Minorities, the Poor, and Survivors of Abuse: HIV-Infected Patients in the US Deep South:

Highly stressed: stressful and traumatic experiences among individuals with HIV/AIDS in the Deep South

A history of traumatic and/or stressful experiences is prevalent among HIV-infected individuals and has been consistently associated with poorer health outcomes. However, little is known about incident stressful experiences and the factors that predict these experiences among HIV-infected individuals. Data from a longitudinal study of 611 HIV-infected individuals in the Southeastern USA were used to examine the frequency and types of incident stress reported in a 27-month period and to determine predictors associated with three incident stress measures (all stressful events, severe stressful events, and traumatic events such as physical assault). Incident stressful experiences frequently occurred among study participants, as 91% reported at least one stressful experience (median=3.5 experiences) and 10% of study participants reported traumatic stress in any given nine-month reporting period. Financial stressors were the most frequently reported by study participants. Greater emotional distress, substance use, and a higher number of baseline stressful experiences were significantly associated with reporting a greater number of incident stressful experiences and any traumatic experiences. Study results indicate that efforts are needed to identify individuals at risk for traumatic events and/or substantial stressors and to address the factors, including mental health and substance abuse, that contribute to these experiences.

Physiological and psychosocial factors that predict HIV-related fatigue

Fatigue is one of the most common and debilitating symptoms experienced by HIV-infected people. We report the results of our longitudinal analysis of physiological and psychosocial factors that were thought to predict changes in HIV-related fatigue in 128 participants over a 1-year period, in an effort to sort out the complex interplay among a comprehensive set of physiological and psychosocial variables. Physiological measures included hepatic function (aspartate aminotransferase, alanine aminotransferase, gamma glutamyl transpeptidase, alkaline phosphatase, total bilirubin, hepatitis C status), thyroid function (thyroid stimulating hormone, thyroxine), HIV viral load, immunologic function (CD4, CD8, CD4/CD8 ratio, CD16, CD8CD38), gonadal function (testosterone, dehydroepiandrosterone), hematologic function (hemoglobin, hematocrit, serum erythropoietin), and cellular injury (lactic acid). Psychosocial measures included childhood and adult trauma, anxiety, depression, social support, stressful life events, and post-traumatic stress disorder (PTSD). Unemployment, not being on antiretroviral therapy, having fewer years since HIV diagnosis, more childhood trauma, more stressful life events, less social support, and more psychological distress (e.g., PTSD, anxiety and depression) put HIV-infected persons at risk for greater fatigue intensity and fatigue-related impairment in functioning during 1-year follow-up. Physiological variables did not predict greater fatigue. Stressful life events had both direct and indirect effects on fatigue.

Incident stressful and traumatic life events and human immunodeficiency virus sexual transmission risk behaviors in a longitudinal, multisite cohort study

OBJECTIVE

To assess the association between incident stressful life events (e.g., sexual and physical assault; housing instability; and major financial, employment, and legal difficulties) and unprotected anal or vaginal sexual intercourse (unprotected sex) among people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (PLWHA).

METHODS

We assessed incident stressful events and unprotected sex over 27 months in 611 participants in an eight-site, five-state study in the Southeast United States. Using mixed-effects logistic models and separately estimating between-person and within-person associations, we assessed the association of incident stressful events with unprotected sex with all partners, HIV-positive partners, and HIV-negative/serostatus-unknown partners.

RESULTS

Incident stressful events reported at one third or more of interviews included major illness, injury or accident (non-HIV-related); major illness of a family member/close friend; death of a family member/close friend; financial stresses; and relationship stresses. In multivariable models, each additional moderately stressful event an individual experienced at a given time point above his or her norm (within-person association) was associated with a 24% to 27% increased odds of unprotected sex for each partner type.

CONCLUSIONS

Risk reduction among PLWHA remains a major focus of efforts to combat the HIV epidemic. Incident stressful events are exceedingly common in the lives of PLWHA and are associated with increased unprotected sex. Efforts to either prevent the occurrence of such events (e.g., financial or relationship counseling) or address their sequelae (e.g., coping skills or other behavioral counseling) may help reduce secondary HIV transmission.

Improving access to mental health services via a clinic-wide mental health intervention in a Southeastern US infectious disease clinic

Stepleman, Hann, Santos, and House (2006) described a brief psychological consultation model, which aims to improve integration of mental health services into HIV primary care. This retrospective chart review sought to examine which patients in our adult Infectious Disease clinic were served by this model in a one-year period. Furthermore, we examined whether the patients who subsequently engage in mental health care differ demographically from the consult population. Results indicated that 26.1% (n=252) of the patients at our Infectious Disease clinic (n=963; 36% female, 75% racial minority) received a mental health consultation. We observed no statistically significant differences between the consult and clinic populations with respect to gender, age, or race. Moreover, 43.3% (n=109) of those patients served by the consult model received specialized psychiatric care. There were statistically significant racial differences between those patients who engaged specialty psychiatric care and those who did not after receiving a consultation (chi(2)(1)=16.65, p<0.001; 70% racial minority in consult vs. 47.7% racial minority in psychiatric care). While our in-clinic consultation service reached a representative population, we had less success recruiting this diverse patient population into traditional psychiatric care. Future efforts will need to examine how mental health consultation and traditional psychiatric services can best reduce barriers to engagement and retention in care.

Treatment considerations for psychiatric syndromes associated with HIV infection

Psychiatric syndromes associated with HIV disease were recognized early in the AIDS epidemic. Public education, new technologies and antiretroviral therapies have resulted in earlier recognition and therapautic interventions of HIV infection, improving the physical health for individuals living with HIV. While HIV-associated psychiatric symptoms have been recognized for more than 20 years, our understanding of the mechanisms underlying psychiatric symptoms among HIV-infected individuals and treatments for these symptoms have not kept pace with advances in HIV therapies. In this article, we discuss current knowledge of the psychiatric symptoms occurring with HIV disease, specifically mood, anxiety and psychotic disorders, evidence-based treatments and treatment considerations, new strategies for the treatments of psychiatric symptoms in HIV disease are also discussed.

Psychosocial functioning among HIV-affected youth and their caregivers in Haiti: implications for family-focused service provision in high HIV burden settings

The study is an analysis of baseline data from a pilot psychosocial support intervention for HIV-affected youth and their caregivers in Haiti. Six sites in Haiti's Central Department affiliated with Partners In Health/Zanmi Lasante (PIH/ZL) and the Haitian Ministry of Health were included. Participants were recruited from a list of HIV-positive patients receiving care at PIH/ZL. The baseline questionnaire was administered from February 2006 to January 2007 with HIV-affected youth (n = 492), ages 10-17, and their caregivers (n = 330). According to findings at baseline, the youth reported high levels of anxiety, including constant fidgeting (86%), restlessness (83%), and worrying a lot (56%). Their parents/caregivers also reported a high level of depressive symptoms, such as low energy (73%), feeling everything is an effort (71%), and sadness (69%). Parents' depressive symptoms were positively associated with their children's psychological symptoms (odds ratio [OR] =1.6-2.4) and psychosocial functioning (OR =1.6 according to parental report). The significant levels of anxiety and depression observed among HIV-affected youth and their caregivers suggest that psychosocial interventions are needed among HIV-affected families in central Haiti and other high HIV burden areas. The results suggest that a family-focused approach to service provision may be beneficial, possibly improving quality of life, as well as psychosocial and physical health-related outcomes among HIV-affected youth and their caregivers, particularly HIV-positive parents.

Overload: impact of incident stressful events on antiretroviral medication adherence and virologic failure in a longitudinal, multisite human immunodeficiency virus cohort study

OBJECTIVE

To examine the influence of incident stressful experiences on antiretroviral medication adherence and treatment outcomes. Past trauma history predicts poorer medication adherence and health outcomes. Human immunodeficiency virus (HIV)-infected individuals experience frequently traumatic and stressful events, such as sexual and physical assault, housing instability, and major financial, employment, and legal difficulties.

METHODS

We measured prospectively incident stressful and traumatic events, medication adherence, and viral load over 27 months in an eight-site, five-state study. Using multivariable logistic and generalized estimating equation modeling, we assessed the impact of incident stressful events on 27-month changes in self-reported medication adherence and virologic failure (viral load = >or=400 c/mL).

RESULTS

Of 474 participants on antiretroviral therapy at baseline, 289 persons were interviewed and still received treatment at 27 months. Participants experiencing the median number of incident stressful events (n = 9) had over twice the predicted odds (odds ratio = 2.32) of antiretroviral medication nonadherence at follow-up compared with those with no events. Stressful events also predicted increased odds of virologic failure during follow-up (odds ratio = 1.09 per event).

CONCLUSIONS

Incident stressful events are exceedingly common in the lives of HIV-infected individuals and negatively affect antiretroviral medication adherence and treatment outcomes. Interventions to address stress and trauma are needed to improve HIV outcomes.

HIV transmission networks

PURPOSE OF REVIEW

Over the past several years, one segment of the complex field of HIV transmission dynamics - heterosexual networks - has dominated theoretical and empirical investigation. This review provides an overview of recent work on HIV risks and networks, with a focus on recent findings in heterosexual network dynamics.

RECENT FINDINGS

Qualitative (ethnographic) assessments have demonstrated the heterogeneity and complexity of heterosexual connections, particularly in Africa, where tradition, official polygamy, and unofficial multiperson arrangements have lead to concurrency of sexual partnerships. A large, quantitative study on Likoma Island, Malawi, demonstrated the considerable, interlocking sexual connections that arise from a high-concurrency sexual setting, even with a low average number of partnerships (low degree) of long duration. Such settings, as suggested by ethnographic studies, may be common in Africa and, coupled with newer information about transmissibility during acute and early infection, may provide a plausible explanation for endemic transmission and possibly for rapid HIV propagation.

SUMMARY

Recognition of high-concurrency, low-degree networks is an important development for understanding HIV transmission dynamics. Their relevance to heterosexual transmission, and possible extension to other epidemiologic settings, reinforces the heterogeneity and complexity of HIV transmission dynamics.

The therapeutic implications of timely linkage and early retention in HIV care

Following HIV diagnosis, linkage to outpatient treatment, antiretroviral initiation, and longitudinal retention in care represent the foundation for successful treatment. While prior studies have evaluated these processes in isolation, a systematic evaluation of successive steps in the same cohort of patients has not yet been performed. To ensure optimal long-term outcomes, a better understanding of the interplay of these processes is needed. Therefore, a retrospective cohort study of patients initiating outpatient care at the University of Alabama at Birmingham 1917 HIV=AIDS Clinic between January 2000 and December 2005 was undertaken. Multivariable models determined factors associated with: late diagnosis=linkage to care (initial CD4 < 350 cells=mm3), timely antiretroviral initiation, and retention across the first two years of care. Delayed linkage was observed in two-thirds of the overall sample (n = 567) and was associated with older age (odds ratio [OR] = 1.31 per 10 years; 95%confidence interval [CI] = 1.06-1.62) and African American race (OR = 2.45; 95% CI = 1.60-3.74). Attending all clinic visits (hazard ratio [HR] = 6.45; 95% CI = 4.47-9.31) and lower initial CD4 counts led to earlier antiretroviral initiation. Worse retention in the first 2 years was associated with younger age (OR = 0.68 per 10 years;95% CI = 0.56-0.83), higher baseline CD4 count, and substance abuse (OR = 1.78; 95% CI = 1.16-2.73). Interventions to improve timely HIV diagnosis and linkage to care should focus on older patients and African Americans while efforts to improve retention should address younger patients, those with higher baseline CD4 counts, and substance abuse. Missed clinic visits represent an important obstacle to the timely initiation of antiretroviral therapy. These data inform development of interventions to improve linkage and retention in HIV care, an emerging area of growing importance.

Coping strategies and patterns of alcohol and drug use among HIV-infected patients in the United States Southeast

Alcohol and drug use are common among HIV-infected patients and are important determinants of secondary transmission risk and medication adherence. As part of the Coping with HIV/AIDS in the Southeast (CHASE) Study, 611 HIV-infected patients were consecutively recruited from eight clinical care sites in five southeastern U.S. states in 2001-2002. We examined the distribution and predictors of alcohol and drug use in this sample with an emphasis on psychosocial predictors of use. In the prior 9 months, 27% of participants drank alcohol and 7% drank to intoxication at least weekly. The most common drugs used at least weekly were marijuana (12%) and crack (5%); 11% used a non-marijuana drug. 7% reported polysubstance use (use of multiple substances at one time) at least weekly. Injection drug use was rare (2% injected at least once in the past 9 months). There were few differences in alcohol and drug use across sociodemographic characteristics. Stronger adaptive coping strategies were the most consistent predictor of less frequent alcohol and drug use, in particular coping through action and coping through relying on religion. Stronger maladaptive coping strategies predicted greater frequency of drinking to intoxication but not other measures of alcohol and drug use. Those with more lifetime traumatic experiences also reported higher substance use. Interventions that teach adaptive coping strategies may be effective in reducing alcohol and substance use among HIV-positive persons.

Trauma, mental health, distrust, and stigma among HIV-positive persons: implications for effective care

Individuals living with HIV often have complicated histories, including negative experiences such as traumatic events, mental illness, and stigma. As the medical community in the United States adapts to managing HIV as a chronic disease, understanding factors such as these negative experiences that may be associated with poorer adherence to treatment regimens, greater HIV risk behavior, and lower patient quality of life becomes critical to HIV care and prevention. In less wealthy nations, these issues are also critical for addressing quality of life as well as medication adherence in the areas where antiretroviral therapies are being made available. This article presents a review of the literature regarding the following psychosocial factors as they relate to HIV/AIDS in the US and globally: traumatic events; mental illness, including depression, anxiety, and posttraumatic stress disorder; lack of trust in the healthcare system and government; and experiences of stigma among individuals with HIV disease. These factors have been found to be prevalent among individuals with HIV/AIDS, regardless of gender or race/ethnicity. Traumatic events, mental illness, distrust, and stigma have also been linked with poorer adherence to medication regimens and HIV risk behavior.