A multisite randomized trial of a motivational intervention targeting multiple risks in youth living with HIV: initial effects on motivation, self-efficacy, and depression

Motivational interviewing for substance use reduction

BACKGROUND

Substance use is a global issue, with around 30 to 35 million individuals estimated to have a substance-use disorder. Motivational interviewing (MI) is a client-centred method that aims to strengthen a person's motivation and commitment to a specific goal by exploring their reasons for change and resolving ambivalence, in an atmosphere of acceptance and compassion. This review updates the 2011 version by Smedslund and colleagues.

OBJECTIVES

To assess the effectiveness of motivational interviewing for substance use on the extent of substance use, readiness to change, and retention in treatment.

SEARCH METHODS

We searched 18 electronic databases, six websites, four mailing lists, and the reference lists of included studies and reviews. The last search dates were in February 2021 and November 2022.

SELECTION CRITERIA

We included randomised controlled trials with individuals using drugs, alcohol, or both. Interventions were MI or motivational enhancement therapy (MET), delivered individually and face to face. Eligible control interventions were no intervention, treatment as usual, assessment and feedback, or other active intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, and assessed the certainty of evidence with GRADE. We conducted meta-analyses for the three outcomes (extent of substance use, readiness to change, retention in treatment) at four time points (post-intervention, short-, medium-, and long-term follow-up).

MAIN RESULTS

We included 93 studies with 22,776 participants. MI was delivered in one to nine sessions. Session durations varied, from as little as 10 minutes to as long as 148 minutes per session, across included studies. Study settings included inpatient and outpatient clinics, universities, army recruitment centres, veterans' health centres, and prisons. We judged 69 studies to be at high risk of bias in at least one domain and 24 studies to be at low or unclear risk. Comparing MI to no intervention revealed a small to moderate effect of MI in substance use post-intervention (standardised mean difference (SMD) 0.48, 95% confidence interval (CI) 0.07 to 0.89; I2 = 75%; 6 studies, 471 participants; low-certainty evidence). The effect was weaker at short-term follow-up (SMD 0.20, 95% CI 0.12 to 0.28; 19 studies, 3351 participants; very low-certainty evidence). This comparison revealed a difference in favour of MI at medium-term follow-up (SMD 0.12, 95% CI 0.05 to 0.20; 16 studies, 3137 participants; low-certainty evidence) and no difference at long-term follow-up (SMD 0.12, 95% CI -0.00 to 0.25; 9 studies, 1525 participants; very low-certainty evidence). There was no difference in readiness to change (SMD 0.05, 95% CI -0.11 to 0.22; 5 studies, 1495 participants; very low-certainty evidence). Retention in treatment was slightly higher with MI (SMD 0.26, 95% CI -0.00 to 0.52; 2 studies, 427 participants; very low-certainty evidence). Comparing MI to treatment as usual revealed a very small negative effect in substance use post-intervention (SMD -0.14, 95% CI -0.27 to -0.02; 5 studies, 976 participants; very low-certainty evidence). There was no difference at short-term follow-up (SMD 0.07, 95% CI -0.03 to 0.17; 14 studies, 3066 participants), a very small benefit of MI at medium-term follow-up (SMD 0.12, 95% CI 0.02 to 0.22; 9 studies, 1624 participants), and no difference at long-term follow-up (SMD 0.06, 95% CI -0.05 to 0.17; 8 studies, 1449 participants), all with low-certainty evidence. There was no difference in readiness to change (SMD 0.06, 95% CI -0.27 to 0.39; 2 studies, 150 participants) and retention in treatment (SMD -0.09, 95% CI -0.34 to 0.16; 5 studies, 1295 participants), both with very low-certainty evidence. Comparing MI to assessment and feedback revealed no difference in substance use at short-term follow-up (SMD 0.09, 95% CI -0.05 to 0.23; 7 studies, 854 participants; low-certainty evidence). A small benefit for MI was shown at medium-term (SMD 0.24, 95% CI 0.08 to 0.40; 6 studies, 688 participants) and long-term follow-up (SMD 0.24, 95% CI 0.07 to 0.41; 3 studies, 448 participants), both with moderate-certainty evidence. None of the studies in this comparison measured substance use at the post-intervention time point, readiness to change, and retention in treatment. Comparing MI to another active intervention revealed no difference in substance use at any follow-up time point, all with low-certainty evidence: post-intervention (SMD 0.07, 95% CI -0.15 to 0.29; 3 studies, 338 participants); short-term (SMD 0.05, 95% CI -0.03 to 0.13; 18 studies, 2795 participants); medium-term (SMD 0.08, 95% CI -0.01 to 0.17; 15 studies, 2352 participants); and long-term follow-up (SMD 0.03, 95% CI -0.07 to 0.13; 10 studies, 1908 participants). There was no difference in readiness to change (SMD 0.15, 95% CI -0.00 to 0.30; 5 studies, 988 participants; low-certainty evidence) and retention in treatment (SMD -0.04, 95% CI -0.23 to 0.14; 12 studies, 1945 participants; moderate-certainty evidence). We downgraded the certainty of evidence due to inconsistency, study limitations, publication bias, and imprecision.

AUTHORS' CONCLUSIONS

Motivational interviewing may reduce substance use compared with no intervention up to a short follow-up period. MI probably reduces substance use slightly compared with assessment and feedback over medium- and long-term periods. MI may make little to no difference to substance use compared to treatment as usual and another active intervention. It is unclear if MI has an effect on readiness to change and retention in treatment. The studies included in this review were heterogeneous in many respects, including the characteristics of participants, substance(s) used, and interventions. Given the widespread use of MI and the many studies examining MI, it is very important that counsellors adhere to and report quality conditions so that only studies in which the intervention implemented was actually MI are included in evidence syntheses and systematic reviews. Overall, we have moderate to no confidence in the evidence, which forces us to be careful about our conclusions. Consequently, future studies are likely to change the findings and conclusions of this review.

Information, Motivation, Behavioral Skills Model in Youth Newly Starting Antiretroviral Treatment

An understanding of adherence among youth newly starting antiretroviral therapy (ART) is critical but understudied. The information-motivation-behavioral skills (IMB) model is often used to understand health behaviors, but has rarely been studied in youth with HIV. In a multi-site sample of 153 youth newly starting ART, structural equation modeling was utilized to test this model. The model was generally supported with information and behavioral skills directly related to the decision to adhere, while motivation was indirectly related through behavioral skills. Results suggest that interventions focusing on improving IMB constructs for medication adherence are important for preventing non-adherence in youth newly starting ART.

Understanding implementation completion of tailored motivational interviewing in multidisciplinary adolescent HIV clinics

Background

Understanding the barriers and facilitators of implementation completion is critical to determining why some implementation efforts fail and some succeed. Such studies provide the foundation for developing further strategies to support implementation completion when scaling up evidence-based practices (EBPs) such as Motivational Interviewing.

Method

This mixed-methods study utilized the Exploration, Preparation, Implementation, and Sustainment framework in an iterative analytic design to compare adolescent HIV clinics that demonstrated either high or low implementation completion in the context of a hybrid Type III trial of tailored motivational interviewing. Ten clinics were assigned to one of three completion categories (high, medium, and low) based on percentage of staff who adhered to three components of implementation strategies. Comparative analysis of staff qualitative interviews compared and contrasted the three high-completion clinics with the three low-completion clinics.

Results

Results suggested several factors that distinguished high-completion clinics compared to low-completion clinics including optimism, problem-solving barriers, leadership, and staff stress and turnover.

Conclusions

Implementation strategies targeting these factors can be added to EBP implementation packages to improve implementation success.

Plain Language Summary

While studies have begun to address adherence to intervention techniques, this is one of the first studies to address organizational adherence to implementation strategies. Youth HIV providers from different disciplines completed interviews about critical factors in both the inner and outer context that can support or hinder an organization's adherence to implementation strategies. Compared to less adherent clinics, more adherent clinics reported more optimism, problem-solving, and leadership strengths and less staff stress and turnover. Implementation strategies addressing these factors could be added to implementation packages to improve implementation success.

Development of a Psychological Intervention to Improve Depressive Symptoms and Enhance Adherence to Antiretroviral Therapy among Adolescents and Young People Living with HIV in Dar es Salaam Tanzania

Background: Interventions that simultaneously target depression and antiretroviral therapy (ART) medication adherence are recommended for improving HIV treatment outcomes and quality of life for adolescents living with HIV. However, evidence is scarce on culturally feasible and acceptable interventions that can be implemented for HIV-positive adolescents in Tanzania. We, therefore, developed a manualized brief psychological intervention that utilizes evidence-based strategies to address depression and ART adherence in adolescents living with HIV in Tanzania. Methods: We used the Theory of Change Enhanced Medical Research Council framework (TOCMRC) for developing complex interventions in health care to develop the intervention in five phases. First, the literature was reviewed to identify potential intervention components. Second, we conducted a situational analysis using qualitative interviews with adolescents living with HIV, health care providers, and caregivers. Third, we conducted a mental health expert workshop; and fourth, theory of change workshops with representatives from the Ministry of Health, mental health professionals, HIV implementing partners, adolescents, and healthcare providers. Lastly, we synthesized results to finalize the intervention and a theory of change map showing the causal pathway for how we expect the developed intervention to achieve its impact. Results: Adolescents living with HIV in Tanzania experience several unmet mental health needs ranging from overwhelming depressive symptoms to not feeling understood by healthcare providers who lack mental health knowledge. Participants perceived psychological intervention that utilizes a task-shifting approach to be acceptable and beneficial to addressing those problems. The novel components of the NITUE intervention included incorporating evidence-based intervention components, namely, cognitive-behavioral therapy, motivational interviewing, and problem solving. In addition, caregiver inclusion in the treatment was essential to ensure access to care, compliance, and improved outcomes. Conclusions: A culturally appropriate brief psychological intervention that utilizes a task-shifting approach to address depression and medication adherence for adolescents living with HIV in Dar es Salaam, Tanzania, was developed. The intervention will be piloted for appropriateness, feasibility, and acceptability and will provide material for a future trial to determine its effectiveness.

Self-Management Frameworks for Youth Living with Human Immunodeficiency Virus

HIV is now a chronic condition that can be managed. Adolescents and emerging adults represent a large proportion of new diagnoses, but struggle with many aspects of HIV-related self-management. Self-management of HIV is critical to maintaining health and involves retention in HIV care, medication adherence to achieve viral suppression, managing substance use, and sexual and general health-related behaviors. This article describes theoretic frameworks for HIV self-management as adapted for youth and reviews self-management interventions developed to improve health outcomes in youth living with HIV identified from a recent systematic review.

Student readiness for e-learning co-production in developing countries higher education institutions

This study set out to conceptualize and empirically establish the determinants and consequences of student readiness for e-learning co-production in the context of higher education institutions in developing countries. Using an online systematized questionnaire and structural equation modeling, data were collected and analyzed from 317 university students in Ghana. The analysis of the findings identified firm resource commitment, student resource commitment, task socialization, self-efficacy, motivation, and effective communication as the determinants of student readiness for e-learning co-production and student satisfaction as its consequence. The findings provide higher education managers with the critical factors for enhancing students' readiness for e-learning co-production. It also provides higher education policymakers with the strategic factors when assessing institutions as well as developing and implementing national policies on higher education e-learning. For academic researchers, this study was limited to the Ghanaian context, thus, limiting the robustness of the conceptual model and the ability to generalize the findings to another cultural context. Thus, future studies should undertake a cross-national comparison between developed and developing countries.

The Prevention of Mother-to-Child HIV/AIDS Transmission at Public Health Centers: A Phenomenology Study

Objective:

Mothers with HIV are likely to transmit the virus to their babies during pregnancy, delivery, or through breastfeeding. According to studies, the risk of mother-to-child HIV transmission among mothers that do not receive any form of treatment during pregnancy is approximately 15-45%. In Indonesia, the lack of a prevention program for HIV led to the provision of antiretroviral therapy (ART) for the prevention of mother-to-child transmission (PMTCT). The policies, financial facilities, the healthcare system, and human resources, including health workers, are factors that influence the PMTCT. This research discusses the perceptions of several doctors and midwives regarding the prevention of mother-to-child transmission at public health centers. Furthermore, information regarding policies and implementation of the PMTCT program at public health centers in Yogyakarta was qualitatively collected through semi-structured interviews.

Methods:

This research involved 6 participants, comprising of 3 heads of public health centers and 3 midwives as the HIV/AIDS program managers. A total of 5 themes were selected for the interview, namely policies of mandatory HIV testing for pregnant mothers, inadequate knowledge of the virus, need for PMTCT training, infrastructure and facilities, and HIV retesting.

Results:

Pregnant mothers are at potential risk of exposing health workers to HIV. They are also prone to contracting the virus due to poor educational background and less exposure to health information. Therefore, midwives need Prongs 3 and 4 to avoid contracting the virus while assisting pregnant mothers. Presently, there is a shortage of health promotion media for PMTCT, which include both electronic and print educational media. Therefore, the implementation of HIV testing in Indonesia is mandatory for pregnant mothers at their first antenatal care (ANC). However, despite the importance of conducting this test before labor, there is no regulation to ensure its implementation.

Conclusion:

The success of HIV mitigation is closely associated with the participation of academicians, policymakers, and community networks in providing collaborative planning strategies for the reduction of its spread, and evaluation of the mitigation result.

A Systematic Review and Meta-Analysis of Interventions for Orphans and Vulnerable Children Affected by HIV/AIDS Worldwide

BACKGROUND

Worldwide, there are more than 13.3 million orphans and vulnerable children affected by Human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) (HIV OVC), defined as individuals below the age of 18 who have lost one or both parents to HIV/AIDS or have been made vulnerable by HIV/AIDS; they are at risk for negative psychosocial and cognitive outcomes.

PURPOSE

This meta-analysis aimed to examine the scientific literature on available interventions for HIV OVC, with a focus on community-based interventions (CBI).

METHODS

Systematic electronic searches were conducted from four databases between October 2016 and April 2017 to identify articles investigating the effectiveness of interventions for HIV OVC. Effect sizes were calculated for each article which provided enough information and data points for analyses.

RESULTS

Seventy-four articles were reviewed, including psychosocial interventions (d = 0.30), cognitive interventions (d = 0.14), social protection interventions (d = 0.36), and community-based interventions (CBI; d = 0.36). Study-specific effect sizes varied widely, ranging from -1.09 to 2.26, that is, from a negative effect to an impressively large positive one, but the majority of studies registered small to medium effects (the overall effect size for all studies was 0.32, SE = 0.03, 95% CI: 0.26-0.37). Social protection interventions had the highest positive outcomes whereas CBI tended to have the fewest significant positive outcomes, with some outcomes worsening instead of improving.

CONCLUSIONS

Overall, interventions provided to OVC have potential for improving cognitive, psychosocial, and risk-behavior outcomes. Social protection interventions and CBI had the highest effect sizes, but CBI had positive effects on fewer outcomes and demonstrated some negative effects. CBI warrant scrutiny for improvement, as they represent an important form of culturally embedded services with potentially long-term benefits to OVC, yet appear to be differentially effective. Successful components of other types of intervention were identified, including cash grants, mentorship, and family therapy. In addition, more research is needed that attends to which interventions may be more effective for specific populations, or that studies cost-effectiveness.

Psychosocial interventions for improving engagement in care and health and behavioural outcomes for adolescents and young people living with HIV: a systematic review and meta-analysis

INTRODUCTION

Adolescents and young people comprise a growing proportion of new HIV infections globally, yet current approaches do not effectively engage this group, and adolescent HIV-related outcomes are the poorest among all age groups. Providing psychosocial interventions incorporating psychological, social, and/or behavioural approaches offer a potential pathway to improve engagement in care and health and behavioural outcomes among adolescents and young people living with HIV (AYPLHIV).

METHODS

A systematic search of all peer-reviewed papers published between January 2000 and July 2020 was conducted through four electronic databases (Cochrane Library, PsycINFO, PubMed and Scopus). We included randomized controlled trials evaluating psychosocial interventions aimed at improving engagement in care and health and behavioural outcomes of AYPLHIV aged 10 to 24 years.

RESULTS AND DISCUSSION

Thirty relevant studies were identified. Studies took place in the United States (n = 18, 60%), sub-Saharan Africa (Nigeria, South Africa, Uganda, Zambia, Zimbabwe) and Southeast Asia (Thailand). Outcomes of interest included adherence to antiretroviral therapy (ART), ART knowledge, viral load data, sexual risk behaviours, sexual risk knowledge, retention in care and linkage to care. Overall, psychosocial interventions for AYPLHIV showed important, small-to-moderate effects on adherence to ART (SMD = 0.3907, 95% CI: 0.1059 to 0.6754, 21 studies, n = 2647) and viral load (SMD = -0.2607, 95% CI -04518 to -0.0696, 12 studies, n = 1566). The psychosocial interventions reviewed did not demonstrate significant impacts on retention in care (n = 8), sexual risk behaviours and knowledge (n = 13), viral suppression (n = 4), undetectable viral load (n = 5) or linkage to care (n = 1) among AYPLHIV. No studies measured transition to adult services. Effective interventions employed various approaches, including digital and lay health worker delivery, which hold promise for scaling interventions in the context of COVID-19.

CONCLUSIONS

This review highlights the potential of psychosocial interventions in improving health outcomes in AYPLHIV. However, more research needs to be conducted on interventions that can effectively reduce sexual risk behaviours of AYPLHIV, as well as those that can strengthen engagement in care. Further investment is needed to ensure that these interventions are cost-effective, sustainable and resilient in the face of resource constraints and global challenges such as the COVID-19 pandemic.

Alcohol Use and Antiretroviral Adherence Among Patients Living with HIV: Is Change in Alcohol Use Associated with Change in Adherence?

Alcohol use increases non-adherence to antiretroviral therapy (ART) among persons living with HIV (PLWH). Dynamic longitudinal associations are understudied. Veterans Aging Cohort Study (VACS) data 2/1/2008-7/31/16 were used to fit linear regression models estimating changes in adherence (% days with ART medication fill) associated with changes in alcohol use based on annual clinically-ascertained AUDIT-C screening scores (range - 12 to + 12, 0 = no change) adjusting for demographics and initial adherence. Among 21,275 PLWH (67,330 observations), most reported no (48%) or low-level (39%) alcohol use initially, with no (55%) or small (39% ≤ 3 points) annual change. Mean initial adherence was 86% (SD 21%), mean annual change was - 3.1% (SD 21%). An inverted V-shaped association was observed: both increases and decreases in AUDIT-C were associated with greater adherence decreases relative to stable scores [p < 0.001, F (4, 21,274)]. PLWH with dynamic alcohol use (potentially indicative of alcohol use disorder) should be considered for adherence interventions.

A group-based mental health intervention for young people living with HIV in Tanzania: results of a pilot individually randomized group treatment trial

BACKGROUND

Increasing numbers of young people living with HIV (YPLWH) have unaddressed mental health challenges. Such challenges are associated with poor antiretroviral therapy (ART) adherence and high mortality. Few evidence-based mental health interventions exist to improve HIV outcomes among YPLWH.

METHODS

This pilot group treatment trial individually randomized YPLWH from two clinical sites in Tanzania, evaluated acceptability, feasibility, and preliminary effectiveness of a mental health intervention, Sauti ya Vijana (SYV; The Voice of Youth), was compared to the local standard-of-care (SOC) for improving ART adherence and virologic suppression. Enrolled YPLWH were 12-24 years of age and responded to mental health and stigma questionnaires, self-reported adherence, objective adherence measures (ART concentration in hair), and HIV RNA at baseline and 6-months (post-intervention). Feasibility and acceptability were evaluated, and potential effectiveness was assessed by comparing outcomes between arms using mixed effects modeling.

RESULTS

Between June 2016 and July 2017, 128 YPLWH enrolled; 105 were randomized and 93 (55 in SYV) followed-up at 6-months and were thereby included in this analysis. Mean age was 18.1 years; 51% were female; and 84% were HIV-infected perinatally. Attendance to intervention sessions was 86%; 6-month follow-up was 88%, and fidelity to the protocol approached 100%. Exploratory analyses of effectiveness demonstrated self-reported adherence improved by 7.3 percentage points (95% CI: 2.2, 12.3); and the pooled standard deviation for all ART concentration values increased by 0.17 units (95% CI: - 0.52, 0.85) in the SYV arm compared to SOC. Virologic suppression rates (HIV RNA < 400 copies/mL) at baseline were 65% in both arms but increased to 75% in the SYV arm while staying the same in the SOC arm (RR 1.13; 95% CI: 0.94, 1.36).

CONCLUSIONS

YPLWH often have poor HIV outcomes, making interventions to improve outcomes in this population critical. This pilot trial of the Tanzania-based SYV intervention demonstrated trends towards improvement in ART adherence and virologic outcomes among YPLWH, supporting efforts to scale the intervention into a fully-powered effectiveness trial.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02888288 . Registered August 9, 2016. Retrospectively registered as first participant enrolled June 16, 2016.

Comparative Effectiveness of Community-Based vs Clinic-Based Healthy Choices Motivational Intervention to Improve Health Behaviors Among Youth Living With HIV: A Randomized Clinical Trial

IMPORTANCE

Youth living with HIV make up one-quarter of new infections and have high rates of risk behaviors but are significantly understudied. Effectiveness trials in real-world settings are needed to inform program delivery.

OBJECTIVE

To compare the effectiveness of the Healthy Choices intervention delivered in a home or community setting vs a medical clinic.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted from November 1, 2014, to January 31, 2018, with 52 weeks of follow-up. Participants, recruited from 5 adolescent HIV clinics in the United States, were youths and young adults living with HIV aged 16 to 24 years who were fluent in English, were currently prescribed HIV medication, had a detectable viral load, and had used alcohol in the past 12 weeks. Individuals with an active psychosis that resulted in an inability to complete questionnaires were excluded. Data were analyzed from May to December, 2019.

INTERVENTIONS

Participants were randomized to receive the Healthy Choices intervention in either a home or clinic setting. Four 30-minute individual sessions based on motivational interviewing to improve (1) medication adherence and (2) drinking behavior were delivered during 10 weeks by trained community health workers. In session 1, participants chose which behavior to discuss first. Using motivational interviewing strategies, the community health worker elicited motivational language, guided the development of an individualized change plan while supporting autonomy, delivered feedback, and addressed knowledge gaps. Session 2 focused on the second target behavior. In subsequent sessions, community health workers reviewed the individualized change plan, monitored progress, guided problem solving, and helped maintain changes made.

MAIN OUTCOMES AND MEASURES

Primary outcomes were viral load and alcohol use change trajectories during 52 weeks of follow-up. Alcohol use severity and frequency were measured using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) (scores range from 0 to 33, with higher scores indicating greater severity of alcohol-related problems) and number of drinks consumed each day over a 30-day period, with timeline followback.

RESULTS

A total of 183 young people living with HIV (145 male [79.2%]; mean [SD] age, 21.4 [1.9] y) were randomized to the home setting (n = 90) or clinical setting (n = 93). Using growth-curve analysis, both groups showed declines in viral load after the intervention: among participants with available viral load information, in the home group, 12 participants (21%) had an undetectable viral load at 16 weeks, 12 (22%) at 28 weeks, and 10 (20%) at 52 weeks; in the clinic group, 16 participants (24%) had an undetectable viral load at 16 weeks, 20 (39%) at 28 weeks, and 18 (35%) at 52 weeks. However, the clinic group maintained gains, whereas those counseled at home had a significantly different and increasing trajectory during follow-up (unstandardized β = -0.07; 95% CI,-0.14 to -0.01; P = .02). A similar pattern was observed in ASSIST scores during follow-up, with reduced ASSIST scores in the clinic group (unstandardized β = -0.44; 95% CI,-0.81 to -0.07; P = .02).

CONCLUSIONS AND RELEVANCE

In this trial, the Healthy Choices intervention resulted in improvements in viral load and alcohol use over 12 months. Unexpectedly, the clinic setting outperformed home-based delivery for viral suppression. Although cross-sectional differences in ASSIST scores were nonsignificant, clinic delivery did improve the trajectory of ASSIST scores during follow-up. Thus, clinics may be the more effective site for interventions aimed at viral load reduction for young people living with HIV.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01969461.

Women of Reproductive Age Living with HIV in Argentina: Unique Challenges for Reengagement in Care

This study evaluated the reasons for not taking antiretroviral treatment (ART) among women of reproductive age who are disengaged from HIV care (have missed pharmacy pickups and physician visits), with the goal of identifying strategies for reengagement in HIV care. Participants were cisgender women (n = 162), 18 to 49 years of age, and who completed sociodemographic, medical history, reasons why they were not taking ART, mental health, motivation, and self-efficacy assessments. Latent class analysis was used for analysis. Women who reported avoidance-based coping (avoid thinking about HIV) had higher depression (U = 608.5, z = −2.7, P = .007), lower motivation (U = 601, z = −2.8, P = .006), and lower self-efficacy (U = 644.5, z = −2.4, P = .017) than those not using this maladaptive strategy. As women living with HIV experience a disproportionate burden of poor health outcomes, interventions focused on the management of depression may improve HIV outcomes and prevent HIV transmission.

Motivational interviewing and culture for urban Native American youth (MICUNAY): A randomized controlled trial

To date, few programs that integrate traditional practices with evidence-based practices have been developed, implemented, and evaluated with urban American Indians/Alaska Natives (AI/ANs) using a strong research design. The current study recruited urban AI/AN teens across northern, central, and southern California during 2014-2017 to participate in a randomized controlled trial testing two cultural interventions that addressed alcohol and other drug (AOD) use. Adolescents were 14-18 years old (inclusive), and either verbally self-identified as AI/AN or were identified as AI/AN by a parent or community member. We tested the added benefit of MICUNAY (Motivational Interviewing and Culture for Urban Native American Youth) to a CWG (Community Wellness Gathering). MICUNAY was a group intervention with three workshops that integrated traditional practices with motivational interviewing. CWGs were cultural events held monthly in each city. AI/AN urban adolescents (N = 185) completed a baseline survey, were randomized to MICUNAY + CWG or CWG only, and then completed a three- and six-month follow-up. We compared outcomes on AOD use, spirituality, and cultural identification. Overall, AOD use remained stable over the course of the study, and we did not find significant differences between these two groups over time. It may be that connecting urban AI/AN adolescents to culturally centered activities and resources is protective, which has been shown in other work with this population. Given that little work has been conducted in this area, longer term studies of AOD interventions with urban AI/AN youth throughout the U.S. are suggested to test the potential benefits of culturally centered interventions.

The impact of a syndemic theory-based intervention on HIV transmission risk behaviour among men who have sex with men in India: Pretest-posttest non-equivalent comparison group trial

This study aimed to examine the effect of a syndemic theory-based intervention to reduce condomless anal intercourse among men who have sex with men (MSM) in India. In 2016/17, a pre- and post-test comparison group design was used to implement a syndemic theory-based intervention among 459 MSM (229, intervention; 230, standard-of-care comparison) recruited through non-governmental organizations in Chandigarh, India. The intervention group received two-session peer-delivered motivational interviewing-based HIV risk reduction counselling and skills training to improve sexual communication/negotiation and condom use self-efficacy, and screening/management of psychosocial health problems. The intervention's effect on consistent condom use was estimated using difference-in-differences (DiD) approach. Mediation analysis assessed the extent to which intervention effects on the outcome were mediated by changes in psychosocial health problems and condom use self-efficacy. A process evaluation assessed implementation fidelity and intervention acceptability. Baseline consistent condom use was 43% in the intervention group and 46% in the standard-of-care group. Baseline survey findings demonstrated that a psychosocial syndemic of problematic alcohol use, internalised homonegativity and violence victimisation synergistically increased condomless anal intercourse. Using DiD, we estimated that the intervention increased consistent condom use with male partners by 16.4% (95% CI: 7.1, 25.7) and with female partners by 28.2% (95% CI: 11.9, 44.4), and decreased problematic alcohol use by 24.3% (95%CI: -33.4, -15.3), depression by 20.0% (95% CI: -27.6, -12.3) and internalised homonegativity by 34.7% (95% CI: -43.6%, -25.8%). The mediation analysis findings suggested that the intervention might have improved consistent condom use by decreasing internalised homonegativity and by increasing condom use self-efficacy. The process evaluation showed high levels of acceptability/satisfaction among participants and high levels of implementation fidelity. A syndemic theory-based intervention tailored for MSM in India is feasible, acceptable, and can reduce HIV transmission risk behaviour as well as problematic alcohol use, depression and internalised homonegativity.

Metropolitan Atlanta Community Adolescent Rapid Testing Initiative: The impact of motivational interviewing and intensive case management on the psychosocial and clinical care outcomes of adolescents and young adults with HIV

Early diagnosis and treatment are critical to preventing HIV-related complications and transmission for adolescents and young adults with HIV. The Metropolitan Atlanta Community Adolescent Rapid Testing Initiative (MACARTI) was a single-center, prospective, nonrandomized, interventional control group study incorporating motivational interviewing psychotherapy strategies with community outreach, HIV testing, and intensive case management. This substudy of MACARTI examined how the motivational interviewing and case management components influenced psychological distress, proactive coping, HIV/AIDS stress, and HIV stigma in association with HIV disease markers (HIV viral load and CD4⁺ T-cell counts). Ninety-eight adolescents and young adults with HIV (M_age = 21.5 ± 1.8, range 18-24) were allocated to either the standard of care (n = 49) or MACARTI (n = 49) arms, and results were compared between these two groups. Baseline and follow-up surveys measured psychological distress, proactive coping, HIV/AIDS stress, and HIV stigma. MACARTI arm assignment was associated with statistically significant reductions in psychological distress (p = .016), HIV/AIDS stress (p = .023), and the use of more reflective coping (p = .016) and strategic planning strategies (p = .001) during the first 6 months. These results did not remain significant at 1-year follow-up but may still provide support for the integration of psychotherapy strategies into HIV identification, linkage, and retention efforts in the future. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The Role of Motivational Interviewing in Children and Adolescents in Pediatric Care

Motivational interviewing (MI) addresses patient ambivalence about a desired goal in a directed, patient-centered manner. MI intervention is established as a therapeutic tool within the pediatric population with positive outcomes for obesity, asthma, medication adherence, and HIV management. MI is especially promising within the adolescent population where increasing independence tends to contribute to poorer health outcomes. Multidisciplinary adaptation of the MI format works well to address traditionally difficult pediatric care issues such as obesity. In the future, MI training of physicians may incorporate an online medium for wider distribution. More research is required to determine the most efficacious style and to support the generalizability and reproducibility of MI interventions for widespread application. [Pediatr Ann. 2019;48(9):e376-e379.].

Motivational Interviewing to Reduce Drug Use and HIV Incidence Among Young Men Who Have Sex With Men in Relationships and Are High Priority for Pre-Exposure Prophylaxis (Project PARTNER): Randomized Controlled Trial Protocol

Background

Men who have sex with men (MSM) currently account for more than two-thirds of new HIV diagnoses in the United States and, among young MSM (YMSM) aged 20 to 29 years, as many as 79% to 84% of new infections occur between primary partners. Contributing to HIV risk, YMSM use drugs at comparatively high rates. To date, no interventions have been developed that specifically address the unique needs of partnered YMSM or incorporate a focus on relationship factors in addressing personal motivation for change.

Objective

The study’s primary aim is to evaluate the efficacy of the PARTNER intervention and evaluate potential moderators or mediators of intervention effects. The study’s secondary aims were to gather ideographic data to inform a future effectiveness implementation study and develop a novel biomarker for pre-exposure prophylaxis (PrEP) adherence by analyzing PrEP drug levels in fingernails.

Methods

PARTNER is a 4-session motivational interviewing–based intervention that integrates video-based communication training to address drug use and HIV prevention among partnered YMSM. This study utilizes a randomized controlled trial design to compare the PARTNER intervention with an attention-matched psychoeducation control arm that provides information about HIV-risk reduction, PrEP, and substance use. Participants are randomized in a 1-to-1 ratio stratified on age disparity between partners, racial composition of the couple, and relationship length. Follow-up assessments are conducted at 3-, 6-, 9-, and 12-months postbaseline. The study recruits and enrolls 240 partnered YMSM aged between 18 to 29 years at a research center in New York City. Participants will be HIV-negative and report recent (past 30-day) drug use and condomless anal sex with casual partners; a nonmonogamous primary partner (regardless of HIV status); or a serodiscordant primary partner (regardless of sexual agreement). Primary outcomes (drug use and HIV sexual transmission risk behavior) are assessed via a Timeline Follow-back interview. Biological markers of outcomes are collected for drug use (fingernail assay), sexual HIV transmission risk (rectal and urethral gonorrhea and chlamydia testing), and PrEP adherence (dried blood spots and fingernails for a novel PrEP drug level assay).

Results

The study opened for enrollment in February 2018. Anticipated completion of enrollment is October 2021. Primary outcome analyses will begin after final follow-up completion.

Conclusions

Existing research on partnered YMSM within the framework of Couples Interdependence Theory (CIT) has suggested that relationship factors (eg, dyadic functioning and sexual agreements) are meaningfully related to drug use and HIV transmission risk. Results pertaining to the efficacy of the proposed intervention and the identification of putative moderators and mediators will substantially inform the tailoring of interventions for YMSM in relationships and contribute to a growing body of relationship science focused on enhancing health outcomes.

Trial Registration

ClinicalTrials.gov NCT03396367; https://clinicaltrials.gov/ct2/show/NCT03396367 (Archived by WebCite at http://www.webcitation.org/78ti7esTc.

International Registered Report Identifier (IRRID)

DERR1-10.2196/13015

Clinic-Based Delivery of the Young Men's Health Project (YMHP) Targeting HIV Risk Reduction and Substance Use Among Young Men Who Have Sex with Men: Protocol for a Type 2, Hybrid Implementation-Effectiveness Trial

BACKGROUND

Young men who have sex with men (YMSM) are disproportionately at risk for HIV and sexually transmitted infections. Adapting and testing the effectiveness of the Young Men's Health Project (YMHP), an efficacious intervention designed to reduce substance use and condomless anal sex (CAS) among YMSM, at clinics in Miami, Detroit, and Philadelphia has the potential to reduce HIV and STI disparities among urban YMSM.

OBJECTIVE

This study (Adolescent Medicine Trials Network for HIV/AIDS Interventions [ATN] 145 YMHP) aims to adapt YMHP for clinic and remote delivery by existing clinic staff and compare their effectiveness in real-world adolescent HIV clinics. This protocol is part of the ATN Scale It Up program described in a recently published article by Naar et al.

METHODS

This is a comparative effectiveness hybrid type-2 trial of the YMHP intervention with 2 delivery formats-clinic-based versus remote delivery-offered following HIV counseling and testing. Phase 1 includes conducting focus groups with youth to obtain implementation feedback about the delivery of the YMHP intervention and intervention components to ensure culturally competent, feasible, and scalable implementation. Phase 2 includes recruitment and enrollment of 270 YMSM, aged 15 to 24 years, 90 at each of the 3 sites. Enrollment will be limited to HIV-negative YMSM who report recent substance use and either CAS or a positive STI test result. Participants will be randomized to receive the YMHP intervention either in person or by remote delivery. Both conditions involve completion of the 4 YMHP sessions and the delivery of pre-exposure prophylaxis information and navigation services. A minimum of 2 community health workers (CHWs) will be trained to deliver the intervention sessions at each site. Sessions will be audio-recorded for Motivational Interviewing Treatment Integrity (MITI) fidelity coding, and CHWs and supervisors will be given implementation support throughout the study period.

RESULTS

Phase 1 focus groups were completed in July 2017 (n=25). Feedback from these focus groups at the 3 sites informed adaptations to the YMHP intervention manual, implementation of the intervention, and recruitment plans for phase 2. Baseline enrollment for phase 2 began in November 2018, and assessments will be at immediate posttest (IP)-, 3-, 6-, 9-, and 12-months after the intervention. Upon collection of both baseline and follow-up data, we will compare the effectiveness and cost-effectiveness of clinic-based versus remote delivery of YMHP in the context of health care access.

CONCLUSIONS

We are conducting YMHP in 3 cities with high rates of YMSM at risk for HIV and STIs. When adapted for real-world clinics, this study will help substance-using YMSM at risk for HIV and STIs and allow us to examine differences in effectiveness and cost by the method of delivery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03488914; https://clinicaltrials.gov/ct2/show/NCT03488914 (Archived by WebCite at http://www.webcitation.org/770WaWWfi).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/11184.

Depression, anxiety, and posttraumatic stress as predictors of immune functioning: differences between youth with behaviorally and perinatally acquired HIV

Youth living with HIV (YLWH) face significant mental health problems, namely depression, anxiety, and PTSD with rates of these disorders higher than in the general population. This study explored the relationship between symptoms of depression, anxiety, and PTSD and biological markers among a sample of 145 YLWH ages 13-25 years. Participants completed the Center for Epidemiologic Studies Depression Scale (CES-D), Generalized Anxiety Disorder-7 Item Scale (GAD-7), and Primary Care-Posttraumatic Stress Disorder Screen (PC-PTSD). Biological markers included CD4 count and viral load (VL) abstracted from medical records. Findings revealed a relationship between depression and anxiety and CD4 count as well as anxiety and VL. The relationship between depression and anxiety and CD4 count and anxiety and VL was moderated by transmission mode (i.e., behavioral versus perinatal). For youth perinatally infected, greater psychological symptoms of depression and anxiety were associated with a decline in CD4 count and increase in VL, but this was not true for youth with behaviorally acquired HIV. These findings point to the need for individualized mental health prevention and intervention services for YLWH.

The Supporting Adolescent Adherence in Vietnam (SAAV) study: study protocol for a randomized controlled trial assessing an mHealth approach to improving adherence for adolescents living with HIV in Vietnam

BACKGROUND

The overall goal of the Supporting Adolescent Adherence in Vietnam (SAAV) study is to improve understanding of an adherence feedback mHealth intervention designed to help adolescents living with HIV (ALHIV) maintain high adherence to antiretroviral therapy (ART), critical to effective treatment. Specifically, we aim to: (1) conduct formative research with Vietnamese ALHIV and their caregivers to better understand adherence challenges and refine the personalized mHealth intervention package; and (2) assess the feasibility, acceptability, and efficacy of the intervention to improve ART adherence by implementing a randomized controlled trial (RCT).

METHODS

The study will utilize mixed methods. The formative phase will include 40 in-depth interviews (IDIs) with 20 adolescent (12-17 years)/caregiver dyads and eight focus group discussions with adolescents, caregivers, and clinicians at the National Hospital for Pediatrics (NHP) in Hanoi, Vietnam. We will also conduct 20 IDIs with older adolescents (18-21 years) who have transitioned to adult care at outpatient clinics in Hanoi. We will then implement a seven-month RCT at NHP. We will recruit 80 adolescents on ART, monitor their adherence for one month to establish baseline adherence using a wireless pill container (WPC), and then randomize participants to intervention versus control within optimal (≥ 95% on-time doses) versus suboptimal (< 95% on-time doses) baseline adherence strata. Intervention participants will receive a reminder of their choice (cellphone text message/call or bottle-based flash/alarm), triggered when they miss a dose, and engage in monthly counseling informed by their adherence data. Comparison participants will receive usual care and offer of counseling at routine monthly clinic visits. After six months, we will compare ART adherence, CD4 count, and HIV viral suppression between arms, in addition to acceptability and feasibility of the intervention.

DISCUSSION

Findings will contribute valuable information on perceived barriers and facilitators affecting adolescents' ART adherence, mHealth approaches as adherence support tools for ALHIV, and factors affecting adolescents' ART adherence. This information will be useful to researchers, medical personnel, and policy-makers as they develop and implement adherence programs for ALHIV, with potential relevance to other chronic diseases during transition from adolescent to adult care.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03031197 . Registered on 21 January 2017.

Psychological therapies for anxiety and depression in children and adolescents with long-term physical conditions

BACKGROUND

Long-term physical conditions affect 10% to 12% of children and adolescents worldwide. These individuals are at greater risk of developing psychological problems, particularly anxiety and depression, sometimes directly related to their illness or medical care (e.g. health-related anxiety). There is limited evidence regarding the effectiveness of psychological therapies for treating anxiety and depression in this population. Therapies designed for children and adolescents without medical issues may or may not be appropriate for use with those who have long-term physical conditions.

OBJECTIVES

This review was undertaken to assess the effectiveness and acceptability of psychological therapies in comparison with controls (treatment-as-usual, waiting list, attention placebo, psychological placebo, or non-psychological treatment) for treating anxiety and depression in children and adolescents with long-term physical conditions.

SEARCH METHODS

We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 27 September 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to May 2016). In addition we searched the Web of Science (Core Collection) (12 October 2018) and conducted a cited reference search for reports of all included trials. We handsearched relevant conference proceedings, reference lists of included articles, and grey literature.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-randomised trials and cross-over trials of psychological therapies for treating anxiety or depression in children with long-term physical conditions were included.

DATA COLLECTION AND ANALYSIS

Abstracts and complete articles were independently reviewed by two authors. Discrepancies were addressed by a third author. Odds ratio (OR) was used for comparing dichotomous data and standardised mean differences (SMD) for comparing continuous data. Meta-analysis was undertaken when treatments, participants, and the underlying clinical question were similar. Otherwise, narrative analysis of data was undertaken.

MAIN RESULTS

Twenty-eight RCTs and one cross-over trial with 1349 participants were included in the review. Most participants were recruited from community settings and hospital clinics in high-income countries. For the primary outcome of treatment efficacy, short-term depression (versus any control), there was low-quality evidence from 16 trials involving 1121 participants suggesting that psychological therapies may be more effective than control therapies (SMD -0.31, 95% CI -0.59 to -0.03; I² = 79%). For the primary outcome of treatment efficacy, short-term anxiety (versus any control), there was inadequate evidence of moderate-quality from 13 studies involving 578 participants to determine whether psychological therapies were more effective than control conditions (SMD -0.26, CI -0.59 to 0.07, I² = 72%). Planned sensitivity analyses could not be undertaken for risk of bias due to the small number of trials that rated high for each domain. Additional sensitivity analysis demonstrated that psychological interventions specifically designed to reduce anxiety or depression were more effective than psychological therapies designed to improve other symptoms or general coping. There was some suggestion from subgroup analyses that they type of intervention (Chi² = 14.75, df = 5 (P = 0.01), I² = 66.1%), the severity of depression (Chi² = 23.29, df = 4 (P = 0.0001), I² = 82.8%) and the type of long-term physical condition (Chi² = 10.55, df = 4 (P = 0.03), I² = 62.1%) may have an impact on the overall treatment effect.There was qualitative (reported), but not quantitative evidence confirming the acceptability of selected psychological therapies for anxiety and depression. There was low-quality evidence that psychological therapies were more effective than control conditions in improving quality of life (SMD 1.13, CI 0.44 to 1.82, I² = 89%) and symptoms of long-term physical conditions (SMD -0.34, CI -0.6 to -0.06, I² = 70%), but only in the short term. There was inadequate low-quality evidence to determine whether psychological therapies were more effective than control conditions at improving functioning in either the short term or long term. No trials of therapies for addressing health-related anxiety were identified and only two trials reported adverse effects; these were unrelated to psychological therapies. Overall, the evidence was of low to moderate quality, results were heterogeneous, and only one trial had an available protocol.

AUTHORS' CONCLUSIONS

A limited number of trials of variable quality have been undertaken to assess whether psychological therapies are effective for treating anxiety and depression in children and adolescents with long-term physical conditions. According to the available evidence, therapies specifically designed to treat anxiety or depression (especially those based on principles of cognitive behaviour therapy (CBT)) may be more likely to work in children and adolescents who have mild to moderate levels of symptoms of these disorders, at least in the short term. There is a dearth of therapies specifically designed to treat health-related anxiety in this age group.

Drug Use and HIV Prevention With Young Gay and Bisexual Men: Partnered Status Predicts Intervention Response

The Young Men's Health Project (YMHP) has shown efficacy in reducing drug use and condomless anal sex (CAS) with casual partners among young gay, bisexual and other men who have sex with men (YGBMSM). The study examined whether relationship status at the time of intervention predicted response to YMHP by comparing baseline (pre-intervention) and follow-up (3, 6, 9, and 12 months post-intervention) data from the original trial. A group of 13 partnered YGBMSM who received YMHP was compared to a matched subsample of single YGBMSM. Among single men, drug use declined significantly at all follow-ups. Among partnered men, drug use was largely stable. While significant reductions were observed at 9 month assessment, 3, 6, and 12 month use did not differ significantly from baseline. Regardless of relationship status, CAS with casual partners declined significantly at 12 month follow-up. Results suggest the incorporation of components which address relationship factors, particularly those associated with drug use, may enhance benefits of YMHP for partnered YGBMSM.

Action and inaction in multi-behaviour recommendations: a meta-analysis of lifestyle interventions

This meta-analysis examined theoretical predictions about the effects of different combinations of action (e.g., start an exercise regime) and of inaction (e.g., reduce screen time, rest in between weight lifting series) recommendations in smoking, diet, and physical activity multiple-domain interventions. The synthesis included 150 research reports of interventions promoting multiple behaviour domain change and measuring change at the most immediate follow-up. The main outcome measure was an indicator of overall change that combined behavioural and clinical effects. There were two main findings. First, as predicted, interventions produced the highest level of change when they included a predominance of recommendations along one behavioural dimension (i.e., predominantly inaction or predominantly action). Unexpectedly, within interventions with predominant action or inaction recommendations, those including predominantly inaction recommendations had greater efficacy than those including predominantly action recommendations. This effect, however, was limited to interventions in the diet and exercise domains, but reversed (greater efficacy for interventions with predominant action vs. inaction recommendations) in the smoking domain. These findings provide important insights on how to best combine recommendations when interventions target clusters of health behaviours.

Correlates of missed clinic visits among youth living with HIV

Youth living with HIV (YLH) have significant problems with attending their medical appointments. Poor attendance, consequently, predicts viral non-suppression and other negative health outcomes. To identity targets of intervention, this cross-sectional study examined correlates of past-year missed clinic visits among YLH (N = 2125) attending HIV clinics in the United States and Puerto Rico. Thirty-six percent of YLH missed two or more visits in the past year. Several factors were associated with missed visits in our regression model. Among sociodemographic characteristics and HIV disclosure status, females (adjusted odds ratio [OR] = 1.63, compared to males), Black YLH or YLH of mixed racial heritage (AORs = 1.76, 1.71, respectively, compared to White YLH), YLH with an unknown route of infection (AOR = 1.86, compared to YLH with perinatal infection), and YLH endorsing HIV disclosure (AOR = 1.37, compared to YLH not endorsing disclosure) were at greater risk for missed visits. Among behavioral health risks, YLH who endorsed marijuana use (AOR = 1.42), frequent other drug use (AOR = 1.60), or a history of incarceration (AOR = 1.27) had greater odds of missed visits than youth not endorsing these risks. Finally, two social-cognitive resources emerged as protective factors: adherence self-efficacy (AOR = .28) and social support (AOR = .88). We discuss how providers working with YLH can improve this population's retention outcomes.

Adherence to antiretroviral therapy, stigma and behavioral risk factors in HIV-infected adolescents in Asia

We studied behavioral risks among HIV-infected and uninfected adolescents using an audio computer-assisted self-interview. A prospective cohort study was initiated between 2013 and 2014 in Malaysia, Thailand, and Vietnam. HIV-infected adolescents were matched to uninfected adolescents (4:1) by sex and age group (12-14 and 15-18 years). We enrolled 250 HIV-infected (48% male; median age 14.5 years; 93% perinatally infected) and 59 uninfected (51% male; median age 14.1 years) adolescents. At enrollment, HIV-infected adolescents were on antiretroviral therapy (ART) for a median (IQR) of 7.5 (4.7-10.2) years, and 14% had HIV-RNA >1000 copies/mL; 19% reported adherence <80%. Eighty-four (34%) HIV-infected and 26 (44%) uninfected adolescents reported having ever smoked cigarettes or drunk alcohol (p = 0.13); 10% of HIV-infected and 17% of uninfected adolescents reported having initiated sexual activity; 6 of the HIV-infected adolescents had HIV-RNA >1000 copies/mL. Risk behaviors were common among adolescents, with few differences between those with and without HIV.

Behavioral Interventions Targeting Alcohol Use Among People Living with HIV/AIDS: A Systematic Review and Meta-Analysis

Alcohol use is often reported among people living with HIV/AIDS (PLWHA) and is associated with increased sexual risk and poor medication adherence. This meta-analysis evaluated the efficacy of behavioral interventions addressing alcohol use among PLWHA. Twenty-one studies (N = 8461 PLWHA) that evaluated an individual-level intervention addressing alcohol use alone or as part of a more comprehensive alcohol/HIV intervention, included a control condition, and were available through December 2016 were included. Independent raters coded study, sample, and intervention content. Weighted mean effect sizes, using random-effects models, were calculated. Results indicate that interventions reduced alcohol consumption, increased condom use, and improved medication adherence relative to controls (d +s = 0.10-0.24). Plasma viral load was also reduced in intervention versus control participants (d + = 0.14, 95% CI = 0.02, 0.26; k = 7). These findings show that behavioral interventions addressing alcohol use can successfully reduce alcohol consumption and also improve HIV-related outcomes among PLWHA.

Using Technology to Improve Adherence to HIV Medications in Transitional Age Youth: Research Reviewed, Methods Tried, Lessons Learned

In transitional age youth living with HIV or AIDS, non-adherence (<80%) to anti-retroviral medication is associated with viral resistance, disease progression, and an increased risk of death. This feasibility study investigated the Maya MedMinder electronic pillbox and cell phone texting with personalized motivational interviewing strategies to improve medication adherence in non-adherent youth. Twenty patients out of 30 identified as non-adherent by the Pediatric HIV team at the Medical University of South Carolina were approached, and 15 were recruited (Ages 12 to 20; 13.3% male, 86.7% female; 100% African-American). Following baseline MedMinder monitoring, subjects were randomized to intervention groups with reminder signals on or off. The time medications were taken was collected by the MedMinder, resulting in adherence scores. All were interviewed for readiness to change utilizing the Motivational Interviewing (MI) Stages of Change scores. Viral load and CD4 labs were scheduled every 6 weeks. Despite monetary incentives and personalized support, recruitment and adherence to the protocol was a challenge. Only 6/15 subjects completed the entire study scheduled for 6-months .Stages of change scores revealed that those that transitioned to making changes had higher CD4 percentages midway through the study. Challenges included missed appointments and labs despite efforts by text and phone to schedule convenient appointment times with participants. Device challenges included the large size of the MedMinder and faulty electronic signaling, especially from rural areas. The methodology was feasible with these patients. This small feasibility study highlights that technological tools to promote adherence and motivational enhancement strategies in teens and young adults who are non-adherent to HIV medication regimens can enhance biomarker outcomes associated with medication adherence.

An integrative review of the efficacy of motivational interviewing in HIV management

OBJECTIVE

The purpose of this integrative review is to examine the use of motivational interviewing (MI) to improve health outcomes in persons living with HIV (PLWH).

METHODS

We reviewed the existing literature, using the PRISMA model. The PubMed, Web of Science, Embase, and CINAHL databases were searched for all relevant studies, using the terms HIV, AIDS, and motivational interviewing.

RESULTS

Of 239 articles identified initially, 19 met our criteria for synthesis. These studies were conducted throughout the world, including the U.S., Thailand, and South Africa. In general, studies that used MI, either alone or in conjunction with other interventions, reported improved adherence, decreased depression, and decreased risky sexual behaviors.

CONCLUSION

This review demonstrates a positive relationship between MI-based interventions and behavioral change, which may lead to improved health outcomes in PLWH.

PRACTICE IMPLICATIONS

Motivational interviewing can be an effective method of therapeutic communication for PLWH, who struggle with adherence, depression, and risky sexual behaviors.

Predictors and Profiles of Antiretroviral Therapy Adherence Among African American Adolescents and Young Adult Males Living with HIV

Adherence to antiretroviral therapy (ART) is crucial for thwarting HIV disease progression and reducing secondary HIV transmission, yet youth living with HIV (YLH) struggle with adherence. The highest rates of new HIV infections in the United States occur in young African American men. A sample of 387 HIV-positive young African American males on ART was selected from a cross-sectional assessment of (YLH) receiving medical care within the Adolescent Trials Network for HIV/AIDS Interventions (ATN) from 2010 to 2012 (12-24 years old, median 22.00, SD 2.08). Participants completed self-reported adherence, demographic, health, and psychosocial measures. Sixty-two percent self-reported 100% ART adherence. Optimal data analysis identified frequency of cannabis use during the past 3 months as the strongest independent predictor of adherence, yielding moderate effect strength sensitivity (ESS) = 27.1, p < 0.001. Among participants with infrequent cannabis use, 72% reported full adherence; in contrast, only 45% of participants who used cannabis frequently reported full adherence. Classification tree analysis (CTA) was utilized to improve classification accuracy and to identify the pathways of ART adherence and nonadherence. The CTA model evidenced a 38% improvement above chance for correctly classifying participants as ART adherent or nonadherent. Participants most likely to be adherent were those with low psychological distress and minimal alcohol use (82% were adherent). Participants least likely to be adherent were those with higher psychological distress and engaged in weekly cannabis use (69% were nonadherent). Findings suggest multiple profiles of ART adherence for young African American males living with HIV and argue for targeted psychosocial interventions.

Parenting Among Adolescents and Young Adults with Human Immunodeficiency Virus Infection in the United States: Challenges, Unmet Needs, and Opportunities

Given the realistic expectations of HIV-infected adolescents and young adults (AYA) to have children and start families, steps must be taken to ensure that youth are prepared to deal with the challenges associated with their HIV and parenting. Literature reviews were conducted to identify published research and practice guidelines addressing parenting or becoming parents among HIV-infected AYA in the United States. Research articles or practice guidelines on this topic were not identified. Given the paucity of information available on this topic, this article provides a framework for the development of appropriate interventions and guidelines for use in clinical and community-based settings. First, the social, economic, and sexual and reproductive health challenges facing HIV-infected AYA in the United States are summarized. Next, family planning considerations, including age-appropriate disclosure of HIV status to those who are perinatally infected, and contraceptive and preconception counseling are described. The impact of early childbearing on young parents is discussed and considerations are outlined during the preconception, antenatal, and postnatal periods with regard to antiretroviral medications and clinical care guidelines. The importance of transitioning AYA from pediatric or adolescent to adult-centered medical care is highlighted. Finally, a comprehensive approach is suggested that addresses not only medical needs but also emphasizes ways to mitigate the impact of social and economic factors on the health and well-being of these young parents and their children.

Psychological distress among Ugandan adolescents living with HIV: Examining stressors and the buffering role of general and religious coping strategies

HIV infection increases the risk of psychological distress among adolescents living with HIV (ALHIV), which, in turn, increases risky behaviours such as medication non-adherence, substance use, and sexual risk-taking. The majority of studies on psychological distress among ALHIV have been conducted in high-income countries; data on the prevalence and correlates of psychological distress among ALHIV in sub-Saharan Africa (SSA) are scarce, yet over two-thirds of the global population of ALHIV resides in SSA. The purpose of this study was to identify the contextually relevant correlates of psychological distress among Ugandan ALHIV. Utilizing the stress and coping framework, we explored the risk and protective factors for psychological distress in cross-sectional sample of 464 ALHIV (aged 12-19; 53% female) at a large HIV treatment centre in Kampala, Uganda. The stressors associated with psychological distress included daily hassles, major negative life events, HIV-related quality of life, and stigma. Protective factors included psychosocial resources such as religious coping, satisfaction with social support, and general coping style and behaviours. Social support and optimism were significantly associated with psychological distress. Findings underscore the need for mental health services for ALHIV in Uganda and other resource-limited settings.

Predictors of Self-Reported Adherence to Antiretroviral Medication in a Multisite Study of Ethnic and Racial Minority HIV-Positive Youth

OBJECTIVE

To test social cognitive predictors of medication adherence in racial/ethnic minority youth living with HIV using a conceptual model.

METHODS

Youth were participants in two descriptive studies by the Adolescent Trials Network for HIV/AIDS Interventions. Minority youth ages 16-24 years who were prescribed antiretroviral medication were included (N = 956). Data were collected through chart extraction and/or laboratory testing and by Audio Computer-Assisted Self-Interview.

RESULTS

39% of youth reported suboptimal adherence. Path analysis was used to explore predictors of medication adherence. Higher self-efficacy predicted higher readiness and adherence. Greater social support predicted higher self-efficacy. Psychological symptoms and substance use were associated with several predictors and lower adherence.

CONCLUSIONS

The model provided a plausible framework for understanding adherence in this population. Culturally competent, but individually tailored, interventions focused on increasing self-efficacy to take medication and reducing risk behaviors (e.g., substance use) may be helpful for racial or ethnic minority youth with HIV.

A longitudinal study of interpersonal relationships among lesbian, gay, and bisexual adolescents and young adults: mediational pathways from attachment to romantic relationship quality

The current study examined the potential for mental health to mediate associations between earlier attachment to parents and peers and later relationship adjustment during adolescence and young adulthood in a sample of sexual minority youth. Secondarily, the study examined associations between peer and parental attachment and relationship/dating milestones. Participants included 219 lesbian, gay, and bisexual youth who participated in six waves of data collection over 3.5 years. Parental attachment was associated with an older age of dating initiation, while peer attachment was associated with longer relationship length. Both peer and parental attachment were significantly associated with mental health in later adolescence and young adulthood. Mental health mediated the association between peer attachment and main partner relationship quality. While the total indirect effect of parental attachment on main partner relationship quality was statistically significant, specific indirect effects were not. Implications for the application of attachment theory and integration of interpersonal factors into mental health intervention with sexual minority youth are discussed.

Meeting the complex needs of individuals living with HIV: a case study approach

This article critically discusses the nursing care and management of a person living with the human immunodeficiency virus (HIV) infection as a long-term condition, requiring highly complex HIV care. Complex HIV care is managed in the secondary care setting. However, recent legislation has motivated shifts in HIV care to the community care setting. This article aims to enhance health professionals' understanding in order to equip practice and district nurses to deliver HIV care provision. Antiretroviral adherence is a prerequisite for disease survival as well as an essential component of complete HIV self-care management. It is therefore imperative that nurses tailor adherence strategies according to each patient's requirements. Case management strategies such as the use of cognitive behavioural therapy to alleviate depressive symptoms will be considered. Furthermore, the use of motivational interviewing for antiretroviral adherence is highlighted as a potential intervention to help patients overcome the physical, psychological and physiological challenges of living with HIV-associated comorbidities. The delivery of integrated HIV care is pivotal for the management of the person living with HIV, as is the facilitation of a self-caring behaviour.

Motivational interviewing targeting risky sex in HIV-positive young Thai men who have sex with men

Motivational interviewing (MI) has been shown to reduce sexual risks among HIV-positive men who have sex with men (HMSM) in the US. We conducted a randomized trial of Healthy Choices, a 4-session MI intervention, targeting sexual risks among 110 HIV-positive youth ages 16-25 years in Thailand. Risk assessments were conducted at baseline, 1 month, and 6 months post-intervention. This report presents the analysis of 74 HMSM in the study. There were 37 HMSM in the Intervention group and 37 in the control group. The proportions of participants having anal sex and having sex with either HIV-uninfected or unknown partners in past 30 days were significantly lower in Intervention group than in Control group at 6 months post-intervention (38 vs. 65 %, p = .04; and 27 vs. 62 %, p < .01, respectively). There were no significant differences in general mental health scores and HIV stigma scores between the two groups at any study visit. Thirty-five (95 %) HMSM in the Intervention group vs. 31 (84 %) in control group attended ≥ 3 sessions. Loss to follow-up was 8 and 30 %, respectively (p = .04). Healthy Choices for young Thai HMSM was associated with sexual risk reduction. Improvements in mental health were noted in Intervention group. Healthy Choices is a promising behavioral intervention and should be further developed to serve the needs of young HMSM in resource-limited countries.

Impact of methamphetamine on infection and immunity

The prevalence of methamphetamine (METH) use is estimated at ~35 million people worldwide, with over 10 million users in the United States. METH use elicits a myriad of social consequences and the behavioral impact of the drug is well understood. However, new information has recently emerged detailing the devastating effects of METH on host immunity, increasing the acquisition of diverse pathogens and exacerbating the severity of disease. These outcomes manifest as modifications in protective physical and chemical defenses, pro-inflammatory responses, and the induction of oxidative stress pathways. Through these processes, significant neurotoxicities arise, and, as such, chronic abusers with these conditions are at a higher risk for heightened consequences. METH use also influences the adaptive immune response, permitting the unrestrained development of opportunistic diseases. In this review, we discuss recent literature addressing the impact of METH on infection and immunity, and identify areas ripe for future investigation.

Adherence-related issues in adolescents and young adults with hematological disorders

Nonadherence to medical recommendations is a widespread problem well documented in a multitude of clinical settings. Nonadherence may adversely affect clinical outcomes such as survival and quality of life and increase health-care-related costs. An understanding of the factors driving nonadherence is key to developing effective adherence-enhancing interventions (AEIs). There are ongoing attempts in contemporary adherence research to better define the various components of adherence, to find optimal measures of adherence and correlations with clinical outcomes, and to create a classification system for AEIs. Nonadherence is also widely prevalent among adolescents and young adults (AYAs) with chronic hematological diseases, affecting up to 50% of patients and increasing with age. Combined use of objective (i.e. electronic monitoring, EM) and subjective (i.e. self-report) measures of adherence may be the preferred approach to assess adherence. The unique physical, social and emotional aspects of the AYA life stage are closely related to intricate causes of nonadherence in AYAs such as problems in transition to adult care. Until proven otherwise, the empirical target in AYAs with hematological disorders should be perfect adherence. Multilevel AEIs, EM feedback and behavioral interventions are among the most effective types of AEIs. Despite the magnitude of the problem, only a handful of AEIs have been evaluated among AYAs with hematological disorders. Thus, this is a field with unmet needs warranting high-quality trials using standardized and well-specified assessment methods and interventions. This review discusses the prevalence, definition, causes and clinical implications of nonadherence among AYAs with hematological disorders, along with strategies to measure and improve adherence.

Reliability and validity of a treatment fidelity assessment for motivational interviewing targeting sexual risk behaviors in people living with HIV/AIDS

This study psychometrically evaluates the Motivational Interviewing Treatment Integrity Code (MITI) to assess fidelity to motivational interviewing to reduce sexual risk behaviors in people living with HIV/AIDS. 74 sessions from a pilot randomized controlled trial of motivational interviewing to reduce sexual risk behaviors in people living with HIV were coded with the MITI. Participants reported sexual behavior at baseline, 3-month, and 6-months. Regarding reliability, excellent inter-rater reliability was achieved for measures of behavior frequency across the 12 sessions coded by both coders; global scales demonstrated poor intraclass correlations, but adequate percent agreement. Regarding validity, principle components analyses indicated that a two-factor model accounted for an adequate amount of variance in the data. These factors were associated with decreases in sexual risk behaviors after treatment. The MITI is a reliable and valid measurement of treatment fidelity for motivational interviewing targeting sexual risk behaviors in people living with HIV/AIDS.

The reproductive health behaviors of HIV-infected young women in the United States: A literature review

HIV-infected young women in the United States have important reproductive health needs that are made more complex by their HIV status. We searched Pubmed and relevant bibliographies to identify 32 articles published from 2001 to July 2012 that described the prevalence, correlates, and characteristics of the sexual activity, relationships, pregnancy intentions, HIV status disclosure, and contraceptive and condom use among US HIV-infected adolescents and young women. Our synthesis of those articles found that, like youth not infected with HIV, substantial proportions of HIV-infected youth were sexually active, and most sought romantic or sexual relationships, though their serostatus may have affected the pace of physical and emotional intimacy. Disclosure was difficult, and large proportions of HIV-infected youth had not disclosed their serostatus to recent partners. A few studies suggest that most HIV-infected young women hoped to have children in the future, but many wanted to avoid pregnancy until later. Only one study described contraceptive use among this population in detail and found that condoms were a primary method of contraception. The results point to substantial gaps in published research, particularly in the areas of pregnancy intentions and contraceptive use. Much more needs to be done in research and health services to better understand and meet the complex health needs of HIV-infected young women.

Young adults remain worse off than adolescents

On a broad range of indicators pertaining to risk taking and access to care, young adults fare worse than younger adolescents or older adults. Vulnerable groups, such as those facing chronic illness and those with unstable living arrangements, fare especially poorly as they transition to adulthood. Fortunately, a confluence of factors, particularly the changing nature of the transition to adulthood in modern society, has led to renewed interest in this critical period of the life cycle. Health science research is increasingly focused on issues faced by young adults, and public health policies designed specifically to address the health and well-being of young adults--notably the Patient Protection and Affordable Care Act in the United States--are now being implemented. Successful efforts at improving the health and well-being of adolescents should be mirrored in efforts to support young adults. A new report based on a broad range of United States national datasets lays out the challenges that must be addressed in these efforts.

A randomized controlled trial of a group motivational interviewing intervention for adolescents with a first time alcohol or drug offense

Group motivational interviewing (MI) interventions that target youth at-risk for alcohol and other drug (AOD) use may prevent future negative consequences. Youth in a teen court setting [n=193; 67% male, 45% Hispanic; mean age 16.6 (SD=1.05)] were randomized to receive either a group MI intervention, Free Talk, or usual care (UC). We examined client acceptance, and intervention feasibility and conducted a preliminary outcome evaluation. Free Talk teens reported higher quality and satisfaction ratings, and MI integrity scores were higher for Free Talk groups. AOD use and delinquency decreased for both groups at 3 months, and 12-month recidivism rates were lower but not significantly different for the Free Talk group compared to UC. Results contribute to emerging literature on MI in a group setting. A longer term follow-up is warranted.

Motivational interviewing targeting risk behaviors for youth living with HIV in Thailand

Healthy Choices, a four-session motivational interviewing-based intervention, reduces risk behaviors among US youth living with HIV (YLWH). We randomized 110 Thai YLWH (16-25 years) to receive either Healthy Choices or time-matched health education (Control) over 12 weeks. Risk behaviors were assessed at baseline, 1, and 6 months post-session. The pilot study was not powered for between-group differences; there were no statistical differences in sexual risks, alcohol use, and antiretroviral adherence between the two groups at any visit. In within-group analyses, Healthy Choices group demonstrated decreases in the proportion of HIV-negative partners (20 vs 8.2%, P = 0.03) and HIV sexual risk scores (4.3 vs 3.3, P = 0.04), and increased trends in the proportion of protected sex (57 vs 76.3%, P = 0.07) from baseline to 1 month post-session. These changes were not sustained 6 months later. No changes were observed in Control group. Healthy Choices has potential to improve sexual risks among Thai YLWH.

Telephone-delivered motivational interviewing targeting sexual risk behavior reduces depression, anxiety, and stress in HIV-positive older adults

BACKGROUND

Few studies have examined the secondary benefits of HIV risk reduction interventions to improve mental health functioning.

PURPOSE

This study aimed to examine the effectiveness of telephone-delivered motivational interviewing (MI) targeting sexual risk behavior to reduce depression, anxiety, and stress in HIV-positive older adults.

METHODS

Participants were 100 HIV-positive adults 45+ years old enrolled in a sexual risk reduction pilot clinical trial of telephone-delivered MI. Participants were randomly assigned to a one-session MI, four-session MI, or standard of care control condition. Telephone interviews at baseline and 3- and 6-month follow-up assessed sexual behavior, depression, anxiety, and stress.

RESULTS

Relative to controls, participants in the one- and four-session MI conditions reported lower levels of depression, anxiety, and stress at 6-month follow-up. No between group differences were observed at 3-month follow-up or between one- and four-session MI participants at 6-month follow-up.

CONCLUSIONS

Preliminary data suggest that telephone-delivered MI to reduce sexual risk behavior may confer secondary benefits of improving mental health functioning in HIV-positive persons.

Motivational interviewing for improving outcomes in youth living with HIV

BACKGROUND

Almost half of all the new HIV infections occur in youth. Motivational interviewing (MI) is a counselling technique that is effective in bringing about positive behavior changes in the general population. It is unclear whether it can be used to improve outcomes in youth living with HIV.

OBJECTIVES

To determine whether MI is effective in improving outcomes in youth living with HIV.

SEARCH METHODS

We used a comprehensive and exhaustive strategy in an attempt to identify all relevant studies, regardless of language or publication status, in electronic databases (PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, LILACS, CINAHL, PsycINFO), conference proceedings and specialised databases from January 1980 to March 2012.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which youth (aged 10 to 24) living with HIV received MI, singly or in combination with another intervention compared to any other intervention, and reporting on the outcomes of interest (adherence to medication, mortality, quality of life, viral load, CD4-positive-T-lymphocyte count, progression to AIDS, retention in care, substance abuse and condom use). All settings were considered.

DATA COLLECTION AND ANALYSIS

We identified 863 references.Two authors independently examined the titles and abstracts of all identified trials, of which 28 full-text articles were closely screened for eligibility based on criteria established a-priori. The included studies were appraised for quality in duplicate. Data were extracted using a pre-tested and standardised form. No meta-analyses were performed.

MAIN RESULTS

Two trials located in the United States, reported in four papers met our inclusion criteria. They enrolled a total of 237 participants and compared motivational interviewing singly to standard of care. None of these trials reported on adherence to HIV medication, mortality or quality of life. Both trials reported reductions in viral load (in the short term) and unprotected sexual acts. A reduction in alcohol use was identified only in one of two studies that reported on this outcome. One trial reported on retention. Retention rates were not affected by the intervention.

AUTHORS' CONCLUSIONS

There is moderate quality evidence, coming from two trials which suggests that MI is effective in reducing short term viral load and unprotected sexual acts. There is moderate quality evidence from one trial that MI is effective in reducing alcohol use. There is a need for more trials which report on outcomes such as adherence to medication, mortality and quality of life in youth.

Two approaches to tailoring treatment for cultural minority adolescents

At this time, compared with mainstream (Caucasian) youth, cultural minority adolescents experience more severe substance-related consequences and are less likely to receive treatment. Although several empirically supported interventions (ESIs), such as motivational interviewing (MI), have been evaluated with mainstream adolescents, fewer published studies have investigated the fit and efficacy of these interventions with cultural minority adolescents. In addition, many empirical evaluations of ESIs have not explicitly attended to issues of culture, race, and socioeconomic background in their analyses. As a result, there is some question about the external validity of ESIs, particularly in disadvantaged cultural minority populations. This review seeks to take a step toward filling this gap, by addressing how to improve the fit and efficacy of ESIs like MI with cultural minority youth. Specifically, this review presents the existing literature on MI with cultural minority groups (adult and adolescent), proposes two approaches for evaluating and adapting this (or other) behavioral interventions, and elucidates the rationale, strengths, and potential liabilities of each tailoring approach.

Patient attitudes towards change in adapted motivational interviewing for substance abuse: a systematic review

Adapted motivational interviewing (AMI) represents a category of effective, directive and client-centered psychosocial treatments for substance abuse. In AMI, patients' attitudes towards change are considered critical elements for treatment outcome as well as therapeutic targets for alteration. Despite being a major focus in AMI, the role of attitudes towards change in AMI's action has yet to be systematically reviewed in substance abuse research. A search of PsycINFO, PUBMED/MEDLINE, and Science Direct databases and a manual search of related article reference lists identified 416 published randomized controlled trials that evaluated AMI's impact on the reduction of alcohol and drug use. Of those, 54 met the initial inclusion criterion by evaluating AMI's impact on attitudes towards change and/or testing hypotheses about attitudes towards change as moderators or mediators of outcome. Finally, 19 studies met the methodological quality inclusion criterion based upon a Newcastle-Ottawa Quality Assessment Scale score ≥ 7. Despite the conceptual importance of attitudes towards change in AMI, the empirical support for their role in AMI is inconclusive. Future research is warranted to investigate both the contextual factors (ie, population studied) as well as deployment characteristics of AMI (ie, counselor characteristics) likely responsible for equivocal findings.

Depression and stigma in high-risk youth living with HIV: a multi-site study

INTRODUCTION

This study explored the relationship between depression, stigma, and risk behaviors in a multi-site study of high-risk youth living with HIV (YLH) in the United States.

METHODS

All youth met screening criteria for either problem level substance use, current sexual risk, and/or suboptimal HIV medication adherence. Problem level substance use behavior was assessed with the CRAFFT, a six-item adolescent screener. A single item was used to screen for current sexual risk and for an HIV medication adherence problem. Stigma and depression were measured via standard self-report measures.

RESULTS

Multiple regression analysis revealed that behavioral infection, older age, more problem behaviors, and greater stigma each contributed to the prediction of higher depression scores in YLH. Associations between depression, stigma, and problem behaviors are discussed. More than half of the youth in this study scored at or above the clinical cut-off for depression. Results highlight the need for depression-focused risk reduction interventions that address stigma in YLH.

DISCUSSION

Study outcomes suggest that interventions are needed to address stigma and depression, not only among youth living with HIV, but in the communities in which they live.