examined how such interventions are delivered to or experienced by PLWH who have been reengaged in care. We conducted qualitative interviews with six case managers and 110 PLWH exiting from a randomized study (HPTN 078) who received a MI-based case management intervention in addition to standard patient-navigation services, or standard services only. Our study provided greater insight into the main findings from HPTN 078, including an in-depth description of the multiple barriers to adherence faced by this largely "out-of-care" population, as well as a more nuanced understanding of the benefits and challenges of implementing MI. A blend of MI plus more intensive interventions may be needed for PLWH facing multiple structural barriers.