Affect regulation, stimulant use, and viral load among HIV-positive persons on anti-retroviral therapy

Body dissatisfaction and methamphetamine use among HIV-positive gay and bisexual men: a pilot study

Methamphetamine use is strongly associated with risky sex and increased reports of HIV and other sexually transmitted infections among gay and bisexual men (GBM) who attend dance/circuit parties. The psychological mechanisms underlying methamphetamine use in this subculture, however, remain unclear. These exploratory findings are from a 2004 dataset measuring body dissatisfaction and drug use among 42 HIV-positive GBM in South Florida who attended at least one bar/club/circuit party within 3 months of participating. A multivariate regression model revealed that body dissatisfaction accounted for a small but significant amount of variance in methamphetamine use. Treatment implications and recommendations for future research are discussed.

Substance use and HIV disease progression in the HAART era: implications for the primary prevention of HIV

Prior to the era of highly active anti-retroviral therapy (HAART), cohort studies provided equivocal evidence to support the hypothesis that substance use predicts more rapid HIV disease progression. The present review examined the effects of substance use on HIV disease progression in cohort studies with follow-up that continued into the HAART era. Of the 20 studies included in this review, 16 observed that substance use predicted at least one indicator of HIV disease progression. Ten of the 11 studies that followed participants exclusively in the HAART era observed an effect of substance use on HIV disease progression. Findings across studies indicate that stimulant use promotes more rapid HIV disease progression and the effects of substance use on HIV disease progression can persist after controlling for self-reported HAART non-adherence. Future investigations that examine the bio-behavioral pathways whereby substance use promotes HIV disease progression should include: measures of HIV genotypic and phenotypic resistance, multi-method assessment of adherence, and assessment of co-morbid infections that are more prevalent among substance users. Although further mechanistic research is needed, findings from existing cohort studies have clear clinical implications. Implementing screening, brief intervention and referral to substance abuse treatment in HIV medical care could optimize health outcomes and decrease HIV transmission rates by boosting the effectiveness of "Test and Treat" approaches to HIV prevention.

Mother-to-child transmission (MTCT) of HIV and drugs of abuse in post-highly active antiretroviral therapy (HAART) era

In the pre-highly active antiretroviral therapy (HAART) era, prenatal "vertical" mother-to-child transmission (MTCT) of HIV was about 25% and exposure of pregnant mothers to drugs of abuse (illicit drugs and tobacco smoking) was a significant contributory factor of MTCT. However, with the introduction of HAART, the rate of MTCT of HIV has decreased to less that 2%. But, it is estimated that currently about 5.1% of pregnant women use illicit drugs and 16.4% smoke tobacco. The residual prevalence of MTCT is of concern and may be related to this continued prevalence of substance use among pregnant mothers. In this report, we review and present evidence that supports the hypothesis that drugs of abuse do have the potential to increase MTCT of HIV in the presence of HAART. Exposure to drugs of abuse during pregnancy may increase MTCT of HIV through a variety of mechanisms that are addressed in detail including possible damage to the placenta, induction of preterm birth, and increasing maternal plasma viral load though a variety of putative mechanisms such as: (a) promoting HIV replication in monocyte/macrophages; (b) increasing the expression of CCR5 receptors; (c) decreasing the expression of CCR5 receptor ligands; (d) increasing the expression of CXCR4 receptors; (e) increasing the expression of DC-SIGN; (f) impairing the efficacy of HAART through drug-drug interaction; and (g) promoting HIV mutation and replication through non-adherence to HAART.

Affective correlates of stimulant use and adherence to anti-retroviral therapy among HIV-positive methamphetamine users

The use of stimulants has important implications for HIV prevention and care. However, few investigations have examined psychological correlates of substance use and adherence to anti-retroviral therapy (ART) among HIV-positive stimulant users. This cross-sectional investigation examined affective correlates of stimulant use and ART adherence among HIV-positive methamphetamine users. In total, 122 HIV-positive men who have sex with men or transgendered individuals on ART who reported using methamphetamine in the past 30 days were recruited from the community. HIV-specific traumatic stress was consistently and independently associated with more frequent cocaine/crack use (but not with methamphetamine use). Positive affect was independently associated with a decreased likelihood of reporting any injection drug use and an increased likelihood of reporting perfect ART adherence. HIV-specific traumatic stress may be an important determinant of increased cocaine/crack use in this population. Positive affect may increase the likelihood that individuals will refrain from injection drug use and achieve high levels of ART adherence.

Psychiatric illness, access and adherence to HAART: a brief review of recent findings and implications for care

This review outlines research since 2006 addressing psychiatric illness and/or co-occurring psychiatric illness and substance abuse as it relates to HAART access and adherence. Highlighted here are effective or promising interventions, or models of care, designed to enhance adherence among HIV-infected individuals with mental illness. Overall, we found that recent studies reinforce earlier findings that co-occurring substance abuse and psychiatric illness are associated with HAART nonadherence. Studies of depression/anxiety disorders among HIV patients reviewed here show that while depression is related to poorer medication adherence, treatment for depression can lead to increased HAART adherence. New studies also suggest that HIV patients with psychiatric diagnoses can effectively maintain HAART adherence with close monitoring by providers. While there are still very few adherence interventions among HIV patients with co-occurring mental illness and substance abuse, promising interventions include cognitive behavioral therapy and integration of mental health services with HIV primary care.

A Pilot Study Investigating the Effects of Trauma, Experiential Avoidance, and Disease Management in HIV-Positive MSM Using Methamphetamine

With high rates of trauma among HIV-positive men who have sex with men (MSM) who use methamphetamine, this preliminary pilot study examined the associations between experiential avoidance, trauma symptoms, and management of a chronic illness. Among a small sample of HIV-positive, methamphetamine-using MSM in a California Bay Area County, greater reported experiential avoidance was significantly related to greater reported trauma and symptoms of traumatic stress. Furthermore, greater reported experiential avoidance was significantly related to reduced self-efficacy of illness management and more frequent methamphetamine use. Although further research is needed, these data suggest that addressing issues of experiential avoidance and trauma could affect behavioral choices and treatment outcomes in this high-risk population.

Improving health outcomes for youth living with the human immunodeficiency virus: a multisite randomized trial of a motivational intervention targeting multiple risk behaviors

OBJECTIVE

To determine if Healthy Choices, a motivational interviewing intervention targeting multiple risk behaviors, improved human immunodeficiency virus (HIV) viral load.

DESIGN

A randomized, 2-group repeated measures design with analysis of data from baseline and 6- and 9-month follow-up collected from 2005 to 2007.

SETTING

Five US adolescent medicine HIV clinics.

PARTICIPANTS

A convenience sample with at least 1 of 3 risk behaviors (nonadherence to HIV medications, substance abuse, and unprotected sex) was enrolled. The sample was aged 16 to 24 years and primarily African American. Of the 205 enrolled, 19 did not complete baseline data collections, for a final sample size of 186. Young people living with HIV were randomized to the intervention plus specialty care (n = 94) or specialty care alone (n = 92). The 3- and 6-month follow-up rates, respectively, were 86% and 82% for the intervention group and 81% and 73% for controls. Intervention Healthy Choices was a 4-session individual clinic-based motivational interviewing intervention delivered during a 10-week period. Motivational interviewing is a method of communication designed to elicit and reinforce intrinsic motivation for change. Outcome Measure Plasma viral load.

RESULTS

Youth randomized to Healthy Choices showed a significant decline in viral load at 6 months postintervention compared with youth in the control condition (beta = -0.36, t = -2.15, P = .03), with those prescribed antiretroviral medications showing the lowest viral loads. Differences were no longer significant at 9 months.

CONCLUSION

A motivational interviewing intervention targeting multiple risk behaviors resulted in short-term improvements in viral load for youth living with HIV. Trial Registration clinicaltrials.gov Identifier: NCT00103532.

Management of common psychiatric conditions in the HIV-positive population

Presentation and management of psychiatric illness in HIV-infected patients can pose a challenge for clinicians. Psychiatric illness can exist premorbidly or result from the progression and treatment of HIV infection, influencing the course of the illness both through behavior and putative biological factors. Mood disorders, anxiety, psychosis, delirium, dementia, and substance abuse disorders all factor heavily into the care of HIV-infected patients. Management, however, continues to draw on small and skewed datasets, and remains largely an extrapolation from seronegative patient experience. The following is a discussion of treatment considerations derived from recent literature, as well as a consideration of judgments that clinicians may make in the absence of available data. The use of antidepressants, stimulants, mood stabilizers, and antipsychotics is discussed, as are precautions that must be taken with the HIV population when using these medications, not only because of side effect vulnerability, but because of significant drug-drug interactions.

Internalized heterosexism among HIV-positive, gay-identified men: implications for HIV prevention and care

Internalized heterosexism (IH), or the internalization of societal antihomosexual attitudes, has been consistently linked to depression and low self-esteem among gay men, and it has been inconclusively associated with substance use and sexual risk in gay and bisexual men. Using structural equation modeling, the authors tested a model framed in social action theory (C. K. Ewart, 1991, 2004) in which IH is associated with HIV transmission risk and poor adherence to HIV antiretroviral therapy (ART) through the mechanisms of negative affect and stimulant use. Data from a sample of 465 gay-identified men interviewed as part of an HIV risk reduction behavioral trial were used to test the fit of the model. Results support the hypothesized model in which IH was associated with unprotected receptive (but not insertive) anal intercourse with HIV-negative or unknown HIV status partners, and with ART nonadherence indirectly via increased negative affect and more regular stimulant use. The model accounted for 15% of the variance in unprotected receptive anal intercourse and 17% of the variance in ART nonadherence. Findings support the potential utility of addressing IH in HIV prevention and treatment with HIV-positive gay men.

Stimulant use is associated with immune activation and depleted tryptophan among HIV-positive persons on anti-retroviral therapy

Cocaine, crack, and methamphetamine are stimulants that promote autonomic nervous system activation. Although these stimulants may have immunomodulatory effects, relatively few studies have examined this possibility. The present cross-sectional investigation utilized baseline data from 127 HIV-positive individuals on anti-retroviral therapy (ART) that were enrolled in a randomized controlled trial. The goal of this study was to examine whether stimulant use is independently associated with immune activation and indices of tryptophan degradation. Forty-four participants reported using stimulants 2-3 times a month or more (i.e., monthly stimulant use) and a sub-set of these (n=27) reported using stimulants once a week or more (i.e., weekly stimulant use) during the past three months. These stimulant-using groups were compared to a group of participants who reported no stimulant use (n=83) during the past three months. Results indicated that individuals who reported either monthly or weekly stimulant use displayed elevated neopterin, a measure of immune activation. Those who reported weekly stimulant use also displayed a markedly elevated HIV viral load and lower tryptophan levels. Even after controlling for self-reported ART non-adherence, weekly stimulant use was independently associated with higher neopterin, elevated HIV viral load, and lower tryptophan. To our knowledge, this is the first study to observe that stimulant use may independently promote immune activation and tryptophan degradation among HIV-positive persons on ART. Further research is needed to replicate these findings and examine the plausible bio-behavioral pathways that may account for the effects of stimulant use on HIV disease markers and depleted tryptophan.

Effects of psychological interventions on neuroendocrine hormone regulation and immune status in HIV-positive persons: a review of randomized controlled trials

We reviewed randomized controlled trials (RCTs) that examined the effects of psychological interventions on HIV disease markers including neuroendocrine hormone regulation and immune status. Utilizing both PubMed and PsycINFO, we searched for RCTs published over the past 20 years (1987-2007). Of the 31 RCTs identified, 14 tested effects of psychological interventions on neuroendocrine regulation or immune status. Despite the fact that there are significant methodological limitations of RCTs that have been conducted to date, psychological interventions for HIV-positive persons have been shown to be efficacious in improving psychological adjustment compared with wait-list or treatment as usual control conditions. However, there is little support for differential efficacy of group-based interventions that have been tested to date, even in comparison with semistructured social support groups. Irrespective of the treatment modality, it seems that interventions that are successful in improving psychological adjustment are more likely to have salutary effects on neuroendocrine regulation and immune status. Psychological interventions represent a viable adjuvant treatment that can assist patients with improving psychological adjustment and potentially enhancing immune status. To inform the development of innovative treatments with potentially superior efficacy, deconstruction trials are necessary to examine the effects of distinct components of multimodal psychological interventions compared with nonspecific social support effects. Effectiveness trials of promising psychological interventions with more representative samples of HIV-positive persons are also needed to provide more definitive information on the clinical utility and potential cost-effectiveness of treatments that have been developed to date.