Mental health: a focus on stress, coping, and mental illness as it relates to treatment retention, adherence, and other health outcomes

Epigenetics in persons living with HIV: trauma, coping, and FKBP5 and SLC6A4 methylation

AIM

People living with HIV (PLWH) have an increased risk for lifetime trauma and mental health difficulties. However, no studies have evaluated stress-related genes in relation to early-life adversity, lifetime trauma, or post-traumatic stress disorder (PTSD) in PLWH.

METHODS

Using bisulfite pyrosequencing, we evaluated DNA methylation (DNAm) in intron 7 of FKBP5, a glucocorticoid feedback regulator, and in the promoter of SLC6A4, the serotonin transporter gene, in whole blood of a random sample of 70 PLWH recruited from an HIV program, and 51 individuals 2 years later (n = 48 at both time points). Exploratory regression analyses were conducted with DNAm in relation to trauma exposure, mental health symptoms, and coping strategies.

RESULTS

Higher DNAm at one site of SLC6A4 was associated with lower levels of anxiety (B = -0.62 (SE = 0.23), p = 0.0109), depression (B = -0.06 (SE = 0.03), p = 0.0435), and PTSD symptoms at baseline (B = -0.03 (SE = 0.01), p = 0.0374). DNAm at FKBP5 was negatively associated with measures of anxiety (B = -0.30 (SE = 0.07), p = 0.0001) and depression symptoms (B = -0.2 (SE = 0.10), p = 0.0103). Various coping strategies were also associated with sites in both genes across time points, e.g. self-blame and substance use.

CONCLUSION

Our findings generate intriguing hypotheses linking mental health symptoms and DNA methylation, to be replicated with larger samples.

Posttraumatic stress disorder and its associations with antiretroviral therapy among veterans with HIV

OBJECTIVES

Posttraumatic stress disorder (PTSD) may affect antiretroviral therapy (ART) response and clinical outcomes for veterans with HIV (VWH) receiving care in the Department of Veterans Affairs (VA). Objectives are to estimate the associations between PTSD and ART nonadherence, modifications, and failure; measure effect modification by number of deployments and combat exposure; and examine how these associations vary over time.

DESIGN

In this prospective cohort study of all VWH on ART who deployed to Iraq and Afghanistan and receive care in the VA ( n  = 3206), patients entered at ART initiation and were censored in December 2022, totaling 22 261 person-years of follow-up.

METHODS

Marginal structural log-binomial and Poisson models were fitted with a time-dependent exposure, adjusted for time-independent and time-dependent confounding and informative censoring, to estimate the associations between PTSD and ART nonadherence, modifications, and failure. Marginal structural shared frailty models were fitted to examine time-varying associations.

RESULTS

PTSD increased the risk [adjusted risk ratio, 95% confidence interval (CI)] of ART nonadherence by 6% (1.06 [1.00, 1.13]) and the rate (adjusted incidence rate ratio, 95% CI) of ART modifications by 38% (1.38 [1.19, 1.58]). Multiple deployments amplified the association with ART nonadherence by 14%; combat exposure did not modify any association examined. The association with ART modifications increased during the first decade post-PTSD-diagnosis but subsequently stabilized.

CONCLUSIONS

PTSD increased ART nonadherence and ART modifications. Providers should screen for PTSD so that it can help guide medical decisions and treatment; particular attention should be paid to Veterans with multiple combat deployments.

The impact of syndemic burden, age, and sexual minority status on internalized HIV stigma among people living with HIV in South Florida

Internalized HIV stigma has been associated with several poor mental and physical health outcomes among people living with HIV (PLWH); yet, little research has explored how internalized HIV stigma may be affected by syndemic burden. This study sought to examine the relationship between syndemic conditions and HIV stigma over and above the potential effects of two social determinants of health, age and sexual minority status, using a linear regression approach (N = 1343). Syndemic burden was significantly positively associated with internalized HIV stigma above and beyond the effects of age and sexual minority status (b = 0.23). Additionally, age (b = -0.02) and being a sexually minority (b = -0.31) were significantly negatively associated with internalized HIV stigma. Findings should inform future treatment targets for this population by specifically working to reduce internalized HIV stigma for people with a greater syndemic burden and, potentially, among young adults and heterosexual PLWH.

Impact of mental disorders on low adherence to antiretroviral therapy in people living with HIV in Spain

The relationship between mental disorders other than depression or anxiety, and low adherence to both antiretroviral treatment (ART) and linkage to HIV care are unclear. The aim of our study was to compare the prevalence of mental disorders in people living with HIV (PLHIV) in Spain who present low versus high adherence to ART. We performed a cross-sectional study comparing two groups of PLHIV: 20 PLHIV with low adherence and 80 PLHIV with high adherence to ART. PLHIV who met at least one of the following criteria were included in the low-adherence group: virological failure (HIV-VL > 50 copies/mL in two consecutive blood samples); low attendance to scheduled clinical visits (≥2 missed visits in last year); irregular administration of ART (≥10 forgotten doses in the last month); and interruption of ART for more than 1 week. Inclusion criteria for high adherence were: PLHIV who had been on stable ART for more than 1 year with an HIV-VL below 50 copies/mL and without missed visits over the previous 12 months. The Millon Clinical Multiaxial Inventory was administered to participants. PLHIV with low adherence showed higher scores for all mental disorders compared with those with high adherence. And, in the multivariate binary logistic regression analysis, drug dependence and post-traumatic stress disorder were independently associated with low adherence (Nagelkerke R2 = 0.0686). In conclusion, PLHIV with poorly controlled HIV infection presented important psychological vulnerabilities. Mental health should be checked at the beginning of ART and during follow-up, especially in PLHIV with low adherence or low linkage to the health care system.

'The tablets make a certain noise': uncovering barriers and enablers related to providing PMTCT services to adolescents and young women living with HIV in Zimbabwe

BACKGROUND

Zimbabwe antenatal HIV prevalence rate is 16.1%. HIV-positive pregnant adolescent girls and young women (AYW) are at high risk to experience perinatal mental health challenges, attributed to a combination of factors including HIV status, stigma and perinatal depression. Perinatal depression and stigma among AYW is understudied in Zimbabwe and may affect short- and long-term health of HIV positive mothers and their children, and can impact treatment adherence.

METHODS

Qualitative data was gathered from four focus group discussions with (2 urban and 2 rural) PMTCT providers (N = 17). Focus group discussions were also conducted among AYW clients (N = 20) from two clinics in Mashonaland East.

RESULTS

Qualitative analyses identified patterns related to: (1) drop out and loss to follow up, (2) retention and adherence, (3) recurring feelings of internalized stigma; and (4) acceptability of potential MH interventions. MH services are not available and AYW have limited access to adherence counseling (1-2 times at onset). Psychological support was not available at either clinic, despite both providers and clients perceiving high rates of stigma, discrimination, and challenges with disclosure. Challenges related to long waits for ART distribution and gaps in disclosure support emerged as barriers. Providers noted that AYW present as anxious (non-diagnosed), and attribute depression to those clients who are lost to follow up, stating lack of time to screen for MH related issues or actively refer them for services. Challenges related to the ability to provide strong advice and support for disclosure also emerged among providers.

CONCLUSIONS

This study can contribute to policy and practice recommendations to better integrate MH into HIV services and develop person-centered service models for HIV positive AYW. HIGHLIGHTSPerinatal adolescents and young women (AYW) living with HIV have gaps in retention and care in the current Zimbabwe PMTCT service model.Mental health stigma must be addressed to integrate mental health into HIV services.HIV providers are aware of the need to provide mental health support to reduce loss to follow-up.Mental health screening and referrals for services are not part of standard care for perinatal HIV positive AYW in Zimbabwe.Linkages between disclosure and AYW mental health was identified as a challenge by HIV providers.Context responsive interventions can support integration of mental health screening, services, and referrals.

The Impact of HIV-Related Stigma on Racial/Ethnic Disparities in Retention in HIV Care Among Adults Living with HIV in Florida

BACKGROUND

Our study examines the effects of distinct HIV stigma subtypes on retention in care and racial-ethnic differences among persons with HIV (PWH).

METHODS

Using Florida Medical Monitoring Project 2015-2017 data, we analyzed patients' clinical and behavioral characteristics. We analyzed 89,889 PWH in Florida (50.0% non-Hispanic Blacks, 20.8% Hispanics, 29.2% non-Hispanic whites). HIV stigma subtypes, negative self-image, anticipated stigma, personalized stigma, and retention in care were examined with logistic regressions.

RESULTS

People with high negative self-image and anticipated stigma were less likely to be retained (CI: 0.84-0.92; 0.47-0.53). The association between HIV-related stigma subtypes and retention in care differed between Black, White, and Hispanic participants. Negative self-image was associated with higher retention rates among Hispanics (CI: 5.64-9.26) and Whites (CI: 1.04-1.27), while low retention rates among Blacks (0.617-0.686). The likelihood of staying in care was lower across all racial-ethnic groups when the anticipated stigma was high or moderate. In contrast, personalized stigma increased retention across all racial-ethnic groups.

CONCLUSION

Results showed that distinct types of HIV stigma differentially impact retention, and these associations differ by race and ethnicity. Future interventions should address the effect HIV stigma subtypes have on racially minoritized PWH retention.

Assessing the Validity of the Social Impact Scale Among a Longitudinal Cohort of Adolescents and Young Adults Living With Perinatally Acquired HIV

BACKGROUND

With few psychometrically evaluated HIV-related stigma measures for adolescents and young adults living with HIV, we examined the developmental applicability (ie, validity) of 2 subscales of the commonly used stigma measure, the Social Impact Scale, among a cohort of adolescents and young adults with perinatally acquired HIV.

SETTING

Data were obtained from a New York City longitudinal study (N = 340). This study primarily comprised Black and Latinx adolescents and young adults with either perinatally acquired HIV or those with perinatal exposure but who are uninfected. Data for this analysis were obtained from the population with perinatally acquired HIV and spanned approximately a 15-year survey period (2003-2018).

METHODS

A confirmatory factor analysis was used at 7 time points to assess whether the Social Rejection and Internalized Shame subscales were consistent in this cohort over time. Overall and individual Cronbach alphas were reported to show the strength of the internal consistency.

RESULTS

The mean age from baseline to follow-up 6 ranged from 12 to 23 years over the study period. The Social Rejection subscale was acceptably valid across follow-up periods with strong factor loadings and Cronbach alphas higher than 0.70. However, the Internalized Shame subscale was less valid among younger adolescents. Starting at follow-up 2, we observed better validity with the Internalized Shame subscale performance.

CONCLUSION

Future research must consider mechanisms for developing and adapting measures from a developmental perspective to best measure the experiences of HIV-related stigma among younger populations.

Identifying the Mental Health Effects of Cumulative Traumatic Exposure in HIV-Affected Youth: A Longitudinal Assessment

INTRODUCTION

Traumatic events (TEs) in early life can precede adult psychopathology. Limited research exists on this relationship in young adults with perinatally acquired HIV-infection (PHIV) or perinatal HIV-exposure without infection (PHEU), who often experience social and health disparities. This study examined TEs experienced in childhood/adolescence and their association with psychiatric and substance use disorders in young adults with PHIV and PHEU.

METHODS

Participants in a New York City-based longitudinal cohort study were assessed for TE exposure at enrollment (mean age = 12 years) and the first 2 follow-up interviews. Past-year psychiatric and substance use disorders were evaluated via psychiatric interview (DISC-IV) at the fifth follow-up interview (mean age = 22 years). Unadjusted and adjusted logistic regression models assessed associations between cumulative childhood/adolescence TEs and young adult psychiatric and substance use outcomes. Group differences were tested for PHIV and PHEU subgroups.

RESULTS

Among 236 participants (60% Black, 51% Latinx), mean cumulative traumatic event count was 3.09 (SD = 1.77); 26% had a past-year psychiatric diagnosis, and 28% had a past-year substance use diagnosis. Increased TEs were associated with past-year psychiatric diagnoses in young adulthood [average marginal effects (AME) 4.21, 95% confidence interval (CI): 0.83 to 7.58]; for PHEU participants, increased TEs were associated with a past-year substance use disorder (AME 15.67, 95% CI: 8.08 to 23.25).

CONCLUSIONS

High levels of TEs in childhood/adolescence may contribute to psychiatric and substance use disorders in young adults with PHIV or PHEU. Research exploring relationships between TE exposure and later psychiatric problems is needed to inform interventions for HIV-affected youth.

Providing Trauma-Informed Care During a Pandemic: How Health Care Workers at Ryan White-Funded Clinics in the Southeastern United States Responded to COVID-19 and Its Effects on Their Well-Being

As HIV/AIDS health care workers (HCWs) deliver services during COVID-19 under difficult conditions, practicing trauma-informed care (TIC) may mitigate negative effects on mental health and well-being. This secondary qualitative analysis of a larger mixed methods study sought to understand the pandemic's impact on HCWs at Ryan White-funded clinics (RWCs) across the southeastern US and assess changes in prioritization of TIC. RWC administrators, providers, and staff were asked about impacts on clinic operations/culture, HCW well-being, institutional support for well-being, and prioritization of TIC. HCWs described strenuous work environments and decreased well-being (eg, increased stress, burnout, fear, and social isolation) due to COVID-19. RWCs initiated novel responses to disruptions of clinic operations and culture to encourage continuity in care and promote HCW well-being. Despite increased awareness of the need for TIC, prioritization remained variable. Implementing and institutionalizing trauma-informed practices could strengthen continuity in care and safeguard HCW well-being during public health emergencies.

Pilot Trial of a Smartphone-Based Intervention to Reduce Alcohol Consumption among Veterans with HIV

Veterans engage in disproportionate levels of alcohol use, which can impact treatment outcomes among veterans with HIV. The TRAC (Tracking and Reducing Alcohol Consumption) intervention, which combines smartphones, mobile breathalyzers, and motivational interviewing (MI), was developed to help reduce alcohol use among this population. This study reports results of an 8-week pilot trial of TRAC among veterans with HIV (N = 10). Participants attended weekly MI sessions conducted via videoconferencing or phone and completed twice-daily self-monitoring of alcohol consumption using breathalyzers and surveys. They also completed pre- and post-intervention questionnaires and a qualitative interview. Analyses explored adherence to self-monitoring tasks, perceptions of the intervention, and preliminary effects of TRAC on alcohol use and readiness to change drinking behavior. Participants completed 76% of breathalyzer readings and 73% of surveys and completed more daytime than evening monitoring tasks. AUDIT hazardous drinking scores significantly decreased between baseline and post-test. Qualitative interviews revealed positive attitudes toward the technologies and MI sessions. Overall, this pilot demonstrated that the TRAC intervention has potential to reduce alcohol use among veterans with HIV, though additional effort is needed to improve adherence to mobile monitoring. Results were used to refine the intervention in preparation for a randomized controlled trial.

"I am scared, I do not want to lie": exploring the impacts of COVID-19 on engagement in care, perceived health, relationship dynamics, and parenting among postpartum women with HIV in South Africa

BACKGROUND

COVID-19 and efforts to manage widespread infection may compromise HIV care engagement. The COVID-19-related factors linked to reduced HIV engagement have not been assessed among postpartum women with HIV, who are at heightened risk of attrition under non-pandemic circumstances. To mitigate the effects of the pandemic on care engagement and to prepare for future public health crises, it is critical to understand how COVID-19 has impacted (1) engagement in care and (2) factors that may act as barriers to care engagement.

METHODS

A quantitative assessment of COVID-19-related experiences was added to a longitudinal cohort study assessing predictors of postpartum attrition from HIV care among women in South Africa. Participants (N = 266) completed the assessment at 6, 12, 18, or 24 months postpartum between June and November of 2020. Those who endorsed one or more challenge related to engagement in care (making or keeping HIV care appointments, procuring HIV medications, procuring contraception, and/or accessing immunization services for infants; n = 55) were invited to complete a brief qualitative interview, which explored the specific factors driving these challenges, as well as other impacts of COVID-19 on care engagement. Within this subset, 53 participants completed an interview; qualitative data were analyzed via rapid analysis.

RESULTS

Participants described key challenges that reduced their engagement in HIV care and identified four other domains of COVID-19-related impacts: physical health, mental health, relationship with a partner or with the father of the baby, and motherhood/caring for the new baby. Within these domains, specific themes and subthemes emerged, with some positive impacts of COVID-19 also reported (e.g., increased quality time, improved communication with partner, HIV disclosure). Coping strategies for COVID-19-related challenges (e.g., acceptance, spirituality, distraction) were also discussed.

CONCLUSIONS

About one in five participants reported challenges accessing HIV care, medications, or services, and they faced complex, multilayered barriers to remaining engaged. Physical health, mental health, relationships with partners, and ability to care for their infant were also affected. Given the dynamic nature of the pandemic and general uncertainty about its course, ongoing assessment of pandemic-related challenges among postpartum women is needed to avoid HIV care disruptions and to support wellbeing.

"I am scared, I do not want to lie": Exploring the impacts of COVID-19 on engagement in care, perceived health, relationship dynamics, and parenting among postpartum women with HIV in South Africa

Background COVID-19 and efforts to manage widespread infection may compromise HIV care engagement. The COVID-19-related factors linked to reduced HIV engagement have not been assessed among postpartum women with HIV, who are at heightened risk of attrition under non-pandemic circumstances. To mitigate the effects of the pandemic on care engagement and to prepare for future public health crises, it is critical to understand how COVID-19 has impacted (1) engagement in care and (2) factors that may act as barriers to care engagement. Methods A quantitative assessment of COVID-19-related experiences was added to a longitudinal cohort study assessing predictors of postpartum attrition from HIV care among women in South Africa. Participants (N = 266) completed the assessment at 6, 12, 18, or 24 months postpartum between June and November of 2020. Those who endorsed one or more challenge related to engagement in care (making or keeping HIV care appointments, procuring HIV medications, procuring contraception, and/or accessing immunization services for infants; n = 55) were invited to complete a brief qualitative interview, which explored the specific factors driving these challenges, as well as other impacts of COVID-19 on care engagement. Within this subset, 53 participants completed an interview; qualitative data were analyzed via rapid analysis. Results Participants described key challenges that reduced their engagement in HIV care and identified four other domains of COVID-19-related impacts: physical health, mental health, relationship with a partner or with the father of the baby, and motherhood/caring for the new baby. Within these domains, specific themes and subthemes emerged, with some positive impacts of COVID-19 also reported (e.g., increased quality time, improved communication with partner, HIV disclosure). Coping strategies for COVID-19-related challenges (e.g., acceptance, spirituality, distraction) were also discussed. Conclusions About one in five participants reported challenges accessing HIV care, medications, or services, and they faced complex, multilayered barriers to remaining engaged. Physical health, mental health, relationships with partners, and ability to care for their infant were also affected. Given the dynamic nature of the pandemic and general uncertainty about its course, ongoing assessment of pandemic-related challenges among postpartum women is needed to avoid HIV care disruptions and to support wellbeing.

The effectiveness of psychoeducation and problem-solving on depression and treatment adherence in adolescents living with HIV in Botswana: an exploratory clinical trial

BACKGROUND

This study aimed to explore the effectiveness of psychological interventions (PI): psychoeducation, problem-solving, and rehearsal strategies on depression and adherence in HIV-infected adolescents in Botswana.

METHODS

Fifty adolescents living with HIV were randomized into control (n = 25) and intervention groups (n = 25), the latter being exposed to five weeks of PI sessions. The PHQ-9 and visual analog scale (VAS) were used to measure the outcomes: depression and adherence at pre-intervention, 5- and 24 weeks post-intervention.

RESULTS

The participants' mean age (SD) was 17.38 years (1.1), the two groups being similar in socio-demographic variables: gender (χ² = 2.22; p = 0.135) and age (U = 285, z =  - 0.55, p = 0.579). The intervention group scored significantly lower on depressive symptoms (PHQ-9 [F (1,50) = 12.0, p = 0.001, ƞ_p² = 0.20]) and higher on adherence score (VAS [F (1,50) = 13.5, p = 0.001, ƞ_p² = 0.22]) than the control group after 5 weeks. The post-hoc analysis showed that the significant improvements in depressive symptoms (z =  - 4.03, p < 0.01, r [effect size] = 0.88) and adherence (z =  - 4.05, p < 0.01, r = 0.88) at post-test in the intervention group were maintained at 24 weeks. This project was registered with ClinicalTrials.gov (NCT05482217).

CONCLUSION

The 5-week PI showed promising effectiveness in addressing depression and adherence in adolescents living with HIV in Botswana.

Clinic screening for adverse childhood experiences in people living with HIV to Improve Care Delivery

Adverse childhood experiences (ACEs) are associated with negative health outcomes; however, screening for ACEs is not routinely performed among people living with HIV (PLWH). We conducted a single-center, cross-sectional pilot study to define the (1) prevalence of ACEs in PLWH and (2) acceptability of ACEs screening in routine out-patient clinical care. One hundred participants completed screening: median age of participants was 49 years (interquartile range: 38.5-59.5), 73% male, 66% Non-Hispanic Black/African American, and 47% gay/lesbian. Clinically significant ACEs score, defined as ≥4, was reported in 51%. High ACEs score was more common among participants <50 years old (64.7% vs. 36.7%; p < 0.01), but the prevalence of ACEs ≥4 did not differ by gender, race, ethnicity, or sexual orientation. Among participants with ≥4 ACEs, 44.4% screened negative on both PHQ-9 and PC-PTSD screens. The majority of participants (89%) reported a positive experience with ACEs screening. The prevalence of clinically significant ACEs in this clinic population of PLWH was more than twice that reported in the general population. Routine ACEs screening can improve delivery of trauma-informed care in the HIV primary care setting.

Internet-based peer support interventions for people living with HIV: A scoping review

Peer support interventions for people living with HIV and AIDS (PLWHA) are effective, but their associated time and material costs for the recipient and the health system make them reachable for only a small proportion of PLWHA. Internet-based interventions are an effective alternative for delivering psychosocial interventions for PLWHA as they are more accessible. Currently, no reviews are focusing on internet-based interventions with peer support components. This scoping review aims to map the existing literature on psychosocial interventions for PLWHA based on peer support and delivered through the internet. We conducted a systematic scoping review of academic literature following methodological guidelines for scoping reviews, and 28 articles met our criteria. We summarized the main characteristics of the digital peer support interventions for PLWHA and how they implemented peer support in a virtual environment. Overall the reported outcomes appeared promising, but more robust evidence is needed.

ImpACT+, a coping intervention to improve clinical outcomes for women living with HIV and sexual trauma in South Africa: study protocol for a randomized controlled trial

Background

Addressing sexual trauma in the context of HIV care is essential to improve clinical outcomes and mental health among women in South Africa. Women living with HIV (WLH) report disproportionately high levels of sexual trauma and have higher rates of posttraumatic stress disorder. Adherence to antiretroviral therapy (ART) may be difficult for traumatized women, as sexual trauma compounds the stress associated with managing HIV and is often comorbid with other mental health disorders, further compromising care engagement and adherence. ART initiation represents a unique window of opportunity for intervention to enhance motivation, increase care engagement, and address the negative effects of trauma on avoidant coping behaviors. Mental health interventions delivered by non-specialists in low- and middle-income countries have potential to treat depression, trauma, and effects of intimate partner violence among WLH. This study will examine the effectiveness of Improving AIDS Care after Trauma (ImpACT +), a task-shared, trauma-focused coping intervention, to promote viral suppression among WLH initiating ART in a South African clinic setting.

Methods

This study will be conducted in Khayelitsha, a peri-urban settlement situated near Cape Town, South Africa. Using a hybrid type 1 effectiveness-implementation design, we will randomize 350 WLH initiating ART to the ImpACT + experimental condition or the control condition (three weekly sessions of adapted problem-solving therapy) to examine the effectiveness of ImpACT + on viral suppression, ART adherence, and the degree to which mental health outcomes mediate intervention effects. ImpACT + participants will receive six once-a-week coping intervention sessions and six monthly maintenance sessions over the follow-up period. We will conduct mental health and bio-behavioral assessments at baseline, 4, 8, and 12 months, with care engagement data extracted from medical records. We will explore scalability using the Consolidated Framework for Implementation Research (CFIR).

Discussion

This trial is expected to yield important new information on psychologically informed intervention models that benefit the mental health and clinical outcomes of WLH with histories of sexual trauma. The proposed ImpACT + intervention, with its focus on building coping skills to address traumatic stress and engagement in HIV care and treatment, could have widespread impact on the health and wellbeing of individuals and communities in sub-Saharan Africa.

Trial registration

Clinicaltrials.gov NCT04793217. Retrospectively registered on 11 March 2021.

HIV and Mental Health Services in the US South: A Meso Analysis

The US South is disproportionately impacted by HIV. Social, cultural, economic, and political characteristics of the South shape access to mental health services leaving adverse impacts on health and wellness outcomes among People Living with HIV. The aim of this paper was to: (a) identify meso factors (at individual, organizational and community-level manifestations) which impact mental health services among People living with HIV in the South of those factors and (b) pose community-articulated recommendation and strategies. Through qualitative interviews with People Living with HIV and service providers, this study found that the meso factors of restricted funding and compounding stigma shaped mental health services in the South. Given the disproportionate rate of HIV, lack of mental health care, and landscape of socio-political factors unique to the region, attention to intervenable meso factors and community-based strategies are needed to enhance mental health services and respond to the HIV epidemic in the US South.

Intimate Partner Violence Victimization and Mental Health Among Men Who Have Sex With Men Living With HIV in Guatemala

Gay, bisexual, and other men who have sex with men (MSM) are disproportionately affected by poor mental health compared to their heterosexual counterparts. One factor that may increase mental health problems among MSM is intimate partner violence (IPV) victimization. The objectives of this study are to (a) describe the prevalence of different forms of IPV victimization experienced by MSM living with HIV in Guatemala City and (b) examine the relationship between IPV victimization and mental health. We analyzed cross-sectional survey data from a cohort of MSM living with HIV in Guatemala City (n = 374) to describe the burden of IPV, including physical, sexual, and emotional IPV. We then examined relationships between lifetime IPV and each form of recent IPV (past 12 months) with self-reported anxiety and depression using multivariable logistic regression. Over a quarter (27.3%) of the participants screened positive for anxiety and nearly one fifth (17.9%) screened positive for depression. Over a quarter of the participants (28.6%) reported ever having experienced any IPV victimization and 8.8% reported having experienced any form of recent IPV. In multivariable analyses, participants who experienced any form of lifetime IPV had roughly twice the odds of experiencing anxiety (OR: 1.86; 95% CI = [1.03, 3.38]) and depression (OR: 2.02; 95% CI = [1.02, 3.99]) compared to those who had not. Participants who experienced recent emotional IPV had over seven times the odds of experiencing anxiety (OR: 7.23; 95% CI = [1.46, 38.85]) compared to those who had not. MSM living with HIV in Guatemala experience a high burden of anxiety, depression, and IPV victimization. Those participants who had experienced lifetime IPV and recent emotional IPV were significantly more likely to screen for anxiety and depression. To improve their mental health, HIV clinics and other health services should provide support for MSM who have experienced IPV victimization.

Narratives of Change From Gay and Bisexual Men Living With HIV in an Emotional Well-Being Intervention

The emotional burden of an HIV diagnosis can impact HIV outcomes and overall well-being. We piloted a four-session individual-level emotional well-being intervention, offered during HIV care visits, for gay and bisexual men living with HIV in Guatemala City who were recently diagnosed or reengaged in care. To assess intervention impact in a contextualized manner, we conducted longitudinal qualitative interviews (n = 3) with study participants (n = 10) over 12 months. Data analysis included thematic coding using NVivo and longitudinal narrative summaries and matrices to identify narratives of change and assess intervention impact. Participants experienced changes in their view of self and diagnosis perceptions, improved physical and mental health, increased interest in sex and relationships, and a clarification of their life goals. The intervention helped participants reach diagnosis acceptance, improve self-esteem, and gain self-efficacy for managing life with HIV. Findings support the importance of integrating emotional well-being into HIV care.

A typology of power in implementation: Building on the exploration, preparation, implementation, sustainment (EPIS) framework to advance mental health and HIV health equity

Background

Persistent inequities in HIV health are due, in part, to barriers to successful HIV-related mental health intervention implementation with marginalized groups. Implementation Science (IS) has begun to examine how the field can promote health equity. Lacking is a clear method to analyze how power is generated and distributed through practical implementation processes and how this power can dismantle and/or reproduce health inequity through intervention implementation. The aims of this paper are to (1) propose a typology of power generated through implementation processes, (2) apply this power typology to expand on the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to advance HIV and mental health equity and (3) articulate questions to guide the explicit examination and distribution of power throughout implementation.

Methods

This paper draws on the work of an Intermediary Purveyor organization implementing trauma-informed care and harm reduction organizational change with HIV service organizations. The expanded framework was developed through analyzing implementation coaching field notes, grant reporting, and evaluation documents, training feedback, partner evaluation interviews, and existing implementation literature.

Results

The authors identify three types of power working through implementation; (1) discursive power is enacted through defining health-related problems to be targeted by intervention implementation, as well as through health narratives that emerge through implementation; (2) epistemic power influences whose knowledge is valued in decision-making and is recreated through knowledge generation; and (3) material power is created through resource distribution and patterns of access to health resources and acquisition of health benefits provided by the intervention. Decisions across all phases and related to all factors of EPIS influence how these forms of power striate through intervention implementation and ultimately affect health equity outcomes.

Conclusions

The authors conclude with a set of concrete questions for researchers and practitioners to interrogate power throughout the implementation process.

Plain language summary

Over the past few years, Implementation Science researchers have committed increased attention to the ways in which the field can more effectively address health inequity. Lacking is a clear method to analyze how implementation processes themselves generate power that has the potential to contribute to health inequity. In this paper, the authors describe and define three types of power that are created and distributed through intervention implementation; discursive power, epistemic power, and material power. The authors then explain how these forms of power shape factors and phases of implementation, using the well-known EPIS (exploration, preparation, implementation, sustainment) framework. The authors draw from their experience working with and Intermediary Purveyor supporting HIV service organizations implementing trauma-informed care and harm reduction organizational change projects. This paper concludes with a set of critical questions that can be used by researchers and practitioners as a concrete tool to analyze the role of power in intervention implementation processes.

Validation of an Arabic Version of the Adherence to Refills and Medications Scale (ARMS)

BACKGROUND

Medication non-adherence is a complex multifactorial phenomenon impacting patients with various health conditions worldwide. Therefore, its detection can improve patient outcomes and minimize the risk of adverse consequences. Even though multiple self-reported medication adherence assessment scales are available, very few of them exist in Arabic language. Therefore, the aim of this study was to validate a newly translated Arabic version of the Adherence to Refills and Medications Scale (ARMS) among patients with chronic health conditions.

METHODS

This is a single-center cross-sectional study that was conducted between October 10th 2018 and March 23rd 2021. ARMS was first translated to Arabic using the forward-backward translation method. The translated scale was then piloted among 21 patients with chronic health conditions (e.g., diabetes, hypertension, etc.…) to examine its reliability and comprehensibility using the test-retest method. Thereafter, the Arabic-translated ARMS was self-administered to adult patients aged ≥18 years with chronic health conditions visiting the primary care clinics of a university-affiliated tertiary care hospital in Riyadh, Saudi Arabia. Construct validity was examined using factor analysis with varimax rotation.

RESULTS

Of the 264 patients who were invited to participate, 202 (76.5%) consented and completed the questionnaire. Most of the participants were males (69.9%), married (75.2%), having a college degree or higher (50.9%), retired or unemployed (65.2%), aged ≥ 50 years (65.2%), and are diabetic (95.9%). The 12-item Arabic-translated ARMS mean score was 17.93 ± 4.90, and the scale yielded good internal consistency (Cronbach's alpha = 0.802) and test-retest reliability (Intraclass correlation coefficient = 0.97). Two factors were extracted explaining 100% of the of the total variance (factor 1 = 52.94% and factor 2 = 47.06%).

CONCLUSIONS

The 12-item Arabic version of ARMS demonstrated good validity and reliability. Therefore, it should help in the detection of medication non-adherence among Arabic-speaking patient population and minimize the risk of adverse consequences.

Psychosocial Mechanisms of Self-rated Successful Aging with HIV: A Structural Equation Model

This study tested a conceptual psychosocial model of self-rated successful aging (SRSA) with HIV. Our sample (n = 356) included older women living with HIV (OWLH): average age 56.5 years, 73% Black. SRSA was assessed using a research-based 10-point scale (higher scores = better outcomes). We conducted adjusted structural equation modeling. The global model included two latent variables-protective attributes (composite of positive psychosocial factors: resilience, personal mastery, optimism, spirituality) and psychological distress (composite of negative psychosocial factors: anxiety, depression, loneliness, internalized HIV-related stigma). The model showed good fit (χ²(58) = 76, p = 0.06; RMSEA = 0.03; CFI = 0.99). Increased protective attributes were associated with improved SRSA both directly and mediated by improved coping with stress. While psychological distress did not have a direct effect on SRSA, it was indirectly associated with worsened SRSA via diminished protective attributes and via decreased coping with stress. Findings suggest the need for interventions enhancing positive and mitigating negative psychosocial factors in OWLH.

Walking and perceived lack of safety: Correlates and association with health outcomes for people living with HIV in rural Zambia

INTRODUCTION

Geographic inaccessibility disproportionately affects health outcomes of rural populations due to lack of suitable transport, prolonged travel time, and poverty. Rural patients are left with few transport options to travel to a health facility. One common option is to travel by foot, which may present additional challenges, such as perceived lack of safety while transiting. We examined the correlates of perceived lack of safety when walking to a health facility and its association with treatment and psychosocial outcomes among adults living with HIV.

METHODS

Data were collected from 101 adults living with HIV in Eastern Province, Zambia. All participants were receiving antiretroviral therapy at one of two health clinics. Perceived lack of safety was measured by asking respondents whether they felt unsafe traveling to and from the health facility in which they were receiving their HIV care. Outcomes included medication adherence, perceived stress, hope for the future, and barriers to pill taking. Linear and logistic regression methods were used to examine the correlates of perceived safety and its association with health outcomes.

RESULTS

Being older, a woman, having a primary education, living farther from a health facility, traveling longer to reach a health facility, and owing money were associated with higher likelihood of feeling unsafe when traveling by foot to health facility. Perceived lack of safety was associated with medication nonadherence, higher level of stress, lower level of agency, and more barriers to pill taking.

CONCLUSIONS

Perceived lack of safety when traveling by foot to a health facility may be a barrier to better treatment and psychosocial outcomes, especially among rural patients. Practitioners and policymakers should consider implementation of differentiated HIV service delivery models to reduce frequent travel to health facilities and to alleviate ART patients' worry about lack of safety when traveling by foot to a health facility.

Lifetime Prevalence and Sociodemographic Correlates of Multifactorial Discrimination Among Middle-Aged and Older Adult Men Who Have Sex with Men

This study describes multifactorial discrimination (discrimination attributed to multiple social identities) among middle-aged and older adult MSM. MSM aged 40+ years (N = 1,193) enrolled in the Multicenter AIDS Cohort Study completed behavioral surveys ascertaining experiences of discrimination and their social identity attributions. Non-proportional odds regressions assessed multifactorial discrimination by age, race/ethnicity, HIV status, and covariates. Twenty-seven percent of participants reported multifactorial discrimination. Adjusted models indicated that middle-aged men were more likely to report multifactorial discrimination compared to older adult men. Racial/ethnic minorities were more likely to report multifactorial discrimination compared to non-Hispanic white participants. These same patterns emerged among the sub-sample of participants living with HIV. To our knowledge, this is the first assessment of multifactorial discrimination in middle-aged and older MSM. Our findings support the deleterious association between multiple-marginalization and multifactorial discrimination. Multilevel interventions targeting interconnected experiences of stigma may improve the health of MSM in transition to older age.

Coping with COVID-19: An Examination of the Role of (Non)Religiousness/(Non)Spirituality

Psychological distress and coping strategies employed during collective trauma events may vary for theists and atheists, as well as others along the (non)religious spectrum. The present study explored these differences via data collected from a US-based sample during the COVID-19 pandemic. Statistical models suggested relationships between maladaptive coping and distress for all participants and potential differences in coping and, in turn, distress between participants high and low in institutional religiousness and individual spirituality. Additionally, all participants, though especially nonreligious participants, appeared less able to engage in adaptive emotion-focused coping strategies. Implications for future research are provided.

Individualized Web-Based Attention Training With Evidence-Based Counseling to Address HIV Treatment Adherence and Psychological Distress: Exploratory Cohort Study

BACKGROUND

The prevalence of mood, trauma, and stressor-related disorders is disproportionately higher among people living with HIV than among individuals without the virus. Poor adherence to HIV treatment and heightened psychological distress have been linked to symptoms associated with these disorders.

OBJECTIVE

The objective of this exploratory pilot study was to develop and implement an intervention that combined individualized web-based attention training with evidence-based counseling to promote HIV treatment adherence and reduce psychological distress among people living with HIV. The study targeted African American and Latino young men who have sex with men, two population groups in the US that continue to experience disparities in HIV treatment outcomes.

METHODS

Study participants with elevated symptoms of depression and suboptimal adherence to antiretroviral therapy were recruited primarily through referrals from Los Angeles health and social service providers as well as postings on social media. Participants enrolled in the 4-week intervention received weekly counseling for adherence and daily access to web-based attention training via their personal mobile devices or computers.

RESULTS

Of the 14 participants who began the intervention, 12 (86%) completed all sessions and study procedures. Using a pretest-posttest design, findings indicate significant improvements in adherence, depressive symptoms, and attention processing. Overall, the proportion of participants reporting low adherence to antiretroviral therapy declined from 42% at baseline to 25% at intervention completion (P=.02, phi=0.68). Mean depressive symptoms measured by the 9 item Patient Health Questionnaire (PHQ-9) showed a substantial reduction of 36% (P=.002, Cohen d=1.2). In addition, participants' attentional processing speeds for all types of stimuli pairings presented during attention training improved significantly (P=.01 and P=.02) and were accompanied by large effect sizes ranging from 0.78 to 1.0.

CONCLUSIONS

Our findings support the feasibility of web-based attention training combined with counseling to improve antiretroviral therapy adherence among patients with psychological distress. Future research should include a larger sample, a control group, and longer-term follow-up.

Experiencias de homofobia y adherencia al tratamiento antirretroviral (TAR) en hombres que tienen sexo con hombres (HSH)

Resumen El objetivo del estudio fue conocer la relación de las experiencias de homofobia con la adherencia al tratamiento anti-retroviral (TAR) en hombres que tienen sexo con hombres (HSH). Para ello, se realizó una encuesta transversal con una muestra por conveniencia de HSH que vivían con VIH (n=340) atendidos en dos instituciones públicas de salud de la Ciudad de México. La información sobre la adherencia al TAR en el mes previo de los participantes y sus experiencias de violencia, discriminación y homofobia internalizada se recopiló mediante un cuestionario. Entre 14% y 33% de los HSH reportaron alguna experiencia de discriminación y entre 41% y 60% experimentaron violencia. Cuando los HSH habían experimentado ambos tipos de estresores, el riesgo de baja adherencia TAR fue mayor (RP=6.49 para mes previo) que cuando habían experimentado sólo una de ellas (RP=4.36 para violencia y RP=5.67 para discriminación). Los profesionales de la salud deben ser sensibles a cómo el ambiente sociocultural puede afectar las prácticas de autocuidado de HSH, incluyendo la adherencia al TAR.

Reducing risk of Type 2 diabetes in HIV: a mixed-methods investigation of the STOP-Diabetes diet and physical activity intervention

AIM

To conduct a mixed-methods feasibility study of the effectiveness and acceptability of an individualized diet and physical activity intervention designed to reduce the risk of Type 2 diabetes experienced by people living with HIV.

METHODS

Participants with impaired fasting glucose and HIV were invited to take part in a 6-month diet and physical activity intervention. Individualized advice to achieve 10 lifestyle goals was delivered monthly. Diabetes risk was assessed pre- and post-intervention by measurement of the glucose and insulin response to a 3-h meal tolerance test. Six-month change was analysed using paired t-tests. Research interviews exploring the acceptability of the intervention and factors influencing behaviour change were conducted with those who participated in the intervention, and those who declined participation.

RESULTS

The intervention (n=28) significantly reduced the following: glucose and insulin, both fasting and postprandial incremental area under the curve (glucose 7.9% and 17.6%; insulin 22.7% and 31.4%, respectively); weight (4.6%); waist circumference (6.2%); systolic blood pressure (7.4%); and triglycerides (36.7%). Interview data demonstrated the acceptability of the intervention. However, participants expressed concern that deliberate weight loss might lead to disclosure of HIV status or association with AIDS-related illness. The belief that antiretroviral medications drove diabetes risk was associated with declining study participation or achieving fewer goals.

CONCLUSIONS

We have demonstrated the beneficial effects of a lifestyle intervention in mitigating the increased risk of Type 2 diabetes associated with HIV. Future interventions should be designed to further reduce the unique barriers that prevent successful outcomes in this cohort.

The Impact of COVID-19 on HIV Treatment and Research: A Call to Action

The impact of the COVID-19 pandemic is far reaching, with devastating effects on individuals, communities, and societies across the world. People with chronic health conditions may be at greater risk of contracting or experiencing complications from COVID-19. In addition to illness or death for those who contract the virus, the physical distancing required to flatten the curve of new cases is having a negative impact on the economy, the effects of which intersect with mental health and other existing health concerns, thus affecting marginalized communities. Given that HIV also has a disproportionate impact on marginalized communities, COVID-19 is affecting people with HIV (PWH) in unique ways and will continue to have an impact on HIV research and treatment after the COVID-19 crisis passes. Using the biopsychosocial framework to contextualize the impact of COVID-19 on PWH, the purpose of this review article is to: (1) outline the similarities and differences between the COVID-19 and HIV pandemics; (2) describe the current and future impact of COVID-19 on PWH; and (3) outline a call to action for scientists and practitioners to respond to the impact of COVID-19 on HIV prevention and treatment.

The role of self-compassion and shame in persons living with HIV/AIDS

Despite the connection between self-compassion, shame, and HIV/AIDS health outcomes in the literature, little is known about the relationship among these variables. Shame and self-compassion work independently of each other and experiences of shame can impede one's ability to engage in self-compassionate responses, which could prevent future health declines. Although shame has been found to mediate the relationship between self-compassion and a variety of mental health outcomes, it has not been examined in the context of HIV/AIDS. The purpose of the current study was to examine how shame mediates the relationship of self-compassion and adherence to HIV/AIDS medications, as well as how shame mediates the relationship of self-compassion and health-related quality of life (HRQL) in people living with HIV (PLWH). This is the first study to look at trait-based shame in PLWH in a sample of 34 patients at an urban outpatient integrated care facility for PLWH. Self-compassion was not correlated with HIV adherence behaviors or HRQL, and shame did not mediate the relationship between self-compassion and adherence or HRQL. However as expected, less shame was related to and predicted better HRQL in PLWH. Self-compassion' relationship to shame, adherence, and HRQL may be context dependent.

Links between sexual trauma exposure and Quality of Life (QoL) domains among people living with HIV in the Southern United States

People living with HIV (PLHIV) in the United States (US) are more likely to experience traumatic events than non-affected peers. Sexual violence is a unique trauma that has important implications for HIV-related treatment and care. The aim of the current study was to examine links between sexual violence and Quality of Life (QoL) among PLHIV in South Carolina - a Southern state that is disproportionately impacted by the HIV epidemic. Specifically, we surveyed 402 PLHIV about their past exposure to sexual traumas and their current QoL across multiple domains. Results indicated that women living with HIV were more likely to have experienced sexual trauma than men. Participants with histories of sexual trauma reported poorer overall QoL, as well as less satisfaction with their health. Multiple regression analyses indicated that exposure to sexual violence was associated with lower QoL in four of six domains, including psychological functioning, independence, social relationships, and environment. Sexual trauma was not associated with physical health QoL in the current study. Surprisingly, sexual trauma was associated with higher spiritual QoL. Findings support the need to screen PLHIV for sexual trauma exposure, adopt trauma-informed practices, and ensure that all PLHIV have access to comprehensive psychological services when indicated.

The health impacts of violence perpetrated by police, military and other public security forces on gay, bisexual and other men who have sex with men in El Salvador

Gay, bisexual and other men who have sex with men face both high levels of violence and a disproportionate burden of poor health outcomes. We explored violence perpetrated against Salvadoran gay, bisexual and other men who have sex with men by public security forces; perceived motivations of violence; and impacts on health. We conducted structured qualitative interviews with 20 participants and used systematic coding and narrative analysis to identify emergent themes. Nearly all participants described the physical, emotional, sexual and/or economic violence by public security forces. Most attributed being targeted to their gender expression and/or perceived sexual orientation. The most common impact was emotional distress, including humiliation, fear and depression; lasting physical injuries were also widely reported. Study participants felt unable to report these incidents for fear of retribution or inaction. Men reported feelings of helplessness and distrust, avoidance of authorities and altering when, where or how often they appeared in public spaces. Programmes and interventions should focus on providing mental health services for LGBTI (lesbian, gay, bisexual, transgender and intersex) victims of violence, educating public security forces on the legal rights of Salvadorans and expanding current LGBTI-inclusive policies to all public security forces.

A novel technology-enhanced internalized stigma and shame intervention for HIV-positive persons with substance use disorders

Internalized stigma, shame, and other negative self-conscious emotions are inadequately addressed barriers to HIV-related self-care, particularly among people actively using substances. Innovative approaches are needed to optimize antiretroviral treatment (ART) adherence as well as engagement in HIV care among people living with HIV and substance use disorders. Based on qualitative feedback from providers and patients, we iteratively developed and conducted a proof-of-concept study of a relatively brief transdiagnostic emotion regulation intervention designed to improve ART adherence care by addressing behavioral and psychological barriers, including internalized stigma and shame, among people living with HIV and active substance use disorders. The final intervention included 5 individual sessions focused on metacognitive awareness of emotions and thoughts, cognitive reframing of dysfunctional thoughts about the self using concepts such as self-compassion, and identifying and reaching the participants' personalized HIV-self-care goal(s). All participants received daily texts querying current emotion and weekly texts querying ART adherence and substance use. To extend the effects of the intervention, we developed a personalized bi-directional text component through which participants received their personalized compassionate self-statements, informed by the intervention content, in response to their answers to emotion queries for 8 weeks after the 5 sessions. The texts modeled using compassionate self-statements as a form of cognitive reframing, consistent with cognitive restructuring of distorted core beliefs. We consented 10 participants living with HIV and problematic substance use in the proof-of-concept pilot. Of the 8 participants who completed all intervention sessions, participants replied to 70% of all text messages sent. All 8 reported strong acceptability of the intervention content. This emotion-focused, technology-enhanced intervention demonstrated proof-of-concept, in that this patient population would participate in this intervention. A larger randomized controlled pilot is needed to determine feasibility and acceptability among people living with HIV and substance use disorders, a hard-to-reach and underserved population.

Predictors of anxiety and depression among newly diagnosed people living with HIV: A longitudinal study

This longitudinal study examined whether past resilience and internalized stigma predicted anxiety and depression among newly diagnosed Spanish-speaking people living with HIV (PLWH). We also analyzed whether coping strategies mediated this relationship. Data were collected at two time points from 119 PLWH. Approximately a third of participants had scores indicative of anxiety symptoms, the same result was found for depressive symptoms. Structural equations modeling revealed that 61% of the variance of anxiety and 48% of the variance of depression 8 months after diagnosis was explained by the proposed model, which yielded a good fit to data. Anxiety and depressive symptoms were significantly and negatively predicted by positive thinking, thinking avoidance, and past resilience, and positively predicted by self-blame. Additionally, anxiety was positively predicted by internalized stigma. Past resilience negatively predicted internalized stigma, self-blame, and thinking avoidance and it positively predicted positive thinking. Internalized stigma positively predicted self-blame. Moreover, internalized stigma had a significant indirect effect on anxiety symptoms through self-blame, and past resilience had significant indirect effects on anxiety symptoms and depressive symptoms through internalized stigma and coping. The results point to the need for clinicians and policy makers to conduct systematic assessments and implement interventions to reduce internalized stigma and train people living with HIV to identify and use certain coping behaviors.

Spirituality and Social Media: The Search for Support Among Black Men Who Have Sex With Men in Tennessee

Young Black Men Who Have Sex With Men (BMSM) have been the subject of much research focused on health disparities in HIV occurrence, stigma, and mental health. Although such research is important, fewer studies focus on other equally salient areas of their lives such as spirituality, religious practices, and social support. Informed by literature on social support, this research endeavors to better understand these dynamics for a group of young BMSM who reside in a metropolitan city in Tennessee. Focus group results and content analysis uncover themes related to religion and resilience; queering Christianity; and virtual spirituality. Participants expressed an overarching need for support, safe spaces, genuine relationships, and godly instruction, conveyed through traditional Black Church involvement and nontraditional Internet usage. Findings are important for strategic, proactive, cross-generational collaboration with young BMSM to holistically meet their varied needs.

HIV Stigma, Mental Health, and Alcohol Use Disorders among People Living with HIV/AIDS in New Orleans

Evidence suggests that HIV-related stigma is a contributing factor to mental health and substance use problems among people living with HIV (PLWH). Limited research, however, has examined the differential effects that multiple stigma constructs, specifically, anticipated, enacted, and internalized stigma may have on mental health and alcohol use disorders among PLWH. Furthermore, no studies have examined this relationship within the larger context of urban life stressors. The purpose of this study was to examine associations of an overall HIV-related stigma measure and four HIV stigma subscales on depression, anxiety, and hazardous drinking among a sample of 380 PLWH in New Orleans. Log-Poisson models with generalized estimating equations were used to estimate relative risks (RR) and 95% confidence intervals (CI). A test of interaction was used to determine presence of effect modification by urban life stressors. Overall, higher levels of HIV-stigma were associated with depressive symptoms (RR 1.67, 95% CI 1.25, 2.23), anxiety symptoms (RR 1.91, 95% CI 1.17, 3.12), and hazardous drinking (RR 1.45, 95% CI 1.02, 2.05). Internalized HIV-stigma (measured using the negative self-image subscale) was associated with all three outcomes and had the highest magnitude point estimates across the four stigma subscales. Urban life stressors, measured by the Urban Life Stressors Scale (ULSS), modified the association between HIV-related stigma and mental health and alcohol use disorders (P < 0.2), highlighting the importance for examining the larger urban environmental context. Findings from this study may inform interventions to reduce HIV-related stigma operating at the individual and structural level.

A Mobile Health App to Improve HIV Medication Adherence: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Adherence to antiretroviral therapy (ART) is essential for allowing persons living with HIV to live longer, healthier lives. However, a large portion of this population has suboptimal adherence and are not virally suppressed. Conventional interventions aimed at improving ART adherence lack portability and scalability, and improvements in adherence are not often sustained. Mobile health (mHealth) ART interventions offer a low-cost and accessible method of improving adherence, but many have limited functionality and do not offer comprehensive support. The combination of an mHealth intervention with a face-to-face adherence intervention and interactive health coaching feature may offer sufficient support in a manner that is sensitive to resource limitations that are often found in HIV treatment settings. This paper details the protocol of a study designed to evaluate the potential of an enhanced mHealth intervention for improving ART adherence.

OBJECTIVE

The primary objective of this study is to assess the feasibility and acceptability of the Fitbit Plus app enhanced with a face-to-face LifeSteps session (Fitbit Plus condition) for improving ART adherence. In addition, we will determine the preliminary efficacy of the intervention by calculating treatment effect sizes.

METHODS

This study will be conducted in 2 phases. The intervention will be developed and piloted with a small group of participants during phase 1. Pilot participants will provide feedback that will be used to refine the intervention for phase 2. In phase 2, a preliminary randomized controlled trial (RCT) comparing Fitbit Plus with a condition that approximates the standard of care (SOC) will be conducted with 60 persons living with HIV. Interviews will be conducted with RCT participants at baseline, and follow-up interviews will be conducted at 1, 3, 6, and 12 months. ART adherence is the primary outcome and will be monitored throughout the study via electronic pill boxes. Effect sizes will be generated using a fractional logit model estimated by generalized estimating equations.

RESULTS

Phase 1 of this trial is complete; data collection for phase 2 is ongoing. Follow-ups with enrolled participants will conclude in January 2020.

CONCLUSIONS

This study will contribute to the literature on ART adherence and may produce an efficacious intervention. Owing to a small sample size, there may be insufficient power to detect statistically significant differences between Fitbit Plus and SOC. However, if Fitbit Plus is found to be acceptable and feasible and yields promising effect size estimates, this pilot study could serve as the foundation for a larger, fully powered trial of Fitbit Plus.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02676128; https://clinicaltrials.gov/ct2/show/NCT02676128.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/15356.

Women's perspectives on ImpACT: a coping intervention to address sexual trauma and improve HIV care engagement in Cape Town, South Africa

HIV-infected women who have experienced sexual violence face unique challenges in their HIV care engagement and adherence to antiretroviral medications (ARVs). Improving AIDS Care after Trauma (ImpACT) is a brief counseling intervention aimed at reducing the negative impact of sexual trauma and HIV, building coping skills, and improving long-term HIV care engagement. We conducted a randomized controlled pilot trial of ImpACT with 64 women initiating ARVs in Cape Town, South Africa, with results suggesting the intervention can reduce PTSD symptoms and increase motivation to adhere to ARVs. For the current study, we abstracted data from ImpACT worksheets completed by 31 participants during intervention sessions, and qualitative responses from post-intervention surveys, to examine mechanisms, facilitators, and barriers to change in the intervention. Data included participant descriptions of the values informing their care, barriers to participation, and perceived benefits of the intervention related to coping with trauma and improving care engagement. During the first session, women reported feelings of shame, sadness, and anger that led to social isolation, mistrust, and damaged relationships. Barriers to participation included work and school demands, issues with transportation, finances, and discomfort in talking about HIV and trauma, particularly in group sessions. Despite these challenges, several women stated they developed more positive thinking, felt more confident, and improved their interpersonal relationships. Participants also reported substantial positive impact on symptoms of sexual trauma and motivation to continue with long-term HIV care, and clearer understanding of barriers and facilitators to ARV adherence. ImpACT is a promising intervention model for building adaptive coping skills and adherence to HIV treatment, informed by personal values, among women with a history of trauma in this high-risk setting. The data also offer insights into strategies to strengthen the intervention, overcome barriers to participation, encourage the practical application of skills, and promote long-term HIV care engagement.

Depressive symptoms, physical symptoms, and health-related quality of life among older adults with HIV

PURPOSE

In the United States, approximately 45% of persons living with HIV (PLHIV) are ≥ 50 years of age. Many older PLHIV have multi-morbidities that complicate HIV infection and/or interfere with, or are exacerbated by, antiretroviral treatment. Physical health symptoms and psychiatric disorders, particularly depression, can worsen life quality in older PLHIV.

METHODS

This study assessed associations among physical symptoms, indicators of HIV-related health status (i.e., time since diagnosis; ever diagnosed with AIDS; having attained viral suppression), depressive symptoms, and health-related quality of life (HRQoL) in older PLHIV. Regression analyses examined data from 296 PLHIV ≥ 50 years of age living in Cincinnati, OH, Columbus, OH, and New York City.

RESULTS

Depressive symptoms and physical symptoms, particularly those related to appearance and sexual functioning, most strongly predicted HRQoL. Indicators of HIV health status did not significantly predict HRQoL. Depressive symptoms were a particularly robust predictor of HRQoL, even when accounting for physical health symptoms.

CONCLUSION

Findings suggest that symptom management is critical to HRQoL in older PLHIV, and symptoms related to physical appearance and sexual functioning should not be overlooked in this growing population.

Religious Coping and Depressive Symptoms Among Black Americans Living with HIV: An Intersectional Approach

This exploratory quantitative study examined the association between religious coping and depressive symptoms among a sample of 216 Black Americans living with HIV (BALWH) in the Southeastern United States. Descriptive analyses and multiple linear regression were used to determine statistically significant associations between religious coping styles and depressive symptoms, and to investigate the potential of sexual orientation and gender to moderate the associations between religious coping styles and depressive symptoms. Negative religious coping, but not positive religious coping, significantly predicted depressive symptoms. Sexual orientation, but not gender, significantly moderated the association between positive religious coping and depressive symptoms so that the relationship was only significant for heterosexual BALWH. Implications of these findings for future research and clinical work with BALWH are discussed.

"If He's Abusing You . . . the Baby Is Going to Be Affected": HIV-Positive Pregnant Women's Experiences of Intimate Partner Violence

Pregnancy represents a time of increased risk for intimate partner violence (IPV), and an HIV diagnosis further increases the vulnerability of this at-risk group. This study explores experiences of recent IPV using qualitative interviews with N = 12 HIV-positive pregnant women recruited from a clinical setting in South Africa, a location with a high global prevalence of IPV and HIV. Partner dynamics around IPV resulted in HIV shame and stigma and adversely affected engagement in HIV care and HIV treatment behaviors. The results highlight the challenges women face in navigating disclosure of both IPV and HIV, accessing necessary support, and engaging in both HIV-related and pregnancy-related care in the context of an abusive relationship.

The Synergistic Impact of Sexual Stigma and Psychosocial Well-Being on HIV Testing: A Mixed-Methods Study Among Nigerian Men who have Sex with Men

Although sexual stigma has been linked to decreased HIV testing among men who have sex with men (MSM), mechanisms for this association are unclear. We evaluated the role of psychosocial well-being in connecting sexual stigma and HIV testing using an explanatory sequential mixed methods analysis of 25 qualitative and 1480 quantitative interviews with MSM enrolled in a prospective cohort study in Nigeria from March/2013-February/2016. Utilizing structural equation modeling, we found a synergistic negative association between sexual stigma and suicidal ideation on HIV testing. Qualitatively, prior stigma experiences often generated psychological distress and perceptions of feeling unsafe, which decreased willingness to seek services at general health facilities. MSM reported feeling safe at the MSM-friendly study clinic but still described a need for psychosocial support services. Addressing stigma and unmet mental health needs among Nigerian MSM has the potential to improve HIV testing uptake.

Acceptability of Mobile Phone-Based Nurse-Delivered Counseling Intervention to Improve HIV Treatment Adherence and Self-Care Behaviors Among HIV-Positive Women in India

We assessed the acceptability of nurse-delivered mobile phone-based counseling to support adherence to antiretroviral treatment (ART) and self-care behaviors among HIV-positive women in India. We conducted open-ended, in-depth interviews with 27 HIV-positive women and 19 key informants at a government ART center in Karnataka, India. Data were analyzed with interpretive techniques. About half of the HIV-positive women owned a mobile phone and many had access to mobile phones of their family members. Most women perceived phone-based counseling as a personalized care approach to get information on demand. Also, women felt that they could discuss mental health issues and ask sensitive information that they would hesitate to discuss face-to-face. Findings indicate that, when compared with text messaging, mobile phone-based counseling could be a more acceptable way to engage with women on ART, especially those with limited literacy. Future studies should focus on testing mobile phone-based information/counseling and adherence interventions that take the local context into account.

Assessing Timely Presentation to Care Among People Diagnosed with HIV During Hospital Admission: A Population-Based Study in Ontario, Canada

Timely presentation to care for people newly diagnosed with HIV is critical to optimize health outcomes and reduce onward HIV transmission. Studies describing presentation to care following diagnosis during a hospital admission are lacking. We sought to assess the timeliness of presentation to care and to identify factors associated with delayed presentation. We conducted a population-level study using health administrative databases. Participants were all individuals older than 16 and newly diagnosed with HIV during hospital admission in Ontario, Canada, between April 1, 2007 and March 31, 2015. We used modified Poisson regression models to derive relative risk ratios for the association between sociodemographic and clinical variables and the presentation to out-patient HIV care by 90 days following hospital discharge. Among 372 patients who received a primary HIV diagnosis in hospital, 83.6% presented to care by 90 days. Following multivariable analysis, we did not find associations between patient sociodemographic or clinical characteristics and presentation to care by 90 days. In a secondary analysis of 483 patients diagnosed during hospitalization but for whom HIV was not recorded as the principal reason for admission, 73.1% presented to care by 90 days. Following multivariable adjustment, we found immigrants from countries with generalized HIV epidemics (RR 1.265, 95% CI 1.133-1.413) were more likely to present to care, whereas timely presentation was less likely for people with a mental health diagnosis (RR 0.817, 95% CI 0.742-0.898) and women (RR 0.748, 95% CI 0.559-1.001). Future work should evaluate mechanisms to facilitate presentation to care among these populations.

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

Body image disturbance is a common problem reported among sexual minority men living with HIV, and is associated with poor antiretroviral therapy (ART) adherence. Recently, a novel integrated intervention (cognitive behavioral therapy for body image and self-care; CBT-BISC) was developed and pilot tested to simultaneously improve body image and ART adherence in this population. Although CBT-BISC has demonstrated preliminary efficacy in improving ART adherence, the mechanisms of change are unknown. Utilizing data from a two-armed randomized controlled trial (N = 44 sexual minority men living with HIV), comparing CBT-BISC to an enhanced treatment as usual (ETAU) condition, sequential process mediation via latent difference scores was assessed, with changes in body image disturbance entered as the mechanism between treatment condition and changes in ART adherence. Participants assigned to CBT-BISC reported statistically significant reductions in body image disturbance post-intervention, which subsequently predicted changes in ART adherence from post-intervention to long term follow-up (b = 20.01, SE = 9.11, t = 2.19, p = 0.028). One pathway in which CBT-BISC positively impacts ART adherence is through reductions in body image disturbance. Body image disturbance represents one, of likely several, mechanism that prospectively predicts ART adherence among sexual minority men living with HIV.

Correlates of Not Using Antiretroviral Therapy Among Transwomen Living with HIV: The Unique Role of Personal Competence

Purpose: This study tested three psychosocial measures for their potential to serve as counseling goals for promoting ART to transgender women living with HIV (TWLH). Methods: Among 69 TWLH, 17.4% were not taking ART; these volunteers were compared to the remainder using multivariate regression analyses. Results: Only one psychosocial measure achieved significance: Personal Competence (Adjusted Odds Ratio = 0.80, 95% CI = 0.67-0.97, P = 0.02). Because this was a continuous measure, assessed on a 7-point scale, the protective adjusted odds ratio of 0.80 represents a 20% reduction in the odds of not taking ART for each unit of increase in this construct. Conclusion: Findings suggest a potential counseling goal for TWLH not taking ART.

Healthcare Empowerment and HIV Viral Control: Mediating Roles of Adherence and Retention in Care

INTRODUCTION

This study assessed longitudinal relationships between patient healthcare empowerment, engagement in care, and viral control in the Women's Interagency HIV Study, a prospective cohort study of U.S. women living with HIV.

METHODS

From April 2014 to March 2016, four consecutive 6-month visits were analyzed among 973 women to assess the impact of Time 1 healthcare empowerment variables (Tolerance for Uncertainty and the state of Informed Collaboration Committed Engagement) on Time 2 reports of ≥95% HIV medication adherence and not missing an HIV primary care appointment since last visit; and on HIV RNA viral control across Times 3 and 4, controlling for illicit drug use, heavy drinking, depression symptoms, age, and income. Data were analyzed in 2017.

RESULTS

Adherence of ≥95% was reported by 83% of women, 90% reported not missing an appointment since the last study visit, and 80% were categorized as having viral control. Logistic regression analyses revealed a significant association between the Informed Collaboration Committed Engagement subscale and viral control, controlling for model covariates (AOR=1.08, p=0.04), but not for the Tolerance for Uncertainty subscale and viral control (AOR=0.99, p=0.68). In separate mediation analyses, the indirect effect of Informed Collaboration Committed Engagement on viral control through adherence (β=0.04, SE=0.02, 95% CI=0.02, 0.08), and the indirect effect of Informed Collaboration Committed Engagement on viral control through retention (β=0.01, SE=0.008, 95% CI=0.001, 0.030) were significant. Mediation analyses with Tolerance for Uncertainty as the predictor did not yield significant indirect effects.

CONCLUSIONS

The Informed Collaboration Committed Engagement healthcare empowerment component is a promising pathway through which to promote engagement in care among women living with HIV.