Variation in health and risk behavior among youth living with HIV

Designing Evidence-Based Preventive Interventions That Reach More People, Faster, and with More Impact in Global Contexts

This article demonstrates the substantial similarities globally among preventive, evidence-based interventions (EBIs) designed to address HIV by providing four examples: an HIV family-focused intervention, the Community Popular Opinion Leader intervention, a South African maternal/child health program, and an EBI for sex workers in India. Each identified the key problems in the target population, utilized well-established social cognitive theories, created processes for engaging the target population, set standards for staff accountability, and included routine data collection to facilitate iterative program improvements over time. Building EBIs based on these common, robust features is an alternative design strategy to replication with fidelity. These components provide a road map for researchers, especially those using new technologies, and for local providers seeking to deliver EBIs that match their clients' and communities' needs. Technology platforms and community organizations may serve as resources for designers of the next generation of EBIs, offering an alternative to repeatedly validating the same interventions and replicating them with fidelity.

Psychological factors related to resilience and vulnerability among youth with HIV in an integrated care setting

Approximately 22% of HIV diagnoses in 2015 occurred among youth aged 13-24. Much is known about the risk factors and psychopathology present in youth living with HIV (YLWH), however, relatively little is known about resiliency in this population. The current study sought to assess factors related to resilience and vulnerability among YLWH as well as the impact of psychosocial factors on these constructs using existing clinical data from an integrated care clinic serving YLWH in the southeastern United States. Data included findings from mental health screeners administered as part of the standard protocol of care for youth aged 13-24 including information about anxiety (GAD-7), post-traumatic stress disorder (PC-PTSD), depression (PHQ-A or PHQ-9), substance use (CRAFFT), and medication adherence (BEHKA-HIV Action subscale) as well as viral load and demographic variables. Hierarchical linear regression was used to determine factors related to biological (viral load) and behavioral indicators of resilience and vulnerability (BEHKA-HIV Action subscale and CRAFFT). Results showed that anxiety was a significant covariate of both biological and behavioral indicators of resilience while gender was a significant factor associated with behavioral indicators of vulnerability. None of the psychological or demographic factors examined in this study were associated with substance use, a behavioral indicator of vulnerability and resilience. Our results support the need for clinicians to screen for and monitor anxiety symptoms among YLWH in integrated care settings in an effort to promote resilience and minimize vulnerability. Practical, evidence-based strategies should be applied in clinical settings to address medication adherence and anxiety among YLWH.

Adult attachment among partnered gay men: patterns and associations with sexual relationship quality

Previous research has found secure adult attachment to be associated positively with dimensions of main partner relationship quality and negatively with sexual risk taking and sex with casual partners among heterosexuals in primary relationships. Potential associations between adult attachment and aspects of relationship functioning have received limited attention among gay men. Data were collected from both members of 344 gay male couples as part of a community survey (M age = 38.6, SD = 9.4). Participants completed a shortened version of the Adult Attachment Inventory (Collins & Read, 1990) and the Dyadic Sexual Communication Scale (Catania, 1998). They reported the frequency of sex with main partners and the number of casual male unprotected sex partners. Data were analyzed using the Actor-Partner Interdependence Model. Securely attached individuals reported the highest levels of sexual communication and men with securely attached partners were the most likely to report having sex with their partners as least once per week. Avoidantly attached men reported significantly more casual unprotected anal intercourse (UAI) partners compared to other attachment styles. Having an avoidantly attached partner was also associated with an increase in the number of UAI partners reported. Attachment style is relevant to the sexual relationship quality and sexual safety of partnered gay men. Cognitive-interpersonal intervention approaches developed to target attachment-related cognitions and behaviors may be relevant to HIV prevention efforts in this population.

The psychological cost of anticipating HIV stigma for HIV-negative gay and bisexual men

Much research has examined the impact of HIV-associated stigma on HIV-positive individuals, but little work has explored its impact on HIV-negative persons. However, many gay and bisexual men may imagine the stigma they would experience upon seroconverting, and this anticipated stigma may be associated with negative mental health. Such concerns may be exacerbated among men who identify with the receptive role during anal sex, because of greater risk for infection. This study examined the association between anticipated HIV stigma and negative affect among 683 HIV-negative gay and bisexual men living in New York City. Anticipated HIV stigma predicted negative affect over and above internalized homonegativity. Sexual role identity was associated directly with anticipated stigma and indirectly with negative affect. Results suggest that anticipated HIV stigma may be an important mental health issue for gay and bisexual men. Public health messaging discussing sexual positioning should be sensitive to the potential for exacerbating anticipated HIV stigma among bottom-identified men.

Rules about casual sex partners, relationship satisfaction, and HIV risk in partnered gay and bisexual men

The authors used latent class analysis to investigate rules guiding nonmonogamy in partnered gay and bisexual men. Data are from a 2010 survey (N = 463) from which those in relationships (n = 191) were analyzed. More than half (56%) were nonmonogamous, and these men responded to 13 rules about sex outside of their relationship. The safe anonymous sex group (34%) included men who indicated that they must use condoms for anal sex and not have sex with people they know. The communication mandate group (19%) included men who indicated that they must talk about outside partners before sex occurs, disclose their relationship status to outside partners, and use condoms for anal sex. The play together group (9%) included men who indicated that they must play with others as a couple, not have anal sex with outside partners, and not spend the night with outside partners. Those in the no salient rule group (37%) were individuals who did not endorse a clear set of rules. These 4 groups (and compared with monogamous men) differed in age, agreement formality and flexibility, relationship satisfaction, and whether anal sex recently occurred with casual partners. This study provides a novel approach for understanding nonmonogamous same-sex relationships and highlights their complexity.

Self-reported penis size and experiences with condoms among gay and bisexual men

As researchers and community-based providers continue to encourage latex condom use as a chief strategy to prevent HIV transmission among men who have sex with men, research is needed to better explore the intersecting associations among penis size (length and circumference), condom feel, ease of finding condoms, recent experience of condom failure (breakage and slippage), and unprotected anal sex. Data were taken from a 2010 community-based survey of self-identified gay and bisexual men in New York City (n = 463). More than half (51.4 %) reported penile length as 6-8 in. long (15-20 cm) and 31.5 % reported penile circumference as 4-6 in. around (10-15 cm). Variation in self-reported penile dimensions was significantly associated with men's attitudes toward the typical/average condom, difficulty finding condoms that fit, and the experience of condom breakage. Men who had engaged in recent unprotected insertive anal intercourse reported significantly higher values for both penile length and circumference, and these men were significantly more likely to report that the average/typical condom was "too tight." Most men had measured their length (86.2 %) and/or circumference (68.9 %), suggesting that penile measurement might be a common and acceptable practice among gay and bisexual men. As HIV and STI prevention providers continue to serve as leading distributers of free condoms, these findings further highlight the need for condom availability to be in a variety of sizes. Improving condom fit and attitudes toward condoms may also improve condom use and minimize condom slippage and breakage.

Sexual risk behavior among youth with perinatal HIV infection in the United States: predictors and implications for intervention development

BACKGROUND

Factors associated with initiation of sexual activity among perinatally human immunodeficiency virus (HIV)-infected (PHIV(+)) youth, and the attendant potential for sexual transmission of antiretroviral (ARV) drug-resistant HIV, remain poorly understood.

METHODS

We conducted cross-sectional and longitudinal analyses of PHIV(+) youth aged 10-18 years (mean, 13.5 years) enrolled in the US-based Pediatric HIV/AIDS Cohort Study between 2007 and 2009. Audio computer-assisted self-interviews (ACASI) were used to collect sexual behavior information.

RESULTS

Twenty-eight percent (95% confidence interval [CI], 23%-33%) (92/330) of PHIV(+) youth reported sexual intercourse (SI) (median initiation age, 14 years). Sixty-two percent (57/92) of sexually active youth reported unprotected SI. Among youth who did not report history of SI at baseline, ARV nonadherence was associated with sexual initiation during follow-up (adjusted hazard ratio, 2.87; 95% CI, 1.32-6.25). Youth living with a relative other than their biological mother had higher odds of engaging in unprotected SI than those living with a nonrelative. Thirty-three percent of youth disclosed their HIV status to their first sexual partner. Thirty-nine of 92 (42%) sexually active youth had HIV RNA ≥5000 copies/mL after sexual initiation. Viral drug resistance testing, available for 37 of these 39 youth, identified resistance to nucleoside reverse transcriptase inhibitors in 62%, nonnucleoside reverse transcriptase inhibitors in 57%, protease inhibitors in 38%, and all 3 ARV classes in 22%.

CONCLUSIONS

As PHIV(+) youth become sexually active, many engage in behaviors that place their partners at risk for HIV infection, including infection with drug-resistant virus. Effective interventions to facilitate youth adherence, safe sex practices, and disclosure are urgently needed.

Stigma and sexual compulsivity in a community-based sample of HIV-positive gay and bisexual men

A better exploration of factors associated with sexual compulsivity (SC) among various subpopulations may help to explain its etiology, development, and course, as well as provide implications for treatment. Criticisms of SC highlight the need to have a better understanding of SC that takes into account both behavioral and psychosocial variables such as stigma, particularly stigma related to sexual orientation and HIV status. The purpose of this study was to investigate the association of SC with sexual behavior and stigma in a sample of HIV-positive gay and bisexual men. A cross-sectional, street-intercept method was adapted to survey a sample of 127 HIV-positive gay and bisexual males at two large-scale LGBT community events in the fall of 2008 and spring of 2009. We found that the number of recent male sexual partners (AOR = 1.05) and internalized HIV stigma (AOR = 8.20) were significantly associated with SC symptomology, while internalized homonegativity and interpersonal HIV stigma were not. These findings contradict many prominent criticisms of SC while highlighting the need to better understand the mechanisms related to the development of SC symptomology and the potential role stigma may have for the psychosexual well-being of HIV-positive gay and bisexual men.

Sexual compulsivity, co-occurring psychosocial health problems, and HIV risk among gay and bisexual men: further evidence of a syndemic

OBJECTIVES

We evaluated whether sexual compulsivity fits into a syndemic framework, in which sexual compulsivity is one of a number of co-occurring psychosocial health problems that increase HIV risk among men who have sex with men (MSM).

METHODS

In 2003 and 2004, we conducted an anonymous cross-sectional survey of MSM in New York City (n = 669) by approaching attendees at gay, lesbian, and bisexual community events. We analyzed data by bivariate and multivariate logistic regression.

RESULTS

We found strong positive interrelationships among syndemic factors including sexual compulsivity, depression, childhood sexual abuse, intimate partner violence, and polydrug use. In bivariate analyses, all syndemic health problems except for childhood sexual abuse were positively related to HIV seropositivity and high-risk sexual behavior. Our multivariate models revealed an array of interrelationships among psychosocial health problems. We found amplified effects of these problems on HIV seropositivity and on the likelihood of engaging in high-risk sexual behavior.

CONCLUSIONS

Our findings support the conclusion that sexual compulsivity is a component of a syndemic framework for HIV risk among MSM. HIV prevention interventions should consider the overlapping and compounding effects of psychosocial problems, including sexual compulsivity.

People with HIV in HAART-era Russia: transmission risk behavior prevalence, antiretroviral medication-taking, and psychosocial distress

Russia has seen one of the world's fastest-growing HIV epidemics. Transmission risk behavior, HAART-taking, and psychosocial distress of the growing population of Russian people living with HIV (PLH) in the HAART era are understudied. Participants of a systematically-recruited cross-sectional sample of 492 PLH in St. Petersburg completed measures of sexual and drug injection practices, adherence, perceived discrimination, and psychosocial distress. Since learning of their status, 58% of participants had partners of HIV-negative or unknown serostatus (mean = 5.8). About 52% reported unprotected intercourse with such partners, with 30% of acts unprotected. Greater perceived discrimination predicted lower condom use. A 47% of IDU PLH still shared needles, predicted by having no primary partner, lower education, and more frequently-encountered discrimination. Twenty-five percentage of PLH had been refused general health care, 11% refused employment, 7% fired, and 6% forced from family homes. Thirty-nine percentage of participants had probable clinical depression, 37% had anxiety levels comparable to psychiatric inpatients, and social support was low. Of the 54% of PLH who were offered HAART, 16% refused HAART regimens, and 5% of those on the therapy took less than 90% of their doses. Comprehensive community services for Russian PLH are needed to reduce AIDS-related psychosocial distress and continued HIV transmission risk behaviors. Social programs should reduce stigma and discrimination, and promote social integration of affected persons and their families.

Do traditional risk factors predict whether men who have sex with men engage in unprotected anal intercourse? The need for locally based research to guide interventions

A great deal of research effort has been expended in an effort to identify the variables which most influence men who have sex with men's (MSM) unsafe sexual behaviors.While a set of predictor variables has emerged, these predict the unsafe behaviors of MSM in some locations but not in others, suggesting the need to investigate the predictive ability of these variables among MSM in previously understudied populations. Therefore, this study examined the ability of previously identified factors to predict unsafe sexual behaviors among MSM in Houston, Texas. Data were collected through a short self-report survey completed by MSM attending the Houston pride festival. The multiethnic participants (N = 109) represented a range of age, educational, and income backgrounds. Fifty-seven percent of the survey respondents had been drunk and/or high in sexual contexts, 19 percent evidenced alcohol dependency, 26 percent reported finding sex partners online and sex with serodiscordant or unknown serostatus partners was common. Compared to men who did not report unprotected anal intercourse (UAI) in the preceding two months, MSM who engaged in UAI were younger and more likely to use alcohol in sexual contexts, meet men online for offline sex, and perceive lower safer sex norms in their community. Although these results were statistically significant, the strength of the relationships was too small to have any practical value. The lack of useful explanatory power underscores the importance of accelerated HIV research that identifies the unique, local factors associated with unsafe sex in other previously understudied populations.

Sexual transmission risk behavior of adolescents With HIV acquired perinatally or through risky behaviors

OBJECTIVE

To describe the prevalence and predictors of the transmission-related behaviors of adolescents with HIV acquired perinatally (perinatal) or through risky behaviors (behavioral).

METHODS

HIV-positive adolescents (n = 166) aged 13-21, receiving care in 3 US cities, reported sexual behaviors, drug use, and psychosocial and demographic characteristics. HIV-related data were abstracted from medical records.

RESULTS

Of 105 sexually experienced adolescents reporting risk history (42 perinatal, 63 behavioral), 49 had engaged in unprotected sex since learning their diagnosis (12 perinatal, 37 behavioral). Of sexually experienced girls, 19 had been pregnant (5 of 24 perinatal, 14 of 31 behavioral). Risk information was provided for 115 of 132 recent sex partners, 61 of whom had unprotected sex with study participants (10 with 8 perinatal participants; 51 with 33 behavioral participants). Recent unprotected sex was associated with sexual abuse during adolescence (adjusted odds ratio = 9.61, 95% CI: 1.07 to 86.12) and greater HIV knowledge (adjusted odds ratio = 1.29, 95% CI: 1.00 to 1.66) when transmission category, age, and sexual orientation were controlled.

CONCLUSIONS

To limit HIV transmission and prevent unplanned pregnancies, developmentally appropriate risk-reduction interventions, and screening and treatment referral for sexual abuse, must be integrated into the care of both perinatally and behaviorally HIV-infected adolescents.

Substance use and its association with psychiatric symptoms in perinatally HIV-infected and HIV-affected adolescents

Drug use in combination with psychiatric illness may lead to unsafe sexual risk behavior and increased risk for secondary HIV transmission among adolescents with HIV infection. We compared the prevalence of substance use for perinatally HIV-infected youth to uninfected adolescents living in families affected by HIV infection, and evaluated the association of psychiatric symptoms with risk of substance use. Among 299 adolescents (196 HIV+, 103 HIV-) aged 12-18 years enrolled in IMPAACT P1055, a multisite US cohort study, 14% reported substance use at enrollment (HIV+: 13%, HIV-: 16%). In adjusted logistic regression models, adolescents had significantly higher odds of substance use if they met symptom criteria for ADHD [adjusted odds ratio (aOR) = 2.7, Wald χ(2) = 5.18, P = 0.02], major depression or dysthymia (aOR = 4.0, Wald χ(2) = 7.36, P = 0.01), oppositional defiant disorder (aOR = 4.8, Wald χ(2) = 12.7, P = 0.001), or conduct disorder (aOR = 15.4, Wald χ(2) = 28.12, P = 0.001). Among HIV-infected youth, those with lower CD4 lymphocyte percentage (CD4% < 25%) had significantly increased risk of substance use (aOR = 2.7, Wald χ(2) = 4.79, P = 0.03). However, there was no overall association of substance use with HIV infection status, and the association between psychiatric symptoms and substance use did not differ by HIV status. Programs to prevent substance use should target both HIV-infected and uninfected adolescents living in families affected by HIV infection, particularly those with psychiatric symptoms.

Sexual compulsivity and sexual risk in gay and bisexual men

Much of our understanding of the association between the Sexual Compulsivity Scale (SCS) and sexual risk behavior among men who have sex with men (MSM) has been limited to samples of HIV positive MSM only. Using data from a community-based survey of gay and bisexual men (n = 1214), this analysis sought to further evaluate the association between the SCS and sexual risk behavior. The SCS was significantly associated with a variety of sexual risk behaviors, including having sex under the influence of club drugs, engaging in unprotected anal sex (receptive or insertive) with partners of the same and/or different HIV serostatus, identity as a barebacker, intentions to have bareback sex, number of recent sex partners, and temptation for unsafe sex. The SCS was also significantly associated with having engaged in a variety of specialized sexual behaviors (i.e., fetishes), many of which can increase HIV transmission risks. Finally, in multivariate analyses, the SCS significantly predicted unprotected sex with a non-main partner even when controlling for race, HIV serostatus, age, identity as a barebacker, and club drug use. These data indicate that the SCS may be able to serve as an indicator to detect HIV-associated sexual risk behavior in community-based samples of gay and bisexual men.

The association between penis size and sexual health among men who have sex with men

Larger penis size has been equated with a symbol of power, stamina, masculinity, and social status. Yet, there has been little research among men who have sex with men assessing the association between penis size and social-sexual health. Survey data from a diverse sample of 1,065 men who have sex with men were used to explore the association between perceived penis size and a variety of psychosocial outcomes. Seven percent of men felt their penis was "below average," 53.9% "average," and 35.5% "above average." Penis size was positively related to satisfaction with size and inversely related to lying about penis size (all ps < .01). Size was unrelated to condom use, frequency of sex partners, HIV status, or recent diagnoses of HBV, HCV, gonorrhea/Chlamydia/urinary tract infections, and syphilis. Men with above average penises were more likely to report HPV and HSV-2 (Fisher's exact p <or= .05). Men with below average penises were significantly more likely to identify as "bottoms" (anal receptive) and men with above average penises were significantly more likely to identify as "tops" (anal insertive). Finally, men with below average penises fared significantly worse than other men on three measures of psychosocial adjustment. Though most men felt their penis size was average, many fell outside this "norm." The disproportionate number of viral skin-to-skin STIs (HSV-2 and HPV) suggest size may play a role in condom slippage/breakage. Further, size played a significant role in sexual positioning and psychosocial adjustment. These data highlight the need to better understand the real individual-level consequences of living in a penis-centered society.

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

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

Reductions in drug use among young people living with HIV

ZIP models were used to detect reductions in drug abuse among young people living with HIV (YPLH) over 15 months when most young people abstain from use. YPLH (n = 171) aged 16 to 29 years were randomly assigned to an 18 session intervention or a delayed-intervention condition. The ZIP models showed significant reductions in abuse of multiple substances over time in the non-delayed intervention. Previous analyses did not find significant reductions. Intervention efficacy often cannot be detected if there are highly skewed distributions of outcomes, such as drug abuse. ZIP modeling offers an opportunity to more reliably detect behavioral changes.

An HIV-preventive intervention for youth living with HIV

As the number of youth infected with HIV rises, secondary prevention programs are needed to help youth living with HIV meet three goals: (a) increase self-care behaviors, medical adherence, and health-related interactions; (b) reduce transmission acts; and (c) enhance their quality of life. This article describes an intervention program for youth living with HIV. Youth engage in small-group activities with other infected peers to modify their behavioral patterns. The intervention aims to (a) reduce substance use and sexual behaviors that may transmit or enhance transmission of the HIV virus; (b) reduce negative impacts of substance use on seeking and utilizing health care, assertiveness, and adherence to health regimens; and (c) enhance the quality of life to maintain behavior changes over time. Interventions that target youth living with HIV are warranted. A variety of delivery strategies are discussed for secondary interventions.

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

CONTEXT

The US Centers for Disease Control and Prevention (CDC) strongly recommend comprehensive risk counceling and services for people living with HIV (PLH); yet, there are no evidence-based counseling protocols.

OBJECTIVE

To examine the effect of a 15-session, individually delivered, cognitive behavioral intervention on a diverse sample of PLH at risk of transmitting to others.

DESIGN

This was a multisite, 2-group, randomized, controlled trial.

PARTICIPANTS

Nine hundred thirty-six HIV-infected participants considered to be at risk of transmitting HIV of 3818 persons screened were randomized into the trial. Participants were recruited in Los Angeles, Milwaukee, New York, and San Francisco.

INTERVENTION

Fifteen 90-minute individually delivered intervention sessions were divided into 3 modules: stress, coping, and adjustment; safer behaviors; and health behaviors. The control group received no intervention until the trial was completed. Both groups completed follow-up assessments at 5, 10, 15, 20, and 25 months after randomization.

MAIN OUTCOME MEASURE

Transmission risk, as measured by the number of unprotected sexual risk acts with persons of HIV-negative or unknown status, was the main outcome measure.

RESULTS

Overall, a significance difference in mean transmission risk acts was shown between the intervention and control arms over 5 to 25 months (chi2 = 16.0, degrees of freedom = 5; P = 0.007). The greatest reduction occurred at the 20-month follow-up, with a 36% reduction in the intervention group compared with the control group.

CONCLUSION

Cognitive behavioral intervention programs can effectively reduce the potential of HIV transmission to others among PLH who report significant transmission risk behavior.

Epidemiology of HIV and AIDS among adolescents and young adults in the United States

PURPOSE

To describe the current status of the human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) epidemic among adolescents and young adults in the United States. Despite reported declines in sexual risk behaviors among adolescents in the past decade, little has been published about the epidemiology of HIV and AIDS among adolescents and young adults in the United States.

METHODS

We analyzed cases of HIV or AIDS diagnosed among persons aged 13 to 24 years and reported to the national HIV/AIDS Reporting System. We used AIDS cases diagnosed from 1985 through 2003 from the 50 states, the District of Columbia, and the U.S. trusts and territories, and we used HIV cases diagnosed in 2003 from 32 states and the U.S. Virgin Islands. We present five-year trends in HIV diagnoses from 1999 through 2003 from 33 surveillance areas that have stable name-based HIV reporting. The data were adjusted for reporting delays and unreported risk factors.

RESULTS

At the end of 2003, 7074 adolescents and young adults, aged 13 to 24 years at the time of diagnosis, were living with AIDS in the United States. Of these, 63% were aged 20 to 24 years. AIDS rates were highest among black persons (63 per 100,000) and youth living in the South (22 per 100,000) and Northeast (18 per 100,000). Among females, the number of diagnosed HIV cases decreased from 1611 cases in 1999 to 1454 in 2003. Among males, the number increased significantly from 1763 in 1999 to 2443 in 2003. The observed increase in the number of HIV diagnoses among males was driven by an increase in HIV diagnoses among young men who have sex with men.

CONCLUSIONS

National case surveillance data for persons aged 13 to 24 years revealed that the burden of HIV and AIDS falls most heavily upon the Southern region of the United States and disproportionately upon black and Hispanic youth. The observed increases in the number of HIV cases among men who have sex with men are congruent with recent reports that suggest a resurgence of HIV among these young men. Our findings highlight the need for intensified HIV prevention efforts within minority communities and among men who have sex with men as well as strengthened efforts to encourage at-risk youth to get tested for HIV.

The role of emotion in decision-making: a cognitive neuroeconomic approach towards understanding sexual risk behavior

Models of decision-making usually focus on cognitive, situational, and socio-cultural variables in accounting for human performance. However, the emotional component is rarely addressed within these models. This paper reviews evidence for the emotional aspect of decision-making and its role within a new framework of investigation, called neuroeconomics. The new approach aims to build a comprehensive theory of decision-making, through the unification of theories and methods from economics, psychology, and neuroscience. In this paper, we review these integrative research methods and their applications to issues of public health, with illustrative examples from our research on young adults' safe sex practices. This approach promises to be valuable as a comprehensively descriptive and possibly, better predictive model for construction and customization of decision support tools for health professionals and consumers.

Predictors of intervention adherence among young people living with HIV

OBJECTIVE

To examine adherence to a 23-session intervention for young people living with HIV.

METHODS

Two hundred eight HIV-positive youth were assigned by small cohort to a behavioral intervention.

RESULTS

Youth with more personal strengths were more likely to attend the intervention; those with more competing environmental demands (eg, employment, school) were less likely to attend the intervention. Using a social support, spiritual hope, or self-destructive and escape coping style was associated with attendance. Youth who reported many sexual partners attended fewer sessions. Adherence varied by cohort assignment.

CONCLUSION

When designing future interventions, high attendance should be considered as a goal.

Differences among sexually abused and nonabused youth living with HIV

Risk behaviors were compared between sexually abused and nonabused youth living with HIV (YLH). Abused YLH were significantly more likely to have attempted suicide, to have been admitted into an alcohol and/or drug treatment program, and to have engaged in crack cocaine use than were nonabused YLH and had a greater number of sexual partners. A significantly higher proportion of abused YLH had been incarcerated in contrast to nonabused youth. There were also significantly greater conduct problems among abused YLH. Finally, abused YLH had significantly higher scores on positive action and social-support coping styles than nonabused youth. Consistent with previous research, abused youth are at higher risk for a variety of negative outcomes and are also similar in many respects to sexually abused youth who are not HIV-positive. The high frequencies of two positive styles of coping among abused YLH were also observed.

Cost-effectiveness of a behavioral intervention for seropositive youth

An intervention for young people living with HIV (YPLH) was effective in reducing the number of partners of unknown serostatus and the number of unprotected sexual risk acts. In this article, we outline new methods to assess the cost-effectiveness of this intervention. Over a period of 3 months, the intervention would avert an estimated 2.02 new infections per 1,000 YPLH. The cost of mounting the intervention was estimated at US 522 dollars/YPLH, with the cost-effectiveness over a 1-year period being US 103,366 dollars/infection averted. Based on standardized estimates of the cost of treating HIV-positive persons and the adjusted quality of life years lost (10.23 for partners of a mean age of 29 years), the cost utility estimate shows that the treatment costs averted exceed the cost of the intervention. Both the methodology of calculating cost-effectiveness and the cost utility of interventions are important for focusing policy makers, clinicians, community providers, and researchers on prevention for persons living with HIV.

Prevention for HIV-seropositive persons: successive approximation toward a new identity

This article presents a three-module intervention based on social action theory that focuses on health promotion and social identity formation for seropositive youth. The modules are designed to reduce transmission of HIV by reducing sexual and substance abuse acts, increasing healthy acts and adherence to care, and maintaining positive behavioral routines. Components of the modules are described, including examples of how these components are implemented in the actual intervention sessions. The importance of using successive approximation to consolidate changes in behavior by defining social roles and personal identities that are consistent with positive behavioral routines is demonstrated. Outcomes of the intervention are presented as well as issues of cost-effectiveness, feasibility, and alternative implementation strategies.

Risk behaviors of youth living with HIV: pre- and post-HAART

OBJECTIVE

To examine the transmission behavior among youth living with HIV (YLH), pre- and post-HAART.

METHODS

Two cohorts were recruited: (1) 349 YLH during 1994 to 1996 and (2) 175 YLH during 1999 to 2000, after the wide availability of HAART. Differences in sexual and substance-use risk acts and quality of life were examined.

RESULTS

Post-HAART YLH were more likely to engage in unprotected sex and substance use, to be more emotionally distressed, and to have lower quality of life than were pre-HAART YLH.

CONCLUSIONS

Targeted interventions for YLH that address reductions in transmission acts and aim to improve quality of life are still needed.

The Healthy Living Project: an individually tailored, multidimensional intervention for HIV-infected persons

The NIMH Healthy Living Project (HLP), a randomized behavioral intervention trial for people living with HIV, enrolled 943 individuals, including women, heterosexual men, injection drug users, and men who have sex with men from Los Angeles, Milwaukee, New York, and San Francisco. The intervention, which is based on qualitative formative research and Ewart's Social Action Theory, addresses three interrelated aspects of living with HIV: stress and coping, transmission risk behavior, and medication adherence. Fifteen 90-minute structured sessions, divided into 3 modules of five sessions each, are delivered to individuals. Sessions are tailored to individuals within a structure that uses role-plays, problem solving, and goal setting techniques. A 'Life Project'--or overarching goal related to personal striving-provides continuity throughout sessions. Because this is an ongoing project with efficacy yet to be established, we do not report intervention outcomes. However, the intervention was designed to be useful for prevention case management, settings where repeated one-on-one contact is possible, and where a structured but highly individualized intervention approach is desired.

Coping effectiveness training for men living with HIV: results from a randomized clinical trial testing a group-based intervention

OBJECTIVE

This randomized clinical trial was designed to compare the effects of a theory-based coping effectiveness training (CET) intervention with an active informational control (HIV-Info) condition and a waiting-list control (WLC) condition on psychological distress and positive mood in HIV-seropositive gay men.

MATERIALS AND METHODS

The authors recruited 149 self-identified gay or bisexual men who were 21 to 60 years of age, reported depressed mood, and had CD4 levels of 200 to 700 cells/mm(3). CET and HIV-Info participants attended 10 90-minute group sessions during the 3-month intervention phase and six maintenance sessions over the remainder of the year. Participants were assessed at baseline and at 3, 6, and 12 months. Data were collected 1992 to 1994, before the introduction of HAART. Analyses were based on the 128 participants who completed the 3-month assessment.

RESULTS

After the 3-month intervention phase, when compared with HIV-Info, CET participants showed significantly greater decreases in perceived stress and burnout, and regression analyses indicated that significant increases in coping self-efficacy mediated the improvements in perceived stress and burnout. Compared with WLC, CET participants also showed significantly greater decreases in anxiety, and regression analyses indicated that significant increases in positive states of mind mediated the improvements in anxiety. Significant treatment group differences for positive morale were maintained at 6 and 12 months. In addition, optimism continued to increase in the CET and HIV-Info treatment groups during the maintenance phase.

CONCLUSIONS

CET can be an effective strategy for managing psychological distress and improving positive psychological states in patients confronting chronic illness.

Risk among young gay and bisexual men living with HIV

The influence of sexual orientation was examined on sexual risk behaviors, disclosure patterns, substance use, and stressful live events among 231 gay and bisexual youth living with HIV. Youth were mainly of ethnic minority heritage: 69.3% were Hispanic, African American, or biracial. Although there were significant differences in gay and bisexual youth's self-label and patterns of sexual attraction and sexual partners, there were few differences in other behavioral risk acts. The frequency of sexual risk acts, substance use, stressful life events, and child sexual abuse were similar for gay and bisexual youth and similar across ethnic groups. Disclosure of sexual orientation was significantly more common among gay youth compared with bisexual youth. Gay and bisexual identification appears to be a more critical factor than ethnicity in placing youth at risk for HIV. Care providers need to screen youth for sexual orientation and behaviors at a young age and inquire about age of partners, substance use, and history of sexual abuse.

Health and risk behaviors over time among youth living with HIV

Health practices and transmission behaviors were examined over time among 25 disabled youth living with HIV (YLH) living in a comprehensive residential care program. YLH were aged 19-24 years (M=23.4 years); 89 per cent of males were gay, bisexual, or transgendered (60% Caucasian); all had physical and mental health problems, as well as substance abuse disorders. YLH were assessed at least four times at 3-month intervals and reported high lifetime rates of sexual and substance-use risk acts. Over four assessments, YLH improved their nutrition and hygiene and decreased their worry about their health status. YLH evidenced no decrease in the frequency of substance use and sexual risk. Depression, self-esteem, and health status also were stable over time. YLH who have a lifetime history of multiple problem behaviors are likely to change slowly over time, even when receiving comprehensive residential care.