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

Looking at Complicating Non-Biological Issues in Women with HIV

INTRODUCTION

The increasing number of women acquiring Human Immunodeficiency Virus (HIV) has resulted in a 'feminization' of the epidemic. In this article we are reviewing whether females are disadvantaged in the epidemic, due to factors independent of the biological differences in sexes.

MATERIALS AND METHODS

We searched MEDLINE and EMBASE for articles with key words 'Women', 'Gender,' and 'HIV' in any field. The search was restricted to articles published in English within the last 10 years (1999-2009). Data were coded independently by two reviewers from 94 selected sources. The coded data were categorized under five commonly encountered concepts; violence, poverty, gender norms, prevention-/treatment-related issues, and Highly Active Anti-Retroviral Treatment (HAART).

RESULTS

The link between inter-partner violence (IPV) and HIV risk for women is observed by many authors. In assessing the link between poverty and HIV, indicators such as food insufficiency and income inequality may be better indicators compared to wealth itself. Although women are disadvantaged with male-dominated gender norms, evidence suggests that the traditional norms are changing in many societies. A positive association between living in urban communities, education, and better HIV knowledge has been observed in females, although it is not always synonymous with reduced risk behavior.

CONCLUSIONS

Women are still disadvantaged in many HIV-related issues such as poverty, violence, and gender norms. At least in Africa, there is evidence of a positive change in spheres of education and gender norms. However, the situation in Asia is largely unexplored.

Post-traumatic stress disorder and HIV: a snapshot of co-occurrence

Although the medical advances in the area of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) have undoubtedly improved the length and quality of life for those who are HIV-affected and medication adherent, there are still many psychosocial obstacles to effective HIV/AIDS medication adherence. Recent research has focused on one such obstacle. The significant link between post-traumatic stress disorder (PTSD) and HIV. This article reports on the nature of this relationship with a cross-sectional study of active clients (n = 186) who were receiving HIV services from community-based settings in the New York City area. With the use of the PTSD Checklist (PCL), this study determined that more than half of the sample tested positively for PTSD. Policy and clinical implications of this and other findings are discussed.

The importance of identifying and treating depression in HIV infected, pregnant women: a review

Women make up approximately half of all HIV infections worldwide. A substantial number of women living with HIV in the United States are of childbearing age and many of these women will become pregnant each year. These women must navigate the complexities of two health concerns (HIV infection and pregnancy) and the complexities of two health care provision systems (obstetrics and infectious disease). The goal of HIV treatment during pregnancy is to optimize health of the mother and minimize risk of vertical transmission. To realize these goals, high levels of adherence to antiretroviral therapy (ART) and periodic contact with medical professionals are required. Depression is not uncommon in pregnant women and has been identified as a robust predictor of non-adherence to ART and implicated in difficulty utilizing prenatal care. The purpose of the current article is to review evidence in support of diagnosis and treatment, when appropriate, of unipolar depression in HIV positive, pregnant women in developed nations. The article begins by defining the scope of the problem. Assessment and treatment options are discussed, followed by suggestions for future research.

Development and validation of a culturally appropriate HIV/AIDS Stigma Scale for Puerto Rican health professionals in training

HIV/AIDS stigma continues to be an obstacle for primary and secondary HIV prevention. Its consequences for the lives of people living with the disease have been well documented and continue to be of great concern for health care providers and researchers in the field. These consequences are worsened when such stigma emanates from health professionals, as this can limit access to services. One of the main obstacles for HIV/AIDS stigma research in Puerto Rico is the absence of quantitative measures to assess HIV/AIDS stigma manifestations among health professionals. In light of this gap in the scientific literature, the main objective of this study was to develop and test the psychometric properties of a culturally appropriate HIV/AIDS Stigma Scale for Puerto Rican health care providers and to develop a reduced form of the scale suitable for use in time-limited clinical settings. The developed measure was based on previous qualitative evidence gathered from Puerto Rican health professionals (Varas-Diaz, Serrano-Garcia, & Toro-Alfonso, 2005) and administered to a sample of 421 health professionals in training. The scale addresses 12 HIV/AIDS stigma dimensions. In quantitative analyses 11 of these dimensions demonstrated satisfactory validity and reliability. These dimensions in turn were subcomponents of a higher-order general stigma factor. Implications and limitations of these findings are discussed.

Health-related beliefs and decisions about accessing HIV medical care among HIV-infected persons who are not receiving care

In the United States, the publically supported national HIV medical care system is designed to provide HIV medical care to those who would otherwise not receive such care. Nevertheless, many HIV-infected persons are not receiving medical care. Limited information is available from HIV-infected persons not currently in care about the reasons they are not receiving care. From November 2006 to February 2007, we conducted five focus groups at community-based organizations and health departments in five U.S. cities to elicit qualitative information about barriers to entering HIV care. The 37 participants were mostly male (n = 29), over the age of 30 (n = 34), and all but one had not received HIV medical care in the previous 6 months. The focus group discussions revealed health belief-related barriers that have often been overlooked by studies of access to care. Three key themes emerged: avoidance and disbelief of HIV serostatus, conceptions of illness and appropriate health care, and negative experiences with, and distrust of, health care. Our findings point to the potentially important influence of these health-related beliefs on individual decisions about whether to access HIV medical care. We also discuss the implications of these beliefs for provider-patient communication, and suggest that providers frame their communications with patients such that they are attentive to the issues identified by our respondents, to better engage patients as partners in the treatment process.

Secondary prevention of HIV infection: the current state of prevention for positives

PURPOSE OF REVIEW

To provide a state-of-the-science review of the literature on secondary prevention of HIV infection or 'prevention for positives' (PfP) interventions.

RECENT FINDINGS

Early work on PfP focused on understanding the dynamics of risky behavior among People Living with HIV/AIDS (PLWH) and on designing, implementing, and evaluating a limited number of interventions to promote safer sexual and drug use behavior in this population (i.e., PfP interventions). Previous meta-analyses demonstrated that PfP interventions can effectively promote safer behavior. However, the understanding of risk dynamics among PLWH and the extant number and breadth of effective PfP interventions were scant. Recent work has addressed some of these problems, yielding greater understanding of risk dynamics and providing additional, effective interventions. Still, only a modest number of recent, rigorously evaluated, effective interventions have been identified. New ideas for creating stronger, more integrated, and effective PfP interventions have emerged that will guide future intervention research and practice.

SUMMARY

There remains much to be done to understand why, when, and under what conditions PLWH practice risk. Substantial work also needs to be performed to design, implement, rigorously evaluate, and when effective, to disseminate widely, additional, evidence-based PfP interventions targeting diverse populations. Directing such interventions to populations of PLWH at greatest risk for transmission of HIV has the potential to yield significant impact on the pandemic.

Exploring HIV stigma and quality of life for persons living with HIV infection

The purpose of this study was to explore the potential contribution of perceived HIV stigma to quality of life for people living with HIV infection. A cross-sectional design explored the contribution of demographic variables, symptoms, and stigma to quality of life in an international sample of 726 people living with HIV infection. Stigma independently contributed a significant 5.3% of the explained variance in quality of life, after removing contributions of HIV-related symptoms and severity of illness. This study empirically documents that perceived HIV stigma had a significantly negative impact upon quality of life for a broad sample of people living with HIV infection.

The role of social capital in successful adherence to antiretroviral therapy in Africa

Agnes Binagwaho and Niloo Ratnayake discuss the implications of a new ethnographic study that explores the reasons for the high rates of adherence to antiretroviral medicines in Africa.

The impact of mental health and traumatic life experiences on antiretroviral treatment outcomes for people living with HIV/AIDS

Potent antiretroviral therapy (ART) has transformed HIV from a death sentence to a chronic illness. Accordingly, the goal of HIV care has shifted from delaying death to achieving optimal health outcomes through ART treatment. ART treatment success hinges on medication adherence. Extensive research has demonstrated that the primary barriers to ART adherence include mental illness, especially depression and substance abuse, as well as histories of traumatic experiences such as childhood sexual and physical abuse. These psychosocial factors are highly prevalent in people living with HIV/AIDS (PLWHA) and predict poor ART adherence, increased sexual risk behaviours, ART treatment failure, HIV disease progression and higher mortality rates. The efficacy of standard mental health interventions, such as antidepressant treatment and psychotherapy, has been well-defined, and a small but growing body of research demonstrates the potential for such interventions to improve ART adherence and reduce sexual risk behaviours. Despite this evidence, mental disorders in PLWHA frequently go undiagnosed and untreated. Challenges to the provision of mental healthcare for PLWHA in HIV clinical settings include time and resource constraints, lack of expertise in psychiatric diagnosis and treatment, and lack of available mental health referral services. Future research should prioritize the evaluation of mental health interventions that are cost-effective and feasible for widespread integration into HIV clinical care; the impact of such interventions on ART adherence and clinical outcomes; and interventions to identify individuals with histories of traumatic experiences and to elucidate the mechanisms through which such histories pose barriers to effective HIV treatment.

Behavioral mediation of the relationship between psychosocial factors and HIV disease progression

The psychological and physical demands of coping with medication side effects and comorbid illnesses can be overwhelming and may influence behaviors, such as medication adherence, substance use, sexual risk behavior, and exercise that, in turn, affect health outcomes. Cross-sectional and prospective studies among diverse populations of persons living with HIV suggest that these behavioral mechanisms may be associated with HIV disease progression. The motivation to change behavior is often highest in the immediate aftermath of a stressor. However, over time the motivation to continue a particular behavior change is often challenged by habits, environmental influences, and psychosocial factors. Furthermore, a number of studies suggest that behavioral mechanisms may mediate the relationship between psychosocial variables (e.g., stress, depression, coping, and social support) and disease progression in HIV. Thus, developing clinical interventions that address these psychosocial factors and enhance protective health behaviors and reduce behaviors that convey risk to health are likely to lessen overall morbidity and mortality among patients living with HIV/AIDS.

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.

Role of depression, stress, and trauma in HIV disease progression

Despite advances in HIV treatment, there continues to be great variability in the progression of this disease. This paper reviews the evidence that depression, stressful life events, and trauma account for some of the variation in HIV disease course. Longitudinal studies both before and after the advent of highly active antiretroviral therapies (HAART) are reviewed. To ensure a complete review, PubMed was searched for all English language articles from January 1990 to July 2007. We found substantial and consistent evidence that chronic depression, stressful events, and trauma may negatively affect HIV disease progression in terms of decreases in CD4 T lymphocytes, increases in viral load, and greater risk for clinical decline and mortality. More research is warranted to investigate biological and behavioral mediators of these psychoimmune relationships, and the types of interventions that might mitigate the negative health impact of chronic depression and trauma. Given the high rates of depression and past trauma in persons living with HIV/AIDS, it is important for healthcare providers to address these problems as part of standard HIV care.