Behavioral aspects of HIV care: adherence, depression, substance use, and HIV-transmission behaviors

A Bayesian approach for investigating the pharmacogenetics of combination antiretroviral therapy in people with HIV

Combination antiretroviral therapy (ART) with at least three different drugs has become the standard of care for people with HIV (PWH) due to its exceptional effectiveness in viral suppression. However, many ART drugs have been reported to associate with neuropsychiatric adverse effects including depression, especially when certain genetic polymorphisms exist. Pharmacogenetics is an important consideration for administering combination ART as it may influence drug efficacy and increase risk for neuropsychiatric conditions. Large-scale longitudinal HIV databases provide researchers opportunities to investigate the pharmacogenetics of combination ART in a data-driven manner. However, with more than 30 FDA-approved ART drugs, the interplay between the large number of possible ART drug combinations and genetic polymorphisms imposes statistical modeling challenges. We develop a Bayesian approach to examine the longitudinal effects of combination ART and their interactions with genetic polymorphisms on depressive symptoms in PWH. The proposed method utilizes a Gaussian process with a composite kernel function to capture the longitudinal combination ART effects by directly incorporating individuals' treatment histories, and a Bayesian classification and regression tree to account for individual heterogeneity. Through both simulation studies and an application to a dataset from the Women's Interagency HIV Study, we demonstrate the clinical utility of the proposed approach in investigating the pharmacogenetics of combination ART and assisting physicians to make effective individualized treatment decisions that can improve health outcomes for PWH.

HIV Support Source: Development of a Distress Screening Measure for Adults with HIV

To provide an effective, multidimensional, and psychometrically valid measure to screen for distress among people with HIV, we developed and assessed the psychometric properties of HIV Support Source, a distress screening, referral, and support program designed to identify the unmet needs of adults with HIV and link them to desired resources and support. Development and testing were completed in three phases: (1) item generation and initial item pool testing (N = 375), (2) scale refinement via exploratory factor analysis (N = 220); external/internal item quality, and judging theoretical and practical implications of items, and (3) confirmatory validation (N = 150) including confirmatory factor analysis along with reliability and validity analyses to corroborate dimensionality and psychometric properties of the final measure. Nonparametric receiver operating characteristic (ROC) curve analyses determined scoring thresholds for depression and anxiety risk subscales. The final measure comprises 17-items representing four domains of concern: emotional well-being, financial and practical needs, physical well-being, and HIV treatment and sexual health, plus one screening item assessing tobacco and substance use. Our analyses showed strong internal consistency reliability, a replicable factor structure, and adequate convergent, discriminant, and known groups validity. Sensitivity of 2-item depression and 2-item anxiety risk subscales was 0.90 and 0.79, respectively. HIV Support Source is a reliable and valid multidimensional measure of distress that also screens for risk for clinically significant depression and anxiety. It can be implemented within a distress screening, referral, and follow-up program to rapidly assess and support the unmet needs of adults with HIV.

Cocaine regulates antiretroviral therapy CNS access through pregnane-x receptor-mediated drug transporter and metabolizing enzyme modulation at the blood brain barrier

BACKGROUND

Appropriate interactions between antiretroviral therapies (ART) and drug transporters and metabolizing enzymes at the blood brain barrier (BBB) are critical to ensure adequate dosing of the brain to achieve HIV suppression. These proteins are modulated by demographic and lifestyle factors, including substance use. While understudied, illicit substances share drug transport and metabolism pathways with ART, increasing the potential for adverse drug:drug interactions. This is particularly important when considering the brain as it is relatively undertreated compared to peripheral organs and is vulnerable to substance use-mediated damage.

METHODS

We used an in vitro model of the human BBB to determine the extravasation of three first-line ART drugs, emtricitabine (FTC), tenofovir (TFV), and dolutegravir (DTG), in the presence and absence of cocaine, which served as our illicit substance model. The impact of cocaine on BBB integrity and permeability, drug transporters, metabolizing enzymes, and their master transcriptional regulators were evaluated to determine the mechanisms by which substance use impacted ART central nervous system (CNS) availability.

RESULTS

We determined that cocaine had a selective impact on ART extravasation, where it increased FTC's ability to cross the BBB while decreasing TFV. DTG concentrations that passed the BBB were below quantifiable limits. Interestingly, the potent neuroinflammatory modulator, lipopolysaccharide, had no effect on ART transport, suggesting a specificity for cocaine. Unexpectedly, cocaine did not breach the BBB, as permeability to albumin and 4 kDa FITC-dextran, as well as tight junction proteins and adhesion molecules remained unchanged. Rather, cocaine selectively decreased the pregnane-x receptor (PXR), but not constitutive androstane receptor (CAR). Consequently, drug transporter expression and activity decreased in endothelial cells of the BBB, including p-glycoprotein (P-gp), breast cancer resistance protein (BCRP), and multidrug resistance-associated protein 4 (MRP4). Further, cytochrome P450 3A4 (CYP3A4) enzymatic activity increased following cocaine treatment that coincided with decreased expression. Finally, cocaine modulated adenylate kinases that are required to facilitate biotransformation of ART prodrugs to their phosphorylated, pharmacologically active counterparts.

CONCLUSION

Our findings indicate that additional considerations are needed in CNS HIV treatment strategies for people who use cocaine, as it may limit ART efficacy through regulation of drug transport and metabolizing pathways at the BBB.

Cocaine Regulates Antiretroviral Therapy CNS Access Through Pregnane-X Receptor-Mediated Drug Transporter and Metabolizing Enzyme Modulation at the Blood Brain Barrier

Background

Appropriate interactions between antiretroviral therapies (ART) and drug transporters and metabolizing enzymes at the blood brain barrier (BBB) are critical to ensure adequate dosing of the brain to achieve HIV suppression. These proteins are modulated by demographic and lifestyle factors, including substance use. While understudied, illicit substances share drug transport and metabolism pathways with ART, increasing the potential for adverse drug:drug interactions. This is particularly important when considering the brain as it is relatively undertreated compared to peripheral organs and is vulnerable to substance use-mediated damage.

Methods

We used an in vitro model of the human BBB to determine the extravasation of three first-line ART drugs, emtricitabine (FTC), tenofovir (TFV), and dolutegravir (DTG), in the presence and absence of cocaine, which served as our illicit substance model. The impact of cocaine on BBB integrity and permeability, drug transporters, metabolizing enzymes, and their master transcriptional regulators were evaluated to determine the mechanisms by which substance use impacted ART central nervous system (CNS) availability.

Results

We determined that cocaine had a selective impact on ART extravasation, where it increased FTC's ability to cross the BBB while decreasing TFV. DTG concentrations that passed the BBB were below quantifiable limits. Interestingly, the potent neuroinflammatory modulator, lipopolysaccharide, had no effect on ART transport, suggesting a specificity for cocaine. Unexpectedly, cocaine did not breach the BBB, as permeability to albumin and tight junction proteins and adhesion molecules remained unchanged. Rather, cocaine selectively decreased the pregnane-x receptor (PXR), but not constitutive androstane receptor (CAR). Consequently, drug transporter expression and activity decreased in endothelial cells of the BBB, including p-glycoprotein (P-gp), breast cancer resistance protein (BCRP), and multidrug resistance-associated protein 4 (MRP4). Further, cytochrome P450 3A4 (CYP3A4) enzymatic activity increased following cocaine treatment that coincided with decreased expression. Finally, cocaine modulated adenylate kinases are required to facilitate biotransformation of ART prodrugs to their phosphorylated, pharmacologically active counterparts.

Conclusion

Our findings indicate that additional considerations are needed in CNS HIV treatment strategies for people who use cocaine, as it may limit ART efficacy through regulation of drug transport and metabolizing pathways at the BBB.

The Impact of COVID-19 on Sexual Behavior and Psychosocial Functioning in a Clinical Sample of Men who have Sex with Men Using HIV Pre-exposure Prophylaxis

The purpose of this study was to evaluate the impact of the Coronavirus Disease 2019 (COVID-19) pandemic on sexual behavior, mental health, and substance use among men who have sex with men (MSM) engaged in pre-exposure prophylaxis (PrEP) care. Generalized linear mixed models and logistic mixed-effect models examined change over time for number of sexual partners, mood, and alcohol consumption. From February 29, 2020 to July 31, 2020, 177 MSM actively engaged in PrEP care were evaluated. The median age was 37 [interquartile range (IQR 30, 51]. Patients in the sample were largely representative of the clinic population and identified as White (73.0%), Black/African American (9.2%), and other race (17.2%), and 11.8% identified as Hispanic/Latino ethnicity. Men reported an average of 2.60 fewer sexual partners (95% CI −4.04, −1.40) during the pandemic compared to pre-COVID-19. Rates of depressive symptoms and alcohol use remained stable and few patients reported substance use. The reduced number of sexual partners may be explained by patients’ efforts to reduce risk of exposure to COVID-19 and low rates of psychosocial symptoms may be indicative of only the highest functioning patients continuing to engage in care. Reductions in sexual partners may offset reduced engagement in care and help mitigate risk of HIV and other sexually transmitted infections (STIs).

Depressive symptoms and associated factors among HIV positive patients attending public health facilities of Dessie town: A cross-sectional study

BACKGROUND

Depressive symptoms are the most common psychiatric complication of Human Immunodeficiency Virus (HIV) infection. They are associated with poor drug adherence, treatment failure, and increase the risk for suicide. There was limited evidence of depressive symptoms among HIV-positive patients in the study area. So, this study aimed to determine the prevalence of depressive symptoms and associated factors among HIV-positive patients attending public health facilities of Dessie town, North-central Ethiopia, 2019.

METHOD

A cross-sectional study was conducted on 380 HIV-positive patients attending ART clinics in Dessie town, North-central Ethiopia, 2019. Samples were selected using systematic random sampling and the data were collected by using structured, pretested, and interviewer-administered questionnaires. Patient Health Questionnaire (PHQ-9) at a cut-off point of 5 was used to assess depressive symptoms. The data were entered by Epi data version 3.1 and analyzed by SPSS version 25. A binary logistic regression model was used to identify factors associated with depressive symptoms. The Adjusted Odds Ratio (AOR) along with a 95% Confidence Interval (CI) was estimated to measure the association. The level of significance was declared at a p-value of less than 0.05.

RESULT

The prevalence of depressive symptoms among HIV positive patients was 15.5% (95% CI: (12.4%, 19.2%)). Age 40-49 years compared to 30-39 years (AOR = 2.96, 95% CI: (1.01, 8.68)), age ≥50 years compared to 30-39 years (AOR = 3.81, 95% CI: (1.05, 13.8)), having perceived stigma (AOR = 10.2, 95%CI: (4.26, 24.4)) taking medication other than Antiretroviral Therapy (ART) (AOR = 2.58, 95% CI: (1.25, 5.33)) and history of opportunistic infections (AOR = 5.17, 95% CI: (1.31, 20.4)) were factors associated with depressive symptoms.

CONCLUSION

The prevalence of depressive symptoms was low compared to previous studies. Age, perceived stigma, taking medication other than ART, and history of opportunistic infections were factors associated with depressive symptoms. Health education and counseling programs should be strengthened and target older patients, patients who took medications other than ART, patients who experienced perceived stigma and patients with a history of history opportunistic infections.

Potential Influences of the COVID-19 Pandemic on Drug Use and HIV Care Among People Living with HIV and Substance Use Disorders: Experience from a Pilot mHealth Intervention

People living with HIV (PLWH) and substance use disorder (SUD) are particularly vulnerable to harmful health consequences of the global COVID-19 pandemic. The health and social consequences of the pandemic may exacerbate substance misuse and poor management of HIV among this population. This study compares substance use and HIV care before and during the pandemic using data collected weekly through an opioid relapse prevention and HIV management mobile-health intervention. We found that during the pandemic, PLWH and SUD have increased illicit substance use and contact with other substance-using individuals and decreased their confidence to stay sober and attend recovery meetings. The proportion of people missing their HIV medications also increased, and confidence to attend HIV follow-up appointments decreased. Optimal support for PLWH and SUD is critical during pandemics like COVID-19, as drug-related and HIV antiretroviral therapy (ART) non-adherence risks such as overdose, unsafe sexual behaviors, and transmission of infectious diseases may unfold.

Quality of Life Among Caregivers of a Vulnerable Population Living with HIV: Caregiving and Relationship Factors

Literature on health-related quality of life (HRQOL) has focused on people living with chronic conditions, with less attention given to HRQOL among informal caregivers. We used cross-sectional dyadic data from both care recipients (CR) living with HIV and the person they identified as their primary informal (unpaid) caregiver (CG) to identify psychosocial and caregiving relationship factors (including, CG role ambivalence and caregiving-related stress) associated with CG HRQOL. We conducted confirmatory factor analysis and structural equation modeling testing. The results highlight interdependent effects of the CG-CR relationship and reveal pathways whereby relationship interactions positively and negatively impact CGs' HRQOL. Affiliative stigma, CG-CR communication, CRs' reciprocity of support and other psychosocial factors indirectly and differentially affected physical and mental HRQOL through effects on secondary stress and role ambivalence. Dyad-focused intervention on interpersonal communication and support exchange may improve HRQOL and resilience of CGs of vulnerable people living with HIV.

Depression symptoms, HIV testing, linkage to ART, and viral suppression among women in a high HIV burden district in KwaZulu-Natal, South Africa: A cross-sectional household study

Achieving the UNAIDS 90-90-90 targets by 2020 is contingent on identifying and addressing mental health challenges that may affect HIV testing and treatment-related behaviors. This study is based on survey data from KwaZulu-Natal, South Africa (2014–2015). HIV positive women who reported higher depression scores had a lower odds of having tested previously for HIV (15–25 years: AOR = 0.90, 95% CI [0.83, 0.98]; 26–49 years: AOR = 0.90, 95% CI [0.84, 0.96]). Because HIV testing behavior represents a gateway to treatment, the findings suggest mental health may be one challenge to attaining the UNAIDS 90-90-90 targets.

Symptoms of generalized anxiety disorder as a risk factor for substance use among adults living with HIV

This study examined the association between symptoms of generalized anxiety disorder (GAD) and substance use among 932 people living with HIV (PLWH) in Florida. PLWH completed a 45-minute questionnaire assessing demographics, symptoms of GAD and depression, and use of substances including alcohol, cigarettes, marijuana, crack/cocaine, and injection drugs. The GAD-7 measured symptoms of anxiety and participants were categorized as experiencing none/mild anxiety (score 0-9) or moderate/severe symptoms (score ≥10). Adjusted binary logistic regressions assessed the association between moderate-severe GAD symptoms and substance use while controlling for covariates, including depressive symptoms. Approximately one-third (31.4%) of the sample reported experiencing moderate/severe symptoms of GAD. After controlling for covariates, PLWH with moderate/severe symptoms of GAD had greater odds of reporting current cigarette use (AOR = 1.70, 95% CI = 1.18-2.45 p = 0.004), past 30-day hazardous alcohol consumption (AOR = 1.50, 95% CI = 1.04-2.16, p = 0.028), and past 12-month non-injection crack/cocaine use (AOR = 1.75, 95% CI = 1.13-2.69, p = 0.011) compared to PLWH reporting none/mild symptoms. Findings demonstrate that moderate/severe GAD symptoms were common among this sample of PLWH in Florida and were associated with use of cigarettes, crack/cocaine, and hazardous alcohol consumption. Future studies should explore interventions to reduce comorbid anxiety and substance use.

HIV Stigma, Depressive Symptoms, and Substance Use

Substance use problems undermine HIV treatment and secondary prevention efforts. Research is needed to better understand predictors of substance use among people living with HIV (PLWH). We examined whether internalized stigma and enacted HIV stigma are associated with three indicators of substance use among PLWH, including numbers of (1) substances used, (2) substances used at moderate to high risk, and (3) times substances were used before sex, through the mediator of depressive symptoms. Participants included 358 PLWH aged 18-35 years from Georgia, United States. At baseline, participants completed measures of internalized and enacted stigma, depressive symptoms, and substance use severity. Substance use was additionally tested with urinalysis. Following baseline, participants reported their use of substances before sex for 28 days through daily text messaging. Data were analyzed using path analysis in R. On average, participants tested positive for 1.24 (range: 0-6) substances used, reported moderate to high risk on 2.01 (range: 0-8) substances, and reported using substances 1.57 (range: 0-20) times before sex over 28 days. Internalized stigma and enacted stigma were associated with greater depressive symptoms, and depressive symptoms were associated with all three indicators of substance use. Moreover, the indirect effects between internalized and enacted stigma with indicators of substance use were significant, suggesting that depressive symptoms partially mediated associations between stigma and substance use. Interventions may be needed to address both stigma and depressive symptoms among PLWH to reduce substance use and support HIV treatment and prevention efforts.

The Utility of Index Case Recruitment for Establishing Couples' Eligibility: An Examination of Consistency in Reporting the Drug Use of a Primary Partner Among Sexual Minority Male Couples

Sexual minority men are disproportionately impacted by substance use, which is associated with greater HIV transmission behaviors. Novel approaches to drug use prevention and treatment are needed. Couple-based approaches have garnered significant attention. The recruitment of couples into substance use interventions has proven challenging. We evaluate an index-case approach to screening participants in couples' research. Seventy index cases, aged 18-29, and their main partner (140 individuals), were recruited. At screening, index participants reported their drug use and their partners' drug use for the previous 30 days. At baseline, both partners reported their drug use over the past 30 days. Individuals' self-reports and perceptions of their partner's concurrency were compared within couples using the κ (Kappa) coefficient. We found high levels of personal predictive accuracy from screening to baseline for cannabis (κ = .81, p < .01) and cocaine/crack (κ = .70, p < .01). Predictive accuracy of index case reporting of their partner's drug use behavior were moderately high among cocaine/crack use (κ = .68, p < .01) and MDMA/GHB/Ketamine (κ = .56, p < .01). Perceived partner similarity for recent drug use was also high for all drugs, with the highest levels among cocaine/crack (κ =.82) and prescription drugs (κ =.81). This study demonstrates that index partners report drug use with differing levels of agreement between drug types. Index recruitment has advantages in determining drug use-related eligibility requirements. Discrepancies in reporting were more frequently false positives, which reduces the risk of screening out potentially eligible couples.

Syndemic factors associated with adherence to antiretroviral therapy among HIV-positive adult heterosexual men

BACKGROUND

Suboptimal adherence to HIV antiretroviral therapy (ART) and concomitant lack of viral control can have severe consequences for health and onward transmission among persons living with HIV. Little is known about the barriers and facilitators of optimal ART adherence among heterosexual HIV-positive men.

METHODS

Structural equation modeling (SEM) was performed to test a theory-derived model of ART adherence using data from a cross-sectional sample of 317 HIV-positive self-identified heterosexual men residing in New York City. We assessed a conceptual model in which mental health (depression, anxiety) and substance use dependence mediated the effects of socio-structural factors (HIV-related stigma, social support) on ART adherence, and subsequently, undetectable viral load.

RESULTS

Structural equation modeling analyses indicated that men who reported higher levels of HIV-related stigma tended to experience higher levels of general anxiety, which in turn was associated with reduced probability of optimal ART adherence. Moreover, men who reported higher levels of social support tended to exhibit less dependence on illicit substance use, which in turn was associated with increased probability of optimal ART adherence. African-American men reported lower ART adherence compared to other racial/ethnic groups.

CONCLUSIONS

Our findings support the hypothesis that substance use dependence and mental health problems, particularly anxiety, may be primary drivers of suboptimal ART adherence among heterosexual men, and that socio-structural factors such as HIV-related stigma and social support are potential modifiable antecedents of these drivers.

Do Symptoms of Depression Interact with Substance Use to Affect HIV Continuum of Care Outcomes?

Few studies examine how depression and substance use interact to affect HIV control. In 14,380 persons with HIV (PWH), we used logistic regression and generalized estimating equations to evaluate how symptoms of depression interact with alcohol, cocaine, opioid, and methamphetamine use to affect subsequent retention in care, maintaining an active prescription for ART, and consistent virologic suppression. Among PWH with no or mild depressive symptoms, heavy alcohol use had no association with virologic suppression (OR 1.00 [0.95-1.06]); among those with moderate or severe symptoms, it was associated with reduced viral suppression (OR 0.80 [0.74-0.87]). We found no interactions with heavy alcohol use on retention in care or maintaining ART prescription or with other substances for any outcome. These results highlight the importance of treating moderate or severe depression in PWH, especially with comorbid heavy alcohol use, and support multifaceted interventions targeting alcohol use and depression.

Prevalence and Associated Factors of Depression among PLHIV in Ethiopia: Systematic Review and Meta-Analysis, 2017

BACKGROUND

Depression is a substantial contributor to the global burden of disease and affects people in all communities across the globe. Depression is the most common psychiatric problem associated with HIV/AIDS and half of all PLWHIV with depression go underdiagnosed and untreated. Psychiatric complications of HIVAIDS delay mental health services in less affluent countries. However, there is lack of study with regard to the pooled estimation prevalence of depression in PLWHIV in Ethiopia.

OBJECTIVES

The aim of this systematic review and meta-analysis is to summarize the most current available evidence from 2010 to March 2017 among adult PLWHIV in Ethiopia.

METHODS

The team explored multiple databases searching methods including MEDLINE/PubMed, PsycINFO, Google Advance Scholar, and Google Scholar to find studies published with the data on the prevalence of depression among PLWHIV. We searched 150 research articles; of these 143 articles were excluded. Subsequently, thirteen articles were used for synthesis prevalence and four studies were included in the synthesis effect of sex on depression among PLWHIV.

RESULTS

The total of pooled estimated prevalence of depression in PLWHIV was 36.65. Estimated prevalence of depression in three studies by using CES-D was 31.19% and in six studies by using PHQ-9 was 37.91%. The remaining four studies used a single tool: Kessler-6 Scale (15.5%), HADS (41.2%), HDSQ (43.9%), and BDI (55.8%). Factors such as age, marital status, living alone, poor medication adherence, poor social support, clinical stages II and III of HIV, stigma, income, and occupation were significantly associated with depression.

CONCLUSIONS AND RECOMMENDATION

The pooled estimate prevalence of depression among PLWHIV was higher than that in the general population. It is better to offer special attention to these populations.

Prevalence and associated factors of depression among patients with HIV/AIDS in Hawassa, Ethiopia, cross-sectional study

BACKGROUND

Globally, 350 million people are affected by depression and 800,000 people die due to suicide every year due to depression. People living with HIV/AIDS face different challenges, including HIV-related perceived stigma, lack of social support and also depression. This study aimed to assess prevalence and factors associated with depressive symptom among people living with HIV/AIDS attending Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia.

METHODS

Hospital-based cross-sectional study was implemented in 2016. A total of 401 HIV-positive patients who had regular visit at Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia were included in the study. Systematic random sampling technique was used to recruit study participants. Patient Health Questionnaire item nine (PHQ-9) was used to assess depressive symptoms. In addition to this, Oslo social support scale and HIV perceived stigma scale were used to assess social support and HIV-related perceived stigma, respectively.

RESULTS

A total of 401 study participants were included in the study, giving a response rate of 96.2%. The mean age of the respondents was 38 years (SD ± 10.23). This study revealed that 48.6% of HIV-positive patients had depression. Patients who had poor social support [AOR = 2.53, (95% CI 1.70, 9.13)], HIV-related perceived stigma [AOR = 2.83, (95% CI 1.78, 4.48)] and CD4 cell count < 200 [AOR = 3.89, (95% CI 1.02, 14.83)] were more likely to have depression as compared to individuals who had good social support, no perceived HIV stigma and CD4 cell count > 200, respectively.

CONCLUSION

Having poor social support, HIV-related perceived stigma and low CD4 cell count (< 200) had statistically significant association with depressive symptom. Training of health workers in ART clinics and availing manuals on assessing mental health issues is useful to screen and treat depression among HIV patients.

Characteristics of Persons Living With HIV Who Have Informal Caregivers in the cART Age of the Epidemic

People living with HIV (PLWH) are aging and many suffer with multimorbidities, making caregiving a relevant and important area of study. The purpose of our study was to understand the occurrence and role of informal caregivers in the current stage of the HIV epidemic. We conducted a Web-based survey with 1,373 PLWH to assess: how many had an informal, unpaid caregiver; the type of relationship with the informal caregiver; and the number of hours the caregiver provided support each day. Among respondents, 333 had an informal caregiver. Blacks, those with low income, individuals who ever had an AIDS diagnosis, those with basic cellphone service, and those living with other comorbid conditions were significantly more likely to have an informal caregiver. Given the demographic profile of those PLWH who were most likely to have caregivers, further study is needed to understand the needs of both caregivers and care recipients.

Risk factors for postpartum depression in women living with HIV attending prevention of mother-to-child transmission clinic at Kenyatta National Hospital, Nairobi

Mothers with HIV are at high risk of a range of psychosocial issues that may impact HIV disease progression for themselves and their children. Stigma has also become a substantial barrier to accessing HIV/AIDS care and prevention services. The study objective was to determine the prevalence and severity of postpartum depression (PPD) among women living with HIV and to further understand the impact of stigma and other psychosocial factors in 123 women living with HIV attending prevention of mother-to-child transmission (PMTCT) clinic at Kenyatta National Hospital located in Nairobi, Kenya. We used the Edinburgh Postnatal Depression Scale and HIV/AIDS Stigma Instrument - PLWHA (HASI - P). Forty-eight percent (N = 59) of women screened positive for elevated depressive symptoms. Eleven (9%) of the participants reported high levels of stigma. Multivariate analyses showed that lower education (OR = 0.14, 95% CI [0.04-0.46], p = .001) and lack of family support (OR = 2.49, 95% CI [1.14-5.42], p = .02) were associated with the presence of elevated depressive symptoms. The presence of stigma implied more than ninefold risk of development of PPD (OR = 9.44, 95% CI [1.132-78.79], p = .04). Stigma was positively correlated with an increase in PPD. PMTCT is an ideal context to reach out to women to address mental health problems especially depression screening and offering psychosocial treatments bolstering quality of life of the mother-baby dyad.

Antiretroviral Medication Adherence and Amplified HIV Transmission Risk Among Sexually Active HIV-Infected Individuals in Three Diverse International Settings

Successful biomedical prevention/treatment-as-prevention (TasP) requires identifying individuals at greatest risk for transmitting HIV, including those with antiretroviral therapy (ART) nonadherence and/or 'amplified HIV transmission risk,' defined as condomless sex with HIV-uninfected/unknown-status partners when infectious (i.e., with detectable viremia or STI diagnosis according to Swiss criteria for infectiousness). This study recruited sexually-active, HIV-infected patients in Brazil, Thailand, and Zambia to examine correlates of ART nonadherence and 'amplified HIV transmission risk'. Lower alcohol use (OR = .71, p < .01) and higher health-related quality of life (OR = 1.10, p < .01) were associated with greater odds of ART adherence over and above region. Of those with viral load data available (in Brazil and Thailand only), 40 % met Swiss criteria for infectiousness, and 29 % had 'amplified HIV transmission risk.' MSM had almost three-fold (OR = 2.89, p < .001) increased odds of 'amplified HIV transmission risk' (vs. heterosexual men) over and above region. TasP efforts should consider psychosocial and contextual needs, particularly among MSM with detectable viremia.

Intentional Medication Nonadherence Because of Interactive Toxicity Beliefs Among HIV-Positive Active Drug Users

BACKGROUND

Drug use poses significant challenges to medical management of HIV infection. Although most research has focused on the influence of intoxication on unintentional adherence to HIV treatment, drug use may also lead to intentional nonadherence, particularly when individuals believe that mixing medications with drugs is harmful. This study examined whether interactive toxicity beliefs predict nonadherence to antiretroviral therapy (ART) over a prospective period of adherence monitoring.

METHODS

Men and women living with HIV who screened positive for drug use and were being treated with ART (n = 530) completed computerized self-interviews and 3 prospective unannounced pill counts to measure ART adherence and provided urine specimens for drug screening and HIV viral load results from medical records.

RESULTS

Results showed that 189 (35%) participants indicated that they intentionally miss their ART when they are using drugs. These participants also reported common beliefs regarding the perceived hazards of mixing HIV medications with alcohol and other drugs. Multivariable models controlled for demographic and health characteristics and frequency of alcohol use showed that intentional nonadherence predicted poorer ART adherence over the prospective month and also predicted poorer treatment outcomes as indexed by unsuppressed HIV viral load.

CONCLUSIONS

These findings extend previous research to show that interactive toxicity beliefs and intentional nonadherence play a significant role in medication nonadherence for a substantial number of people living with HIV and should be actively addressed in HIV clinical care.

The interaction of active substance use, depression, and antiretroviral adherence in methadone maintenance

BACKGROUND

Adherence to highly active antiretroviral therapy (HAART) remains crucial in successfully treating HIV. While active substance use and depression are both associated with each other and with HAART nonadherence, little is known about their interaction. An understanding of the interaction of substance use and depressive symptoms on HAART adherence can inform adherence-enhancing interventions as well as interventions that target substance use and depression.

PURPOSE

We tested an interaction between substance use and depression on HAART adherence among methadone maintenance patients.

METHOD

We assessed substance use, depressive symptoms, and HAART adherence among 100 HIV-infected individuals receiving methadone maintenance in The Bronx, New York. Regressions were performed on adherence using an interaction term comprised of substance use and depressive symptoms. MODPROBE was used to assess significant interactions.

RESULTS

Any use of illicit substances was associated with HAART nonadherence (p = 0.043). Cannabis was the single substance of abuse most strongly associated with nonadherence (p = 0.003). Depressive symptoms approached significance in bivariate analysis (p = 0.066). In regression analysis, a significant interaction was found between illicit substance use and depressive symptoms [OR (95% CI) 1.23 (1.06-1.44), p = 0.007], where illicit substance use was associated with nonadherence in individuals with lower depressive symptoms, but not among those with depressive symptoms at higher levels. No individual substances interacted with depressive symptoms on adherence.

CONCLUSION

Though substance use and depressive symptoms interacted on HAART adherence, they did not have a synergistic effect. Continued substance use (51% of the sample) suggests an unmet need for treatment, even in methadone maintenance. Further examinations of the interplay of substance use and depression on HAART adherence are warranted.

[Quality of life in elderly patients living with HIV/AIDS]

This study's objective was to evaluate quality of life in older adults living with HIV/AIDS and the associations with socio-demographic, economic, and clinical characteristics, using a cross-sectional design. Data were collected on demographics, disease history, and economic status according to the Brazilian Economic Classification Criterion and Targeted Quality of Life Instrument (HAT-QoL). A total of 201 elderly participated, with the following characteristics: males (63.7%), single or divorced (51.3%), economic classes C, D, or E (61.7%), and low schooling (53.7%). Nearly two-thirds (130, or 64.7%) had been infected by the sexual route. The following were significantly correlated with two or up to seven domains in the HAT-QoL: age, individual and family income, and time since diagnosis. Quality of life in elderly living with HIV/AIDS showed the lowest scores in the domains related to concern over disclosure of their diagnosis, sexual activity, and financial concerns. Age, income, and time since diagnosis were the variables that most accounted for altered quality of life.

Latent class profiles of internalizing and externalizing psychosocial health indicators are differentially associated with sexual transmission risk: Findings from the CFAR network of integrated clinical systems (CNICS) cohort study of HIV-infected men engaged in primary care in the United States

OBJECTIVE

To examine whether latent class indicators of negative affect and substance use emerged as distinct psychosocial risk profiles among HIV-infected men, and if these latent classes were associated with high-risk sexual behaviors that may transmit HIV.

METHODS

Data were from HIV-infected men who reported having anal intercourse in the past 6 months and received routine clinical care at 4 U.S. sites in the Centers for AIDS Research Network of Integrated Clinical Systems cohort (n = 1,210). Latent class membership was estimated using binary indicators for anxiety, depression, alcohol and/or drug use during sex, and polydrug use. Generalized estimating equations modeled whether latent class membership was associated with HIV sexual transmission risk in the past 6 months.

RESULTS

Three latent classes of psychosocial indicators emerged: (a) internalizing (15.3%; high probability of anxiety and major depression); (b) externalizing (17.8%; high probability of alcohol and/or drug use during sex and polydrug use); (c) low psychosocial distress (67.0%; low probability of all psychosocial factors examined). Internalizing and externalizing latent class membership were associated with HIV sexual transmission risk, compared to low psychosocial class membership; externalizing class membership was also associated with higher sexual transmission risk compared to internalizing class membership.

CONCLUSIONS

Distinct patterns of psychosocial health characterize this sexually active HIV-infected male patient population and are strongly associated with HIV sexual transmission risk. Public Health intervention efforts targeting HIV sexual risk transmission may benefit from considering symptom clusters that share internalizing or externalizing properties.

Interactive effects of neurocognitive impairment and substance use on antiretroviral non-adherence in HIV disease

While numerous studies have established the adverse independent effects of clinical conditions including neurocognitive dysfunction, psychiatric illness, and substance abuse/dependence on medication adherence among HIV-infected adults, fewer have studied their interactive effects. The current study examined this issue among 204 HIV-infected participants based upon current neurocognitive functioning and DSM-IV-diagnosed psychiatric illness and current substance abuse or dependence. Results confirmed that participants with any of these risk factors demonstrated poorer adherence than individuals with no risk factors. A neurocognitive status × substance abuse/dependence interaction was also identified such that participants with impaired neurocognition and a co-occurring substance abuse/dependence diagnosis demonstrated the poorest adherence. Results confirm the deleterious impact of these risk factors in isolation and also identify a specific interactive effect for individuals with comorbid neurocognitive impairment and a substance abuse/dependence disorder. Findings highlight the need for interventions that simultaneously address these problems.

Observational research on NCDs in HIV-positive populations: conceptual and methodological considerations

Noncommunicable diseases (NCDs) account for a growing burden of morbidity and mortality among people living with HIV in low- and middle-income countries (LMICs). HIV infection and antiretroviral therapy interact with NCD risk factors in complex ways, and research into this "web of causation" has so far been largely based on data from high-income countries. However, improving the understanding, treatment, and prevention of NCDs in LMICs requires region-specific evidence. Priority research areas include: (1) defining the burden of NCDs among people living with HIV, (2) understanding the impact of modifiable risk factors, (3) evaluating effective and efficient care strategies at individual and health systems levels, and (4) evaluating cost-effective prevention strategies. Meeting these needs will require observational data, both to inform the design of randomized trials and to replace trials that would be unethical or infeasible. Focusing on Sub-Saharan Africa, we discuss data resources currently available to inform this effort and consider key limitations and methodological challenges. Existing data resources often lack population-based samples; HIV-negative, HIV-positive, and antiretroviral therapy-naive comparison groups; and measurements of key NCD risk factors and outcomes. Other challenges include loss to follow-up, competing risk of death, incomplete outcome ascertainment and measurement of factors affecting clinical decision making, and the need to control for (time-dependent) confounding. We review these challenges and discuss strategies for overcoming them through augmented data collection and appropriate analysis. We conclude with recommendations to improve the quality of data and analyses available to inform the response to HIV and NCD comorbidity in LMICs.

Perceived mental health status of drug users with HIV: concordance between caregivers and care recipient reports and associations with caregiving burden and reciprocity

Because caregivers' monitoring of care recipients' mental health status likely facilitates provision of needed forms of assistance, the current study examines relationship factors associated with agreement in caregiver- and recipient self-reports of recipients' mental health status. Participants were former or current injection drug using persons with HIV/AIDS and their main caregivers (N = 258 dyads). Care recipients completed the Center for Epidemiologic Studies Depression scale and caregivers responded to a single item rating their recipients' mental health. Nearly two-thirds (64.7 %) of dyads agreed on care recipients' mental health status (κ = .26, p < .001). More secondary stressors of care, less reciprocity, and care recipients' greater physical limitations, substance use, and younger age predicted greater agreement on recipients' having poorer mental health. Greater secondary stressors and lower income were associated with less agreement on care recipients' mental health. Findings, which suggest that promoting reciprocity and alleviating secondary stressors of caregiving may help facilitate these caregivers' improved assessment of their care recipients' mental health status, have implications to dyadic approaches to promote drug users' HIV health outcomes.

Association of major depressive episode with negative outcomes of tuberculosis treatment

BACKGROUND

Pulmonary tuberculosis (TB) persists an important contributor to the burden of diseases in developing countries. TB control success is based on the patient's compliance to the treatment. Depressive disorders have been negatively associated with compliance of therapeutic schemes for chronic diseases. This study aimed to estimate the significance and magnitude of major depressive episode as a hazard factor for negative outcomes (NO), including abandon or death in patients receiving TB treatment.

METHODOLOGY/PRINCIPAL FINDINGS

A longitudinal study was conducted to evaluate the association of major depressive episode (MDE), as measured by a 5-item version of the Center for Epidemiological Studies Depression Scale (CES-D) with NO to TB treatment. Patients with confirmed TB were enrolled before the start of TB treatment. Baseline measurements included socio-demographic variables as well as the CES-D, which was also applied every month until the end of the treatment. Death and treatment default were assessed monthly. Survivor function (SF) for NO according to MDE status (CES-D≥6) at baseline (MDEb) was estimated. Cox's Regression was performed for bivariate analyses as well as for the multivariate model. A total of 325 patients accepted to participate in the study, of which 34 where excluded for diagnosis of MDR-TB. NO was observed in 24 patients (8.2%); 109 (37%) presented MDEb. Statistically significant difference was found on the SF of patients with and without MDEb (0.85 vs. 0.96, p-value = 0.002). The hazard ratio for NO, controlled for age, sex, marital status and instruction level was 3.54 (95%CI 1.43-8.75; p-value = 0.006).

CONCLUSION

The presence of MDE at baseline is associated to NO of TB treatment. Targeting detection and treatment of MDE may improve TB treatment outcomes.

Sexual behaviour and desire to discuss mental health as reported by HIV-infected men who have sex with men

We assessed sexually transmitted infection risk behaviours and desire to discuss mental health, as reported by 426 HIV-infected men who have sex with men receiving HIV care in eight urban clinics. Most of these patients (90%) had begun HIV care >1 year ago. In the past year, 74% had multiple sexual partners, 75% engaged in anal intercourse, 48% had >1 HIV-uninfected partner and 82% used illegal psychoactive drugs. Among those reporting anal intercourse, approximately 61% reported using a condom during the most recent episode. Among all patients, 70% wanted to talk with their clinicians about how they felt mentally or emotionally. Using a two-tailed chi-squared test, we found that patients who engaged in unprotected receptive anal sex were more likely to want such a conversation than those who did not (80% versus 62%, P < 0.01); and those who engaged in unprotected insertive anal sex were also more likely to want such a conversation (81% versus 63%, P < 0.01). The findings highlight the prevalence of risky sexual behaviour and of mental health concerns in the participating patient population. Patients reporting risky sexual behaviour were more likely to want to discuss how they felt mentally or emotionally than those not reporting such behaviour.

The development of an inventory to assess the structural barriers to clinic attendance and pill-taking amongst users of antiretroviral therapy

In addition to personal and psychological factors, structural factors may reduce the likelihood of optimal adherence to antiretroviral therapy (ART) among persons living with HIV. In this mixed-method study we report on the development of a scale to assess the salience of various structural barriers to ART adherence. After following conventional guidelines for scale development, two scales measuring structural barriers to adherence to clinic attendance and pill-taking were administered to 291 patients receiving ART at a public hospital in South Africa. Both exploratory and higher order factor analysis indicated that a single underlying general factor was appropriate for both scales. The final scales consisted of 12 items for the structural barriers to clinic attendance scale and 13 items for the structural barriers to medication-taking scale. Both scales displayed excellent internal consistency with Cronbach alpha coefficients above 0.80. Research to determine the construct validity of the scales may be a next step in this line of research.

Psychosocial and cultural correlates of depression among Hispanic men with HIV infection: a pilot study

Depression is a common mental health condition among persons with human immunodeficiency virus (HIV) infection. Depression influences quality of life, social relationships and adherence to medication therapy. Little is known about depression among Hispanic men with HIV infection. The purpose of this pilot study was to describe the relationships of depression to other psychosocial factors (self-esteem, Hispanic stress, substance abuse and violence) and cultural factors (familism and Hispanic stress) among a sample of Hispanic men with HIV infection. Using a cross-sectional, descriptive research design a convenience sample of 46 Hispanic men with HIV infection was recruited and surveyed from the South Florida area of the USA. The majority of the participants (65%; n = 30) were depressed. In addition, the majority of participants reported high familism and self-esteem and low Hispanic stress. A history of substance abuse and childhood and adult violence were common. Significant relationships were noted between depression, and self-esteem, Hispanic stress, substance abuse, and adult physical violence. Healthcare providers need to be aware of the high rates of depression, substance abuse and violence that may occur among Hispanic men with HIV infection. More research is needed to further explore the relationship of these factors, as well as to determine the impact that these variables have on adherence to medication therapy among Hispanic men with HIV infection.

Impact of HIV antiretroviral therapy on depression and mental health among clients with HIV in Uganda

OBJECTIVE

With wide-reaching harmful effects of depression, and the absence of psychiatric treatment in most HIV care programs in sub-Saharan Africa, we examined the effects of antiretroviral therapy (ART) on depression and other mental health indicators.

METHODS

602 patients (302 non-ART, 300 ART) were followed for the first 12 months of HIV care in Uganda, with assessments at entry into care and Months 6 and 12. Mental health was assessed with measures of depression, hopelessness, and internalized HIV stigma; physical health functioning was assessed as an explanatory variable.

RESULTS

Thirteen percent had clinical depression, 57% had elevated depressive symptoms, and CD4 cell count was negatively correlated with measures of depression at baseline. Significant reductions in elevated depressive symptoms (time: odds ratio [95% confidence interval] = 0.53 [0.43-0.64]) and hopelessness (time: β = -0.12, p < .001) were observed in both the ART and non-ART groups, but the drop in depression was greater among ART patients in intention-to-treat multivariate analysis (ART × time: p < .001). When added to the regression models, change in physical health functioning predicted positive longitudinal change on measures of depression, hopelessness, and internalized stigma (all p values < .001), yet ART status remained a significant independent predictor of each (ART × time: p values ranged from < .05 to < .001). Most mental health benefits of ART were experienced in the first 6 months of care.

CONCLUSIONS

These findings demonstrate the mental health benefits of HIV care and ART. However, in some people, mental health problems persist once physical health is stabilized, in which case mental health treatment may be needed.

Frequency and risk factors for HIV-associated neurocognitive disorder and depression in older individuals with HIV in northeastern Brazil

BACKGROUND

The study was undertaken to describe the frequency of HIV-associated neurocognitive disorders (HAND) and depressive symptoms in an older population with human immunodeficiency virus (HIV).

METHODS

A cross-sectional analysis of patients aged 50 years or older infected with HIV was carried out in an outpatient setting in Brazil from March to November 2008. Patients selected were submitted to cognitive evaluation using the Mini-Mental State Examination and International HIV Dementia Scale, and also to functional and depression evaluations.

RESULTS

Among the 52 patients evaluated, the frequency of neurocognitive disorder was 36.5%, while for dementia the frequency was 13.5%. No risk factors were identified. Among the patients with cognitive impairment, 73.7% had cortical impairment. The frequency of depressive symptoms was of 34.6%. The female gender was identified as a risk factor (p = 0.018) and patients with depressive symptoms had greater functional impairment (p < 0.001).

CONCLUSION

HAND and depressive symptoms are common in an older population. Patients with cognitive impairment achieved lower scores on the cortical assessment scales. Depressive symptoms are a stronger factor for functional impairment.

Tangible resources for preparing patients for antiviral therapy for chronic hepatitis C

BACKGROUND

Chronic hepatitis C (HCV) infected patients with coexisting mental health and/or substance abuse issues face significant barriers to treatment and are often deferred. This paper sought to highlight critical pre-treatment strategies and provide tangible resources for HCV clinicians to facilitate preparation and successful treatment of these patients.

METHODS

Guided by the clinical experience of our liver center, a large, tertiary academic medical center, and informed by the extant literature, we summarize pre-treatment strategies and specific resources and recommendations for HCV providers.

RESULTS

Four key pre-treatment strategies include: 1) screening for mental health/substance abuse issues using brief, reliable and validated instruments; 2) locating and establishing collaborative care with mental health and substance abuse specialists; 3) using a motivational interviewing communication style; and 4) addressing adherence-related issues.

CONCLUSIONS

HCV clinicians are in a unique position to prepare patients with coexisting mental health and/or substance abuse issues for antiviral therapy.

Living with HIV: responses to a mantram intervention using the critical incident research method

OBJECTIVES

The objective of this study was to identify and describe ways that a spiritually based intervention of silently repeating a mantram-sacred word or phrase-was used as a coping strategy for managing human immunodeficiency virus (HIV) disease.

DESIGN

The design was a qualitative research method, the critical incident technique.

SETTINGS/LOCATION

The study was conducted at an academically affiliated Veterans Affairs Hospital in southern California.

SUBJECTS

The subjects were outpatient adults living with HIV (n=32) who were receiving care through HIV clinics, community agencies, and HIV providers.

INTERVENTIONS

Subjects who participated in the intervention arm of a randomized controlled trial that tested the efficacy of a 5-weekly group mantram intervention were interviewed 2 months postintervention. Follow-up telephone interviews were specifically aimed at identifying instances of mantram use, and also participant perceptions of intervention usefulness or nonusefulness.

OUTCOME MEASURES

The outcome measures comprised categorization and comparison of the types and frequency of incidents reported, describing ways that the intervention was "helpful" or "not helpful" in managing stressors of HIV disease.

RESULTS

Participants reported a total of 185 incidents. Analysis and classification of the incidents resulted in eight mutually exclusive categories, including Increasing calm and/or peace, Mastering the technique, Changing my viewpoint, Increasing personal awareness, Adjusting behaviors, Managing physical symptoms, Increasing spirituality, and Enhancing relationships.

CONCLUSIONS

This study shows support for the benefits of the mantram intervention for adults with HIV. Additionally, the spiritually based mantram repetition intervention was found to be more helpful in providing a convenient, portable tool for managing a wide range of situations related to living with HIV disease.

The role of prospective memory in medication adherence: a review of an emerging literature

Although neurocognitive impairment is an established risk factor for medication nonadherence, standard neurocognitive tests developed for clinical purposes may not fully capture the complexities of non-adherence behavior or effectively inform theory-driven interventions. Prospective memory, an innovative cognitive construct describing one's ability to remember to do something at a later time, is an understudied factor in the detection and remediation of medication non-adherence. This review orients researchers to the construct of prospective memory, summarizes empirical evidence for prospective memory as a risk factor for non-adherence, discusses the relative merits of current measurement techniques, and highlights potential prospective memory-focused intervention strategies. A comprehensive literature review was conducted of published empirical studies investigating prospective memory and medication adherence. Overall, reviewed studies suggest that prospective memory is an important component of medication adherence, providing incremental ecological validity over established predictors. Findings indicate that prospective memory-based interventions might be an effective means of improving adherence.

Prospective associations between HIV-related stigma, transmission risk behaviors, and adverse mental health outcomes in men who have sex with men

BACKGROUND

The vast majority of research on HIV-related stigma has been cross sectional, and few studies have examined whether experiencing stigma is associated with sexual risk behaviors.

PURPOSE

The purpose of this study is to examine the prospective relationships between experiencing HIV-related stigma and symptoms of anxiety and depression, as well as sexual transmission risk behavior.

METHODS

The sample included HIV-infected men who have sex with men (n = 314) who participated in a secondary HIV-prevention study at their primary care site. Participants were assessed at baseline, and then completed follow-up assessments at 3, 6, 9, and 12 months.

RESULTS

Experiencing HIV-related stigma was prospectively associated with symptoms of depression (β = 0.16, p < .001), panic (β = 0.11, p = .01), and generalized anxiety (β = 0.05, p = .05). In addition, perceiving HIV-related stigma was prospectively associated with transmission risk behaviors, including unprotected receptive or insertive anal intercourse with HIV-seronegative or status unknown partners (β = 0.06, p = .047).

CONCLUSIONS

Experiencing HIV-related stigma may increase risk for sexual transmission risk behavior and mental health problems.

Changes in depression in a cohort of Danish HIV-positive individuals: time for routine screening

BACKGROUND

The aim of this study was to follow a cohort of HIV-positive individuals for 3 years in order to assess changes in depression, adherence, unsafe sex and emotional strains from living with HIV.

METHODS

Participants were assessed for depression, adherence, emotional strain and unsafe sex via a questionnaire. The Beck Depression Inventory II (BDI) was used to assess the prevalence and severity of depressive symptoms. Patients with a BDI score of 20 or above (moderate to major depression) were offered a clinical evaluation by a consultant psychiatrist.

RESULTS

In 2005, 205 HIV-positive individuals participated in the study. Symptoms of depression (BDI >14) were observed in 77 (38%) and major depression (BDI ≥20) in 53 (26%) individuals. In 2008, 148 participants were retested (72% of original sample). Depression (BDI >14) was observed in 38 (26%) and symptoms of major depression (BDI ≥20) in 24 (16%) individuals. Patients at risk of moderate to major depression were more likely to be non-adherent to medications, to practice unsafe sex and to suffer from emotional strains compared with patients not at risk of depression, both at baseline (2005) and follow-up (2008).

CONCLUSION

This study demonstrated a decline in depression scores over time and an association between the risk of depression and low medication adherence, stress and unsafe sex. We recommend routine screening for depression to be conducted regularly to provide full evaluations and relevant psychiatric treatment.

Trauma, dissociation, and antiretroviral adherence among persons living with HIV/AIDS

BACKGROUND

There are approximately 1,000,000 persons living with HIV/AIDS (PLH) in the United States; to reduce rates of new infection and curb disease progression, adherence to HIV medication among PLH is critical. Despite elevated trauma rates in PLH, no studies to date have investigated the relationship between dissociation, a specific symptom of trauma, and HIV medication adherence. We hypothesized that Post-Traumatic Stress Disorder (PTSD) symptoms would be associated with lower adherence, and that dissociation would moderate this relationship.

METHODS

Forty-three individuals with HIV were recruited from community-based clinics to participate in a cross-sectional study. The relationship of trauma, dissociation, and their interaction to the probability of antiretroviral adherence was assessed using a hierarchical binary logistic regression analysis.

RESULTS

Among 38 eligible participants, greater PTSD was associated with lower odds of adherence (OR = .92, p < .05). Dissociation moderated the effect of PTSD on adherence, resulting in lower odds of adherence (OR = .95, p < .05). PTSD symptoms were significantly associated with lower odds of adherence in individuals reporting high levels of dissociation (OR = .86, p < .05) but not in those reporting low levels of dissociation (OR = 1.02, p > .05).

CONCLUSIONS

This is the first study to demonstrate a relationship between dissociation and medication adherence. Findings are discussed in the context of clinical management of PLH with trauma histories and the need for interventions targeting dissociative symptomatology to optimize adherence.

Improving coping skills for self-management of treatment side effects can reduce antiretroviral medication nonadherence among people living with HIV

Background

Human immunodeficiency virus (HIV) treatment side effects have a deleterious impact on treatment adherence, which is necessary to optimize treatment outcomes including morbidity and mortality.

Purpose

To examine the effect of the Balance Project intervention, a five-session, individually delivered HIV treatment side effects coping skills intervention on antiretroviral medication adherence.

Methods

HIV+ men and women (N = 249) on antiretroviral therapy (ART) with self-reported high levels of ART side effect distress were randomized to intervention or treatment as usual. The primary outcome was self-reported ART adherence as measured by a combined 3-day and 30-day adherence assessment.

Results

Intent-to-treat analyses revealed a significant difference in rates of nonadherence between intervention and control participants across the follow-up time points such that those in the intervention condition were less likely to report nonadherence. Secondary analyses revealed that intervention participants were more likely to seek information about side effects and social support in efforts to cope with side effects.

Conclusions

Interventions focusing on skills related to ART side-effects management show promise for improving ART adherence among persons experiencing high levels of perceived ART side effects.

Secondary prevention of HIV in the United States: past, current, and future perspectives

To provide a synopsis of past, current, and potential next-generation approaches to prevention for positives (PfP) interventions in the United States. For a variety of reasons, PfP interventions, with the goals of limiting HIV transmission from people living with HIV/AIDS (PLWHA) to others and protecting the health of PLWHA, did not appear with any frequency in the United States until about 2000. Even today, the number and breadth of evidence-based PfP interventions is very limited. Nevertheless, meta-analytic evidence demonstrates that such interventions can be effective, perhaps even more so than interventions targeting HIV-uninfected individuals. We review early and more recent PfP interventions and suggest that next-generation PfP interventions must involve behavioral and biologic components and target any element that affects HIV risk behavior and/or infectivity. Next-generation PfP interventions should include increased HIV testing to identify additional PLWHA, components to initiate and maintain HIV care, to initiate antiretroviral therapy and promote adherence, and to reduce sexual and injection drug use risk behavior, as well as ancillary treatments and referrals to services. Comprehensive next-generation PfP interventions, including all of these elements and effective linkages among them, are discussed.

Antiretroviral therapy adherence among patients living with HIV/AIDS in Thailand

The importance of antiretroviral therapy adherence for patients living with HIV/AIDS has been well documented. Despite this critical need, many do not follow prescribed regimens. To examine the barriers that lead to non-adherence, we used cross-sectional survey data from a randomized controlled intervention trial in northern and north-eastern Thailand. Of the 507 patients that were enrolled in the trial, we analyzed 386 patients on antiretroviral therapy in order to examine the barriers to adherence. In addition to demographic characteristics, depressive symptoms, physical health, access to care, social support, and internalized shame, HIV disclosure and family communication were examined. The correlation analysis revealed that adherence is significantly associated with internalized shame, access to care, depressive symptoms, and family communication. Based on the multiple logistic regression analysis, depressive symptoms, access to care, HIV disclosure, and family communication were significant predictors of adherence. Having depressive symptoms remains a significant barrier to adherence, while access to care, HIV disclosure, and family communication play important positive roles. Our findings underscore the critical importance of addressing these various challenges that can influence adherence to antiretroviral therapy.

Pharmacotoxicology of monocyte-macrophage nanoformulated antiretroviral drug uptake and carriage

Limitations inherent to antiretroviral therapy (ART) in its pharmacokinetic properties remain despite over 15 years of broad use. Our laboratory has pioneered a means to improve ART delivery through monocyte-macrophage carriage of nanoformulated drug-encapsulated particles (nanoART). To this end, our prior works sought to optimize nanoART size, charge, and physical properties for cell uptake and antiretroviral activities. To test the functional consequences of indinavir, ritonavir, and efavirenz formulations we investigated relationships between human monocyte and macrophage cytotoxicities and nanoART dose, size, surfactant, and preparation. Wet-milled particles were more cytotoxic to monocytes-macrophages than those prepared by homogenization; with concurrent induction of tumor necrosis factor-alpha. Interestingly, pure suspensions of indinavir and ritonavir at 0.5 mM, and efavirenz at 0.1 mM and 0.5 mM also proved cytotoxic. Individual surfactants and formulated fluconazole neither affected cell function or viability. Although nanoART did not alter brain tight junction proteins ZO-2 and occludin, 0. 5mM ritonavir formulations did alter brain transendothelial electric resistance. These results underscore the potential importance of evaluating the physicochemical and functional properties of nanoART before human evaluations.

Predictors of nonadherence to highly active antiretroviral therapy among HIV-infected South Indians in clinical care: implications for developing adherence interventions in resource-limited settings

In light of the increasing availability of generic highly active antiretroviral therapy (HAART) in India, further data are needed to examine variables associated with HAART nonadherence among HIV-infected Indians in clinical care. We conducted a cross-sectional analysis of 198 HIV-infected South Indian men and women between January and April 2008 receiving first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based HAART. Nonadherence was defined as taking less than 95% of HAART doses in the last 1 month, and was examined using multivariable logistic regression models. Half of the participants reported less than 95% adherence to HAART, and 50% had been on HAART for more than 24 months. The median CD4 cell count was 435 cells per microliter. An increased odds of nonadherence was found for participants with current CD4 cell counts greater than 500 cells per microliter (adjusted odds ratio [AOR]: 2.22 [95% confidence interval {CI}: 1.04-4.75]; p = 0.038), who were on HAART for more than 24 months (AOR: 3.07 [95% CI: 1.35-7.01]; p = 0.007), who reported alcohol use (AOR: 5.68 [95%CI: 2.10-15.32]; p = 0.001), who had low general health perceptions (AOR: 3.58 [95%CI: 1.20-10.66]; p = 0.021), and who had high distress (AOR: 3.32 [95%CI: 1.19-9.26]; p = 0.022). This study documents several modifiable risk factors for nonadherence in a clinic population of HIV-infected Indians with substantial HAART experience. Further targeted culturally specific interventions are needed that address barriers to optimal adherence.

Monitoring medication adherence by unannounced pill counts conducted by telephone: reliability and criterion-related validity

BACKGROUND

Although demonstrated valid for monitoring medication adherence, unannounced pill counts conducted in patients' homes are costly and logistically challenging. Telephone-based unannounced pill counts offer a promising adaptation that resolves most of the limitations of home-based pill counting.

PURPOSE

We tested the reliability and criterion-related validity of a telephone-based unannounced pill count assessment of antiretroviral adherence.

METHOD

HIV-positive men and women (N = 89) in Atlanta, Georgia, completed a telephone-based unannounced pill count and provided contemporaneous blood specimens to obtain viral loads; 68 participants also received an immediate second pill count conducted during an unannounced home visit.

RESULTS

A high degree of concordance was observed between the number of pills counted on the telephone and in the home (intraclass correlation [ICC] = .981, p < .001) and percent of pills taken (ICC = .987, p < .001). Adherence obtained by the telephone count and home count reached 92% agreement (Kappa coefficient = .94). Adherence determined by telephone-based pill counts also corresponded with patient viral load, providing evidence for criterion-related validity.

CONCLUSION

Unannounced telephone-based pill counts offer a feasible objective method for monitoring medication adherence.