Outcomes from a group intervention for coping with HIV/AIDS and childhood sexual abuse: reductions in traumatic stress

A Pilot Randomized Control Trial of the Striving Towards EmPowerment and Medication Adherence (STEP-AD) Intervention for Black Women Living with HIV

Black women living with HIV (BWLWH) face adversities associated with lower HIV medication adherence, viral non-suppression, and mental health symptoms (e.g., post-traumatic stress disorder) such as trauma/violence, racism, HIV-related discrimination/stigma, and gender-related stressors. We developed the first intervention based in cognitive behavioral therapy and culturally congruent coping for BWLWH to increase medication adherence and decrease PTSD symptoms by enhancing resilience, self-care, engagement in care, and coping for trauma, racism, HIV-related discrimination/stigma, and gender-related stressors. A pilot randomized control trial was conducted with BWLWH and histories of trauma who were at risk for their HIV viral load remaining or becoming detectable (i.e., below 80% medication adherence, detectable viral load in the past year, and/or missed HIV-related appointments). 119 BWLWH were assessed at baseline and 70 met inclusion criteria, completed one session of Life-Steps adherence counseling, and were randomized to either nine sessions of STEP-AD (Striving Towards EmPowerment and Medication Adherence) or ETAU (enhanced treatment as usual consisting of biweekly check-ins). Women completed a post intervention follow up assessment (3 months post baseline) and 3-month post intervention follow-up (6 months post baseline). Via STATA the difference-in-difference methodology with mixed models compared STEP-AD to ETAU on changes in outcomes over time. BWLWH in STEP-AD compared to E-TAU had significantly higher ART adherence (estimate = 9.36 p = 0.045) and lower likelihood of being clinically diagnosed with PTSD (OR = .07, estimate = - 2.66, p = 0.03) as well as borderline significance on higher CD4 count (estimate = 161.26, p = 0.05). Our findings suggest preliminary efficacy of STEP-AD in improving ART adherence, mental health, and immune function.

Childhood trauma associated with psychotic-like experiences among people living with HIV: The chain mediation effect of stigma and resilience

BACKGROUND

Previous research established the associations between childhood trauma and psychosis, but the effects of childhood trauma on psychotic-like experiences (PLEs) among people living with HIV (PLWH) and the potential mediation mechanisms in these associations remain unclear.

OBJECTIVE

This study aimed to investigate the effects of childhood trauma on PLEs, as well as the chain mediation roles of stigma and resilience in this relationship. Furthermore, we explored whether the aforementioned associations differed when hallucinatory experiences (HEs) and delusional experiences (DEs) were separately modeled.

PARTICIPANTS AND SETTING

The sample included 333 outpatients participants (95.2 % males, Mage = 28.24 ± 7.12) living with HIV recruited from Hunan Province, China; and data were collected with a cross-sectional survey.

METHOD

The hypothesized chain mediation models were examined using SPSS PROCESS macro 3.3 software.

RESULTS

Various influencing mechanisms of childhood trauma on HEs and DEs were examined in this study. Our results showed that, (a) childhood trauma directly exerted negative effect on HEs, while the chain mediation effect of stigma and resilience were not statistically significant. Conversely, (b) childhood trauma exerted no direct influence on DEs but rather through the chain mediation effect of stigma and resilience.

CONCLUSIONS

The identification of two different routes between that childhood trauma can have on HEs and DEs highlighted the importance of tailored prevention and intervention among PLWH with a history of childhood trauma.

A Trauma-Informed, Geospatially Aware, Just-in-Time Adaptive mHealth Intervention to Support Effective Coping Skills Among People Living With HIV in New Orleans: Development and Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

In 2020, Greater New Orleans, Louisiana, was home to 7048 people living with HIV-1083 per 100,000 residents, 2.85 times the US national rate. With Louisiana routinely ranked last in indexes of health equity, violent crime rates in Orleans Parish quintupling national averages, and in-care New Orleans people living with HIV surviving twice the US average of adverse childhood experiences, accessible, trauma-focused, evidence-based interventions (EBIs) for violence-affected people living with HIV are urgently needed.

OBJECTIVE

To meet this need, we adapted Living in the Face of Trauma, a well-established EBI tailored for people living with HIV, into NOLA GEM, a just-in-time adaptive mobile health (mHealth) intervention. This study aimed to culturally tailor and refine the NOLA GEM app and assess its acceptability; feasibility; and preliminary efficacy on care engagement, medication adherence, viral suppression, and mental well-being among in-care people living with HIV in Greater New Orleans.

METHODS

The development of NOLA GEM entailed identifying real-time tailoring variables via a geographic ecological momentary assessment (GEMA) study (n=49; aim 1) and place-based and user-centered tailoring, responsive to the unique cultural contexts of HIV survivorship in New Orleans, via formative interviews (n=12; aim 2). The iOS- and Android-enabled NOLA GEM app leverages twice-daily GEMA prompts to offer just-in-time, in-app recommendations for effective coping skills practice and app-delivered Living in the Face of Trauma session content. For aim 3, the pilot trial will enroll an analytic sample of 60 New Orleans people living with HIV individually randomized to parallel NOLA GEM (intervention) or GEMA-alone (control) arms at a 1:1 allocation for a 21-day period. Acceptability and feasibility will be assessed via enrollment, attrition, active daily use through paradata metrics, and prevalidated usability measures. At the postassessment time point, primary end points will be assessed via a range of well-validated, domain-specific scales. Care engagement and viral suppression will be assessed via past missed appointments and self-reported viral load at 30 and 90 days, respectively, and through well-demonstrated adherence self-efficacy measures.

RESULTS

Aims 1 and 2 have been achieved, NOLA GEM is in Beta, and all aim-3 methods have been reviewed and approved by the institutional review board of Tulane University. Recruitment was launched in July 2023, with a target date for follow-up assessment completion in December 2023.

CONCLUSIONS

By leveraging user-centered development and embracing principles that elevate the lived expertise of New Orleans people living with HIV, mHealth-adapted EBIs can reflect community wisdom on posttraumatic resilience. Sustainable adoption of the NOLA GEM app and a promising early efficacy profile will support the feasibility of a future fully powered clinical trial and potential translation to new underserved settings in service of holistic survivorship and well-being of people living with HIV.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05784714; https://clinicaltrials.gov/ct2/show/NCT05784714.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47151.

Coping Strategies and Symptoms of Mental Health Disorders Among People with HIV Initiating HIV Care in Cameroon

Little is known about the coping strategies used among people with HIV (PWH), especially in sub-Saharan Africa, and the extent to which adaptive or maladaptive coping strategies are associated with symptoms of mental health disorders. We interviewed 426 PWH initiating HIV care in Cameroon and reported the prevalence of adaptive and maladaptive coping strategies, overall and by presence of symptoms of depression, anxiety, and PTSD. Log binominal regression was used to estimate the association between each type of coping strategy (adaptive or maladaptive) and symptoms of each mental health disorder, separately. Adaptive and maladaptive coping strategies were commonly reported among PWH enrolling in HIV care in Cameroon. Across all mental health disorders assessed, greater maladaptive coping was associated with higher prevalence of depression, anxiety, and PTSD. Adaptive coping was not associated with symptoms of any of the mental health disorders assessed in bivariate or multivariable models. Our study found that PWH endorsed a range of concurrent adaptive and maladaptive coping strategies. Future efforts should explore the extent to which coping strategies change throughout the HIV care continuum. Interventions to reduce maladaptive coping have the potential to improve the mental health of PWH in Cameroon.

The Relation between Depressive Symptoms and Unsafe Sex among MSM Living with HIV

In people living with HIV (PLWH), a positive association is often found between depressive symptoms and unsafe sex, which means sex without a condom. However, the results of such studies are inconclusive. The present study compared the numbers of safe and unsafe sexual contacts from men who have sex with men (MSM) (N = 159), living with HIV and attending a mental health clinic, with those of HIV-negative MSM in the general population (N = 198). We determined whether the presence of depressive symptoms was associated with unsafe sex in either of the two study populations. The depressive symptoms were measured with the Inventory of Depressive Symptoms (IDS), (MSM living with HIV) and with the 2012 Sexual Health Monitor (HIV-negative MSM). Finally, we determined whether MSM living with HIV with depressive symptoms, who received psychiatric treatment as usual, engaged in fewer unsafe sexual contacts one year after baseline. The mental-health-treatment-seeking MSM living with HIV engaged in more unsafe sexual contact than the MSM comparison group without HIV. Neither the treatment-seeking MSM living with HIV nor the MSM without HIV in the general population exhibited a relationship between depressive symptoms and unsafe sex. Moreover, the successful treatment of depressive symptoms in the treatment group did not lead to any reduction in the number of unsafe sexual contacts. Further research is needed to develop interventions that might be effective for MSM living with HIV with mental health symptoms to reduce the number of unsafe sexual contacts.

Effects of Early-Life Adversities on Neuropsychiatric and Executive Functions in HIV-Positive Adults

OBJECTIVE

Adverse childhood experiences (ACEs) contribute to elevations in neuropsychiatric and neurocognitive symptoms in HIV+ adults. Emerging data suggest that exposures to threat-related and deprivation-related ACEs may have differential impacts on function, with threat exposure contributing to neuropsychiatric symptoms, and deprivation contributing to executive dysfunction. Yet, it remains unclear how specific types of ACEs impact neuropsychiatric and neurocognitive symptoms in HIV+ adults. Hence, the current study examined whether these two dimensions of adversity contribute differentially to neuropsychiatric symptoms and executive dysfunction in HIV+ adults.

METHODS

We included a sample of demographically matched HIV+ (N = 72) and HIV-negative (N = 85) adults. Standardized self-report measures assessed threat-related (interpersonal violence) and deprivation-related (poverty/neglect) ACEs, as well as neuropsychiatric symptoms (depression, anxiety, apathy). A brief battery of neuropsychological tests assessed executive functions.

RESULTS

Compared to HIV-negative participants, HIV+ participants reported significantly higher rates of threat exposure (51% vs. 67%, p = .04), while rates of deprivation did not differ significantly (8% vs. 13%, p = .38). In the HIV+ sample, threat exposure was associated with neuropsychiatric symptoms (p < .01) but not executive dysfunction (p = .75). By contrast, deprivation was associated with executive dysfunction, at a trend level (p = .09), but not with neuropsychiatric symptoms (p = .70).

CONCLUSIONS

Our data suggest that, relative to HIV-negative samples, HIV+ samples experience higher rates of threat-related ACEs, which contribute to neuropsychiatric symptom elevations. Moreover, our preliminary findings suggest that different types of ACEs could be associated with different profiles of neuropsychiatric and neurocognitive difficulty in HIV+ adults, highlighting the importance of considering dimensions of adversity in future studies.

ImpACT+, a coping intervention to improve clinical outcomes for women living with HIV and sexual trauma in South Africa: study protocol for a randomized controlled trial

Background

Addressing sexual trauma in the context of HIV care is essential to improve clinical outcomes and mental health among women in South Africa. Women living with HIV (WLH) report disproportionately high levels of sexual trauma and have higher rates of posttraumatic stress disorder. Adherence to antiretroviral therapy (ART) may be difficult for traumatized women, as sexual trauma compounds the stress associated with managing HIV and is often comorbid with other mental health disorders, further compromising care engagement and adherence. ART initiation represents a unique window of opportunity for intervention to enhance motivation, increase care engagement, and address the negative effects of trauma on avoidant coping behaviors. Mental health interventions delivered by non-specialists in low- and middle-income countries have potential to treat depression, trauma, and effects of intimate partner violence among WLH. This study will examine the effectiveness of Improving AIDS Care after Trauma (ImpACT +), a task-shared, trauma-focused coping intervention, to promote viral suppression among WLH initiating ART in a South African clinic setting.

Methods

This study will be conducted in Khayelitsha, a peri-urban settlement situated near Cape Town, South Africa. Using a hybrid type 1 effectiveness-implementation design, we will randomize 350 WLH initiating ART to the ImpACT + experimental condition or the control condition (three weekly sessions of adapted problem-solving therapy) to examine the effectiveness of ImpACT + on viral suppression, ART adherence, and the degree to which mental health outcomes mediate intervention effects. ImpACT + participants will receive six once-a-week coping intervention sessions and six monthly maintenance sessions over the follow-up period. We will conduct mental health and bio-behavioral assessments at baseline, 4, 8, and 12 months, with care engagement data extracted from medical records. We will explore scalability using the Consolidated Framework for Implementation Research (CFIR).

Discussion

This trial is expected to yield important new information on psychologically informed intervention models that benefit the mental health and clinical outcomes of WLH with histories of sexual trauma. The proposed ImpACT + intervention, with its focus on building coping skills to address traumatic stress and engagement in HIV care and treatment, could have widespread impact on the health and wellbeing of individuals and communities in sub-Saharan Africa.

Trial registration

Clinicaltrials.gov NCT04793217. Retrospectively registered on 11 March 2021.

A Qualitative Study of the Impact of HIV on Intimacy and Sexuality Among Older Childhood Sexual Abuse Survivors Living with HIV

Childhood sexual abuse (CSA) is a traumatic event known to influence health outcomes, and the rate of CSA among people living with HIV is more than twice that of the general population. Individuals living with HIV with a history of CSA may find establishing intimacy and sexual relations more challenging due to the dual adverse impact of HIV and CSA. This study aimed to explore the effects of HIV on intimacy and sexuality among older CSA survivors living with HIV. We collected data from 24 older adults living with HIV (OALH) aged 50 and older with a history of CSA in South Carolina via in-depth, semi-structured, one-on-one interviews. We used a thematic analysis approach comprising discussion of initial thoughts and key concepts, identifying and reconciling codes, and naming emergent themes for analysis. Five themes emerged: rejection, avoidance, vulnerability, relationship with a partner living with HIV, and no or low sexual intimacy. Study participants reported that they desired to establish intimate relationships; however, living with HIV impacted their ability to do so, affecting their overall health and quality of life. Our findings suggest that addressing the intimacy and sexuality of older CSA survivors living with HIV is warranted in their continuum of care to improve their health outcomes and overall quality of life.

Mental Health Mediates the Association Between Gender-Based Violence and HIV Treatment Engagement in US Women

BACKGROUND

Gender-based violence (GBV) is associated with poorer engagement in HIV care and treatment. However, there is a dearth of research on the psychological (eg, mental health) and structural (eg, food insecurity) factors that mediate and moderate this association. GBV could lead to poor mental health, which in turn affects adherence, whereas food insecurity could worsen the effect of GBV on engagement in care. This study uses data from the Women's Interagency HIV Study to address these gaps.

METHODS

Women completed 6 assessments from 2013 to 2016 on GBV, mental health, food insecurity, adherence to antiretroviral therapy, and missed HIV care appointments in the past 6 months. Multilevel logistic regression models estimated associations between GBV and engagement in care and whether associations were mediated by depression, generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD) and moderated by food insecurity.

RESULTS

GBV was associated with higher odds of suboptimal adherence (adjusted odds ratio: 1.88; 95% confidence interval: 1.24 to 2.87) and missed appointments (adjusted odds ratio: 1.76; 95% confidence interval: 1.16 to 2.67). The association between GBV and adherence was mediated by depressive symptoms, GAD, and PTSD, accounting for 29.7%, 15.0%, and 16.5%, respectively, of the total association. The association between GBV and missed appointments was mediated by depression and GAD, but not PTSD, with corresponding figures of 25.2% and 19.7%. Associations did not differ by food insecurity.

CONCLUSIONS

GBV is associated with suboptimal engagement in care, which may be explained by mental health. Interventions should address women's mental health needs, regardless of food insecurity, when improving engagement in HIV care.

COVID-19-related stressful experiences and posttraumatic stress disorder symptoms among college students in China: A moderated mediation model of perceived control over the future and empathy

The current study aims to investigate the mediating effect of perceived control over the future and the moderating effect of empathy on the association between stressful experiences and PTSD symptoms among college students in China in response to COVID-19. A sample of 1,225 college students (70.69% were female, M age = 20.22 years, SD = 2.02) were recruited using web-based surveys at wave 1 (W1) and wave 2 (W2) longitudinally. Results showed that COVID-19-related stressful experiences were significantly associated with PTSD symptoms. Perceived control over the future partially mediated the relationship between these two variables ( indirect effect size = 0.09, p < 0.01). Empathy significantly moderated the path from perceived control over the future to PTSD symptoms, suggesting that the association was stronger for individuals with higher levels of empathy. Findings suggest a protective effect of perceived control over the future on college students’ PTSD symptoms during the COVID-19 pandemic. Such a protective effect was intensified by empathy. Future intervention to manage PTSD symptoms should be tailored to positive future expectations and empathy.

Interventions for addressing trauma among people with HIV: a narrative review

Traumatic experiences are disproportionately prevalent among people with HIV and adversely affect HIV-related health outcomes. As part of a national cooperative agreement funded by the Health Resources and Services Administration's HIV/AIDS Bureau, we searched the literature for interventions designed to address trauma among people with HIV in the U.S. Our search yielded 22 articles on 14 studies that fell into five intervention categories: expressive writing, prolonged exposure therapy, coping skills, cognitive-behavioral approaches integrated with other methods, and trauma-informed care. Thematic elements among the interventions included adaptating existing interventions for subpopulations with a high burden of trauma and HIV, such as transgender women and racial/ethnic minorities; addressing comorbid substance use disorders; and implementing organization-wide trauma-informed care approaches. Few studies measured the effect of the interventions on HIV-related health outcomes. To address the intersecting epidemics of HIV and trauma, it is critical to continue developing, piloting, and evaluating trauma interventions for people with HIV, with the goal of wide-scale replication of effective interventions in HIV settings.

Mental Health in Women Living With HIV: The Unique and Unmet Needs

Women living with HIV (WLWH) experience depression, anxiety, and posttraumatic stress symptoms at higher rates than their male counterparts and more often than HIV-unaffected women. These mental health issues affect not only the well-being and quality of life of WLWH, but have implications for HIV management and transmission prevention. Despite these ramifications, WLWH are under-treated for mental health concerns and they are underrepresented in the mental health treatment literature. In this review, we illustrate the unique mental health issues faced by WLWH such as a high prevalence of physical and sexual abuse histories, caregiving stress, and elevated internalized stigma as well as myriad barriers to care. We examine the feasibility and outcomes of mental health interventions that have been tested in WLWH including cognitive behavioral therapy, mindfulness-based interventions, and supportive counseling. Future research is required to address individual and systemic barriers to mental health care for WLWH.

Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review

BACKGROUND

People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people.

OBJECTIVE

To identify candidate psychological and non-pharmacological treatments for future research.

DESIGN

Mixed-methods systematic review.

PARTICIPANTS

Adults aged ≥ 18 years with a history of complex traumatic events.

INTERVENTIONS

Psychological interventions versus control or active control; pharmacological interventions versus placebo.

MAIN OUTCOME MEASURES

Post-traumatic stress disorder symptoms, common mental health problems and attrition.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017.

REVIEW METHODS

Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist.

RESULTS

One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference -0.90, 95% confidence interval -1.14 to -0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs.

LIMITATIONS

Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented.

CONCLUSIONS

Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder.

FUTURE WORK

Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017055523.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.

Psychological and pharmacological interventions for posttraumatic stress disorder and comorbid mental health problems following complex traumatic events: Systematic review and component network meta-analysis

BACKGROUND

Complex traumatic events associated with armed conflict, forcible displacement, childhood sexual abuse, and domestic violence are increasingly prevalent. People exposed to complex traumatic events are at risk of not only posttraumatic stress disorder (PTSD) but also other mental health comorbidities. Whereas evidence-based psychological and pharmacological treatments are effective for single-event PTSD, it is not known if people who have experienced complex traumatic events can benefit and tolerate these commonly available treatments. Furthermore, it is not known which components of psychological interventions are most effective for managing PTSD in this population. We performed a systematic review and component network meta-analysis to assess the effectiveness of psychological and pharmacological interventions for managing mental health problems in people exposed to complex traumatic events.

METHODS AND FINDINGS

We searched CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, International Pharmaceutical Abstracts, MEDLINE, Published International Literature on Traumatic Stress, PsycINFO, and Science Citation Index for randomised controlled trials (RCTs) and non-RCTs of psychological and pharmacological treatments for PTSD symptoms in people exposed to complex traumatic events, published up to 25 October 2019. We adopted a nondiagnostic approach and included studies of adults who have experienced complex trauma. Complex-trauma subgroups included veterans; childhood sexual abuse; war-affected; refugees; and domestic violence. The primary outcome was reduction in PTSD symptoms. Secondary outcomes were depressive and anxiety symptoms, quality of life, sleep quality, and positive and negative affect. We included 116 studies, of which 50 were conducted in hospital settings, 24 were delivered in community settings, seven were delivered in military clinics for veterans or active military personnel, five were conducted in refugee camps, four used remote delivery via web-based or telephone platforms, four were conducted in specialist trauma clinics, two were delivered in home settings, and two were delivered in primary care clinics; clinical setting was not reported in 17 studies. Ninety-four RCTs, for a total of 6,158 participants, were included in meta-analyses across the primary and secondary outcomes; 18 RCTs for a total of 933 participants were included in the component network meta-analysis. The mean age of participants in the included RCTs was 42.6 ± 9.3 years, and 42% were male. Nine non-RCTs were included. The mean age of participants in the non-RCTs was 40.6 ± 9.4 years, and 47% were male. The average length of follow-up across all included studies at posttreatment for the primary outcome was 11.5 weeks. The pairwise meta-analysis showed that psychological interventions reduce PTSD symptoms more than inactive control (k = 46; n = 3,389; standardised mean difference [SMD] = -0.82, 95% confidence interval [CI] -1.02 to -0.63) and active control (k-9; n = 662; SMD = -0.35, 95% CI -0.56 to -0.14) at posttreatment and also compared with inactive control at 6-month follow-up (k = 10; n = 738; SMD = -0.45, 95% CI -0.82 to -0.08). Psychological interventions reduced depressive symptoms (k = 31; n = 2,075; SMD = -0.87, 95% CI -1.11 to -0.63; I2 = 82.7%, p = 0.000) and anxiety (k = 15; n = 1,395; SMD = -1.03, 95% CI -1.44 to -0.61; p = 0.000) at posttreatment compared with inactive control. Sleep quality was significantly improved at posttreatment by psychological interventions compared with inactive control (k = 3; n = 111; SMD = -1.00, 95% CI -1.49 to -0.51; p = 0.245). There were no significant differences between psychological interventions and inactive control group at posttreatment for quality of life (k = 6; n = 401; SMD = 0.33, 95% CI -0.01 to 0.66; p = 0.021). Antipsychotic medicine (k = 5; n = 364; SMD = -0.45; -0.85 to -0.05; p = 0.085) and prazosin (k = 3; n = 110; SMD = -0.52; -1.03 to -0.02; p = 0.182) were effective in reducing PTSD symptoms. Phase-based psychological interventions that included skills-based strategies along with trauma-focused strategies were the most promising interventions for emotional dysregulation and interpersonal problems. Compared with pharmacological interventions, we observed that psychological interventions were associated with greater reductions in PTSD and depression symptoms and improved sleep quality. Sensitivity analysis showed that psychological interventions were acceptable with lower dropout, even in studies rated at low risk of attrition bias. Trauma-focused psychological interventions were superior to non-trauma-focused interventions across trauma subgroups for PTSD symptoms, but effects among veterans and war-affected populations were significantly reduced. The network meta-analysis showed that multicomponent interventions that included cognitive restructuring and imaginal exposure were the most effective for reducing PTSD symptoms (k = 17; n = 1,077; mean difference = -37.95, 95% CI -60.84 to -15.16). Our use of a non-diagnostic inclusion strategy may have overlooked certain complex-trauma populations with severe and enduring mental health comorbidities. Additionally, the relative contribution of skills-based intervention components was not feasibly evaluated in the network meta-analysis.

CONCLUSIONS

In this systematic review and meta-analysis, we observed that trauma-focused psychological interventions are effective for managing mental health problems and comorbidities in people exposed to complex trauma. Multicomponent interventions, which can include phase-based approaches, were the most effective treatment package for managing PTSD in complex trauma. Establishing optimal ways to deliver multicomponent psychological interventions for people exposed to complex traumatic events is a research and clinical priority.

Improving the quality of care for female rape survivors at Scottish Livingstone Hospital, Molepolole, Botswana: A quality improvement cycle

BACKGROUND

Rape is prevalent in Botswana, but there has been limited research undertaken to improve the quality of healthcare for female rape survivors in this clinical setting. Research can not only influence the health outcomes of victims but also has the potential to inform policy.

AIM

The aim of this study was to improve the quality of care for female rape survivors in Scottish Livingstone Hospital, Molepolole, Botswana.

SETTING

The setting is Scottish Livingstone Hospital, Molepolole, Botswana.

METHODS

This study was a qualitative cycle, using the normal steps of performing a baseline audit of clinical practice, planning and implementing changes and re-audit.

RESULTS

A total of 124 patient records were audited, comprising 62 patient records at baseline and re-audit. The mean age of victims was 23 years and the age category with the highest incidence of rape ranged between 12 and 20 years, constituting 47% of patients' records. During the baseline audit, only one out of 10 structural standards was met, while at re-audit eight structural standards were fully met. Although none of the process standards were met during both audits, statistically significant improvements in performance (p 0.05) were shown in six out of 10 criteria at re-audit.

CONCLUSION

The quality of care for female rape survivors is suboptimal in our setting. However, simple interventions to improve the structure in place for patients and upskilling the entire practice team to align care to current international standards can improve the overall quality of healthcare.

Listening to the Therapeutic Needs of Male Survivors of Childhood Sexual Abuse

Childhood sexual abuse of males is not uncommon with estimated prevalence rates across countries and different studies indicating that 8% of boys experience sexual abuse before age 18. A number of adverse outcomes are recognized in terms of mental health, behavioral, and relational difficulties. However, research also indicates that there is potential for healing. The present study explores the barriers, benefits, and processes involved in engagement in formal therapy for adult survivors of CSA from the male survivor's point of view. Nine men spoke of their treatment experiences in response to semistructured interviews. Participants were all members of a group for male survivors of sexual abuse. Seven participants reported benefiting from treatment. Interpretative phenomenological analysis (IPA) of the interviews identified three superordinate themes: "motivation to engage in treatment," "developing a connection with treatment providers," and "changing thinking about the abuse." These themes reveal a number of obstacles that are encountered in seeking treatment including stigma, process barriers, and engagement of a skilled and empathic therapist. For the men who were able to take part in therapy despite these barriers, improved quality of life were noted through the two primary mechanisms of relationship and changed thinking. Key changes in thinking included developing an awareness that they were not responsible for the abuse, understanding the effects of abuse, and developing an identity distinct from the experience of abuse. These changes in thinking occurred within the context of a robust therapeutic relationship.

Learning to address multiple syndemics for people living with HIV through client perspectives on CBT

OBJECTIVE

The mental health burden among people living with HIV/AIDS (PLWHA) is high and often involves multiple comorbid psychological and substance use-related psychosocial problems. These co-occurring problems, or syndemics, additively impair engagement in HIV disease management. Existing psychotherapies for mental health and HIV health have generally focused on a single psychosocial problem and little research exists to guide future psychotherapies that address multiple mental health issues.

METHOD

To address this gap in understanding, we conducted qualitative interviews with multiply comorbid PLWHA (N = 30) who completed cognitive-behavioural therapy (CBT) for depression and medication adherence.

RESULTS

Themes emerged regarding participants' perspectives on how overlapping substance use and mood disorders interacted to reduce the benefit of CBT. Substance use was a dominant theme compared to other syndemics, highlighting the need for integrated mental health and substance use interventions. Interviews also suggested modifications of which psychosocial concerns participants felt should be prioritized in treatment delivery. Finally, participants described content they would want in a psychotherapy intervention, including intimacy and sexual health.

CONCLUSIONS

Future psychotherapeutic interventions for syndemic problems and HIV self-care will need to comprehensively address complex concerns, including issues salient to the overall well-being of PLWHA. This may improve client engagement and, ultimately, mental, and physical health outcomes. Clinical or methodological significance of this article: Although mental health comorbidity is common and often complex among clients living with HIV, little research exists to guide psychotherapy for such intricate mental health concerns. The current study used content analysis of in-depth qualitative interviews with clients living with HIV and multiple mental health comorbidities who had recently completed cognitive-behavioural therapy. Recommendations based on these findings suggest strategies for clinicians working with similar clients to consider and offers suggestions for future treatment development research.

A systematic review and meta-analysis of group treatments for adults with symptoms associated with complex post-traumatic stress disorder

BACKGROUND

No previous meta-analyses have specifically investigated the effectiveness of psychological group therapy for symptoms associated with complex interpersonal trauma, including whether trauma memory processing (TMP) therapies are superior to psychoeducational approaches alone.

METHODS

A systematic review identified 36 randomised control trials (RCTs) which were included in the meta-analysis.

RESULTS

Large significant effect sizes were evident for TMP interventions when compared to usual care for three outcome domains including: PTSD (k = 6, g = -0.98, 95% CI -1.53, -0.43), Depression (k = 7, g = -1.12, 95% CI -2.01, -0.23) and Psychological Distress (k = 6, g = -0.98, 95% CI 1.66, -0.40). When TMP and psychoeducation interventions were directly compared, results indicated a small non-significant effect in favour of the former for PTSD symptoms, (k = 4, g = -0.34, 95% CI -1.05, 0.36) and small non-significant effect sizes in favour of the latter for Depression (k = 3, g = 0.29, 95% CI -0.83, 1.4) and Psychological Distress (k = 6, g = 0.19, 95% CI -0.34, 0.71).

LIMITATIONS

Heterogeneity and a limited number of high quality RCTs, particularly in the Substance Misuse and Dissociation domains, resulted in uncertainty regarding meta-analytical estimates and subsequent conclusions.

CONCLUSIONS

Results suggest that TMP interventions are useful for traumatic stress whereas non-TMP interventions can be useful for symptoms of general distress (e.g. anxiety and depression). Thus, both TMP and psychoeducation can be useful for the treatment of complex interpersonal trauma symptoms and further research should unravel appropriate sequencing and dose of these interventions.

Attraction Versus Action in Pedophilic Desire: The Role of Personality Traits and Childhood Experience

OBJECTIVE

Comparison of pedophilic individuals who do and do not refrain from sexually engaging with children may offer critically important information regarding the differential contributors to pedophilic attraction versus behavior. This study compared 5 traits that are potentially contributory to pedophilic attraction or behavior in both minor-attracted persons (MAPs) who refrain from sexually engaging with minors (nonacting MAPs) and those who have acted on pedophilic attractions and subsequently entered the criminal justice system (forensic MAPs).

METHODS

Subjects included 195 nonacting MAPs, 50 forensic MAPs, and 60 healthy controls. Data on nonacting MAPs were drawn from an online survey, and data on the other 2 groups were based on prior in-person evaluations. Measures included the Millon Clinical Multiaxial Inventory-II (MCMI-II), Barratt Impulsiveness Scale (BIS-11), the MAP Questionnaire, and the Sexual History Questionnaire (SHQ).

RESULTS

Both MAP groups scored higher than healthy controls on the domains of socially inhibited personality traits, propensity toward cognitive distortions, and subjects' own childhood sexual abuse (CSA). Forensic MAPs scored higher than nonacting MAPs on the CSA domain, but the 2 MAP groups differed little on the other 2 domains. Forensic MAPs also scored higher than the other 2 groups on the antisocial domain, whereas nonacting MAPs did not differ from controls on this measure. Nonacting MAPs scored higher than controls on impulsivity.

CONCLUSIONS

Antisocial personality traits may be a primary driver of pedophilic behavior that is unrelated to pedophilic attraction. Socially inhibited personality traits and propensity toward cognitive distortions are associated with pedophilic attraction, although the direction of causation is not clear. CSA seems to increase the risk of both attraction and behavior.

The Relationship Between Posttraumatic Stress Disorder Symptoms and Posttraumatic Growth Among HIV-Infected Men Who Have Sex With Men in Beijing, China: The Mediating Roles of Coping Strategies

The traumatic experience of contracting and living with HIV/AIDS may produce a myriad of mental health problems, especially posttraumatic stress disorder (PTSD) symptoms, and conversely, bring posttraumatic growth (PTG), that is, positive changes resulting from a struggle with trauma. The growing body of research into the relationship between PTSD symptoms and PTG has produced mixed results. In addition, some research has suggested that psychosocial and cognitive factors may mediate the development of PTG after trauma exposure. Specifically, individuals experience fewer psychological symptoms and better mental health when adaptive coping strategies align with stressors; however, little research is available on the relationship and the mediating effect of coping strategies on the link of PTSD symptoms and PTG among HIV-infected men who have sex with men (MSM) in China. The aims of the current study were to investigate the relationship between PTSD symptoms and PTG as well as the potential mediating effects of coping strategies through which PTSD symptoms contributes to PTG among this vulnerable population. One hundred and forty HIV-positive MSM were recruited from the Beijing Center for Disease Prevention and Control and were asked to complete a battery of self-administered questionnaires, covering sociodemographic and HIV-related characteristics, coping strategies (i.e., problem-solving, seeking social support, self-blame, and wishful thinking), PTSD symptoms, and PTG. Results showed that, after controlling for sociodemographic and HIV-related variables, a negative linear relationship was found between PTSD symptoms and PTG. In addition, problem-solving and self-blame played significant mediating roles in the association between PTSD symptoms and PTG. The mediating effects of seeking social support and engaging in wishful thinking on the PTSD symptoms and PTD link were, however, non-significant. The present study contributes to an understanding of the association between PTSD symptoms and PTG and underscores the mediators through which individuals gain growth from traumatic experience in the context of HIV infection in Beijing, China. Given these findings, the future efforts at psychological intervention should differentiate and target various types of coping strategies, especially focusing on enhancing problem-solving skills and decreasing self-blame, in response to the promotion of positive growth among HIV-infected MSM.

Toward evidence-based anti-human trafficking policy: a rapid review of CSE rehabilitation and evaluation of Indian legislation

This paper (a) examines the evidence base around rehabilitation of victims of trafficking for commercial sexual exploitation (CSE), (b) identifies the extent that India's proposed 2016 Trafficking of Persons (Prevention, Protection, and Rehabilitation) Bill reflects scientific and experiential evidence, and (c) discusses how gaps in the proposed bill can be informed by evidence. A rapid review of empirical studies on policies and interventions addressing rehabilitation of CSE victims was conducted. Although evidence is lacking, research suggests that cross-sectoral collaboration, training and monitoring law enforcement, psychotherapeutic interventions and care provided by short-term shelters, reintegration, and recognizing victims' rights improve the success of rehabilitative efforts. The proposed legislation does not sufficiently reflect evidence around successful rehabilitation efforts and suggests that implementing the bill as it currently stands would change little of the existing structures to support victims in receiving adequate services or successfully reintegrating into society.

Quality of life in HIV-infected Chinese women and their family caregivers: an intervention study

China is experiencing a rapid increase in the number of HIV-infected women. In this study, we describe the development and preliminary evaluation of an intervention tailored for Chinese HIV-infected women and caregivers to improve their self- and family management, with goals of enhancing their physical quality of life (QOL) and decreasing their depressive symptomatology. Forty-one HIV-infected women and their caregivers were recruited from two premier Chinese hospitals from July 2014 through March 2016. Participants were randomized to either the control or intervention arm for the Self- and Family Management Intervention (SAFMI). Each study dyad in the intervention arm received three counseling sessions with a nurse interventionist. At baseline, immediate post-intervention (month 1) and follow-up (month 3), the participants were assessed by a self-reported survey. Generalized Hierarchical Linear Modeling was used to evaluate the efficacy of the intervention. Chinese HIV-infected women in the intervention arm had significantly higher probability of higher physical QOL at month 1 and lower probability of clinically meaningful depressive symptomatology at month 3 compared with women in the control arm. In contrast, the effects of the intervention were less salient for caregivers. This study represents one of the first in China to include family caregivers in HIV management. Feasibility and acceptability were high, in that family members were willing to join the study, learn about HIV, and practice new skills to support the HIV-infected women in their lives. A larger trial is needed to fully evaluate this intervention which shows promising preliminary effects in promoting physical QOL and decreasing depressive symptomatology among Chinese HIV-infected women.

Acculturation, family cohesion, and mental health among Latinos living with HIV on the U.S.-Mexico border

OBJECTIVE

The objective of the study was to investigate whether acculturation to U.S. culture is associated with greater posttraumatic stress disorder (PTSD) symptomatology through diminished family cohesion among Latinos living with HIV on the U.S.-Mexico border.

METHOD

Baseline survey data were analyzed from a sample of Latinos seeking HIV care from a publicly funded HIV clinic in El Paso, Texas. We used a regression-based bootstrapping approach to test our mediation hypothesis.

RESULTS

A total of 248 Latinos living with HIV completed the survey, with 96.4% being of Mexican descent, 19.4% female (gender self-identification), and 63.7% nonheterosexual (sexual orientation self-identification). Family cohesion mediated the relationship between U.S. acculturation and PTSD symptom scores (a1 ⁎ b1 = .03, 95% confidence interval [.01-.06]), an effect independent of acculturation to Latino culture.

CONCLUSIONS

Acculturation to U.S. culture may negatively impact mental health through weakening family bonds in this vulnerable population. (PsycINFO Database Record

Correlates of Condom use Among Community College Women: The Role of Victimization, Substance Use, and Mental Health Symptoms

Research is needed to understand intersecting health risks among community college students. Applying a syndemic framework, the present research explored childhood sexual victimization, adolescent sexual victimization, intimate partner violence (IPV), marijuana use, alcohol consumption, and symptoms of depression and post-traumatic stress disorder as additive as well as interactive correlates of women's condom use. Questionnaires were administered to a sample of 212 women between the ages of 18 to 24 attending a community college. A series of logistic regression analyses documented that an increased number of psychosocial risk factors was associated with not using a condom during sexual intercourse. Experiencing both adolescent sexual victimization and lifetime intimate partner violence (IPV), compared to experiencing one form of victimization, increased the odds of not using a condom. Endorsing both lifetime IPV and past year marijuana use, compared to endorsing only one of these factors, also increased the odds of not using a condom. These findings highlight the importance of targeting intersections between adolescent sexual victimization, IPV, marijuana use, and sexual risk behavior when developing educational programs for community college women.

Risk-taking, revictimisation and perpetration of sexual violence in ten southern African countries

This paper reports the results of a cross-sectional survey of 11- to 16-year-old school-going youths in ten southern African countries. The survey instrument recorded both the experience of coerced sex and the perpetration of forced sex. There were prominent school and community risk factors for increased risk-taking behaviours, revictimisation and the perpetration of sexual violence. This supports the idea that the local culture can reinforce the antisocial consequences of sexual abuse of boys and girls. There was a suggestion that the school environment can compound the effects of child sexual abuse in terms of conscious knowledge, high-risk behaviour, the risk of revictimisation and disdain for the safety of others.

Developing an Emotion- and Memory-Processing Group Intervention for PTSD with complex features: a group case series with survivors of repeated interpersonal trauma

Individuals who experience repeated interpersonal trauma exposure often present with posttraumatic stress disorder (PTSD) with more complex features. There is currently no consensus regarding whether current evidence-based interventions for PTSD need to be tailored to better account for these complex features. However, one recommended adaptation is to adopt a phase-based or sequenced approach involving three phases, each with a distinct function. This paper describes the development of a 12-session Emotion- and Memory-Processing Group Programme, adapted from Cloitre's Skills Training in Affective and Interpersonal Regulation (STAIR) phase-based treatment protocol. A single case series provided a preliminary examination of the group-based intervention's efficacy for three groups of women with a history of repeated interpersonal trauma and PTSD with complex features (N = 15; age 19-46 years) at The Haven Sexual Assault Referral Centre in London. Results revealed significant reductions in: PTSD, complex features of PTSD, and depression, along with improvements in process measures of maladaptive cognitions and emotion processing. Results from this case series demonstrate that an Emotion- and Memory-Processing Group Programme holds promise for treating individuals with a history of interpersonal trauma in outpatient settings, and provides evidence to warrant the completion of a feasibility trial.

A randomized controlled trial to enhance coping and posttraumatic growth and decrease posttraumatic stress disorder in HIV-Infected men who have sex with men in Beijing, China

Although HIV-infected men who have sex with men (MSM) constitute a newly emerged high-risk group in China, little research outside Western countries is available on effective intervention programs to enhance their well-being. The purpose of this randomized controlled trial was to evaluate the efficacy of a group intervention program designed to improve the well-being and adaptive coping strategies of 60 HIV-infected MSM in Beijing, China, randomly assigned either to the intervention group for participation in four weekly sessions or to the control group for placement on a waiting list. They all completed measurements at pre- and postintervention. Compared with the control group, the intervention group reported significantly increased problem-focused coping strategies and levels of posttraumatic growth (PTG) as well as decreased symptoms of posttraumatic stress disorder (PTSD) at the completion of the intervention. In addition, mediation analysis showed that changes in problem-focused coping strategies mediated the intervention effect on increases in PTG; however, the mediating effect of coping strategies on the association of intervention and PTSD was not significant. This study provides empirical evidence for conducting psychological intervention to promote the well-being of HIV-infected MSM. The findings also elucidate the mechanism through which intervention improved PTG.

Striving Towards Empowerment and Medication Adherence (STEP-AD): A Tailored Cognitive Behavioral Treatment Approach for Black Women Living With HIV

In the U.S. Black women with HIV face numerous psychosocial challenges, particularly trauma, racism, HIV-related discrimination, and gender role expectations, that are associated with negative HIV health outcomes and low medical treatment adherence. Yet many of these factors are unaddressed in traditional cognitive behavioral approaches. This study presents a case series of a tailored cognitive behavioral treatment approach for Black women living with HIV. Striving Towards EmPowerment and Medication Adherence (STEP-AD) is a 10-session treatment aimed at improving medication adherence for Black women with HIV by combining established cognitive behavioral strategies for trauma symptom reduction, strategies for coping with race- and HIV-related discrimination, gender empowerment, problem-solving techniques for medication adherence, and resilient coping. A case series study of five Black women with HIV was conducted to evaluate the preliminary acceptability and feasibility of the treatment and illustrate the approach. Findings support the potential promise of this treatment in helping to improve HIV medication adherence and decrease trauma symptoms. Areas for refinement in the treatment as well as structural barriers (e.g., housing) in the lives of the women that impacted their ability to fully benefit from the treatment are also noted.

Impact of Sexual Trauma on HIV Care Engagement: Perspectives of Female Patients with Trauma Histories in Cape Town, South Africa

South African women have disproportionately high rates of both sexual trauma and HIV. To understand how sexual trauma impacts HIV care engagement, we conducted in-depth qualitative interviews with 15 HIV-infected women with sexual trauma histories, recruited from a public clinic in Cape Town. Interviews explored trauma narratives, coping behaviors and care engagement, and transcripts were analyzed using a constant comparison method. Participants reported multiple and complex traumas across their lifetimes. Sexual trauma hindered HIV care engagement, especially immediately following HIV diagnosis, and there were indications that sexual trauma may interfere with future care engagement, via traumatic stress symptoms including avoidance. Disclosure of sexual trauma was limited; no women had disclosed to an HIV provider. Routine screening for sexual trauma in HIV care settings may help to identify individuals at risk of poor care engagement. Efficacious treatments are needed to address the psychological and behavioral sequelae of trauma.

Cancer treatment experiences among survivors of childhood sexual abuse: A qualitative investigation of triggers and reactions to cumulative trauma

ABSTRACTObjective:Some 25% of women and 8% of men in the United States have experienced childhood sexual abuse (CSA) before the age of 18. For these individuals, healthcare visits and interactions can be retraumatizing due to perceived similarities to past abuse (e.g., pain, undressing, lack of control). However, no prior studies have provided formal qualitative analyses regarding CSA survivors' reactions to cancer treatment. Therefore, our study's objective was to identify key themes pertaining to CSA survivors' cancer treatment experiences.

METHOD

Male and female members of the Amazon Mechanical Turk (N = 159, mean age = 44.27 years, SD = 10.02) participated in an anonymous online survey study. The inclusion criteria included reporting: history of CSA; a diagnosis of colorectal, gynecological, breast, or skin cancer; and experience of triggers and/or difficulties during cancer treatment. Participants' responses to open-ended questions were analyzed using inductive thematic analysis.

RESULTS

We identified two primary themes describing CSA survivors' experiences: Theme 1: treatment-related triggers (key subthemes: procedure-related, provider-related, and emotional triggers); and Theme 2: questioning the meaning of cumulative trauma (e.g., "Why me again?").

SIGNIFICANCE OF RESULTS

For CSA survivors, cancer and its treatment can trigger thoughts and emotions associated with the original abuse as well as negative evaluations of themselves, the world, and their future. Our findings are consistent with past research on CSA survivors' experiences in non-cancer healthcare settings and add to the literature by highlighting their struggles during cancer treatment. The present results can inform further research on trauma survivors' reactions to cancer treatment and give cancer care providers the context they need to understand and sensitively serve a substantial yet often overlooked patient group.

Treating Posttraumatic Stress Symptoms Among People Living with HIV: a Critical Review of Intervention Trials

The prevalence rate of posttraumatic stress disorder (PTSD) among people living with HIV (PLWH) is significantly higher than the rate among the general population. Moreover, PTS symptoms have been linked with numerous negative health-related outcomes in PLWH. While these findings suggest that studies evaluating the efficacy of treatments for PTS symptoms among PLWH are sorely needed, according to prior reviews, such studies are lacking. The purpose of the present systematic review was to provide an updated critical evaluation of treatment studies that targeted PTS among PLWH. Following PRIMSA guidelines, we searched PubMed and PsycINFO and identified eight articles (representing seven studies) evaluating the impact of various individual and group treatments on PTS symptoms. The limited evidence base to date precludes clinical recommendations for this population. Future studies should examine the efficacy of existing evidence-based treatments for PTSD among PLWH and then, if necessary, evaluate the impact of any treatment modifications for this population.

Psychological interventions for post-traumatic stress disorder in people living with HIV in Resource poor settings: a systematic review

OBJECTIVE

Post-traumatic stress disorder is pervasive in low- and middle-income countries. There is evidence to suggest that post-traumatic stress disorder is more common among people living with HIV than non-infected matched controls. We carried out a systematic review of interventions for adult post-traumatic stress disorder from resource poor settings with a focus on people living with HIV.

METHODS

We included all studies that investigated interventions for adult post-traumatic stress disorder from resource poor settings with a focus on interventions that were either randomised controlled trials or observational cohort studies carried out from 1980 to May 2015.

RESULTS

Of the 25 articles that were identified for full review, two independent reviewers identified seven studies that met our study inclusion criteria. All randomised controlled trials (RCT) (n = 6) used cognitive behavioural therapy-based interventions and focused on people living with HIV in resource poor settings. There was only one study focusing on the use of lay counsellors to address post-traumatic stress disorder but core competencies were not described. There were no intervention studies from Africa, only an observational cohort study from Rwanda.

CONCLUSION

Rigorously evaluated interventions for adult post-traumatic stress disorder in people living with HIV are rare. Most were undertaken in resource poor settings located in high-income countries. There is a need for research on the development and implementation of appropriate interventions for post-traumatic stress disorder in people living with HIV in low- and middle-income countries.

Anxiety and Depressive Symptoms Among People Living with HIV and Childhood Sexual Abuse: The Role of Shame and Posttraumatic Growth

There is a critical need to examine protective and risk factors of anxiety and depressive symptoms among people living with HIV in order to improve quality of life. Structural equation modeling was used to examine the associations between HIV-related shame, sexual abuse-related shame, posttraumatic growth, and anxiety and depressive symptoms among a cohort of 225 heterosexual women and men who have sex with men (MSM) living with HIV who have experienced childhood sexual abuse (CSA). Higher sexual abuse-related shame was related to more anxiety and depressive symptoms for heterosexual women. Higher posttraumatic growth predicted less anxiety symptoms for only heterosexual women. Higher posttraumatic growth predicted less depressive symptoms for heterosexual women and MSM, but the magnitude of this effect was stronger for heterosexual women than MSM. Psychosocial interventions may need to be tailored to meet the specific needs of heterosexual women and MSM living with HIV and CSA.

Exploring the Impact of Childhood Abuse on HIV Social and Attitudinal Factors Among Adults With and Without this History in Sub-Saharan Africa: Findings from NIMH Project Accept (HPTN 043)

Using data from four sites in three African countries, this community randomized study examined the association between childhood sexual and/or physical abuse (CSA and/or CPA) and HIV disclosure, HIV-related stigma, stress, and social support among adults with and without a history of abuse. A history of abuse among men was associated with higher levels of adult-reported stress and HIV-related stigma, and with significantly lower rates of HIV test result disclosure to current partners. Women with a history of CSA and/or CPA had significantly higher perceived stigma, discrimination and stress. Although childhood abuse was significantly associated with adult stress and stigmatization, participants with histories of CSA and/or CPA also reported significantly higher perceived social support compared to people without such experiences. These findings may reflect support received in response to disclosure of CSA or CPA or emotional ambivalence in relationships that have been found to be associated with child abuse. We conclude that it is critical for HIV prevention interventions to advocate for the primary prevention of child abuse, for early identification of adolescents and adults who report experiencing childhood abuse, and to address stigma and stress-related attitudinal, behavioral and relationship difficulties experiences as an aftermath of early abuse that increase their risk of HIV.

Group psychotherapy for female adult survivors of interpersonal psychological trauma: a preliminary study in Scotland

BACKGROUND

There is limited evidence on manualised group interventions that facilitate the development of trauma recovery skills, affect regulation and meaning making for survivors of interpersonal trauma.

AIM

The study aimed to provide preliminary evidence on the effectiveness of group psychotherapy (based on Trauma Recovery and Empowerment Model, TREM) for psychological distress in adult survivors of interpersonal trauma.

METHOD

Participants were a consecutive series of female patients (n = 71) from the waiting lists of five National Health Service (NHS) Boards in Scotland. Participants completed a set of self-rated measures (PCL, CORE, SCL-90, DES and RSES) at baseline, mid-intervention, post-intervention and 3-month follow-up.

RESULTS

Effect sizes were small to medium across measures and assessment points at post-treatment and follow-up. With regard to clinical significance, at post-treatment, a proportion of 9.9% to 54.9% of participants achieved clinical significance across measures. At follow-up, a proportion of 9.9% to 62.0% of participants achieved clinical significance across measures.

CONCLUSIONS

Group psychotherapy may be useful for a proportion of participants and especially so for symptoms of dissociation and self-esteem. Survivors of interpersonal trauma should be offered a choice of individual or group treatment modalities to reduce drop-out rate and maximise outcomes.

EXPERIENCE OF FORCED SEX AND SUBSEQUENT SEXUAL, DRUG, AND MENTAL HEALTH OUTCOMES: AFRICAN AMERICAN AND HISPANIC WOMEN IN THE SOUTHEASTERN UNITED STATES

OBJECTIVES

This cross-sectional study examined African American and Hispanic women's (N = 1,509) self-reports of unwanted forced sex and its association with behavioral and mental health outcomes after the event.

METHODS

Twenty percent of the women had experienced forced sex (1st occurrence at age 15 years or younger for 10%, 1st occurrence at older than 15 years of age for 10%).

RESULTS

Regardless of when forced sex 1st occurred, women were more likely to have engaged in unprotected vaginal and anal sex, to have had multiple unprotected sex partners, to have sexually transmitted infections, to have reported binge drinking and illicit drug use, and to exhibit distress and have received mental health counseling.

CONCLUSIONS

Forced sex may have wide-ranging behavioral and mental health consequences years later.

Violence Against Women in Selected Areas of the United States

OBJECTIVES

We determined the prevalence of recent emotional, physical, and sexual violence against women and their associations with HIV-related risk factors in women living in the United States.

METHODS

We performed an assessment of women ages 18 to 44 years with a history of unprotected sex and 1 or more personal or partner HIV risk factors in the past 6 months from 2009 to 2010. We used multivariable logistic regression to examine the association of experiencing violence.

RESULTS

Among 2099 women, the prevalence of emotional abuse, physical violence, and sexual violence in the previous 6 months was 31%, 19%, and 7%, respectively. Nonmarried status, food insecurity, childhood abuse, depression symptomology, and posttraumatic stress disorder were significantly associated with multiple types of violence. All types of violence were associated with at least 3 different partner or personal HIV risk behaviors, including unprotected anal sex, previous sexually transmitted infection diagnosis, sex work, or partner substance abuse.

CONCLUSIONS

Our data suggested that personal and partner HIV risk behaviors, mental illness, and specific forms of violence frequently co-occurred in the lives of impoverished women. We shed light on factors purported to contribute to a syndemic in this population. HIV prevention programs in similar populations should address these co-occurring issues in a comprehensive manner.

Resilience Moderates the Association Between Childhood Sexual Abuse and Depressive Symptoms Among Women with and At-Risk for HIV

Childhood sexual abuse (CSA) places women at risk for HIV infection and once infected, for poor mental health outcomes, including lower quality of life and depressive symptoms. Among HIV-positive and demographically matched HIV-negative women, we investigated whether resilience and HIV status moderated the relationships between CSA and health indices as well as the relationships among CSA, depressive symptoms, and health-related quality of life (HRQOL). Participants included 202 women (138 HIV+, 64 HIV-, 87 % African American) from the Women's Interagency HIV Study Chicago CORE Center site. Results indicated that in both HIV-positive and HIV-negative women, higher resilience significantly related to lower depressive symptoms and higher HRQOL. CSA related to higher depressive symptoms only for women scoring low in resilience. Interventions to promote resilience, especially in women with a CSA history, might minimize depressive symptoms and poor HRQOL among HIV-positive and HIV-negative women.

The effect of psychosocial syndemic production on 4-year HIV incidence and risk behavior in a large cohort of sexually active men who have sex with men

BACKGROUND

Cross-sectional studies have suggested that co-occurring epidemics or "syndemics" of psychosocial health problems may accelerate HIV transmission among men who have sex with men (MSM) in the United States. We aimed to assess how 5 syndemic conditions (depressive symptoms, heavy alcohol use, stimulant use, polydrug use, and childhood sexual abuse) affected HIV incidence and sexual risk behavior over time.

METHODS

Eligible men in a large prospective cohort of sexually active HIV-uninfected MSM completed HIV testing and behavioral surveys at baseline and every 6 months for 48 months. We examined interrelationships between psychosocial problems and whether these interactions increased the odds of HIV risk behaviors and risk of seroconversion over study follow-up.

RESULTS

Among 4295 men, prevalence of psychosocial conditions was substantial at baseline and was positively associated with each other. We identified a statistically significant positive dose-response relationship between numbers of syndemic conditions and HIV seroconversion for all comparisons (with the greatest hazard among those with 4-5 conditions, adjusted hazard ratio = 8.69; 95% confidence interval: 4.78 to 15.44). The number of syndemic conditions also predicted increased HIV-related risk behaviors over time, which mediated the syndemic-HIV seroconversion association.

CONCLUSIONS

The accumulation of syndemic psychosocial problems predicted HIV-related sexual risk behaviors and seroconversion in a large sample of US MSM. Given the high prevalence of syndemic conditions among MSM and the moderate effect sizes attained by traditional brief behavioral interventions to date, the HIV prevention agenda requires a shift toward improved assessment of psychosocial comorbidities and stronger integration with mental health and substance abuse treatment services.

Efficacy of an HIV/STI sexual risk-reduction intervention for African American adolescent girls in juvenile detention centers: a randomized controlled trial

Few HIV/STI interventions exist for African American adolescent girls in juvenile detention. The objective was to evaluate the efficacy of an intervention to reduce incident STIs, improve HIV-preventive behaviors, and enhance psychosocial outcomes. We conducted a randomized controlled trial among African American adolescent girls (13-17 years, N = 188) in juvenile detention from March 2011 to May 2012. Assessments occurred at baseline and 3- and 6-months post-randomization and included: audio computer-assisted self-interview, condom skills assessment, and self-collected vaginal swab to detect Chlamydia and gonorrhea. The Imara intervention included three individual-level sessions and four phone sessions; expedited partner therapy was offered to STI-positive adolescents. The comparison group received the usual care provided by the detention center: STI testing, treatment, and counseling. At the 6-month assessment (3-months post-intervention), Imara participants reported higher condom use self-efficacy (p < 0.001), HIV/STI knowledge (p < 0.001), and condom use skills (p < 0.001) compared to control participants. No significant differences were observed between trial conditions in incident Chlamydia or gonorrhea infections, condom use, or number of vaginal sex partners. Imara for detained African American adolescent girls can improve condom use skills and psychosocial outcomes; however, a critical need for interventions to reduce sexual risk remains.

Future directions for interventions targeting PTSD in HIV-infected adults

Although studies consistently report high rates of comorbid posttraumatic stress disorder (PTSD) and HIV infection, development and testing of PTSD treatment interventions in HIV-infected adults is limited. As such, the purpose of this review was twofold. First, this review augments the three existing reviews of research for PTSD in HIV-infected adults conducted within the past 10 years. We found two empirically supported cognitive-behavioral therapy-based interventions for the treatment of trauma-related symptoms in HIV-infected adults. Due to the continued limited number of effective interventions for this population, a second aim of our review was to draw from the expansive field of effective PTSD interventions for the general population to propose ways that future clinical intervention research may be tailored for HIV-infected adults. Therefore, in addition to a review, we conceptualized this paper as an opportunity to generate an ideal preview of the field of intervention research in this population.

Association between childhood physical abuse, unprotected receptive anal intercourse and HIV infection among young men who have sex with men in Vancouver, Canada

Introduction

The association between childhood sexual abuse and HIV risk among men who have sex with men (MSM) is well established. However, no studies have examined the potential impact of other forms of childhood maltreatment on HIV incidence in this population.

Methods

We explored the impact of child physical abuse (CPA) on HIV seroconversion in a cohort of gay/bisexual men aged 15 to 30 in Vancouver, Canada. Cox proportional hazard models were used, controlling for confounders.

Results

Among 287 participants, 211 (73.5%) reported experiencing CPA before the age of 17, and 42 (14.6%) reporting URAI in the past year. After a median of 6.6 years follow-up, 16 (5.8%) participants HIV-seroconverted. In multivariate analysis, CPA was significantly associated with HIV seroconversion (adjusted hazard ratio [AHR] = 4.89, 95% confidence interval (CI): 1.65–14.48), after controlling for potential confounders.

Conclusion

Our study uncovered a link between childhood physical violence and HIV incidence. Results highlight an urgent need for screening of young gay and bisexual men for histories of violence, and social and structural supports to prevent HIV transmission in this population.

Interaction between 5-HTTLPR polymorphism and abuse history on adolescent African-American females' condom use behavior following participation in an HIV prevention intervention

Not everyone exposed to an efficacious human immunodeficiency virus (HIV) intervention will reduce sexual risk behaviors, yet little is known about factors associated with "failure to change" high-risk sexual behaviors post-intervention. History of abuse and polymorphisms in the serotonin transporter gene (5-HTT) may be associated with non-change. The current study sought to identify genetic, life history, and psychosocial factors associated with adolescents' failure to change condom use behaviors post-participation in an HIV prevention intervention. A sub-set of participants from a clinic-based sample of adolescent African-American females (N = 254) enrolled in a randomized trial of an HIV-prevention was utilized for the current study. Forty-four percent did not increase their condom use from baseline levels 6 months after participating in the sexually transmitted infection (STI)/HIV prevention intervention. In multivariable logistic regression analysis, an interaction between abuse and 5-HTTLPR group was significantly associated with non-change status, along with partner communication frequency scores at follow-up. Follow-up tests found that having a history of abuse was significantly associated with greater odds of non-change in condom use post-intervention for only those with the s allele. For those with ll allele, participants with higher partner communication frequency scores were at decreased odds of non-change in condom use post-intervention. Thus, STI/HIV interventions for adolescent females may consider providing a more in-depth discussion and instruction on how to manage and overcome fear or anxiety related to being assertive in sexual decisions or sexual situations. Doing so may improve the efficacy of STI/HIV prevention programs for adolescent women who have experienced abuse in their lifetime.

Gender moderates the influence of psychosocial factors and drug use on HAART adherence in the context of HIV and childhood sexual abuse

This study aimed to examine gender moderation within a stress and coping model of HIV medication adherence in adults with a history of childhood sexual abuse (CSA). Sequelae of CSA, including negative coping, psychological distress, and drug use, interfere with adherence to highly active antiretroviral treatment (HAART). These obstacles to adherence are likely moderated by gender. Gender may particularly influence the mediational effect of drug use on adherence. Participants included 206 adults living with HIV/AIDS and CSA. Categorical/continuous variable methodology in a structural equation modeling framework was used to test a multigroup model with women and men. Gender significantly moderated several effects in the model. For women, the effect of psychological distress on HAART adherence was mediated by drug use and the effect of drug use on viral load was mediated by HAART adherence. Among men, drug use did not significantly impact adherence. Since gender appears to moderate the effect of drug use on medication adherence, it is particularly important to address drug use within the context of HIV disease management in women with a history of CSA. Further, interventions to increase HAART adherence should take trauma history, gender, and drug abuse into account when assessing efficacy.

Evidence-based treatment for adult women with child abuse-related Complex PTSD: a quantitative review

INTRODUCTION

Effective first-line treatments for posttraumatic stress disorder (PTSD) are well established, but their generalizability to child abuse (CA)-related Complex PTSD is largely unknown.

METHOD

A quantitative review of the literature was performed, identifying seven studies, with treatments specifically targeting CA-related PTSD or Complex PTSD, which were meta-analyzed, including variables such as effect size, drop-out, recovery, and improvement rates.

RESULTS

Only six studies with one or more cognitive behavior therapy (CBT) treatment conditions and one with a present centered therapy condition could be meta-analyzed. RESULTS indicate that CA-related PTSD patients profit with large effect sizes and modest recovery and improvement rates. Treatments which include exposure showed greater effect sizes especially in completers' analyses, although no differential results were found in recovery and improvement rates. However, results in the subgroup of CA-related Complex PTSD studies were least favorable. Within the Complex PTSD subgroup, no superior effect size was found for exposure, and affect management resulted in more favorable recovery and improvement rates and less drop-out, as compared to exposure, especially in intention-to-treat analyses.

CONCLUSION

Limited evidence suggests that predominantly CBT treatments are effective, but do not suffice to achieve satisfactory end states, especially in Complex PTSD populations. Moreover, we propose that future research should focus on direct comparisons between types of treatment for Complex PTSD patients, thereby increasing generalizability of results.

The impact of substance use, sexual trauma, and intimate partner violence on sexual risk intervention outcomes in couples: a randomized trial

BACKGROUND

Few HIV prevention interventions focus on sexual risk reduction as mutual process determined by couple members, though risk behaviors are inter-dependent.

PURPOSE

This trial examined the impact of substance use, history of sexual trauma, and intimate partner violence on sexual risk associated with participation in a risk reduction intervention.

METHODS

HIV seroconcordant and serodiscordant multicultural couples in Miami, Florida (n = 216) were randomized to group (n = 112) or individual (n = 104) couple-based interventions.

RESULTS

Group intervention participants increased condom use in couples in which women had a history of sexual trauma [F(2,221) = 3.39, p = 0.036] and by partners of alcohol users. History of sexual trauma was a determinant of conflict resolution, predicting negative communication and intimate partner violence.

CONCLUSIONS

Results emphasize the need for group sexual risk reduction interventions targeting sexual trauma, partner violence, and substance use among HIV seroconcordant and serodiscordant couples.