Overload: impact of incident stressful events on antiretroviral medication adherence and virologic failure in a longitudinal, multisite human immunodeficiency virus cohort study

Stigma, coping strategies, distress and wellbeing in individuals with cervical dystonia: a cross-sectional study

Cervical dystonia (CD) is a movement disorder which causes sustained muscle contractions in the neck leading to abnormal postures and repetitive movements. As it is a highly visible condition, people with CD can experience stigma, which may lead to unhelpful coping strategies and increased psychological distress. This study investigated whether adaptive and maladaptive coping strategies mediate the relationship between stigma and psychological outcomes in people with CD. A total of 114 adults with CD completed measures of stigma, coping, health-related quality of life (HRQOL), psychological distress (depression, anxiety, stress), and psychological wellbeing at one time point. Participants' levels of distress were high, compared to the general population. Correlational analyses showed increased stigma and maladaptive coping (e.g. substance use, behavioural disengagement) were both significantly related to increased distress, lower wellbeing and lower HRQOL, whereas higher adaptive coping (e.g. acceptance, humour) was only related to higher wellbeing. In a parallel mediation model, maladaptive coping strategies mediated the relationship between stigma and distress, HRQOL and wellbeing, but adaptive coping strategies did not. These findings suggest that maladaptive coping may play an important role in explaining the relationship between stigma and some aspects of distress and wellbeing in CD. Interventions which focus on reducing different aspects of maladaptive coping may be helpful to improve wellbeing as well as reducing stigma.

Neigh G, Jovanovic T, Michopoulos V. HIV Interacts with Posttraumatic Stress Disorder to Impact Fear Psychophysiology in Trauma-Exposed Black Women

Background

The prevalence of posttraumatic stress disorder (PTSD) among people living with HIV (PLWH) is higher than in the general population and can impact health behaviors. The influence of HIV on PTSD psychophysiology requires further investigation due to implications for the treatment of PTSD in PLWH.

Objective

Utilizing fear-potentiated startle (FPS), we aimed to interrogate the influence of PTSD and HIV on fear responses.

Materials and Methods

Women (18-65 years of age) recruited from the Women's Interagency HIV Study in Atlanta, GA (n = 70, 26 without HIV and 44 with HIV), provided informed consent and completed a semistructured interview to assess trauma exposure and PTSD symptom severity. Participants also underwent an FPS paradigm to assess fear acquisition and extinction: Psychophysiological indices that measure how individuals learn new fear and then subsequently attempt to suppress this fear.

Results

Women with PTSD, who did not have HIV, exhibited a greater startle response compared to women without PTSD or HIV during late acquisition to both the danger cue, reinforced conditioned stimulus (CS+, p = 0.013)), and the safety cue, non-reinforced conditioned stimulus (CS-, p = 0.046)), whereas women living with HIV (WLH) and PTSD demonstrated blunted fear responses compared to women with PTSD only. During extinction, WLH comorbid with PTSD exhibited an increased fear response during the extinction period in comparison to all other groups (p = 0.023). Women without PTSD demonstrated a reduction in the fear response during extinction regardless of HIV status.

Conclusion

Our findings indicate that HIV further modifies fear psychophysiology in WLH with comorbid PTSD, highlighting the importance of considering HIV status in conjunction with PTSD treatment.

The longitudinal association of stressful life events with depression remission among SHARP trial participants with depression and hypertension or diabetes in Malawi

Depressive disorders are leading contributors to morbidity in low- and middle-income countries and are particularly prevalent among people with non-communicable diseases (NCD). Stressful life events (SLEs) are risk factors for, and can help identify those at risk of, severe depressive illness requiring more aggressive treatment. Yet, research on the impact of SLEs on the trajectory of depressive symptoms among NCD patients indicated for depression treatment is lacking, especially in low resource settings. This study aims to estimate the longitudinal association of SLEs at baseline with depression remission achievement at three, six, and 12 months among adults with either hypertension or diabetes and comorbid depression identified as being eligible for depression treatment. Participants were recruited from 10 NCD clinics in Malawi from May 2019-December 2021. SLEs were measured by the Life Events Survey and depression remission was defined as achieving a Patient Health Questionaire-9 (PHQ-9) score <5 at follow-up. The study population (n = 737) consisted predominately of females aged 50 or higher with primary education and current employment. At baseline, participants reported a mean of 3.5 SLEs in the prior three months with 90% reporting ≥1 SLE. After adjustment, each additional SLE was associated with a lower probability of achieving depression remission at three months (cumulative incidence ratio (CIR) 0.94; 95% confidence interval: 0.90, 0.98, p = 0.002), six months (0.95; 0.92, 0.98, p = 0.002) and 12 months (0.96; 0.94, 0.99, p = 0.011). Re-expressed per 3-unit change, the probability of achieving depression remission at three, six, and 12 months was 0.82, 0.86, and 0.89 times lower per 3 SLEs (the median number of SLEs). Among NCD patients identified as eligible for depression treatment, recent SLEs at baseline were associated with lower probability of achieving depression remission at three, six, and 12 months. Findings suggest that interventions addressing SLEs during integrated NCD and depression care interventions (e.g., teaching and practicing SLE coping strategies) may improve success of depression treatment among adult patient populations in low-resource settings and may help identify those at risk of severe and treatment resistant depression.

Adverse childhood experiences, mental illness, HIV and offending among female inmates in Durban, South Africa

Background

Childhood adversities and adult trauma are common among female inmates. Associations have been documented with childhood adversities and mental illness, personality disorders, human immunodeficiency virus (HIV) and violent offending. However, no such study had been conducted in South Africa (SA), despite the high prevalence of HIV and trauma in SA.

Aim

To measure the prevalence of childhood adversities and adult trauma; and to determine if there is a relationship between childhood adversities, mental illness, personality disorders, HIV and violent offending among female inmates.

Setting

The study was conducted at the largest correctional centre in Durban, KwaZulu-Natal, South Africa.

Methods

This cross-sectional, descriptive study randomly recruited 126 female inmates. The World Health Organization's Adverse Childhood Experiences- International Questionnaire (WHO ACE-IQ) was used to measure childhood adversities; the Structured Clinical Interview for the Diagnostics and Statistical Manual-5 Research Version (SCID 5-RV) was used to diagnose mental illness; and a structured questionnaire was used to measure adult trauma. Human immunodeficiency virus data was confirmed from prison medical records.

Results

Elevated rates of individual childhood adversities and adult trauma were found. Associations were found between cumulative childhood adversities and post-traumatic stress disorder (PTSD), alcohol use disorder, substance use disorder, borderline personality disorder, and HIV.

Conclusion

Female inmates are a highly traumatised population. Prison mental health services should provide trauma-informed and trauma-focussed care to improve inmates' mental health outcomes and decrease recidivism.

Contribution

This study contributes to the emerging literature on adverse childhood experiences (ACEs) and their associations among incarcerated female populations, in a low- and middle-income, South African setting.

HIV status affects PTSD symptom severity, psychophysiology, and heart rate variability in women with low but not high exposure to childhood maltreatment

Objective

People living with HIV (PLWH) experience high rates of childhood trauma exposure, which is a significant risk factor for the development of posttraumatic stress disorder (PTSD). Because Black Americans living in urban environments are exposed to high levels of trauma, suffer from chronic PTSD, and are at increased risk for HIV infection, it is important to understand how HIV status interacts with childhood maltreatment to influence PTSD symptom severity and underlying psychophysiology.

Methods

The current cross-sectional study assessed whether HIV status interacts with childhood maltreatment to influence PTSD symptom severity and heart rate variability during a dark-enhanced startle (DES) task in 88 Black women with (n=30) and without HIV (n=58).

Results

HIV was associated with greater PTSD symptom severity only in women with low levels of childhood maltreatment (p=.024). Startle potentiation during DES was highest in women living without HIV and with high childhood maltreatment (p=.018). In women who had experienced low levels of childhood maltreatment, respiratory sinus arrhythmia (RSA) was lower during the dark phase of DES in women living without HIV than women living with HIV (WLWH), (p=.046). RSA during the light phase of DES was lower in WLWH than in women living without HIV (p=.042).

Conclusion

In the current sample of Black women, HIV status was associated with PTSD symptom severity in a manner dependent on level of childhood maltreatment, suggesting that HIV status may be an important factor to consider for behavioral and pharmacological treatment strategies for PTSD. Additionally, HIV status is associated with lower percent potentiation to darkness and lower RSA during the light phase of DES, suggesting physiological mechanisms by which HIV may contribute to PTSD symptoms in individuals exposed to low levels of childhood maltreatment.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47151.

Predicting salivary cortisol and sexual behavior stigma among MSM in the American Men's Internet Survey 2019

Physiological stress levels in response to sexual behavior stigma among men who have sex with men (MSM) in the United States (US) are understudied. The current study aims to explore the relationship between sexual behavior stigma and salivary cortisol both overall and stratified by race/ethnicity. If such an association exists, it may suggest that sexual behavior stigma can be physiologically measured or indicated by the presence of heightened salivary cortisol. A subsample of 667 MSM participants from the 2019 American Men's Internet Survey (AMIS; N = 10,129) submitted morning (AM) and evening (PM) saliva cortisol samples using at-home mail-in collection kits. Average daily cortisol and daily cortisol change were calculated; simple linear regressions estimated associations between cortisol measures and sexual behavior stigma characterized in four different ways (ever and recent experience of individual stigma items; average ever and recent experience of three stigma scales: stigma from family and friends, anticipated healthcare stigma, general social stigma). Participants reported a mean age of 36.0 years (SD = 14.9), with most being non-Hispanic white (n = 480, 72.0%), Hispanic (n = 164, 12.3%), or Black/African American (n = 146, 10.9%), and identified as homosexual/gay (n = 562, 84.3%). Reporting ever experiencing healthcare providers gossiping was significantly associated with higher PM cortisol (β = 0.12, p = 0.001) and higher average daily cortisol (β = 0.11, p = 0.004), while reporting ever experiencing police refusing to protect was associated with higher AM cortisol (β = 0.08, p = 0.03) and higher average daily cortisol (β = 0.09, p = 0.02). Recent experiences of stigma were not significant predictors of any measure of cortisol. Measures of salivary cortisol may be used to characterize sexual behavior stigma among MSM populations, however more insight is needed to determine its exact relationship and strength.

Two or more significant life-events in 6-months are associated with lower rates of HIV treatment and virologic suppression among youth with HIV in Uganda and Kenya

Youth living with HIV in sub-Saharan Africa have poor HIV care outcomes. We determined the association of recent significant life-events with HIV antiretroviral treatment (ART) initiation and HIV viral suppression in youth aged 15-24 years living with HIV in rural Kenya and Uganda. This was a cross-sectional analysis of 995 youth enrolled in the SEARCH Youth study. At baseline, providers assessed recent (within 6 months) life-events, defined as changes in schooling/employment, residence, partnerships, sickness, incarceration status, family strife or death, and birth/pregnancy, self-reported alcohol use, being a parent, and HIV-status disclosure. We examined the frequencies of events and their association with ART status and HIV viral suppression (<400 copies/ul). Recent significant life-events were prevalent (57.7%). Having >2 significant life-events (aOR = 0.61, 95% CI:0.45-0.85) and consuming alcohol (aOR = 0.61, 95% CI:0.43-0.87) were associated with a lower odds of HIV viral suppression, while disclosure of HIV-status to partner (aOR = 2.39, 95% CI:1.6-3.5) or to family (aOR = 1.86, 95% CI:1.3-2.7), being a parent (aOR = 1.8, 95% CI:1.2-2.5), and being single (aOR = 1.6, 95% CI:1.3-2.1) had a higher odds. This suggest that two or more recent life-events and alcohol use are key barriers to ART initiation and achievement of viral suppression among youth living with HIV in rural East Africa.Trial registration: ClinicalTrials.gov identifier: NCT03848728..

The Relationship between Personality Traits and Compliance with the COVID-19 Preventive Measures in Kosovo

The COVID-19 pandemic urged systematic restrictive measures in order to avoid the spread of the virus. Different countries applied different restrictive measures; however, their efficacy was vastly dependent on the willingness of the people to comply with them. How people perceived the pandemic yielded different adaptive behavior to preventative measures. In this direction, individual characteristics (i.e., personality) seem very important. The current study aimed to map a relationship between personality structure as postulated within the five-factor model of personality with the tendency to comply with preventive measures, as mediated by perceived stress and concerns over coronavirus. In a sample of 3252 adults, we found that the traits of openness, agreeableness, and conscientiousness directly and positively predicted compliance. However, concerns over coronavirus partially but positively mediated the relationship between agreeableness and conscientiousness on compliance. Perceived stress, on the other hand, was not a significant mediator, although it was significantly and positively predicted by neuroticism but negatively by extraversion. These findings showed that different personality traits have different direct effects on compliance with preventative measures.

Exploring the Association between Negative Emotions and COVID-19 Vaccine Acceptance: A Cross-Sectional Analysis of Unvaccinated Adults in Sweden

The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on individuals’ mental health. This study aimed to investigate how negative emotions toward the COVID-19 pandemic, including feeling anxious, depressed, upset, and stressed, were associated with COVID-19 vaccine acceptance in Sweden. The study is a cross-sectional online survey conducted between 21–28 May 2021, using three nested hierarchical logistic regression models to assess the association. The study included 965 unvaccinated individuals, 51.2% (n = 494) of whom reported their intention to get vaccinated. We observed graded positive associations between reported negative emotions and vaccine acceptance. Individuals who experienced economic stress had lower odds of vaccine acceptance while having a positive opinion of the government’s response to COVID-19 was associated with higher odds of being vaccine-acceptant. In conclusion, unvaccinated individuals experiencing negative emotions about the pandemic were more willing to get the vaccine. On the contrary, those with a negative opinion about the government’s response, and those that had experienced economic stress were less likely to accept the immunization.

Recent Stressful Life Events, Lifetime Traumatic Events, Missed Visits, and Antiretroviral Adherence Among Black Women With HIV in the Southeastern United States: A Cross-sectional Study

ABSTRACT

Lifetime traumatic events are prevalent among people with HIV and consistently associated with deleterious HIV outcomes. Yet, little is known about the impact of recent stressful events on health outcomes among Black women with HIV (WWH). This cross-sectional study assessed the prevalence of recent stressful events and lifetime traumatic events and their association with HIV outcomes in Black WWH (n = 200) in the Southeastern United States. We evaluated the association between stressful events and HIV outcomes using chi-square tests and unadjusted and adjusted logistic regression analyses. In the unadjusted analyses, missed visits were associated with higher odds of recent stressful events (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.04-1.16) and lifetime traumatic events (OR 1.15, 95% CI 1.05-1.26). In the adjusted analysis, exposure to recent stressful events was independently associated with missed visits (adjusted OR 1.08, 95% CI 1.01-1.15). Interventions addressing recent stressful events are warranted.

HIV-serodifferent couples' perspectives and practices regarding HIV prevention strategies: A mixed methods study

A substantial proportion of heterosexually acquired HIV infections in the U.S. occur between partners in primary relationships characterized by mixed HIV status. The U.S. Centers for Disease Control and Prevention have issued guidelines prioritizing HIV-serodifferent couples for primary HIV prevention, including treatment-as-prevention and pre-exposure prophylaxis (PrEP). Yet, very little research has been conducted to understand the perspectives and practices of HIV-serodifferent couples regarding HIV prevention strategies in the U.S. To help fill this gap, we conducted a mixed methods study with 27 mostly Black/African American and Latinx HIV-serodifferent heterosexual couples residing in New York City to explore their knowledge, attitudes, practices, and perspectives regarding combination HIV prevention, including condoms, PrEP and viral control. All couples expressed the desire to maintain viral suppression in the HIV-positive partner, which was not always achieved. There was considerable heterogeneity in the use of HIV prevention methods by couples; and several patterns emerged that were largely driven by gender and relationship dynamics. Female partners, in particular, expressed high levels of anxiety around transmission of HIV and thus desired multiple methods of protection. Healthcare providers should consider couples' psychosocial well-being, relationship quality, and other motivational factors when helping to tailor HIV preventative care for mixed-status couples.

Mechanisms of quality-of-life improvement in treatment for alcohol use disorder

OBJECTIVE

For individuals in alcohol use disorder (AUD) treatment, many argue that holistic indicators such as quality of life (QoL) should be more consistently used in addition to drinking-related indicators. QoL increases from pre- to post-AUD treatment, but the mechanisms are unclear. The present study examined the roles of positive and negative affect in QoL change during AUD treatment and additionally explored the relationship between QoL change and medication adherence.

METHOD

We examined the mediating roles of end-of-treatment positive affect (i.e., vigor) and negative affect (i.e., stress and tension) in the relationship between baseline (BL) and 26-week QoL among participants in the Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence study randomized to medication management (MM; n = 468) or medication management plus combined behavioral intervention (MMCBI; n = 479) for AUD. We also explored whether changes in QoL were associated with medication adherence.

RESULTS

Change in psychological health QoL was mediated by increased vigor (i.e., positive affect) and decreased stress, and change in environmental QoL was mediated by decreased stress. There were also differences by treatment group, with stress mediating changes in environmental QoL among participants in MM, and vigor mediating changes in psychological health QoL among participants in MMCBI. Medication adherence was not associated with greater QoL after controlling for posttreatment alcohol use.

CONCLUSIONS

The present study identified potential mechanisms of QoL change in AUD treatment, thus contributing to the growing knowledge surrounding alternative indicators of treatment success for AUD treatment and recovery. Targeting affective states and stress during treatment may improve QoL and recovery outcomes for persons with AUD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Impact of COVID-19 on the HIV Care Continuum in a Large Urban Southern Clinic

Access to care is essential for people with HIV (PWH) but may have been affected during the COVID-19 pandemic. We conducted a retrospective cross-sectional study of adult PWH receiving care in a large southeastern comprehensive care clinic in the United States. Patients in care between January 1, 2017, and July 30, 2020, were included. Race/ethnicity, sex, HIV-1 RNA, CD4 + lymphocyte count were included as baseline covariates. Outcomes included clinic attendance, receipt of HIV-1 RNA PCR testing, and virologic suppression (HIV-1 RNA < 200 copies/mL); outpatient encounters included new patient encounters, follow-up visits, and mental health encounters. Total medical encounters, including telemedicine, decreased by 827 visits (33%) when comparing the second quarters of 2019 and 2020. New patient encounters decreased by 23.5% from 81 to 62 during this period. The second quarter of 2020 saw the lowest number of new patient visits since 2017. HIV-1 RNA testing and the proportion of patients with virologic suppression decreased during the pandemic (p < 0.001 for both). Total mental health encounters, on the other hand, increased by 14% during April-June 2020 compared to April-June 2019. Mental health electronic communications increased by 60% from 312 to 500 during the same period, with a 20% increase in medication refills. The COVID-19 pandemic affected outpatient visits, viral load surveillance, and virologic suppression but led to an increase in mental health encounters in a comprehensive care clinic setting.

The Effect of Initial Patient Experiences and Life Stressors on Predicting Lost to Follow-Up in Patients New to an HIV Clinic

We conducted a prospective cohort study of 450 patients new to an HIV clinic in Houston, TX, to examine the roles of life stressors and initial care experiences in predicting being lost to follow-up in the first year of care. Patients completed a self-administered survey following their initial provider visit. In logistic regression models, patients who reported better experiences with the HIV provider at the first visit were less likely to be lost to follow-up at 6 months (aOR = 0.866, p = 0.038) and 12 months (aOR = 0.825, p = 0.008). Patients with a higher burden of stressful life events were more likely to be lost to follow-up at 6 months (aOR = 1.232, p = 0.037) and 12 months (aOR = 1.263, p = 0.029). Assessments of patient experience and life stressors at the initial visit have potential to predict patients at risk of dropping out of care.

A Systematic Review of Gender-Based Violence Prevention and Response Interventions for HIV Key Populations: Female Sex Workers, Men Who Have Sex With Men, and People Who Inject Drugs

Gender-based violence (GBV) is that perpetrated based on sex, gender identity, or perceived adherence to socially defined gender norms. This human rights violation is disproportionately experienced by HIV key populations including female sex workers (FSW), people who inject drugs (PWID), and men who have sex with men (MSM). Consequently, addressing GBV is a global priority in HIV response. There is limited consensus about optimal interventions and little known about effectiveness. Our systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered in International Prospective Register of Systematic Reviews. Peer-reviewed and non-peer-reviewed literature were searched for articles that described a GBV prevention or response intervention specifically for key populations including FSW, PWID, and MSM. Results were organized by level(s) of implementation and pillars of a comprehensive GBV response: prevention, survivor support, and accountability/justice. Of 4,287 articles following removal of duplicates, 32 unique interventions (21 FSW, seven PWID, and nine MSM, not mutually exclusive) met inclusion criteria, representing 13 countries. Multisectoral interventions blended empowerment, advocacy, and crisis response with reductions in violence. Individual-level interventions included violence screening and response services. Violence-related safety promotion and risk reduction counseling within HIV risk reduction programming reduced violence. Quantitative evaluations were limited. Violence prevention and response interventions for FSW, PWID, and MSM span individual, community, and multisectoral levels with evidence of promising practices at each level. The strongest evidence supported addressing violence in the context of sexually transmitted infection/HIV risk reduction. As interventions continue to emerge, the rigor of accompanying evaluations must simultaneously advance to enable clarity on the health and safety impact of GBV prevention and response programming.

Successful virologic outcomes over time among HAART-treated HIV-infected patients

Few large studies evaluated the effects of time trends on virologic suppression in people living with HIV/AIDS (PLWHA) in China. To address this, An retrospective observational longitudinal study was conducted. We examined annual trends in the rate of virologic suppression, the viral load at the time of virologic suppression, and other determinants of virologic suppression in Zhejiang Province, China in PLWHA between January 2013 and July 2018. Patients who received a treatment regimen for at least 24 weeks were included. Virologic suppression was defined as VL ≤50 copies/mL. Generalized estimating equation logistic regression models were used to adjust for covariates. We included 16,265 patients with 45023 tests. The proportion of patients who experienced an unsuccessful virologic outcome decreased continuously throughout the observation period (18.14% to 6.64%). Time was significantly negatively associated with detectable VL (all ORs <1). Other factors were positively associated with detectable VL, including patients <30 years of age, single, non-adherent to treatment, and with a follow-up CD4 count <200 cells/µL. Patients infected through homosexual transmission and those with a longer ART duration were more likely to reach virologic suppression. We demonstrated outstanding time trend improvements in the virological outcomes of PLWHA in China.

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

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

Stress Among a Sample of Returning Citizens Living with HIV and Substance Use Disorder: A Mixed Methods Analysis

This mixed-methods study asks: among a sample of returning citizens living with HIV and substance use disorder, how is stress experienced; and what are the leading stressors and stress-coping strategies? Data is from a parent study that randomized 36 people to a yoga intervention and 36 people to treatment as usual. Qualitative analysis found that securing basic life needs was more acute in early reentry, and challenges with HIV acceptance were greater among those with a more recent HIV diagnosis. Social support was the most widely employed coping strategy but many lacked social networks. Post-program, multiple regression found older age(β = - 0.38, p < .05), greater income(β = - 0.002, p < .01), shorter incarceration(β = .03, p < .01) and randomization to yoga(β = 6.92, p < .01) predicted lower levels of stress. Results indicate that reentry needs for people living with HIV and substance use disorder include basic life needs, social supports, and stress-coping interventions that address physical and mental stress symptoms (such as yoga).

The Factor Structure of the Brief Cope: A Systematic Review

The Brief COPE is a widely used measure of coping that contains 28 items on 14 factors. Researchers have shortened the inventory, but the factor structure remains debated. A systematic review of peer-reviewed studies published in English between 1997 and 2021 was conducted to determine if a more parsimonious number of factors could be identified. Cumulative Index for Nursing and Allied Health, PsycINFO, PsycARTICLES, Medline, PubMed, and Scopus databases were searched using keywords "Brief COPE" and "factor, valid*, or psychometric.*" Searching yielded 573 articles; cited references added 38; 85 articles met inclusion criteria. Principal components analysis and confirmatory factor analysis were major analytic strategies used (28% and 27%, respectively). Only eight studies analyzed the original 14-factor structure. Factors identified ranged from 2 to 15, with dichotomous factors most frequently identified (25%; n = 21). A smaller number of factors may be able to represent the Brief COPE. Research is needed to test a condensed instrument.

"I just keep quiet about it and act as if everything is alright" - The cascade from trauma to disengagement among adolescents living with HIV in western Kenya

INTRODUCTION

There are approximately 1.7 million adolescents living with HIV (ALHIV, ages 10 to 19) globally, including 110,000 in Kenya. While ALHIV experience poor retention in care, limited data exist on factors underlying disengagement. We investigated the burden of trauma among disengaged ALHIV in western Kenya, and its potential role in HIV care disengagement.

METHODS

We performed in-depth qualitative interviews with ALHIV who had disengaged from care at two sites, their caregivers and healthcare workers (HCW) at 10 sites, from 2018 to 2020. Disengagement was defined as not attending clinic ≥60 days past a missed scheduled visit. ALHIV and their caregivers were traced through phone calls and home visits. Interviews ascertained barriers and facilitators to adolescent retention in HIV care. Dedicated questions elicited narratives surrounding traumatic experiences, and the ways in which these did or did not impact retention in care. Through thematic analysis, a conceptual model emerged for a cascade from adolescent experience of trauma to disengagement from HIV care.

RESULTS

Interviews were conducted with 42 disengaged ALHIV, 34 caregivers and 28 HCW. ALHIV experienced a high burden of trauma from a range of stressors, including experiences at HIV disclosure or diagnosis, the loss of parents, enacted stigma and physical or sexual violence. A confluence of factors - trauma, stigma and isolation, and lack of social support - led to hopelessness and depression. These factors compounded each other, and resulted in complex mental health burdens, poor antiretroviral adherence and care disengagement. HCW approaches aligned with the factors in this model, suggesting that these areas represent targets for intervention and provision of trauma-informed care.

CONCLUSIONS

Trauma is a major factor underlying disengagement from HIV care among Kenyan adolescents. We describe a cascade of factors representing areas for intervention to support mental health and retention in HIV care. These include not only the provision of mental healthcare, but also preventing or addressing violence, trauma and stigma, and reinforcing social and familial support surrounding vulnerable adolescents. In this conceptualization, supporting retention in HIV care requires a trauma-informed approach, both in the individualized care of ALHIV and in the development of strategies and policies to support adolescent health outcomes.

Stress and worry in the 2020 coronavirus pandemic: relationships to trust and compliance with preventive measures across 48 countries in the COVIDiSTRESS global survey

The COVIDiSTRESS global survey collects data on early human responses to the 2020 COVID-19 pandemic from 173 429 respondents in 48 countries. The open science study was co-designed by an international consortium of researchers to investigate how psychological responses differ across countries and cultures, and how this has impacted behaviour, coping and trust in government efforts to slow the spread of the virus. Starting in March 2020, COVIDiSTRESS leveraged the convenience of unpaid online recruitment to generate public data. The objective of the present analysis is to understand relationships between psychological responses in the early months of global coronavirus restrictions and help understand how different government measures succeed or fail in changing public behaviour. There were variations between and within countries. Although Western Europeans registered as more concerned over COVID-19, more stressed, and having slightly more trust in the governments' efforts, there was no clear geographical pattern in compliance with behavioural measures. Detailed plots illustrating between-countries differences are provided. Using both traditional and Bayesian analyses, we found that individuals who worried about getting sick worked harder to protect themselves and others. However, concern about the coronavirus itself did not account for all of the variances in experienced stress during the early months of COVID-19 restrictions. More alarmingly, such stress was associated with less compliance. Further, those most concerned over the coronavirus trusted in government measures primarily where policies were strict. While concern over a disease is a source of mental distress, other factors including strictness of protective measures, social support and personal lockdown conditions must also be taken into consideration to fully appreciate the psychological impact of COVID-19 and to understand why some people fail to follow behavioural guidelines intended to protect themselves and others from infection. The Stage 1 manuscript associated with this submission received in-principle acceptance (IPA) on 18 May 2020. Following IPA, the accepted Stage 1 version of the manuscript was preregistered on the Open Science Framework at https://osf.io/g2t3b. This preregistration was performed prior to data analysis.

Design and Development of a Risk Classification Instrument for Virological Failure in HIV, Using Psychosocial Determinants of Health: Preliminary Evidence from a South American Country

Predictive approaches in HIV to estimate a patient's risk to present with relevant health outcomes, such as hospitalizations and AIDS-related death, long before they happen, could be highly useful. We aimed to develop a risk classification instrument for virological failure through a scoring system that identifies patients with a low, medium, and high risk after six months of ART treatment. A case-control design was implemented through 355 HIV-positive Colombian adults who were assessed using the designed instrument. The variables with independent predictive values were selected using logistic regression analysis, and the diagnostic performance of the prediction score was evaluated using the area under the curve. The prediction score included relevant psychosocial and biological risk factors, some of them modifiable variables like substance use and low health literacy. The area under the curve value for the total prediction score was 0.85 (CI 0.80-0.90). Therefore, this instrument could be a valuable tool to identify at-risk patients of virological failure. In low and middle-income countries, the associated risk factors of virological failure are little known. Assessing such risk would lead to make individualized decisions regarding the patient's management and minimize the chance of non-desirable outcomes.

Profiles of HIV Care Disruptions Among Adult Patients Lost to Follow-up in Zambia: A Latent Class Analysis

BACKGROUND

Patients report varied barriers to HIV care across multiple domains, but specific barrier patterns may be driven by underlying, but unobserved, behavioral profiles.

METHODS

We traced a probability sample of patients lost to follow-up (>90 days late) as of July 31, 2015 from 64 clinics in Zambia. Among those found alive, we ascertained patient-reported reasons for care disruptions. We performed latent class analysis to identify patient subgroups with similar patterns of reasons reported and assessed the association between class membership and care status (ie, disengaged versus silently transferred to a new site).

RESULTS

Among 547 patients, we identified 5 profiles of care disruptions: (1) "Livelihood and Mobility" (30.6% of the population) reported work/school obligations and mobility/travel as reasons for care disruptions; (2) "Clinic Accessibility" (28.9%) reported challenges with attending clinic; (3) "Mobility and Family" (21.9%) reported family obligations, mobility/travel, and transport-related reasons; (4) "Doubting Need for HIV care" (10.2%) reported uncertainty around HIV status or need for clinical care, and (5) "Multidimensional Barriers to Care" (8.3%) reported numerous (mean 5.6) reasons across multiple domains. Patient profiles were significantly associated with care status. The "Doubting Need for HIV Care" class were mostly disengaged (97.9%), followed by the "Multidimensional Barriers to Care" (62.8%), "Clinic Accessibility" (62.4%), "Livelihood and Mobility" (43.6%), and "Mobility and Family" (23.5%) classes.

CONCLUSION

There are distinct HIV care disruption profiles that are strongly associated with patients' current engagement status. Interventions targeting these unique profiles may enable more effective and tailored strategies for improving HIV treatment outcomes.

Depression and Sexual Trauma Among Adolescent Girls and Young Women in HIV-Prevention Research in Tanzania

PURPOSE

Clinical trials are necessary to test HIV-prevention strategies among adolescent girls and young women in sub-Saharan Africa. Psychosocial risk factors that increase girls' and young women's vulnerability for HIV may also impact their experiences in clinical trials. A better understanding of psychosocial risks among girls and young women enrolled in HIV-prevention research is needed. This analysis explores depression and sexual trauma among adolescent girls and young women enrolled in a mock microbicide trial in Tanzania.

METHODS

We collected cross-sectional data from 135 HIV-negative adolescent girls and young women between 15 and 21 in Dar es Salaam, Tanzania enrolled in a mock microbicide trial. Depression, sexual behavior, and sexual trauma were measured. Sexual trauma and demographic variables were entered into a multivariate binomial logistic regression model predicting depression.

FINDINGS

Overall, 27% of participants had moderate-to-severe depression. The most commonly endorsed items were anhedonia (lack of interest/pleasure) and low mood, which were reported by 78% of participants. Thoughts of suicide or self-harm were endorsed by 17% of participants. Coerced/forced first sex was reported by 42% of participants. Participants reporting coerced/forced first sex had 3.16 times the likelihood of moderate-to-severe depression.

CONCLUSIONS

Depression and coerced/forced sex were common among participants in an HIV-prevention mock clinical trial in Tanzania. When enrolling adolescent girls and young women in HIV-prevention trials in sub-Saharan Africa, our research suggests the need for a trauma-informed approach, referrals for trauma and depression, and interventions that address the impact of depression and trauma on HIV prevention, clinical trial adherence, and clinical outcomes.

Trauma exposure, PTSD, and suboptimal HIV medication adherence among marginalized individuals connected to public HIV care in Miami

Individuals living with HIV report disproportionately high levels of trauma exposure and PTSD symptoms, both which have been associated with suboptimal ART adherence. Often conflated, the question arises as to which construct is driving subsequent HIV self-care behavior. Given the HIV disparities among Black and Hispanic/Latinx individuals, and that Miami is a geographic region with a high racial/ethnic minority make up and a unique socioeconomic environment, it is important to explore factors related to HIV outcomes in Miami to mitigate its uncontrolled epidemic. This study aimed to examine the association of trauma exposure, PTSD symptoms, and relevant additional key factors with adherence to ART among a sample of majority Black and Hispanic/Latinx individuals who are economically marginalized receiving public HIV care in Miami, FL (N = 1237) via a cross-sectional survey. Sequential linear regression was used to examine the study aim in four blocks: (1) trauma, (2) PTSD symptoms, and key covariates of ART adherence including (3) depression and substance use (potential psychological covariates), and (4) indicators of socioeconomic status (potential structural covariates). In the first block, trauma exposure was associated with worse adherence. However, in the second block, the association with trauma dropped and PTSD was significantly associated with worse adherence. Of note, for those experiencing high levels of trauma exposure, adherence was negatively impacted regardless of PTSD. When other key factors associated with adherence were entered in the third and fourth blocks, neither trauma exposure nor PTSD were uniquely significant. In this final model, depression, substance use, and unstable housing were uniquely associated with worse adherence. Trauma-informed models of HIV care that holistically address co-occurring factors are warranted to cater to communities with HIV health disparities and keep them from falling off the HIV care continuum.

Patterns of acquired HIV-1 drug resistance mutations and predictors of virological failure in Moshi, Northern Tanzania

Emergence of HIV drug resistance poses a serious risk of inactivity to all currently approved antiretroviral drugs. Profiles of HIV drug resistance mutations (HIVDRM) and virological failure (VF) are not extensively studied in Tanzania. This study aimed to determine HIVDRM and predictors of VF in HIV-infected individuals failing first-line HIV drugs in Moshi, Northern Tanzania. A case-control study was conducted at Kilimanjaro Christian Medical Centre, Mawenzi, Pasua and Majengo health facilities with HIV-care and treatment clinics from October, 2017 to August, 2018. Cases and controls were HIV-infected individuals with VF and viral suppression (VS) respectively. HIV-1 reverse transcriptase and protease genes were amplified and sequenced. Stanford University's HIV drug resistance database and REGA subtyping tool 3.0 determined HIVDRM and HIV-1 subtypes respectively. Odds ratios (OR) with 95% confidence interval (95% CI) investigated predictors of VF. P-value < 5% was considered statistically significant. A total of 124 participants were recruited, of whom 63 (50.8%) had VF, 61 (49.2%) had VS and 82 (66.1%) were females. Median [IQR] age and duration on ART were 45 [35-52] years and 72 [48-104] months respectively. Twenty-five out of 26 selected samples from cases were successfully sequenced. Twenty-four samples (96%) had at least one major mutation conferring resistance to HIV drugs, with non-nucleoside analogue reverse transcriptase inhibitor (NNRTI)-resistance associated mutations as the majority (92%). Frequent NNRTI-resistance associated mutations were K103N (n = 11), V106M (n = 5) and G190A (n = 5). Prevalent nucleoside analogue reverse transcriptase inhibitors-resistance associated mutations were M184V (n = 17), K70R (n = 7) and D67N (n = 6). Dual-class resistance was observed in 16 (64%) samples. Thirteen samples (52%) had at least one thymidine analogue-resistance associated mutation (TAM). Three samples (12%) had T69D mutation with at least 1 TAM. Two samples (8%) had at least one mutation associated with protease inhibitor resistance. Age [aOR = 0.94, 95% CI (0.90-0.97), p < 0.001] and occupation [aOR = 0.35, 95% CI (0.12-1.04), p = 0.059] associated with VF. In conclusion, HIV drug resistance is common among people failing antiretroviral therapy. Resistance testing will help to guide switching of HIV drugs.

Testing Mindful Awareness as a Moderator in the Association Between HIV-Related Stress and Drug and Alcohol Use Problems Among People Living with HIV

Objectives

People living with HIV (PLWH) are disproportionately affected by stressful life events. HIV-related stress adds to general life stressors to increase health risks among this population. Stress has not only been associated with HIV progression but it is also linked to HIV transmission risk behavior (e.g., substance use). Older adults living with HIV (OALWH) experience additional age-related stress and are at increased risk for substance use. Mindfulness buffers against stress for PLWH; however, research has yet to examine mindfulness as a buffer between HIV-related stress and substance use for OALWH.

Methods

Participants were 130 OALWH (M _age = 54.65, SD = 4.20) and 74.6% were Black. The majority were male (69.2%), and nearly half identified as heterosexual (48.5%). A hierarchical linear regression examined the main and interactive effects of mindful awareness and two types of HIV-related stress (e.g., stigma and rumination) on alcohol and drug use problems.

Results

In step one of the model, we examined HIV stigma (β = .231, p = .015) and found no significant interaction with mindful awareness. In step two, HIV rumination (β = .288, p = .001) was added. We found a significant interaction (β = .196, p = .020), indicating those with low mindful awareness and high rumination reported the greatest substance use problems. Exploratory analyses revealed an indirect effect of HIV stigma on substance use through HIV rumination as well as a significant effect for second-stage moderated mediation.

Conclusions

These findings support mindful awareness as a buffer against HIV rumination for OALWH. Further, our results have important implications for the utility of mindfulness-based interventions (MBIs) with OALWH and comorbid substance use disorders.

Life Chaos is Associated with Reduced HIV Testing, Engagement in Care, and ART Adherence Among Cisgender Men and Transgender Women upon Entry into Jail

Life chaos, the perceived inability to plan for and anticipate the future, may be a barrier to the HIV care continuum for people living with HIV who experience incarceration. Between December 2012 and June 2015, we interviewed 356 adult cisgender men and transgender women living with HIV in Los Angeles County Jail. We assessed life chaos using the Confusion, Hubbub, and Order Scale (CHAOS) and conducted regression analyses to estimate the association between life chaos and care continuum. Forty-eight percent were diagnosed with HIV while incarcerated, 14% were engaged in care 12 months prior to incarceration, mean antiretroviral adherence was 65%, and 68% were virologically suppressed. Adjusting for sociodemographics, HIV-related stigma, and social support, higher life chaos was associated with greater likelihood of diagnosis while incarcerated, lower likelihood of engagement in care, and lower adherence. There was no statistically significant association between life chaos and virologic suppression. Identifying life chaos in criminal-justice involved populations and intervening on it may improve continuum outcomes.

Intimate Partner Violence Experiences Among Men Living with HIV in Rural Appalachia

There has been limited study of the syndemic link between HIV and intimate partner violence (IPV) among rural populations in the United States. We utilized the Revised Conflict Tactics Scale-2 to examine the past year prevalence, type (psychological aggression, physical assault, and sexual assault), and the impact of IPV on HIV clinical outcomes among men living with HIV in rural Appalachia. Approximately 39% of participants experienced some type of IPV in the preceding year, with 67% of those individuals experiencing more than 1 type of IPV. Approximately 77% of participants endorsing IPV exposure experienced psychological aggression. Most participants exposed to psychological aggression (70%) and/or physical assault (57%) were both victims and perpetrators, and those experiencing sexual assault reported being exclusively victims (65%). There were no significant differences in clinical outcomes including viral load and CD4 count, which may be secondary to small sample size derived from a clinic population with a high rate of virologic suppression (94%). This study demonstrates the need to assess IPV exposure in men living with HIV and further highlights the intricacies of relationship violence in these individuals.

Gender Disparities in Traumatic Life Experiences and Antiretroviral Therapy Adherence Among People Living with HIV in South Carolina

People living with HIV are at increased risk for experiencing trauma, which may be linked to reduced adherence to antiretroviral therapy (ART), making it more difficult to achieve and maintain viral suppression. The current study sought to assess whether traumatic life experiences were associated with lower ART adherence among a diverse sample of people living with HIV in South Carolina. A cross-sectional survey was completed by 402 individuals receiving HIV care from a large immunology center. Principal component analysis revealed three primary categories of trauma experience (extreme violence/death-related trauma, physical and sexual assault, and accidental/disaster-related trauma). Multivariable logistic regression models using complete case analysis and multiple imputation were used to determine the associations between experiencing each trauma category and ART adherence. Complete case analysis showed that overall, participants who reported exposure to any trauma were 58% less likely to be adherent to their ART (adjusted OR 0.42; 95% CI 0.21-0.86) compared to respondents who did not experience trauma. Participants exposed to extreme violence/death-related trauma were 63% less likely to be adherent to their ART (adjusted OR 0.37; 95% CI 0.15-0.95) compared to respondents who did not experience trauma. Participants exposed to physical and sexual assault were 65% less likely (adjusted OR 0.35; 95% CI 0.16-0.77) and those who reported experiencing accidental/disaster-related trauma were 56% less likely (adjusted OR 0.44; 95% CI 0.21-0.93) to report being ART adherent compared to participants who did not experience trauma. Analyses with multiple imputation yielded similar findings as the complete case analyses. When the data were analyzed separately by gender, the associations between overall trauma, extreme violence/death-related trauma, and physical and sexual assault were statistically significant for men using complete case and multiple imputation analyses. There were no statistically significant associations between trauma and ART adherence among women. Findings highlight the need to adopt trauma-informed approaches and integrate trauma- and gender-specific interventions into HIV clinical care in the Southern United States.

Longitudinal engagement trajectories and risk of death among new ART starters in Zambia: A group-based multi-trajectory analysis

BACKGROUND

Retention in HIV treatment must be improved to advance the HIV response, but research to characterize gaps in retention has focused on estimates from single time points and population-level averages. These approaches do not assess the engagement patterns of individual patients over time and fail to account for both their dynamic nature and the heterogeneity between patients. We apply group-based trajectory analysis-a special application of latent class analysis to longitudinal data-among new antiretroviral therapy (ART) starters in Zambia to identify groups defined by engagement patterns over time and to assess their association with mortality.

METHODS AND FINDINGS

We analyzed a cohort of HIV-infected adults who newly started ART between August 1, 2013, and February 1, 2015, across 64 clinics in Zambia. We performed group-based multi-trajectory analysis to identify subgroups with distinct trajectories in medication possession ratio (MPR, a validated adherence metric based on pharmacy refill data) over the past 3 months and loss to follow-up (LTFU, >90 days late for last visit) among patients with at least 180 days of observation time. We used multinomial logistic regression to identify baseline factors associated with belonging to particular trajectory groups. We obtained Kaplan-Meier estimates with bootstrapped confidence intervals of the cumulative incidence of mortality stratified by trajectory group and performed adjusted Poisson regression to estimate adjusted incidence rate ratios (aIRRs) for mortality by trajectory group. Inverse probability weights were applied to all analyses to account for updated outcomes ascertained from tracing a random subset of patients lost to follow-up as of July 31, 2015. Overall, 38,879 patients (63.3% female, median age 35 years [IQR 29-41], median enrollment CD4 count 280 cells/μl [IQR 146-431]) were included in our cohort. Analyses revealed 6 trajectory groups among the new ART starters: (1) 28.5% of patients demonstrated consistently high adherence and retention; (2) 22.2% showed early nonadherence but consistent retention; (3) 21.6% showed gradually decreasing adherence and retention; (4) 8.6% showed early LTFU with later reengagement; (5) 8.7% had early LTFU without reengagement; and (6) 10.4% had late LTFU without reengagement. Identified groups exhibited large differences in survival: after adjustment, the "early LTFU with reengagement" group (aIRR 3.4 [95% CI 1.2-9.7], p = 0.019), the "early LTFU" group (aIRR 6.4 [95% CI 2.5-16.3], p < 0.001), and the "late LTFU" group (aIRR 4.7 [95% CI 2.0-11.3], p = 0.001) had higher rates of mortality as compared to the group with consistently high adherence/retention. Limitations of this study include using data observed after baseline to identify trajectory groups and to classify patients into these groups, excluding patients who died or transferred within the first 180 days, and the uncertain generalizability of the data to current care standards.

CONCLUSIONS

Among new ART starters in Zambia, we observed 6 patient subgroups that demonstrated distinctive engagement trajectories over time and that were associated with marked differences in the subsequent risk of mortality. Further efforts to develop tailored intervention strategies for different types of engagement behaviors, monitor early engagement to identify higher-risk patients, and better understand the determinants of these heterogeneous behaviors can help improve care delivery and survival in this population.

Antiretroviral Adherence Trajectories Among Black Americans Living with HIV

Black people living with HIV (BPLWH) are less likely to adhere to antiretroviral treatment than are members of other racial/ethnic groups. Data were combined from two studies of BPLWH (n = 239) to estimate adherence trajectories using a semiparametric, group-based modeling strategy over three time-points (spanning 6 months). Analyses identified three groups of individuals (high-stable, moderately low-stable, low-decreasing). Multinomial logistic regressions were used to predict trajectory membership with multiple levels of socio-ecological factors (structural, institutional/health system, community, interpersonal/network, individual). Older age was associated with being in the high-stable group, whereas substance use, lower perceived treatment effectiveness, and lower quality healthcare ratings were related to being in the moderately low-stable group. In sum, multiple socio-ecological factors contribute to adherence among BPLWH and thus could be targeted in future intervention efforts.

Pathways to Health: an Examination of HIV-Related Stigma, Life Stressors, Depression, and Substance Use

BACKGROUND

Despite antiretroviral treatment (ART) being an efficacious treatment for HIV, essentially making it a chronic non-terminal illness, two related and frequent concerns for many people living with HIV/AIDS (PLWHA) continue to be HIV-related stigma and life stress. These two variables are frequently associated with depression, substance use, and poorer functional health. Studies to date have not fully examined the degree to which these constructs may be associated within one model, which could reveal a more nuanced understanding of how HIV-related stigma and life stress affect functional health in PLWHA.

METHODS

The current study employed hybrid structural equation modeling to examine the interconnectedness and potential indirect relationships of HIV-related stigma and life stress to worse health through substance use and depression, controlling for ART adherence and age. Participants were 240 HIV-infected individuals who completed a biopsychosocial assessment battery upon screening for an RCT on treating depression in those infected with HIV.

RESULTS

Both HIV-related stigma and stressful life events were directly related to depression, and depression was directly related to health. There were significant indirect effects from stigma and stress to health via depression. There were no significant effects involving substance use.

CONCLUSION

It is important to continue to develop ways to address stigma, stressful life events, and their effects on distress in those living with HIV. Expanding our knowledge of disease progression risk factors beyond ART adherence is important to be able to design adjuvant interventions, particularly because treatment means that people living with HIV have markedly improved life expectancy and that successful treatment means that HIV is not transmittable to others.

Shifting to the long view: engagement of pregnant and postpartum women living with HIV in lifelong antiretroviral therapy services

Introduction: The advent of policies promoting lifelong antiretroviral therapy (ART) for all pregnant and postpartum women living with HIV has shifted focus from short-term prevention of mother-to-child transmission (PMTCT) to lifelong engagement in ART services. However, disengagement from care threatens the long-term treatment and prevention benefits of lifelong ART. Areas covered: A framework for considering the unique aspects of ART for pregnant and postpartum women is presented along with a review of the literature on maternal engagement in care in sub-Saharan Africa and a discussion of potential interventions to sustain engagement in lifelong ART. Expert opinion: Engaging women and mothers in ART services for life is critical for maternal health, PMTCT, and prevention of sexual transmission. Evidence-based interventions exist to support engagement in care but most focus on periods of mother-to-child transmission risk. In the long term, life transitions and health-care transfers are inevitable. Thus, interventions that can reach beyond a single facility or provide a bridge between health services should be prioritized. Multicomponent interventions will also be essential to address the numerous intersecting barriers to sustained engagement in ART services.

Adverse childhood experiences, mental health, substance use, and HIV-related outcomes among persons with HIV

While persons with HIV (PWH) have benefited from significant advances in treatment and resulting longevity, mental health problems remain elevated in this population. Adverse childhood experiences (ACEs) are common among PWH and may negatively affect mental health and HIV-related outcomes. We examined the association between ACEs, depression and anxiety symptoms, substance use, antiretroviral therapy (ART) adherence, and HIV-clinical indicators in a sample of 584 PWH at risk for unhealthy alcohol use enrolled in a primary care-based alcohol intervention study. The sample was 96.9% male, 63.0% non-Hispanic white, with an average age of 49.0 years. ACEs were highly prevalent: 82.5% reported ≥1 ACE, including 34.2% reporting 1-2 ACEs, 25.0% reporting 3-4 ACEs, and 23.3% reporting ≥5 ACEs. Adjusting for demographics, having 1-2, 3-4 or ≥5 ACEs was significantly associated with anxiety (ORs (95%CI): 3.41 (1.13-10.33), 4.36 (1.42-3.36), and 3.96 (1.28-12.19), respectively) and poorer mental health quality of life (Betas (SE): -3.21 (1.40), -6.23 (1.51), and -7.09 (1.54), respectively), but not with other outcomes. Trauma-informed interventions to reduce anxiety and improve mental health quality of life in PWH may reduce the negative health sequelae of ACEs.

Tailoring Cognitive Behavioral Therapy for Trauma-Exposed Persons Living With HIV

This Treatment Development Report describes the need for evidence-based psychosocial trauma-focused treatment for people living with comorbid posttraumatic stress disorder (PTSD) and HIV. Individuals with HIV have higher rates of exposure to traumatic events and PTSD than the general public, and they also experience additional consequences of PTSD on the management of their chronic disease (e.g., established link between PTSD symptoms and lack of adherence to antiretroviral therapy [ART]). We used the empirically-supported ADAPT-ITT approach to consider the initial steps in adapting evidence-based Cognitive Processing Therapy (CPT) for individuals with PTSD and HIV. This paper reviews a case example that involved various clinical issues that may arise when providing trauma-focused treatment for people living with HIV including HIV-stigma, disease management, and the need for making multicultural adaptations to psychotherapy. This case example illustrates how trauma-focused treatment may benefit from enhancement to address additional barriers that may arise over the course of PTSD treatment in this population. Feasibility of engaging and delivering a "full dose" of evidence-based PTSD treatment among individuals living with HIV is discussed. While evidence-based treatments can reduce PTSD symptom severity, issues related to chronic disease coping and HIV-related stigma management could be integrated to augment the efficacy of treatment for individuals with HIV. Adaptive intervention research targeting PTSD in persons living with HIV warrants further attention, especially given the association between PTSD and adherence to ART.

Therapy Adherence and Emotional Awareness and Regulation in Persons With Human Immunodeficiency Virus

Adherence to antiretroviral therapy (ART) is a key issue for people with human immunodeficiency virus. Optimal adherence leads to benefits in terms of survival and quality of life, which do not occur with incomplete adherence. One factor that may influence adherence to ART is emotional unawareness deficits. To explore this possibility, we assessed emotional deficits and measured adherence in 100 adults using both self-report and viral load testing. Results showed that people classified as adherent in both measurements were more likely to have a greater awareness of their own emotions. Participants classified as nonadherent were more likely to have a reduced ability to recognize the emotions of others. Difficulty in recognizing one's own emotions, otherwise known as alexithymia, and impairment of the ability to recognize other's emotions may contribute to nonadherence to ART. Consequently, after repeated studies to confirm the findings, it can be considered a target for psychological therapies aimed at increasing adherence.

Psychiatric Illness, Substance Use, and Viral Suppression Among HIV-Positive Men of Color Who Have Sex with Men in Los Angeles

For individuals living with human immunodeficiency virus (HIV), viral suppression positively affects quality and length of life and reduces risks for HIV transmission. Men of color who have sex with men (MoCSM) who have been diagnosed with HIV have disproportionately low rates of viral suppression, with concomitant increases in incidence. We identified specific social, structural, and psychiatric factors associated with viral suppression among a sample of 155 HIV-positive MoCSM. Cigarette smoking and biological markers of recent drug use were significantly associated with detectable viral load. In contrast, individuals reporting a history of psychiatric illness during medical examination were more likely to be virally suppressed. Further analyses demonstrated that psychiatric illness may affect virologic outcomes through increased probability of being prescribed HIV medications. Alternatively, cigarette smoking and drug use appear to negatively affect subsequent HIV Care Continuum milestones such as medication adherence. Findings provide support for comprehensive intervention programs that emphasize prevention and treatment of cigarette, methamphetamine, and other drug use, and promote improved connection to psychiatric care. Continual achievement of this goal may be a crucial step to increase rates of viral suppression and slow HIV incidence in communities of MoCSM in Los Angeles and other urban areas.

Paradoxical effect of social support among people living with HIV: A diary study investigating the buffering hypothesis

OBJECTIVE

The aim of this study was to examine the buffering role of time-varying received and provided support in the relationship between stress and end-of-day mood among people living with HIV. In addition, the moderating role of intimate relationships in this buffering effect was verified.

METHODS

The participants included 115 patients with a confirmed diagnosis of HIV infection. The data were collected using an online diary method. For five consecutive days (from Monday to Friday), participants completed an online time-stamped questionnaire in the evening to assess their end-of day-mood, stress related to a central hassle on any given day and social support that was received and provided.

RESULTS

The results of the multilevel analysis showed that daily provided, but not received, support had the following partial buffering effect: the association between negative affect and stress was weaker on days with higher support provision. However, this effect was limited to those participants who were in an intimate relationship; the opposite effect was observed in single participants.

CONCLUSION

These findings suggest that the buffering effect of daily support may be modified by other social resources, such as being in an intimate relationship, and when they are not available, it can even become detrimental.

HIV-Related Stress and Life Chaos Mediate the Association Between Poverty and Medication Adherence Among People Living with HIV/AIDS

HIV treatment depends on high-levels of antiretroviral therapy (ART) adherence, which is severely impeded by poverty. Men and women living with HIV infection (N = 92) completed computerized interviews of demographic and health characteristics, poverty markers, stressful life events, and life chaos, as well as unannounced pill counts to determine prospective medication adherence and medical record chart abstractions for HIV viral load. Poverty markers were associated with both stressors and chaos, and the direct effects of all three factors predicted ART non-adherence. The multiple mediation model showed that accounting for stressors and chaos resulted in a non-significant association between poverty markers and ART adherence. The indirect effect of poverty markers on adherence through life chaos was significant, whereas the indirect effect of poverty markers on adherence through stressors was not significant. Factors that render HIV-related stress and create chaos offer intervention targets that are more amenable to change than poverty itself.

Depressed mood during the menopausal transition: is it reproductive aging or is it life?

BACKGROUND

Although there has been noteworthy attention to both depressed mood symptoms and majordepressive disorder during the menopausal transition (MT), recently investigators have questioned whether there is an over-pathologizing of the MT by emphasizing hormonal effects on depression and deflecting attention from the everyday conditions of women's lives as they relate to depressed mood. In addition, fluctuation of mood over short periods of time may not be captured by measures of depressed mood symptoms such as the CESD, especially when administered using a reference period such as a week or more. The purpose of this study was to examine the association of menopausal transition factors, health-related factors, stress factors, social factors and symptoms with repeated measures of depressed mood reported for a 24 h period.

METHODS

Seattle Midlife Women's Health Study participants (n = 291, 6977 observations) provided data from 1990 to 2013 including annual questionnaires, symptom diaries and urine specimens assayed for hormones several times per year. Multilevel modeling was used to test bivariate and multivariable models accounting for depressed mood severity.

RESULTS

In individual models with age as the measure of time, being in early postmenopause, exercising more, and being partnered were associated with less severe depressed mood; greater perceived stress, having a history of sexual abuse, difficulty getting to sleep, early awakening, and awakening at night were each associated with higher depressed mood severity. In a multivariable model (n = 234, 6766 observations), being older, being in the early postmenopause, exercising more, being partnered, were associated with less severe depressed mood; reporting greater perceived stress, history of sexual abuse, difficulty getting to sleep and early awakening were associated with more severe depressed mood.

CONCLUSIONS

Clinicians need to consider the context in which midlife women experience the menopausal transition and mood symptoms as well as hormonal transitions during this part of the lifespan.

Impact of stressful death or divorce in people with HIV: A prospective examination and the buffering effects of religious coping and social support

This study examined the impact of a stressful death/divorce on psychological and immune outcomes in people with HIV. People with HIV with stressful death/divorce were examined from before the event to up to 12 months later (n = 45); controls were assessed at similar intervals (n = 112). Stressful deaths/divorces were associated with increased viral load and anxiety over time (ps ≤ .014), but not CD4+ or depression. Increased use of religious coping after the stressful death/divorce was associated with slower increases in viral load (p = .010). These data suggest people with HIV should consider the potentially elevated risk of transmission after such events and seek appropriate monitoring and care.

Violence From a Sexual Partner is Significantly Associated With Poor HIV Care and Treatment Outcomes Among Female Sex Workers in the Dominican Republic

BACKGROUND

Female sex workers (FSWs) experience high rates of violence from their sexual partners. Although violence is associated with HIV risk behaviors among FSWs, there is limited evidence on the association between violence and HIV treatment outcomes.

METHODS

We analyzed data from a socio-behavioral survey with a cohort of FSWs living with HIV in the Dominican Republic (n = 268) to describe the burden of violence from a sexual partner in the last 6 months. We assessed the relationship between violence and HIV treatment outcomes, comparing findings across 2 types of sexual partners: intimate partners and clients.

RESULTS

Nearly one-fifth of women (18.3%) experienced violence in the last 6 months. More women experienced violence from an intimate partner (12.3%) than a client (8.3%), with some (2.6%) reporting both. Although violence from an intimate partner was significantly associated with not currently being on antiretroviral treatment [ART; adjusted odds ratio (AOR): 4.05, 95% confidence interval (CI): 1.00 to 16.36] and missing an ART dose in the last 4 days (AOR: 5.26, 95% CI: 1.91 to 14.53), violence from a client was associated with never having received HIV care (AOR: 2.85, 95% CI: 1.03 to 7.92) and ever interrupting ART (AOR: 5.45, 95% CI: 1.50 to 19.75).

CONCLUSIONS

Violence from a sexual partner is associated with poor HIV treatment outcomes among FSWs. Different patterns by type of partner reflect how relationship dynamics may influence these associations. Violence prevention and support services should be tailored based on type of partner. Violence screening and referrals should be integrated into HIV care services for FSWs to improve their health and reduce ongoing transmission.

Seeking Safety Group Therapy for Co-Occurring Substance Use Disorder and PTSD among Transgender Women Living with HIV: A Pilot Study

Transgender women living with HIV experience high rates of substance use, violence, and post-traumatic stress disorder (PTSD). Seeking Safety is a manualized, present-focused, cognitive-behavioral therapy program designed to address co-occurring substance use and PTSD. Seeking Safety has evidence of efficacy in a variety of populations but had not been evaluated specifically with people living with HIV or transgender women. We pilot-tested a 12-session Seeking Safety program with a group of transgender women living with HIV who reported substance use and a history of violence. Seven transgender women living with HIV were recruited from two HIV primary care clinics in San Francisco and completed pre- and post-intervention assessments. Participants attended an average of 8 of the 12 sessions. Mean scores for all three outcome measures improved: PTSD symptom scores declined 17.5%, alcoholism screening scores declined 23.9%, and drug abuse screening scores declined 68.8%, on average. Despite the small sample, this pilot study showed Seeking Safety to be a promising intervention among transgender women living with HIV. The findings are encouraging and justify larger studies of Seeking Safety among transgender women and other people living with HIV who experience high rates of substance use and PTSD.

Mobile Phone Ecological Momentary Assessment of Daily Stressors Among People Living With HIV: Elucidating Factors Underlying Health-Related Challenges in Daily Routines

Stressful life events and daily hassles affect people living with HIV (PLWH). However, capturing stress-related events and cognitive impairment is often plagued with recall biases. Incorporating reliable information technology, such as mobile phones, can be a resourceful method for measuring health behaviors (MHB). We report findings from an MHB pilot study with 32 African American, Latino/Hispanic, and White PLWH from Los Angeles. Participants reported perceived stressors in their daily routines using a smartphone Ecological Momentary Assessment (EMA) application. Participants self-initiated in-the-moment stressful events reports for up to 6 weeks. Stressful event EMAs queried perceived stress levels (1-10 scale) and open-ended text descriptions. Qualitative analysis of participant text responses was completed using grounded thematic coding. Participants reported multiple stressors in their daily routines, impacting activities of daily living or daily functioning. Eliciting input from PLWH via EMA in real time is a novel approach for assessing and identifying sources of stress.

Stressful and traumatic life events as disruptors to antiretroviral therapy adherence

Stressful and traumatic life events (STLEs) are common among HIV-infected individuals and may affect health behaviors such as adherence to antiretroviral (ARV) therapy, with important implications for treatment outcomes. We examined the association between STLEs and ARV adherence among 289 US-based participants enrolled between 7/1/2010 and 9/1/2013 in a study of depression treatment for HIV-infected patients. Participants received monthly telephone calls to assess STLEs and pill count-based ARV adherence. Inverse probability of observation weighting was combined with multiple imputation to address missing data. Participants were mostly male (71%) and black (63%), with a median age of 45 years. Median monthly adherence was 96% (interquartile range (IQR): 85-100%). Participants experienced a mean of 2.48 STLEs (range: 0-14) in the previous month. The presence of ≥2 STLEs was associated with a mean change in adherence of -3.67% (95% confidence interval (CI): -7.12%, -0.21%) and decreased likelihood of achieving ≥95% adherence (risk ratio (95% CI) = 0.82 (0.71, 0.95)). For each additional STLE, the mean adherence change was -0.90% (95% CI: -1.79%, 0.00%). STLEs were associated with poorer ARV adherence, including decreased likelihood of adhering to ≥95% of ARV doses. This level of adherence has a critical role in regimen effectiveness and prevention of resistance.

Life Chaos and Perceived Social Support Among Methamphetamine-Using Men Who Have Sex With Men Engaging in Transactional Sexual Encounters

OBJECTIVE

Social support and life chaos have been inversely associated with increased risk of HIV infection. The purpose of this study was to explore among a sample of HIV-negative methamphetamine-using men who have sex with men (MSM) the association between engaging in transactional sex, life chaos, and low social support.

METHODS

HIV-negative methamphetamine-using MSM completed an online questionnaire between July and October 2012 about recent substance use and sexual behavior. Bivariate and multivariate tests were used to obtain statistically significant associations between demographic characteristics, engaging in transactional sex, life chaos, and the participants' perception of their social support.

RESULTS

Of the 325 participants, 23.7% reported engaging in transactional sex, 45.2% reported high life chaos, and 53.5% reported low perceived social support. Participants who engaged in transactional sex were more likely to have high life chaos than participants who did not (aOR = 1.70, 95% CI = [1.01, 2.84]); transactional sex was not associated with social support. Participants with high life chaos were more out about their sexual orientation (aOR = 2.29, 95% CI = [1.18, 4.42]) and more likely to perceive they had low social support (aOR = 3.78, 95% CI = [2.31, 6.22]) than participants with low life chaos. Non-Latinos perceived they had less social support than Latinos (aOR = 0.48, 95% CI = [0.25, 0.92]).

CONCLUSIONS

Methamphetamine-using MSM engaging in transactional sex experience more life chaos than those who do not engage in transactional sex. Outness, perceived social support, and ethnicity are associated with life chaos.