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A Prospective Study of Intimate Partner Violence as a Risk Factor for Detectable Plasma Viral Load in HIV-Positive Women Engaged in Transactional Sex in Mombasa, Kenya. AIDS Behav 2016; 20:2065-77. [PMID: 27142058 DOI: 10.1007/s10461-016-1420-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We conducted a prospective cohort study to evaluate intimate partner violence (IPV) as a risk factor for detectable plasma viral load in HIV-positive female sex workers (FSWs) on antiretroviral therapy (ART) in Kenya. IPV in the past year was defined as ≥1 act of physical, sexual, or emotional violence by the index partner (i.e. boyfriend/husband). The primary outcome was detectable viral load (≥180 copies/ml). In-depth interviews and focus groups were included to contextualize results. Analyses included 195 women (570 visits). Unexpectedly, IPV was associated with significantly lower risk of detectable viral load (adjusted relative risk 0.21, 95 % CI 0.05-0.84, p-value = 0.02). Qualitative findings revealed that women valued emotional and financial support from index partners, despite IPV. IPV was not a major barrier to ART adherence. The observed association between IPV and lower risk of detectable viral load in FSWs may be due to unmeasured personal and relationship factors, warranting further research.
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Betancourt TS, Brennan RT, Vinck P, VanderWeele TJ, Spencer-Walters D, Jeong J, Akinsulure-Smith AM, Pham P. Associations between Mental Health and Ebola-Related Health Behaviors: A Regionally Representative Cross-sectional Survey in Post-conflict Sierra Leone. PLoS Med 2016; 13:e1002073. [PMID: 27505186 PMCID: PMC4978463 DOI: 10.1371/journal.pmed.1002073] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 05/31/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Little attention has been paid to potential relationships between mental health, trauma, and personal exposures to Ebola virus disease (EVD) and health behaviors in post-conflict West Africa. We tested a conceptual model linking mental health and trauma to EVD risk behaviors and EVD prevention behaviors. METHODS AND FINDINGS Using survey data from a representative sample in the Western Urban and Western Rural districts of Sierra Leone, this study examines associations between war exposures, post-traumatic stress disorder (PTSD) symptoms, depression, anxiety, and personal EVD exposure (e.g., having family members or friends diagnosed with EVD) and EVD-related health behaviors among 1,008 adults (98% response rate) from 63 census enumeration areas of the Western Rural and Western Urban districts randomly sampled at the height of the EVD epidemic (January-April 2015). Primary outcomes were EVD risk behaviors (14 items, Cronbach's α = 0.84) and EVD prevention behaviors (16 items, Cronbach's α = 0.88). Main predictors comprised war exposures (8 items, Cronbach's α = 0.85), anxiety (10 items, Cronbach's α = 0.93), depression (15 items, Cronbach's α = 0.91), and PTSD symptoms (16 items, Cronbach's α = 0.93). Data were analyzed using two-level, population-weighted hierarchical linear models with 20 multiply imputed datasets. EVD risk behaviors were associated with intensity of depression symptoms (b = 0.05; 95% CI 0.00, 0.10; p = 0.037), PTSD symptoms (b = 0.10; 95% CI 0.03, 0.17; p = 0.008), having a friend diagnosed with EVD (b = -0.04; 95% CI -0.08, -0.00; p = 0.036), and war exposures (b = -0.09; 95% CI -0.17, -0.02; p = 0.013). EVD prevention behaviors were associated with higher anxiety (b = 0.23; 95% CI 0.06, 0.40; p = 0.008), having a friend diagnosed with EVD (b = 0.15; 95% CI 0.04, 0.27; p = 0.011), and higher levels of war exposure (b = 0.45; 95% CI 0.16, 0.74; p = 0.003), independent of mental health. PTSD symptoms were associated with lower levels of EVD prevention behavior (b = -0.24; 95% CI -0.43, -0.06; p = 0.009). CONCLUSIONS In post-conflict settings, past war trauma and mental health problems are associated with health behaviors related to combatting EVD. The associations between war trauma and both EVD risk behaviors and EVD prevention behaviors may be mediated through two key mental health variables: depression and PTSD symptoms. Considering the role of mental health in the prevention of disease transmission may help fight continuing and future Ebola outbreaks in post-conflict Sierra Leone. This sample is specific to Freetown and the Western Area and may not be representative of all of Sierra Leone. In addition, our main outcomes as well as personal EVD exposure, war exposures, and mental health predictors rely on self-report, and therefore raise the possibility of common methods bias. However, the findings of this study may be relevant for understanding dynamics related to EVD and mental health in other major capital cities in the EVD-affected countries of West Africa.
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Affiliation(s)
- Theresa S. Betancourt
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
| | - Robert T. Brennan
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Patrick Vinck
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Emergency Medicine, Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Tyler J. VanderWeele
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Dayo Spencer-Walters
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Joshua Jeong
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | | | - Phuong Pham
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Emergency Medicine, Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
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Depressive symptoms and substance use as mediators of stigma affecting men who have sex with men in Lesotho: a structural equation modeling approach. Ann Epidemiol 2016; 26:551-556. [PMID: 27425206 DOI: 10.1016/j.annepidem.2016.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 03/30/2016] [Accepted: 06/03/2016] [Indexed: 01/25/2023]
Abstract
PURPOSE Research on the relationship between sexual orientation-related stigma and risks for HIV among men who have sex with men (MSM) is limited. This study tests a hypothesis that substance use and depressive symptoms mediate the relationship between stigma in the health care system and HIV-related risk practices among MSM in Maseru, Lesotho. METHODS In 2014, we conducted a cross-sectional study among MSM in Lesotho accrued via respondent-driven sampling including a survey and biological testing for HIV. The hypothesis was tested using structural equation modeling. RESULTS Of the 318 participants, 22.3% had experienced stigma in the health care system. Stigma in the health care system was associated with depression (β = 0.329, P = .018) and alcohol use (β = 1.417, P = .001). Noninjection illicit drug use (β = 0.837, P = .039) and alcohol use (β = 0.282, P = .000) significantly predicted number of sex partners. Stigma was directly associated with condomless anal sex (β = 0.441, P = .036), and no indirect association was found. CONCLUSIONS Alcohol use and depressive symptoms mediate the relationship between MSM stigma in the health care system and reported number of sex partners. The implications are significant with a focus on the need for comprehensive interventions addressing stigma and mental health when aiming to improve more proximal HIV-related risk practices for MSM.
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Perry NS, Wade Taylor S, Elsesser S, Safren SA, O’Cleirigh C. The Predominant Relationship Between Sexual Environment Characteristics and HIV-Serodiscordant Condomless Anal Sex Among HIV-Positive Men Who Have Sex with Men (MSM). AIDS Behav 2016; 20:1228-35. [PMID: 26395194 DOI: 10.1007/s10461-015-1202-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In some studies, situational factors have been shown to be stronger predictors of condomless sex than individual risk factors. Cross-sectional relationships between condomless anal sex (CAS) with HIV-serodiscordant partners and risk factors across ecological levels (individual, sexual environment) were examined using a sample (N = 60) of HIV-positive men who have sex with men (MSM) who reported multiple recent episodes of CAS. Negative binomial regressions were used to evaluate the association of contextual risk factors (e.g., substance use during sex, transactional sex, public sex, sex at a sex party) with recent condomless sex, controlling for demographics and mental health. Results demonstrated that sexual environment factors, particularly sex under the influence of drugs or alcohol (B = .019, p < .05), transactional sex (B = .035, p < .01), and public sex (B = .039, p < .01) explained a large proportion of the variance in CAS. Only sex at a sex party was not related to CAS (p = .39). For each additional sexual environment in which men engaged, their rates of CAS increased (B = .39, p < .01). Secondary prevention interventions that are tailored to the proximal sexual environment could be maximally effective, particularly if they address substance use and other challenging sexual situations.
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Zhu Y, Liu J, Qu B, Hu B, Zhang Y. Relationship between quality of life and unprotected anal intercourse among Chinese men who have sex with men: a cross-sectional study. BMC Public Health 2016; 16:382. [PMID: 27165001 PMCID: PMC4862160 DOI: 10.1186/s12889-016-3076-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 05/04/2016] [Indexed: 12/03/2022] Open
Abstract
Background The prevalence of unprotected anal intercourse (UAI) is high among Chinese men who have sex with men (MSM). As important aspects of quality of life (QOL), psychological health and social relationships have been found to be associated with UAI among MSM, which was of great concern for intervening on UAI. Methods We conducted a cross-sectional study in Zhengzhou, Henan province, and in Huludao, Liaoning province, China, to measure quality of life (QOL) using the brief version of the World Health Organization Quality of Life (WHOQOL-BREF). Cronbach's α coefficient was used to test the internal consistency of the questionnaire items, and construction validity was assessed by exploratory factor analysis. T-test, chi-square test and multivariate logistic analysis were carried out to test the relationship between quality of life and unprotected anal intercourse. Results The questionnaires of 320 of the 373 men who have sex with men that were surveyed met our validity criteria (response rate: 85.8 %). A total of 161 subjects (50.3 %) reported having unprotected anal sex in the last 6 months. The results of univariate analysis indicated that having unprotected anal sex was significantly associated with psychological health (PSYCH), social relationships (SOCIL), age, and marital status (P-value <0.05). The 3 items (“Negative feelings”, “Hopeness on your life”, and “Be able to concentrate”) in the PSYCH subscale were associated with UAI significantly (P-value <0.05). Multivariate analysis showed that psychological health (adjusted odd ratio (AOR) 0.979, 95 % confidence interval (CI) 0.961-0.998) was independent factor affecting the likelihood of having UAI in the population of Chinese MSM, and participants who aged 45 or more had higher odds of UAI (AOR 3.986, 95 % CI 1.199-13.255). Conclusions WHOQOL-BREF was acceptable for evaluating the quality of life of MSM. Psychological health, as one important aspect of quality of life, was negatively associated with unprotected anal intercourse. The finding underscored the needs to incorporate the strategies on improving psychological health into the UAI intervention to reduce the HIV transmission among MSM.
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Affiliation(s)
- Yaxin Zhu
- Department of Health Statistics, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning Province, 110122, People's Republic of China
| | - Jie Liu
- Department of Health Statistics, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning Province, 110122, People's Republic of China
| | - Bo Qu
- Department of Health Statistics, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning Province, 110122, People's Republic of China.
| | - Bingxue Hu
- Department of Health Statistics, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning Province, 110122, People's Republic of China
| | - Yang Zhang
- Department of Health Statistics, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning Province, 110122, People's Republic of China
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Skalski LM, Watt MH, MacFarlane JC, Proeschold-Bell RJ, Stout JE, Sikkema KJ. Mental Health and Substance Use Among Patients in a North Carolina HIV Clinic. N C Med J 2015; 76:148-55. [PMID: 26510216 DOI: 10.18043/ncm.76.3.148] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The HIV/AIDS epidemic is a significant public health concern in North Carolina, and previous research has pointed to elevated mental health distress and substance use among HIV-infected populations, which may impact patients' adherence to medications. The aims of this study were to describe the prevalence of mental health and substance use issues among patients of a North Carolina HIV clinic, to examine differences by demographic characteristics, and to examine factors associated with suboptimal adherence to HIV medications. METHODS This study was a secondary analysis of clinical data routinely collected through a health behavior questionnaire at a large HIV clinic in North Carolina. We analyzed data collected from February 2011 to August 2012. RESULTS The sample included 1,398 patients. Overall, 12.2% of patients endorsed current symptomology indicative of moderate or severe levels of depression, and 38.6% reported receiving a psychiatric diagnosis at some point in their life. Additionally, 19.1% had indications of current problematic drinking, and 8.2% reported problematic drug use. Nearly one-quarter (22.1%) reported suboptimal adherence to HIV medications. Factors associated with poor adherence included racial/ethnic minority, age less than 35 years, and indications of moderate or severe depression. LIMITATIONS The questionnaire was not completed systematically in the clinic, which may limit generalizability, and self-reported measures may have introduced social desirability bias. CONCLUSION Patients were willing to disclose mental health distress, substance use, and suboptimal medication adherence to providers, which highlights the importance of routinely assessing these behaviors during clinic visits. Our findings suggest that treating depression may be an effective strategy to improve adherence to HIV medications.
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Affiliation(s)
- Linda M Skalski
- doctoral student, Department of Psychology and Neuroscience, Duke University, Durham, North Carolina
| | - Melissa H Watt
- assistant research professor, Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Jessica C MacFarlane
- research assistant, Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Rae Jean Proeschold-Bell
- assistant research professor, Duke Global Health Institute and Center for Health Policy & Inequalities Research, Duke University, Durham, North Carolina
| | - Jason E Stout
- associate professor of medicine, Department of Medicine, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Kathleen J Sikkema
- professor, Department of Psychology and Neuroscience, Duke University; professor, Global Health Institute, Duke University; director, social and behavioral sciences, Duke Center for AIDS Research, Duke University; director of clinical psychology, Department of Psychology and Neuroscience, Duke University, Durham, North Carolina
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Duffy M, Sharer M, Cornman H, Pearson J, Pitorak H, Fullem A. Integrating Mental Health and HIV Services in Zimbabwean Communities: A Nurse and Community-led Approach to Reach the Most Vulnerable. J Assoc Nurses AIDS Care 2015; 28:186-198. [PMID: 26525564 DOI: 10.1016/j.jana.2015.09.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 09/23/2015] [Indexed: 11/26/2022]
Abstract
Alcohol use and depression negatively impact adherence, retention in care, and HIV progression, and people living with HIV (PLWH) have disproportionately higher depression rates. In developing countries, more than 76% of people with mental health issues receive no treatment. We hypothesized that stepped-care mental health/HIV integration provided by multiple service professionals in Zimbabwe would be acceptable and feasible. A three-phase mixed-method design was used with a longitudinal cohort of 325 nurses, community health workers, and traditional medicine practitioners in nine communities. During Phase 3, 312 PLWH were screened by nurses for mental health symptoms; 28% were positive. Of 59 PLWH screened for harmful alcohol and substance use, 36% were positive. Community health workers and traditional medicine practitioners screened 123 PLWH; 54% were positive for mental health symptoms and 29% were positive for alcohol and substance abuse. Findings indicated that stepped-care was acceptable and feasible for all provider types.
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Tsai AC, Venkataramani AS. The causal effect of education on HIV stigma in Uganda: Evidence from a natural experiment. Soc Sci Med 2015; 142:37-46. [PMID: 26282707 DOI: 10.1016/j.socscimed.2015.08.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 08/01/2015] [Accepted: 08/06/2015] [Indexed: 12/22/2022]
Abstract
RATIONALE HIV is highly stigmatized in sub-Saharan Africa. This is an important public health problem because HIV stigma has many adverse effects that threaten to undermine efforts to control the HIV epidemic. OBJECTIVE The implementation of a universal primary education policy in Uganda in 1997 provided us with a natural experiment to test the hypothesis that education is causally related to HIV stigma. METHODS For this analysis, we pooled publicly available, population-based data from the 2011 Uganda Demographic and Health Survey and the 2011 Uganda AIDS Indicator Survey. The primary outcomes of interest were negative attitudes toward persons with HIV, elicited using four questions about anticipated stigma and social distance. RESULTS Standard least squares estimates suggested a statistically significant, negative association between years of schooling and HIV stigma (each P < 0.001, with t-statistics ranging from 4.9 to 14.7). We then used a natural experiment design, exploiting differences in birth cohort exposure to universal primary education as an instrumental variable. Participants who were <13 years old at the time of the policy change had 1.36 additional years of schooling compared to those who were ≥13 years old. Adjusting for linear age trends before and after the discontinuity, two-stage least squares estimates suggested no statistically significant causal effect of education on HIV stigma (P-values ranged from 0.21 to 0.69). Three of the four estimated regression coefficients were positive, and in all cases the lower confidence limits convincingly excluded the possibility of large negative effect sizes. These instrumental variables estimates have a causal interpretation and were not overturned by several robustness checks. CONCLUSION We conclude that, for young adults in Uganda, additional years of education in the formal schooling system driven by a universal primary school intervention have not had a causal effect on reducing negative attitudes toward persons with HIV.
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Affiliation(s)
- Alexander C Tsai
- Massachusetts General Hospital, MGH Global Health, Boston, MA, USA; Harvard Center for Population and Development Studies, Cambridge, MA, USA; Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Atheendar S Venkataramani
- Massachusetts General Hospital, MGH Global Health, Boston, MA, USA; Harvard Center for Population and Development Studies, Cambridge, MA, USA; Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Audet CM, Gutin SA, Blevins M, Chiau E, Alvim F, Jose E, Vaz LME, Shepherd BE, Dawson Rose C. The Impact of Visual Aids and Enhanced Training on the Delivery of Positive Health, Dignity, and Prevention Messages to Adult Patients Living with HIV in Rural North Central Mozambique. PLoS One 2015; 10:e0130676. [PMID: 26147115 PMCID: PMC4493138 DOI: 10.1371/journal.pone.0130676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 05/24/2015] [Indexed: 12/02/2022] Open
Abstract
Introduction Positive health, dignity, and prevention (PHDP) interventions target people living with HIV and AIDS (PLHIV) to promote well-being and prevent onward transmission. Concern that increased life expectancy and improved well-being would lead to increased risky sexual behaviour and subsequent HIV transmission motivated researchers to test novel strategies to support treatment adherence, encourage safer sex, STI treatment and partner testing, prevention of mother to child transmission, and support uptake of family planning. Methods We assessed the number and type of PHDP messages delivered to PLHIV before and after the implementation of an educational intervention for health providers combined with the distribution of visual job aids and monthly technical assistance. Results From April 21, 2013 to March 20, 2014, we documented 54,731 clinical encounters at three rural health centres in Zambézia province, Mozambique from 9,248 unique patients. The percentage of patients who received all seven PHDP messages during their last three visits was 1.9% pre-intervention vs. 13.6% post- intervention (p=<0.001). Younger patients (25 years vs. 35) and those with a recent HIV diagnosis (two weeks vs. two years) had higher odds of receiving any PHDP message (Odds Ratio [OR]: 1.22 and 2.79, respectively). Patients >59 days late collecting medications were not more likely to receive adherence messages than adherent patients (p=0.17). Discussion Targeting HIV prevention efforts to PLHIV is an effective HIV prevention approach to eliminate HIV transmission. Despite intensive training and support, PHDP message delivery remained unacceptably low in rural Mozambique. Patients at high risk for treatment abandonment were not more likely to be counselled about adherence and support measures, something that needs to be addressed. Conclusions We need to develop novel strategies to motivate health care providers to deliver these messages more consistently to all patients and develop a system that assists counsellors and clinicians to quickly and effectively determine which messages should be delivered.
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Affiliation(s)
- Carolyn M. Audet
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Departments of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, United States of America
- * E-mail:
| | - Sarah A. Gutin
- Community Health Systems, School of Nursing, University of California San Francisco, San Francisco, California, United States of America
| | - Meridith Blevins
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Elvino Chiau
- Friends in Global Health, Maputo and Quelimane, Mozambique
| | - Fernanda Alvim
- Friends in Global Health, Maputo and Quelimane, Mozambique
| | - Eurico Jose
- Friends in Global Health, Maputo and Quelimane, Mozambique
| | - Lara M. E. Vaz
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Bryan E Shepherd
- Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
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Tsai AC, Burns BFO. Syndemics of psychosocial problems and HIV risk: A systematic review of empirical tests of the disease interaction concept. Soc Sci Med 2015; 139:26-35. [PMID: 26150065 DOI: 10.1016/j.socscimed.2015.06.024] [Citation(s) in RCA: 159] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 06/11/2015] [Accepted: 06/22/2015] [Indexed: 01/13/2023]
Abstract
In the theory of syndemics, diseases co-occur in particular temporal or geographical contexts due to harmful social conditions (disease concentration) and interact at the level of populations and individuals, with mutually enhancing deleterious consequences for health (disease interaction). This theory has widespread adherents in the field, but the extent to which there is empirical support for the concept of disease interaction remains unclear. In January 2015 we systematically searched 7 bibliographic databases and tracked citations to highly cited publications associated with the theory of syndemics. Of the 783 records, we ultimately included 34 published journal articles, 5 dissertations, and 1 conference abstract. Most studies were based on a cross-sectional design (32 [80%]), were conducted in the U.S. (32 [80%]), and focused on men who have sex with men (21 [53%]). The most frequently studied psychosocial problems were related to mental health (33 [83%]), substance abuse (36 [90%]), and violence (27 [68%]); while the most frequently studied outcome variables were HIV transmission risk behaviors (29 [73%]) or HIV infection (9 [23%]). To test the disease interaction concept, 11 (28%) studies used some variation of a product term, with less than half of these (5/11 [45%]) providing sufficient information to interpret interaction both on an additive and on a multiplicative scale. The most frequently used specification (31 [78%]) to test the disease interaction concept was the sum score corresponding to the total count of psychosocial problems. Although the count variable approach does not test hypotheses about interactions between psychosocial problems, these studies were much more likely than others (14/31 [45%] vs. 0/9 [0%]; χ2 = 6.25, P = 0.01) to incorporate language about "synergy" or "interaction" that was inconsistent with the statistical models used. Therefore, more evidence is needed to assess the extent to which diseases interact, either at the level of populations or individuals, to amplify HIV risk.
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Affiliation(s)
- Alexander C Tsai
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States; Harvard Center for Population and Development Studies, Cambridge, MA, United States; Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Bridget F O Burns
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States
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Audet CM, Wagner LJ, Wallston KA. Finding meaning in life while living with HIV: validation of a novel HIV meaningfulness scale among HIV-infected participants living in Tennessee. BMC Psychol 2015; 3:15. [PMID: 25945254 PMCID: PMC4419455 DOI: 10.1186/s40359-015-0070-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 04/22/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND People living with HIV who maintain a positive outlook on their future may manage stress better than those who do not, leading to improved coping behaviors and better health outcomes. METHODS While studying 125 HIV+ adults participating in two clinical trials of expressive writing we assessed their HIV-specific meaningfulness of life with a short, unidimensional scale (the HIVMS). RESULTS The HIVMS had a strong Cronbach's alpha (0.80) and acceptable test-retest reliability (0.70). HIVMS scores were strongly correlated with measures of perceived control, optimism, and psychological well-being. Participants with lower HIVMS scores had higher probability of non-adherence to antiretroviral medication, suggesting a decreased ability to manage their illness successfully. Neither the control nor expressive writing intervention groups showed increased HIVMS scores. CONCLUSIONS Future research is necessary to determine the effect of HIV meaning on long-term health outcomes and to develop interventions that can significantly improve a person's perception of their meaning in life.
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Affiliation(s)
- Carolyn M Audet
- Department of Health Policy, Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave Suite 750, Nashville, TN 37203 USA
| | - Lois J Wagner
- Nursing and Allied Health, Regents Online Campus Collaborative, Tennessee Board of Regents, Memphis, USA
| | - Kenneth A Wallston
- School of Nursing, Vanderbilt University, 421 Godchaux Hall, Nashville, TN 37240 USA
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Medication adherence in people dually treated for HIV infection and mental health conditions: test of the medications beliefs framework. J Behav Med 2015; 38:632-41. [PMID: 25835435 DOI: 10.1007/s10865-015-9633-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 03/19/2015] [Indexed: 12/24/2022]
Abstract
Beliefs about medication necessity and concerns predict treatment adherence in people with a wide-array of medical conditions, including HIV infection. However, medication beliefs have not been examined in people dually treated with psychotropic medications and antiretroviral therapy. In the current study, we used a prospective design to investigate the factors associated with adherence to psychotropic medications and antiretrovirals among 123 dually treated persons living with HIV. We used unannounced phone-based pill counts to monitor adherence to psychiatric and antiretroviral medications over a 6-week period. Hierarchical regression models included demographic, health and psychosocial characteristics as predictors of adherence followed by medication necessity and concerns beliefs. Results showed that medication necessity beliefs predicted both antiretroviral and psychiatric medication adherence over and above established predictors of adherence. Medication concerns also predicted psychotropic adherence, but not antiretroviral adherence. These models accounted for 31 and 22 % of the variance in antiretroviral and psychotropic adherence, respectively. Findings suggest that the necessity-concerns medication beliefs framework has utility in understanding adherence to multiple medications and addressing these beliefs should be integrated into adherence interventions.
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HIV status disclosure, depressive symptoms, and sexual risk behavior among HIV-positive young men who have sex with men. J Behav Med 2015; 38:507-17. [PMID: 25773478 DOI: 10.1007/s10865-015-9624-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 02/14/2015] [Indexed: 11/27/2022]
Abstract
The rate of HIV infection among young men who have sex with men (YMSM) is increasing in the United States, and targeted research is needed to inform interventions aimed at reducing HIV transmission in this population. This study aims to understand the association between HIV status disclosure and sexual risk behavior among HIV-positive YMSM. A particular focus is given to depressive symptoms and their potential role in explaining the association between HIV disclosure and sexual risk behavior. In a sample of 991 YMSM receiving care at 20 clinics across the United States, Univariate and multivariate analyses were conducted to explore these associations. Approximately one-half (52.4 %) of participants reported disclosing to their current sexual/romantic partner. Disclosure to family members was negatively associated with sexual risk behavior. Also, depressive symptoms were positively associated with sexual risk behavior. We discuss the implications of our findings for future research and intervention.
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Mimiaga MJ, Biello K, Reisner SL, Crane HM, Wilson J, Grasso C, Kitahata MM, Mathews WC, Mayer KH, Safren SA. Latent class profiles of internalizing and externalizing psychosocial health indicators are differentially associated with sexual transmission risk: Findings from the CFAR network of integrated clinical systems (CNICS) cohort study of HIV-infected men engaged in primary care in the United States. Health Psychol 2015; 34:951-9. [PMID: 25642839 DOI: 10.1037/hea0000189] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To examine whether latent class indicators of negative affect and substance use emerged as distinct psychosocial risk profiles among HIV-infected men, and if these latent classes were associated with high-risk sexual behaviors that may transmit HIV. METHODS Data were from HIV-infected men who reported having anal intercourse in the past 6 months and received routine clinical care at 4 U.S. sites in the Centers for AIDS Research Network of Integrated Clinical Systems cohort (n = 1,210). Latent class membership was estimated using binary indicators for anxiety, depression, alcohol and/or drug use during sex, and polydrug use. Generalized estimating equations modeled whether latent class membership was associated with HIV sexual transmission risk in the past 6 months. RESULTS Three latent classes of psychosocial indicators emerged: (a) internalizing (15.3%; high probability of anxiety and major depression); (b) externalizing (17.8%; high probability of alcohol and/or drug use during sex and polydrug use); (c) low psychosocial distress (67.0%; low probability of all psychosocial factors examined). Internalizing and externalizing latent class membership were associated with HIV sexual transmission risk, compared to low psychosocial class membership; externalizing class membership was also associated with higher sexual transmission risk compared to internalizing class membership. CONCLUSIONS Distinct patterns of psychosocial health characterize this sexually active HIV-infected male patient population and are strongly associated with HIV sexual transmission risk. Public Health intervention efforts targeting HIV sexual risk transmission may benefit from considering symptom clusters that share internalizing or externalizing properties.
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Declining prevalence of probable depression among patients presenting for antiretroviral therapy in rural Uganda: the role of early treatment initiation. AIDS Behav 2015; 19:19-26. [PMID: 24788780 DOI: 10.1007/s10461-014-0785-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Little is known about trends in depression at antiretroviral therapy (ART) initiation among people living with HIV (PLHIV) in low- and middle-income countries. We used data from an ongoing cohort of treatment-naïve PLHIV in rural Uganda to estimate secular trends in depression among PLHIV at ART initiation. We fitted linear regression models with depression symptom severity as the outcome variable and year of cohort entry (2005-2012) as the explanatory variable, adjusting for socio-demographic variables and assessing physical health score, body mass index (BMI), and CD4 count as potential mediators of a secular trend in depression symptom severity. There was a statistically significant negative association between year of entry and depression symptom severity, suggesting a 3.1 % relative decline in the mean depression symptom severity score at ART initiation in each year of study recruitment after the first year. This trend remained statistically significant after inclusion of baseline socio-demographic characteristics to the model and appeared to be driven by improved physical health scores, but not CD4 count or BMI.
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Lovejoy TI, Heckman TG, Sikkema KJ, Hansen NB, Kochman A. Changes in sexual behavior of HIV-infected older adults enrolled in a clinical trial of standalone group psychotherapies targeting depression. AIDS Behav 2015; 19:1-8. [PMID: 24668254 DOI: 10.1007/s10461-014-0746-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
By 2015, one-half of all HIV-positive persons in the U.S. will be 50-plus years of age, and as many as 30 % of older adults living with HIV/AIDS continue to engage in unprotected sexual intercourse. Contemporary positive prevention models often include mental health treatment as a key component of HIV prevention interventions. This secondary data analysis characterized longitudinal patterns of sexual behavior in HIV-positive older adults enrolled in a randomized controlled trial of group mental health interventions and assessed the efficacy of psychosocial treatments that targeted depression to reduce sexual risk behavior. Participants were 295 HIV-positive adults ≥50 years of age experiencing mild to severe depressive symptoms, randomized to one of three study conditions: a 12-session coping improvement group intervention, a 12-session interpersonal support group intervention, or individual therapy upon request. Approximately one-fifth of participants reported one or more occasions of unprotected anal or vaginal intercourse with HIV-negative sexual partners or persons of unknown HIV serostatus over the study period. Changes in sexual behavior did not vary by intervention condition, indicating that standalone treatments that target and reduce depression may be insufficient to reduce sexual risk behavior in depressed HIV-positive older adults.
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Affiliation(s)
- Travis I Lovejoy
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA,
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Improving mental health among people living with HIV: a review of intervention trials in low- and middle-income countries. Glob Ment Health (Camb) 2015; 2:e19. [PMID: 26435843 PMCID: PMC4589870 DOI: 10.1017/gmh.2015.17] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
People living with HIV (PLWH) experience greater psychological distress than the general population. Evidence from high-incomes countries suggests that psychological interventions for PLWH can improve mental health symptoms, quality of life, and HIV care engagement. However, little is known about the effectiveness of mental health interventions for PLWH in low and middle-income countries (LMICs), where the large majority of PLWH reside. This systematized review aims to synthesize findings from mental health intervention trials with PLWH in LMICs to inform the delivery of mental health services in these settings. A systematic search strategy was undertaken to identify peer-reviewed published papers of intervention trials addressing negative psychological states or disorders (e.g., depression, anxiety) among PLWH in LMIC settings. Search results were assessed against pre-established inclusion and exclusion criteria. Data from papers meeting criteria were extracted for synthesis. Twenty-six papers, published between 2000 and 2014, describing 22 unique interventions were identified. Trials were implemented in sub-Saharan Africa (n=13), Asia (n=7), and the Middle East (n=2), and addressed mental health using a variety of approaches, including cognitive-behavioral (n=18), family-level (n=2), and pharmacological (n=2) treatments. Four randomized controlled trials reported significant intervention effects in mental health outcomes, and eleven preliminary studies demonstrated promising findings. Among the limited mental health intervention trials with PLWH in LMICs, few demonstrated efficacy. Mental health interventions for PLWH in LMICs must be further developed and adapted for resource-limited settings to improve effectiveness.
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Tsai AC. Reliability and validity of depression assessment among persons with HIV in sub-Saharan Africa: systematic review and meta-analysis. J Acquir Immune Defic Syndr 2014; 66:503-11. [PMID: 24853307 PMCID: PMC4096047 DOI: 10.1097/qai.0000000000000210] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to systematically review the reliability and validity of instruments used to screen for major depressive disorder or assess depression symptom severity among persons with HIV in sub-Saharan Africa. DESIGN Systematic review and meta-analysis. METHODS A systematic evidence search protocol was applied to 7 bibliographic databases. Studies examining the reliability and/or validity of depression assessment tools were selected for inclusion if they were based on the data collected from HIV-positive adults in any African member state of the United Nations. A random-effects meta-analysis was used to calculate pooled estimates of depression prevalence. In a subgroup of studies of criterion-related validity, the bivariate random-effects model was used to calculate pooled estimates of sensitivity and specificity. RESULTS Of 1117 records initially identified, I included 13 studies of 5373 persons with HIV in 7 sub-Saharan African countries. Reported estimates of Cronbach alpha ranged from 0.63 to 0.95, and analyses of internal structure generally confirmed the existence of a depression-like construct accounting for a substantial portion of variance. The pooled prevalence of probable depression was 29.5% [95% confidence interval (CI): 20.5 to 39.4], whereas the pooled prevalence of major depressive disorder was 13.9% (95% CI: 9.7 to 18.6). The Center for Epidemiologic Studies Depression scale was the most frequently studied instrument, with a pooled sensitivity of 0.82 (95% CI: 0.73 to 0.87) for detecting major depressive disorder. CONCLUSIONS Depression-screening instruments yielded relatively high false positive rates. Overall, few studies described the reliability and/or validity of depression instruments in sub-Saharan Africa.
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Affiliation(s)
- Alexander C. Tsai
- Chester M. Pierce, MD Division of Global Psychiatry, Department of Psychiatry, Massachusetts General Hospital (MGH), Boston, United States
- MGH Center for Global Health, Boston, United States
- Harvard Medical School, Boston, United States
- Mbarara University of Science and Technology, Mbarara, Uganda
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Blashill AJ, Mayer KH, Crane HM, Baker JS, Willig JH, Willig AL, Grasso C, O'Cleirigh C, Safren SA. Body mass index, depression, and condom use among HIV-infected men who have sex with men: a longitudinal moderation analysis. ARCHIVES OF SEXUAL BEHAVIOR 2014; 43:729-734. [PMID: 23979782 PMCID: PMC3933471 DOI: 10.1007/s10508-013-0155-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 05/04/2013] [Accepted: 06/22/2013] [Indexed: 06/01/2023]
Abstract
Findings have been inconsistent regarding the association of obesity and sexual risk behaviors. The purpose of the current study was to assess the prospective nature of body mass index (BMI), depression, and their interaction in predicting condom use during anal intercourse among HIV-infected men who have sex with men (MSM). The sample (N = 490) was obtained from a large, HIV clinical cohort from four sites across the U.S. The following inclusion criteria were employed: identification as MSM and had completed at least one wave of patient-reported measures (e.g., depression, as measured by the PHQ-9) in the clinical cohort study. Longitudinal linear mixed-effects modeling revealed a significant BMI by depression interaction. Depressive symptoms were predictive of less frequent condom use for obese but not overweight men. Analogous results were found in regard to comparisons between normal weight and overweight men. Obesity, in the context of depression, is a risk factor for unprotected anal intercourse among HIV-infected MSM. Cognitive behavioral interventions to reduce HIV transmission risk behaviors among HIV-infected MSM should adopt an integrated perspective, combining sexual risk reduction with treatment for depression and body-related concerns.
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Affiliation(s)
- Aaron J Blashill
- Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 7th Floor, Boston, MA, 02114, USA,
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Dawson Rose C, Webel A, Sullivan KM, Cuca YP, Wantland D, Johnson MO, Brion J, Portillo CJ, Corless IB, Voss J, Chen WT, Phillips JC, Tyer-Viola L, Rivero-Méndez M, Nicholas PK, Nokes K, Kemppainen J, Sefcik E, Eller LS, Iipinge S, Kirksey K, Chaiphibalsarisdi P, Davila N, Hamilton MJ, Hickey D, Maryland M, Reid P, Holzemer WL. Self-compassion and risk behavior among people living with HIV/AIDS. Res Nurs Health 2014; 37:98-106. [PMID: 24510757 PMCID: PMC4158433 DOI: 10.1002/nur.21587] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2013] [Indexed: 11/12/2022]
Abstract
Sexual risk behavior and illicit drug use among people living with HIV/AIDS (PLWHA) contribute to poor health and onward transmission of HIV. The aim of this collaborative multi-site nursing research study was to explore the association between self-compassion and risk behaviors in PLWHA. As part of a larger project, nurse researchers in Canada, China, Namibia, Puerto Rico, Thailand and the US enrolled 1211 sexually active PLWHA using convenience sampling. The majority of the sample was male, middle-aged, and from the US. Illicit drug use was strongly associated with sexual risk behavior, but participants with higher self-compassion were less likely to report sexual risk behavior, even in the presence of illicit drug use. Self-compassion may be a novel area for behavioral intervention development for PLWHA.
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Affiliation(s)
- Carol Dawson Rose
- UCSF School of Nursing, Dept. of Community Health Systems, San Francisco, CA 94143-0608, T: (415) 713-5252, F: (415) 476-4076
| | - Allison Webel
- Case Western Reserve University, Bolten School of Nursing
| | | | | | - Dean Wantland
- Office of Research & Evaluation, Rutgers College of Nursing
| | | | - John Brion
- The Ohio State University College of Nursing
| | | | | | | | | | | | | | | | - Patrice K. Nicholas
- Global Health and Academic Partnerships, Brigham and Women's Hospital and MGH Institute of Health Professions
| | | | | | | | | | | | - Kenn Kirksey
- Nursing Strategic Initiatives, Lyndon B. Johnson Hospital – Executive Administration, Harris Health System
| | | | | | | | - Dorothy Hickey
- Momentum AIDS Program & Assistant Adjunct Clinical Professor at New York City College of Technology
| | - Mary Maryland
- Chicago State University College of Health Sciences, Department of Nursing
| | - Paula Reid
- School of Nursing, The University of North Carolina at Wilmington
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Blank MB, Himelhoch SS, Balaji AB, Metzger DS, Dixon LB, Rose CE, Oraka E, Davis-Vogel A, Thompson WW, Heffelfinger JD. A multisite study of the prevalence of HIV with rapid testing in mental health settings. Am J Public Health 2014; 104:2377-84. [PMID: 24524493 DOI: 10.2105/ajph.2013.301633] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We estimated HIV prevalence and risk factors among persons receiving mental health treatment in Philadelphia, Pennsylvania, and Baltimore, Maryland, January 2009 to August 2011. METHODS We used a multisite, cross-sectional design stratified by clinical setting. We tested 1061 individuals for HIV in university-based inpatient psychiatric units (n = 287), intensive case-management programs (n = 273), and community mental health centers (n = 501). RESULTS Fifty-one individuals (4.8%) were HIV-infected. Confirmed positive HIV tests were 5.9% (95% confidence interval [CI] = 3.7%, 9.4%) for inpatient units, 5.1% (95% CI = 3.1%, 8.5%) for intensive case-management programs, and 4.0% (95% CI = 2.6%, 6.1%) for community mental health centers. Characteristics associated with HIV included Black race, homosexual or bisexual identity, and HCV infection. CONCLUSIONS HIV prevalence for individuals receiving mental health services was about 4 times as high as in the general population. We found a positive association between psychiatric symptom severity and HIV infection, indicating that engaging persons with mental illness in appropriate mental health treatment may be important to HIV prevention. These findings reinforce recommendations for routine HIV testing in all clinical settings to ensure that HIV-infected persons receiving mental health services are identified and referred to timely infectious disease care.
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Affiliation(s)
- Michael B Blank
- Michael B. Blank and David S. Metzger are with the Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia. Seth S. Himelhoch is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore. Alexandra B. Balaji, Charles E. Rose, and James D. Heffelfinger are with the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lisa B. Dixon is with the Department of Psychiatry, Columbia University, New York, NY. Emeka Oraka is with ICF International, Atlanta. Annet Davis-Vogel is with the HIV/AIDS Prevention Research Division, University of Pennsylvania, Philadelphia. William W. Thompson is with the Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta
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Wilson PA, Stadler G, Boone MR, Bolger N. Fluctuations in depression and well-being are associated with sexual risk episodes among HIV-positive men. Health Psychol 2014; 33:681-5. [PMID: 24467260 DOI: 10.1037/a0035405] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Research has suggested a weak association between depression and sexual risk behavior in men who have sex with men (MSM). The purpose of this study was to investigate the relationship between within-person fluctuations in depression and well-being and episodes of sexual risk-taking among HIV-positive MSM. METHODS One hundred six sexually active HIV-positive MSM living in New York City completed a structured weekly survey over 6 weeks. In Weeks 1, 3, and 5, they responded to items assessing their sexual behavior, depression, and well-being in the prior week. Multilevel logistic regression analyses were conducted to explore the relationship between changes in levels of depression and well-being, and episodes of unprotected anal intercourse (UAI). RESULTS Within-person deviations from participants' average levels of depression and well-being were associated with the probability of risk. The probability of a risk episode was higher in weeks when depression was higher than participants' average levels (any UAI episode: odd ratio [OR] = 1.71, 95% confidence interval [CI] [1.00, 2.90], p < .05; serodiscordant UAI episode: OR = 2.49, 95% CI [1.31, 4.73], p < .05). The probability of a risk episode was lower in weeks when well-being was higher than participants' average levels (any UAI: OR = 0.40, 95% CI [0.22, 0.74], p < .05; serodiscordant UAI: OR = 0.42, 95% CI [0.22, 0.81], p < .05). Between-person differences in depression and well-being were not associated with risk episodes (ps > .05). CONCLUSION This study is among the first to examine the association of within-person changes in depression and well-being with sexual risk behavior in a diverse sample. It contributes new evidence to literature exploring the relationship between depression and sexual risk. Future research should employ longitudinal designs to explore pathways linking within-person changes in depression with risk behavior.
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Affiliation(s)
- Patrick A Wilson
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health
| | | | - Melissa R Boone
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health
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Murray LK, Skavenski S, Michalopoulos LM, Bolton PA, Bass JK, Familiar I, Imasiku M, Cohen J. Counselor and client perspectives of Trauma-focused Cognitive Behavioral Therapy for children in Zambia: a qualitative study. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2014; 43:902-14. [PMID: 24400677 PMCID: PMC4087094 DOI: 10.1080/15374416.2013.859079] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This study examined Zambian counselors, children, and caregivers' perceptions of an evidence-based treatment (EBT) for trauma (Trauma-Focused Cognitive Behavioral Therapy [TF-CBT]) utilized in Zambia to address mental health problems in children. Semistructured interviews were conducted with local counselors trained in TF-CBT (N = 19; 90% of those trained; 12 female) and children/caregivers who had received TF-CBT in a small feasibility study (N = 18; 86% of the children and N = 16; 76% of the caregivers) who completed TF-CBT (total completed; N = 21). Each client was asked six open-ended questions, and domain analysis was used to explore the data. Counselors were positive about the program, liked the structure and flexibility, reported positive changes in their clients, and discussed the cultural adaptation around activities and language. Counselors stated the training was too short, and the supervision was necessary. Challenges included client engagement and attendance, availability of location, funding, and a lack of community understanding of "therapy." Children and caregivers stated multiple positive changes they attributed to TF-CBT, such as better family communication, reduction of problem behaviors, and ability to speak about the trauma. They recommended continuing the program. This study brings a critical examination of providers' and clients' perspectives of the implementation of an EBT for children in a low-resource setting. Clinical implications include changing implementation methods based on responses. Research implications include future study directions such as an effectiveness trial of TF-CBT and an examination of implementation factors.
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Affiliation(s)
- Laura K Murray
- a Department of Mental Health , Johns Hopkins University Bloomberg School of Public Health
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Pantalone DW, Huh D, Nelson KM, Pearson CR, Simoni JM. Prospective predictors of unprotected anal intercourse among HIV-seropositive men who have sex with men initiating antiretroviral therapy. AIDS Behav 2014; 18:78-87. [PMID: 23640652 DOI: 10.1007/s10461-013-0477-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Contemporary HIV prevention efforts are increasingly focused on those already living with HIV/AIDS (i.e., "prevention with positives"). Key to these initiatives is research identifying the most risky behavioral targets. Using a longitudinal design, we examined socio-demographic and psychosocial factors that prospectively predicted unprotected anal intercourse (UAI) in a sample of 134 HIV-seropositive men who have sex with men (MSM) initiating, changing, or re-starting an antiretroviral therapy regimen as part of a behavioral intervention study. Computer-based questionnaires were given at baseline and 6 months. In a sequential logistic regression, baseline measures of UAI (step 1), socio-demographic factors such as Latino ethnicity (step 2), and psychosocial factors such as crystal methamphetamine use, greater life stress, and lower trait anxiety (step 3) were predictors of UAI at 6 months. Problem drinking was not a significant predictor. Prevention efforts among MSM living with HIV/AIDS might focus on multiple psychosocial targets, like decreasing their crystal methamphetamine use and teaching coping skills to deal with life stress.
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Affiliation(s)
- David W Pantalone
- Department of Psychology, University of Massachusetts, 100 Morrissey Boulevard, Boston, MA, 02125, USA,
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Pence BW, Whetten K, Shirey KG, Yao J, Thielman NM, Whetten R, Itemba D, Maro V. Factors associated with change in sexual transmission risk behavior over 3 years among HIV-infected patients in Tanzania. PLoS One 2013; 8:e82974. [PMID: 24367575 PMCID: PMC3867466 DOI: 10.1371/journal.pone.0082974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 11/07/2013] [Indexed: 02/06/2023] Open
Abstract
Background The reduction of HIV transmission risk behaviors among those infected with HIV remains a major global health priority. Psychosocial characteristics have proven to be important correlates of sexual transmission risk behaviors in high-income countries, but little attention has focused on the influence of psychosocial and psychological factors on sexual transmission risk behaviors in African cohorts. Methodology and Principal Findings The CHAT Study enrolled a representative sample of 499 HIV-infected patients in established HIV care and 267 newly diagnosed HIV-infected individuals from the Kilimanjaro Region of Tanzania. Participants completed in-person interviews every 6 months for 3 years. Using logistic random effects models to account for repeated observations, we assessed sociodemographic, physical health, and psychosocial predictors of self-reported unprotected sexual intercourse. Among established patients, the proportion reporting any recent unprotected sex was stable, ranging between 6–13% over 3 years. Among newly diagnosed patients, the proportion reporting any unprotected sex dropped from 43% at baseline to 11–21% at 6–36 months. In multivariable models, higher odds of reported unprotected sex was associated with female gender, younger age, being married, better physical health, and greater post-traumatic stress symptoms. In addition, within-individual changes in post-traumatic stress over time coincided with increases in unprotected sex. Conclusions and Significance Changes in post-traumatic stress symptomatology were associated with changes in sexual transmission risk behaviors in this sample of HIV-infected adults in Tanzania, suggesting the importance of investing in appropriate mental health screening and intervention services for HIV-infected patients, both to improve mental health and to support secondary prevention efforts.
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Affiliation(s)
- Brian W. Pence
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail: (BWP); (KW)
| | - Kathryn Whetten
- Center for Health Policy & Inequalities Research, Duke Global Health Institute, Sanford School of Public Policy, Duke University, Durham, North Carolina, United States of America
- * E-mail: (BWP); (KW)
| | - Kristen G. Shirey
- Center for Health Policy & Inequalities Research, Duke Global Health Institute, Sanford School of Public Policy, Duke University, Durham, North Carolina, United States of America
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Jia Yao
- Center for Health Policy & Inequalities Research, Duke Global Health Institute, Sanford School of Public Policy, Duke University, Durham, North Carolina, United States of America
| | - Nathan M. Thielman
- Division of Infectious Diseases, Department of Medicine, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Rachel Whetten
- Center for Health Policy & Inequalities Research, Duke Global Health Institute, Sanford School of Public Policy, Duke University, Durham, North Carolina, United States of America
| | | | - Venance Maro
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
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Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis. J Int AIDS Soc 2013; 16:18640. [PMID: 24242258 PMCID: PMC3833107 DOI: 10.7448/ias.16.3.18640] [Citation(s) in RCA: 715] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 08/22/2013] [Accepted: 08/29/2013] [Indexed: 01/20/2023] Open
Abstract
Introduction Adherence to HIV antiretroviral therapy (ART) is a critical determinant of HIV-1 RNA viral suppression and health outcomes. It is generally accepted that HIV-related stigma is correlated with factors that may undermine ART adherence, but its relationship with ART adherence itself is not well established. We therefore undertook this review to systematically assess the relationship between HIV-related stigma and ART adherence. Methods We searched nine electronic databases for published and unpublished literature, with no language restrictions. First we screened the titles and abstracts for studies that potentially contained data on ART adherence. Then we reviewed the full text of these studies to identify articles that reported data on the relationship between ART adherence and either HIV-related stigma or serostatus disclosure. We used the method of meta-synthesis to summarize the findings from the qualitative studies. Results Our search protocol yielded 14,854 initial records. After eliminating duplicates and screening the titles and abstracts, we retrieved the full text of 960 journal articles, dissertations and unpublished conference abstracts for review. We included 75 studies conducted among 26,715 HIV-positive persons living in 32 countries worldwide, with less representation of work from Eastern Europe and Central Asia. Among the 34 qualitative studies, our meta-synthesis identified five distinct third-order labels through an inductive process that we categorized as themes and organized in a conceptual model spanning intrapersonal, interpersonal and structural levels. HIV-related stigma undermined ART adherence by compromising general psychological processes, such as adaptive coping and social support. We also identified psychological processes specific to HIV-positive persons driven by predominant stigmatizing attitudes and which undermined adherence, such as internalized stigma and concealment. Adaptive coping and social support were critical determinants of participants’ ability to overcome the structural and economic barriers associated with poverty in order to successfully adhere to ART. Among the 41 quantitative studies, 24 of 33 cross-sectional studies (71%) reported a positive finding between HIV stigma and ART non-adherence, while 6 of 7 longitudinal studies (86%) reported a null finding (Pearson's χ2=7.7; p=0.005). Conclusions We found that HIV-related stigma compromised participants’ abilities to successfully adhere to ART. Interventions to reduce stigma should target multiple levels of influence (intrapersonal, interpersonal and structural) in order to have maximum effectiveness on improving ART adherence.
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Simoni JM, Wiebe JS, Sauceda JA, Huh D, Sanchez G, Longoria V, Andres Bedoya C, Safren SA. A preliminary RCT of CBT-AD for adherence and depression among HIV-positive Latinos on the U.S.-Mexico border: the Nuevo Día study. AIDS Behav 2013; 17:2816-29. [PMID: 23812892 DOI: 10.1007/s10461-013-0538-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We conducted a preliminary RCT among 40 HIV-positive Latinos of Mexican descent on the U.S.-Mexico border who indicated imperfect adherence and depressive symptomatology. Participants were randomly assigned to culturally adapted cognitive-behavioral therapy for adherence and depression with an alarmed pillbox or usual care. Outcomes were depressive symptoms (self-report and blind clinician ratings), adherence (self-report and electronic pillbox), and biological markers. The intervention, delivered in English and Spanish, proved feasible and acceptable. Generalized estimating equations in intent-to-treat analyses showed some effects of "moderate" to "large" size, with maintenance over time. For example, intervention (vs. control) participants demonstrated at post-intervention a greater drop in BDI scores (OR = -3.64, p = 0.05) and greater adherence according to the electronic pillbox (OR = 3.78, p = 0.03). Biological markers indicated some relative improvement for CD4 count but not VL. The promising results suggest a larger trial to determine efficacy is warranted.
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Affiliation(s)
- Jane M Simoni
- Department of Psychology, University of Washington, 3909 W. Stevens Way NE, Campus Box 351525, Seattle, WA, 98195-1525, USA,
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80
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Parhami I, Fong TW, Siani A, Carlotti C, Khanlou H. Documentation of psychiatric disorders and related factors in a large sample population of HIV-positive patients in California. AIDS Behav 2013; 17:2792-801. [PMID: 23247363 DOI: 10.1007/s10461-012-0386-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This retrospective cohort study examined electronic medical records of HIV-positive patients in California (N = 7,834) to find the prevalence of any psychiatric condition and the associations between several factors and the likelihood of these disorders. Approximately 53 % of the patients in this study had a documented psychiatric condition, including 23 % who had a mood disorder, 19 % who had a substance-related disorder, and 16 % who had an anxiety disorder. After controlling for potential confounders, significant positive associations (p < 0.001) were found between female gender and the presence of any mood disorder (adjusted odds ratio [95 % confidence interval, 95 %CI] = 1.58 [1.26-1.99]) or anxiety disorder (AOR = 1.54 [1.18-2.02]) and between homosexual orientation and the presence of any psychiatric condition (AOR = 1.33 [1.15-1.55]), mood disorder (AOR = 1.71 [1.42-2.07]), or anxiety disorder (AOR = 1.41 [1.22-1.88]). There were also significant negative associations between African-American race and the presence of any psychiatric condition (AOR = 0.68 [0.60-0.77]), mood disorder (AOR = 0.74 [0.64-0.86]), anxiety disorder (AOR = 0.43 [0.36-0.52]), or substance-related disorder (AOR = 0.78 [0.67-0.91]) and between state/federal insurance and the presence of any psychiatric condition (AOR = 0.70 [0.62-0.79]), mood disorder (AOR = 0.71 [0.62-0.80]), or anxiety disorder (AOR = 0.77 [0.66-0.89]).
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Affiliation(s)
- Iman Parhami
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA,
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81
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Does effective depression treatment alone reduce secondary HIV transmission risk? Equivocal findings from a randomized controlled trial. AIDS Behav 2013; 17:2765-72. [PMID: 23975476 DOI: 10.1007/s10461-013-0600-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Depressed mood has been associated with HIV transmission risk behavior. To determine whether effective depression treatment could reduce the frequency of sexual risk behavior, we analyzed secondary outcome data from a 36-week, two-arm, parallel-design, randomized controlled trial, in which homeless and marginally housed, HIV-infected persons with comorbid depressive disorders were randomized to receive either: (a) directly observed treatment with the antidepressant medication fluoxetine, or (b) referral to a local public mental health clinic. Self-reported sexual risk outcomes, which were measured at 3, 6, and 9 months, included: total number of sexual partners, unprotected sexual intercourse, unprotected sexual intercourse with an HIV-uninfected partner or a partner of unknown serostatus, and transactional sex. Estimates from generalized estimating equations regression models did not suggest consistent reductions in sexual risk behaviors resulting from treatment. Mental health interventions may need to combine depression treatment with specific skills training in order to achieve durable impacts on HIV prevention outcomes.
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82
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Mavhu W, Berwick J, Chirawu P, Makamba M, Copas A, Dirawo J, Willis N, Araya R, Abas MA, Corbett EL, Mungofa S, Laver SM, Cowan FM. Enhancing psychosocial support for HIV positive adolescents in Harare, Zimbabwe. PLoS One 2013; 8:e70254. [PMID: 23894625 PMCID: PMC3720910 DOI: 10.1371/journal.pone.0070254] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 06/20/2013] [Indexed: 11/18/2022] Open
Abstract
Background There is a recognized gap in the evidence base relating to the nature and components of interventions to address the psycho-social needs of HIV positive young people. We used mixed methods research to strengthen a community support group intervention for HIV positive young people based in Harare, Zimbabwe. Methods A quantitative questionnaire was administered to HIV positive Africaid support group attendees. Afterwards, qualitative data were collected from young people aged 15–18 through tape-recorded in-depth interviews (n = 10), 3 focus group discussions (FGDs) and 16 life history narratives. Data were also collected from caregivers, health care workers, and community members through FGDs (n = 6 groups) and in-depth interviews (n = 12). Quantitative data were processed and analysed using STATA 10. Qualitative data were analysed using thematic analysis. Results 229/310 young people completed the quantitative questionnaire (74% participation). Median age was 14 (range 6–18 years); 59% were female. Self-reported adherence to antiretrovirals was sub-optimal. Psychological well being was poor (median score on Shona Symptom Questionnaire 9/14); 63% were at risk of depression. Qualitative findings suggested that challenges faced by positive children include verbal abuse, stigma, and discrimination. While data showed that support group attendance is helpful, young people stressed that life outside the confines of the group was more challenging. Caregivers felt ill-equipped to support the children in their care. These data, combined with a previously validated conceptual framework for family-centred interventions, were used to guide the development of the existing programme of adolescent support groups into a more comprehensive evidence-based psychosocial support programme encompassing caregiver and household members. Conclusions This study allowed us to describe the lived experiences of HIV positive young people and their caregivers in Zimbabwe. The findings contributed to the enhancement of Africaid’s existing programme of support to better promote psychological well being and ART adherence.
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Affiliation(s)
- Webster Mavhu
- Zimbabwe AIDS Prevention Project, Department of Community Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
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83
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Lovejoy TI. Telephone-delivered motivational interviewing targeting sexual risk behavior reduces depression, anxiety, and stress in HIV-positive older adults. Ann Behav Med 2013; 44:416-21. [PMID: 22956397 DOI: 10.1007/s12160-012-9401-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Few studies have examined the secondary benefits of HIV risk reduction interventions to improve mental health functioning. PURPOSE This study aimed to examine the effectiveness of telephone-delivered motivational interviewing (MI) targeting sexual risk behavior to reduce depression, anxiety, and stress in HIV-positive older adults. METHODS Participants were 100 HIV-positive adults 45+ years old enrolled in a sexual risk reduction pilot clinical trial of telephone-delivered MI. Participants were randomly assigned to a one-session MI, four-session MI, or standard of care control condition. Telephone interviews at baseline and 3- and 6-month follow-up assessed sexual behavior, depression, anxiety, and stress. RESULTS Relative to controls, participants in the one- and four-session MI conditions reported lower levels of depression, anxiety, and stress at 6-month follow-up. No between group differences were observed at 3-month follow-up or between one- and four-session MI participants at 6-month follow-up. CONCLUSIONS Preliminary data suggest that telephone-delivered MI to reduce sexual risk behavior may confer secondary benefits of improving mental health functioning in HIV-positive persons.
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Affiliation(s)
- Travis I Lovejoy
- Mental Health and Clinical Neurosciences Division, Portland Veterans Affairs Medical Center, Portland, OR 97239, USA.
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84
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Pellowski JA, Kalichman SC, Matthews KA, Adler N. A pandemic of the poor: social disadvantage and the U.S. HIV epidemic. AMERICAN PSYCHOLOGIST 2013; 68:197-209. [PMID: 23688088 PMCID: PMC3700367 DOI: 10.1037/a0032694] [Citation(s) in RCA: 300] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The U.S. HIV/AIDS epidemic has evolved over the past 30 years and is now concentrated in socially marginalized and disenfranchised communities. The health disparities in this epidemic are striking, with most HIV infections occurring in sexual minorities and communities of color. While widely recognized, the health disparities in HIV and AIDS are not often discussed. In this article, we examine the factors underlying health disparities in the U.S. HIV epidemic. We first discuss the interlocking relationships between biological, social, and behavioral factors that drive HIV/AIDS epidemics. Guided by a well-established conceptual model of health disparities, we then describe the social positions of those most affected by HIV and AIDS, particularly racial and gender groups. Structural and economic conditions-including environmental resources, constraints, access to care, and psychosocial influences-are examined in relation to HIV disease trajectories. Greater attention to contextual factors and comorbidities is needed to reduce the health disparities in HIV/AIDS.
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85
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Is bipolar disorder a risk factor for HIV infection? J Affect Disord 2013; 146:66-70. [PMID: 23017541 DOI: 10.1016/j.jad.2012.08.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 08/20/2012] [Accepted: 08/22/2012] [Indexed: 11/20/2022]
Abstract
HIV/AIDS is an extremely important public health challenge. Bipolar disorder spectrum has a significant prevalence, reported to be around 2.6%. This study analyses the relationship between sexual behaviors among MDQ positive and MDQ negative patients and its influence in HIV infection, and the impact of HIV diagnosis in both groups. Two hundred outpatients from a specialized clinic for HIV-care located in Walter Cantídio's University Hospital in Fortaleza, Brazil answered to a demographic questionnaire, the Mood Disorder Questionnaire (MDQ) and a sexual behavior questionnaire based on WHO's Behavioral Surveillance Surveys (BSS). Fifteen percent (N=30) of all HIV positive patients were MDQ+. The MDQ+ group was more likely to: be or have been married, have offspring, have sex with commercial and non-regular partners, have infrequent condom use with non-regular partners and of not have used condom in their first sex. Despite more sexual practices among MDQ+ patients before HIV diagnosis, these patients had a more significant reduction of all behaviors after HIV diagnosis than the MDQ- group.
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86
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Martin AM, Benotsch EG, Perschbacher Lance S, Green M. Transmission risk behaviors in a subset of HIV-positive individuals: The role of narcissistic personality features. PERSONALITY AND INDIVIDUAL DIFFERENCES 2013. [DOI: 10.1016/j.paid.2012.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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87
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King R, Wamai N, Khana K, Johansson E, Lindkvist P, Bunnell R. "Maybe his blood is still strong": a qualitative study among HIV-sero-discordant couples on ART in rural Uganda. BMC Public Health 2012; 12:801. [PMID: 22984868 PMCID: PMC3599002 DOI: 10.1186/1471-2458-12-801] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 09/13/2012] [Indexed: 01/17/2023] Open
Abstract
Background HIV-negative members of sero-discordant couples are at high risk for HIV acquisition but few behavioral prevention interventions have been implemented in sub-Saharan Africa and discordance is not well understood by couples themselves. Methods In this nested sub-study, we interviewed 40 HIV sero-discordant couples before and after a 6-month behavioral intervention that was comprised of four group discussions on specific HIV prevention and care topics. The content of the sessions included: 1) understanding HIV serodiscordance and reducing risk, 2) couple communication, 3) reproductive health and HIV serodiscordance, 4) coping with HIV serodiscordance and ongoing support. Couple members were interviewed individually. Data were analyzed thematically using ‘Framework Analysis’ which incorporated dyadic factors to address couple issues. Results Analysis revealed pre-identified concepts and emergent themes that were relevant to the final conceptual model. Four major categories of factors affecting couple relations, beliefs and current risk behaviors emerged: intervention factors, structural/contextual factors, physical health factors, and past risk behavior. The topics within the intervention most relevant were communication and reproductive health. The contextual factors highlighted by couples were gender norms around sexual decision-making and multiple partnerships. Individual beliefs regarding HIV serodiscordance persisted over all time points for some couples. Interestingly, some couple members had divergent views about their HIV status; some believing the HIV-negative member was negative while others described multiple beliefs around the negative member’s blood surely being positive for HIV. Couple communication emerged as an important theme mediating beliefs and behavior. Conclusions In addition to biomedical and behavioral interventions, HIV-serodiscordant couple interventions must embrace the contextual complexity and cultural understanding of HIV infection and discordance as well as the dynamic nature of couple communication to influence risk behavior.
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Affiliation(s)
- Rachel King
- Global Health Sciences, University of California, San Francisco, C/O Makerere University School of Public Health, Kampala, Uganda.
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88
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Donenberg GR, Emerson E, Brown LK, Houck C, Mackesy-Amiti ME. Sexual experience among emotionally and behaviorally disordered students in therapeutic day schools: an ecological examination of adolescent risk. J Pediatr Psychol 2012; 37:904-13. [PMID: 22467883 PMCID: PMC3437680 DOI: 10.1093/jpepsy/jss056] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 03/05/2012] [Accepted: 03/06/2012] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE This study examined gender differences in family, peer, partner, and mental health characteristics related to sexual experience among emotionally and behaviorally disordered students in therapeutic day schools, a population at elevated risk for negative sexual health outcomes. METHODS A total of 417 13- to 20-year-old adolescents reported on their family functioning, peer and partner relationship characteristics, mental health problems, and self-reported sexual behavior. RESULTS For boys and girls, peer influence and conduct problems predicted sexual experience, and family dysfunction was related to negative peer influence. Greater rejection sensitivity was related to less sexual experience for boys and girls. The final path model revealed indirect effects of family dysfunction on boys' but not girls' sexual experiences. CONCLUSIONS Findings underscore the utility of an ecological approach to understand social and personal mechanisms that increase risk and mitigate negative outcomes among emotionally and behaviorally disordered boys and girls in therapeutic day schools.
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Affiliation(s)
- Geri R Donenberg
- School of Public Health, University of Illinois at Chicago, 1603 West Taylor Street, Chicago, IL 60612, USA.
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89
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Vanable PA, Carey MP, Brown JL, Littlewood RA, Bostwick R, Blair D. What HIV-positive MSM want from sexual risk reduction interventions: findings from a qualitative study. AIDS Behav 2012; 16:554-63. [PMID: 21993565 DOI: 10.1007/s10461-011-0047-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
To facilitate the development of a tailored intervention that meets the needs of HIV-positive men who have sex with men (HIV-positive MSM), we conducted formative research with 52 HIV-positive MSM. We sought to (a) identify major barriers to consistent condom use, (b) characterize their interest in sexual risk reduction interventions, and (c) elicit feedback regarding optimal intervention format. Men identified several key barriers to consistent condom use, including treatment optimism, lessened support for safer sex in the broader gay community, challenges communicating with partners, and concerns about stigmatization following serostatus disclosure. Many men expressed an interest in health promotion programming, but did not want to participate in an intervention focusing exclusively on safer sex. Instead, they preferred a supportive group intervention that addresses other coping challenges as well as sexual risk reduction. Study results reveal important considerations for the development of appealing and efficacious risk reduction interventions for HIV-positive MSM.
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Affiliation(s)
- Peter A Vanable
- Center for Health & Behavior, Department of Psychology, Syracuse University, 430 Huntington Hall, Syracuse, NY 13244, USA.
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90
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Brown JL, Diclemente RJ. Secondary HIV prevention: novel intervention approaches to impact populations most at risk. Curr HIV/AIDS Rep 2012; 8:269-76. [PMID: 21837443 DOI: 10.1007/s11904-011-0092-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This paper reviews recent secondary prevention interventions designed to reduce sexual risk behaviors among people living with HIV/AIDS (PLWHA). A summary of findings from previous meta-analyses and narrative reviews of interventions is provided. Next, novel HIV prevention approaches for PLWHA are reviewed. The review reports on the efficacy of interventions delivered in primary care settings or by technology-formats, interventions that also address mental health difficulties, and programs to address particular at-risk populations (eg, men who have sex with men). A critique of recent interventions for people living with HIV/AIDS is provided as well as suggestions for future research.
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Affiliation(s)
- Jennifer L Brown
- Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA.
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91
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Tsai AC, Hung KJ, Weiser SD. Is food insecurity associated with HIV risk? Cross-sectional evidence from sexually active women in Brazil. PLoS Med 2012; 9:e1001203. [PMID: 22505852 PMCID: PMC3323512 DOI: 10.1371/journal.pmed.1001203] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 03/01/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Understanding how food insecurity among women gives rise to differential patterning in HIV risks is critical for policy and programming in resource-limited settings. This is particularly the case in Brazil, which has undergone successive changes in the gender and socio-geographic composition of its complex epidemic over the past three decades. We used data from a national survey of Brazilian women to estimate the relationship between food insecurity and HIV risk. METHODS AND FINDINGS We used data on 12,684 sexually active women from a national survey conducted in Brazil in 2006-2007. Self-reported outcomes were (a) consistent condom use, defined as using a condom at each occasion of sexual intercourse in the previous 12 mo; (b) recent condom use, less stringently defined as using a condom with the most recent sexual partner; and (c) itchy vaginal discharge in the previous 30 d, possibly indicating presence of a sexually transmitted infection. The primary explanatory variable of interest was food insecurity, measured using the culturally adapted and validated Escala Brasiliera de Segurança Alimentar. In multivariable logistic regression models, severe food insecurity with hunger was associated with a reduced odds of consistent condom use in the past 12 mo (adjusted odds ratio [AOR] = 0.67; 95% CI, 0.48-0.92) and condom use at last sexual intercourse (AOR = 0.75; 95% CI, 0.57-0.98). Self-reported itchy vaginal discharge was associated with all categories of food insecurity (with AORs ranging from 1.46 to 1.94). In absolute terms, the effect sizes were large in magnitude across all outcomes. Underweight and/or lack of control in sexual relations did not appear to mediate the observed associations. CONCLUSIONS Severe food insecurity with hunger was associated with reduced odds of condom use and increased odds of itchy vaginal discharge, which is potentially indicative of sexually transmitted infection, among sexually active women in Brazil. Interventions targeting food insecurity may have beneficial implications for HIV prevention in resource-limited settings.
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Affiliation(s)
- Alexander C Tsai
- Robert Wood Johnson Health and Society Scholars Program, Harvard University, Cambridge, Massachusetts, USA.
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92
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Hansen NB, Brown LJ, Tsatkin E, Zelgowski B, Nightingale V. Dissociative experiences during sexual behavior among a sample of adults living with HIV infection and a history of childhood sexual abuse. J Trauma Dissociation 2012; 13:345-60. [PMID: 22545567 PMCID: PMC3342020 DOI: 10.1080/15299732.2011.641710] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Little attention has been given to the occurrence of dissociative symptoms during sexual behavior in adults who have experienced childhood sexual abuse (CSA). For this study, 57 adults living with HIV infection who had experienced CSA and were entering a treatment study for traumatic stress completed study assessments and clinical interviews, including a 15-item scale of dissociative experiences during sexual behavior. Predictor variables included Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnoses of posttraumatic stress disorder (PTSD) and dissociative disorders, rape by an intimate partner, duration of CSA, number of perpetrators of CSA, and current sexual satisfaction. A multiple regression analysis was conducted to identify significant associations between predictors and dissociation during sex. Mean differences by clinical diagnosis were also examined. Results indicated that PTSD, dissociative disorders, rape by an intimate partner, duration of CSA, and number of perpetrators of CSA were associated with increased dissociation during sexual behavior. Dissociation during sex likely increases vulnerability to sexual revictimization and risky sexual behavior. Standard behavioral prevention interventions may be ineffective for sexual situations when dissociation occurs, and prevention efforts should be integrated with mental health care for those who have experienced CSA.
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Affiliation(s)
- Nathan B Hansen
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 06511, USA.
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93
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Wu ES, Rothbard A, Blank MB. Using psychiatric symptomatology to assess risk for HIV infection in individuals with severe mental illness. Community Ment Health J 2011; 47:672-8. [PMID: 21479681 DOI: 10.1007/s10597-011-9402-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Accepted: 03/30/2011] [Indexed: 11/26/2022]
Abstract
In this study, we use the Colorado Symptom Index, a measure of psychiatric symptomatology, to identify vulnerable subgroups within the severely mentally ill population at elevated risk for HIV infection. Baseline data on 228 HIV positive and 281 HIV negative participants from two clinical trials were used. With years to HIV diagnosis as our primary endpoint, Kaplan-Meier estimates were calculated to find a CSI cut-off score, and a Cox proportional hazards model was used to obtain relative risks of infection for the two CSI categories created by the cut point. We found that a CSI score ≥ 30 was associated with a 47% increased risk for HIV infection (P < 0.01). While this study establishes the foundation for using CSI scores to identify a vulnerable subgroup within the SMI community, further studies should develop effective approaches to mitigate psychiatric symptomatology in order to examine the impact on HIV transmission risky behaviors.
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Affiliation(s)
- Evan S Wu
- Department of Psychiatry, Center for Mental Health Policy and Services Research, University of Pennsylvania, Philadelphia, PA, USA.
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94
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Meade CS, Fitzmaurice GM, Sanchez AK, Griffin ML, McDonald LJ, Weiss RD. The relationship of manic episodes and drug abuse to sexual risk behavior in patients with co-occurring bipolar and substance use disorders: a 15-month prospective analysis. AIDS Behav 2011; 15:1829-33. [PMID: 20859672 DOI: 10.1007/s10461-010-9814-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Risky sexual behavior is common among individuals with bipolar and substance use disorders. This 15-month prospective study examined the effects of between-subject differences and within-subject changes in mood symptoms and drug use on sexual risk behavior among 61 patients with both disorders. Participants completed five post-treatment follow-up assessments at 3-month intervals. Using a multivariate mixed-effects model analysis, more average weeks of mania (between-subject difference) was associated with greater sexual risk, but change in weeks of mania (within-subject change) was not; depression was unrelated to sexual risk. In addition, within-subject increases in days of cocaine use predicted increases in sexual risk. Results underscore the importance of substance abuse treatment and suggest that bipolar patients with active and/or recurrent mania are in need of targeted HIV prevention services. Further research is needed to test whether individual differences in impulsivity may explain the association between mania and sexual risk.
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Affiliation(s)
- Christina S Meade
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA.
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95
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Nightingale VR, Sher TG, Mattson M, Thilges S, Hansen NB. The effects of traumatic stressors and HIV-related trauma symptoms on health and health related quality of life. AIDS Behav 2011; 15:1870-8. [PMID: 21667297 DOI: 10.1007/s10461-011-9980-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The study identified relations among traumatic stressors, HIV-related trauma symptoms, comorbid medical conditions, and health related quality of life (HRQL) in individuals with HIV. Participants (N = 118) completed a structured clinical interview on HIV as a traumatic stressor and other severe traumatic stressors and completed the Impact of Event Scale to assess HIV-related trauma symptoms and the Medical Outcomes Study 36-item Short Form (SF-36) to assess HRQL. Medical chart reviews determined comorbid conditions. Path analysis findings indicated participants with prior severe traumatic stressors experienced their HIV diagnosis as traumatic and in turn were more likely to have current HIV-related trauma symptoms which were negatively related to HRQL. HIV as a traumatic stressor was related to coronary artery diseases and HRQL. Traumatic stressors and HIV-related trauma symptoms impact health in individuals with HIV and highlight the need for psychological interventions prior to diagnosis and throughout treatment.
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Affiliation(s)
- Vienna R Nightingale
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT 06510, USA.
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96
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Chibanda D, Mesu P, Kajawu L, Cowan F, Araya R, Abas MA. Problem-solving therapy for depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV. BMC Public Health 2011; 11:828. [PMID: 22029430 PMCID: PMC3210104 DOI: 10.1186/1471-2458-11-828] [Citation(s) in RCA: 189] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2010] [Accepted: 10/26/2011] [Indexed: 12/21/2022] Open
Abstract
Background There is limited evidence that interventions for depression and other common mental disorders (CMD) can be integrated sustainably into primary health care in Africa. We aimed to pilot a low-cost multi-component 'Friendship Bench Intervention' for CMD, locally adapted from problem-solving therapy and delivered by trained and supervised female lay workers to learn if was feasible and possibly effective as well as how best to implement it on a larger scale. Method We trained lay workers for 8 days in screening and monitoring CMD and in delivering the intervention. Ten lay workers screened consecutive adult attenders who either were referred or self-referred to the Friendship Bench between July and December 2007. Those scoring above the validated cut-point of the Shona Symptom Questionnaire (SSQ) for CMD were potentially eligible. Exclusions were suicide risk or very severe depression. All others were offered 6 sessions of problem-solving therapy (PST) enhanced with a component of activity scheduling. Weekly nurse-led group supervision and monthly supervision from a mental health specialist were provided. Data on SSQ scores at 6 weeks after entering the study were collected by an independent research nurse. Lay workers completed a brief evaluation on their experiences of delivering the intervention. Results Of 395 potentially eligible, 33 (8%) were excluded due to high risk. Of the 362 left, 2% (7) declined and 10% (35) were lost to follow-up leaving an 88% response rate (n = 320). Over half (n = 166, 52%) had presented with an HIV-related problem. Mean SSQ score fell from 11.3 (sd 1.4) before treatment to 6.5 (sd 2.4) after 3-6 sessions. The drop in SSQ scores was proportional to the number of sessions attended. Nine of the ten lay workers rated themselves as very able to deliver the PST intervention. Conclusion We have found preliminary evidence of a clinically meaningful improvement in CMD associated with locally adapted problem-solving therapy delivered by lay health workers through routine primary health care in an African setting. There is a need to test the effectiveness of this task-shifting mental health intervention in an appropriately powered randomised controlled trial. Trial registration ISRCTN: ISRCTN25476759
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Affiliation(s)
- Dixon Chibanda
- Department of Psychiatry, University of Zimbabwe, Harare, Zimbabwe.
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97
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Mental health and HIV sexual risk behavior among patrons of alcohol serving venues in Cape Town, South Africa. J Acquir Immune Defic Syndr 2011; 57:230-7. [PMID: 21372724 DOI: 10.1097/qai.0b013e3182167e7a] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Alcohol-serving venues in South Africa provide a location for HIV prevention interventions due to risk factors of patrons in these establishments. Understanding the association between mental health and risk behaviors in these settings may inform interventions that address alcohol use and HIV prevention. METHODS Participants (n = 738) were surveyed in 6 alcohol-serving venues in Cape Town to assess post-traumatic stress disorder (PTSD) and depression symptoms, traumatic experiences, sexual behavior, and substance use. Logistic regression models examined whether traumatic experiences predicted PTSD and depression. Generalized linear models examined whether substance use, PTSD, and depressive symptoms predicted unprotected sexual intercourse. Men and women were analyzed separately. RESULTS Participants exhibited high rates of traumatic experiences, PTSD, depression, alcohol consumption, and HIV risk behaviors. For men, PTSD was associated with being hit by a sex partner, physical child abuse, sexual child abuse and HIV diagnosis; depression was associated with being hit by a sex partner, forced sex and physical child abuse. For women, both PTSD and depression were associated with being hit by a sex partner, forced sex, and physical child abuse. Unprotected sexual intercourse was associated with age, frequency and quantity of alcohol use, drug use, and PTSD for men and frequency and quantity of alcohol use, depression, and PTSD for women. CONCLUSION Mental health in this setting was poor and was associated with sexual risk behavior. Treating mental health and substance-use problems may aid in reducing HIV infection. Sexual assault prevention and treatment after sexual assault may strengthen HIV prevention efforts.
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98
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Sikkema KJ, Hansen NB, Kochman A, Santos J, Watt MH, Wilson PA, Delorenzo A, Laudato J, Mayer G. THE DEVELOPMENT AND FEASIBILITY OF A BRIEF RISK REDUCTION INTERVENTION FOR NEWLY HIV-DIAGNOSED MEN WHO HAVE SEX WITH MEN. JOURNAL OF COMMUNITY PSYCHOLOGY 2011; 39:717-732. [PMID: 22228917 PMCID: PMC3249751 DOI: 10.1002/jcop.20463] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Men who have sex with men (MSM) represent more than half of all new HIV infections in the United States. Utilizing a collaborative, community based approach, a brief risk reduction intervention was developed and pilot tested among newly HIV-diagnosed MSM receiving HIV care in a primary care setting. Sixty-five men, within 3 months of diagnosis, were randomly assigned to the experimental condition or control condition and assessed at baseline, 3-month, and 6-month follow-up. Effect sizes were calculated to explore differences between conditions and over time. Results demonstrated the potential effectiveness of the intervention in reducing risk behavior, improving mental health, and increasing use of ancillary services. Process evaluation data demonstrated the acceptability of the intervention to patients, clinic staff, and administration. The results provide evidence that a brief intervention can be successfully integrated into HIV care services for newly diagnosed MSM and should be evaluated for efficacy.
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People with HIV in HAART-era Russia: transmission risk behavior prevalence, antiretroviral medication-taking, and psychosocial distress. AIDS Behav 2011; 15:767-77. [PMID: 20803063 DOI: 10.1007/s10461-010-9793-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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100
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Safren SA, Blashill AJ, O'Cleirigh CM. Promoting the sexual health of MSM in the context of comorbid mental health problems. AIDS Behav 2011; 15 Suppl 1:S30-4. [PMID: 21331799 PMCID: PMC3610408 DOI: 10.1007/s10461-011-9898-x] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Despite the moderate efficacy of HIV prevention interventions for at risk gay, bisexual, and other men who have sex with men (MSM), MSM continue to represent the largest group of new HIV infections and the largest number of individuals living with HIV in the US. Environmental factors such as sexual minority stress increase the vulnerability of MSM for mental health problems. These mental health problems can be a barrier to consistently engaging in self-care health behaviors such as sexual risk reduction. We consider the following observations critical to identifying priorities for HIV prevention among MSM: (1) gay, bisexual and other MSM have higher rates of mental health problems than general population estimates; (2) these mental health problems co-occur with each other and interact synergistically to increase HIV risk; and (3) comorbid mental health problems may compromise the impact of prevention programs, and integrating treatment of mental health issues into prevention programs may improve program efficacy. Novel prevention interventions for at risk MSM that integrate programming with the treatment of co-occurring and interfering mental health issues are the most promising avenue to increase prevention intervention efficacy and effectiveness. By addressing significant mental health issues and supporting broad based prevention efforts at the individual and community level, there is also the potential to improve the overall quality of life and public mental health of gay, bisexual, and other MSM.
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Affiliation(s)
- Steven A Safren
- Massachusetts General Hospital and Harvard Medical School, 1 Bowdoin Sq, 7th Floor, Boston, MA 02114, USA.
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