The impact of mental health and substance abuse factors on HIV prevention and treatment

An mHealth Intervention for Gay and Bisexual Men's Mental, Behavioral, and Sexual Health in a High-Stigma, Low-Resource Context (Project Comunică): Protocol for a Randomized Controlled Trial

BACKGROUND

The World Health Organization reported that 80% of new HIV diagnoses in Europe in 2014 occurred in Central and Eastern Europe. Romania has a particularly high HIV incidence, AIDS prevalence, and number of related deaths. HIV incidence in Romania is largely attributed to sexual contact among gay and bisexual men. However, homophobic stigma in Romania serves as a risk factor for HIV infection for gay and bisexual men. The Comunică intervention aims to provide a much-needed HIV risk reduction strategy, and it entails the delivery of motivational interviewing and cognitive behavioral therapy skills across 8 live text-based counseling sessions on a mobile platform to gay and bisexual men at risk of HIV. The intervention is based on the information-motivation-behavior and minority stress models. There is preliminary evidence suggesting that Comunică holds promise for reducing gay and bisexual men's co-occurring sexual (eg, HIV transmission risk behavior), behavioral (eg, heavy alcohol use), and mental (eg, depression) health risks in Romania.

OBJECTIVE

This paper describes the protocol for a randomized controlled trial designed to test the efficacy of Comunică in a national trial.

METHODS

To test Comunică's efficacy, 305 gay and bisexual men were randomized to receive Comunică or a content-matched education attention control condition. The control condition consisted of 8 time-matched educational modules that present information regarding gay and bisexual men's identity development, information about HIV transmission and prevention, the importance of HIV and sexually transmitted infection testing and treatment, heavy alcohol use and its associations with HIV transmission risk behavior, sexual health communication, finding social support, and creating sexual health goals. Participants undergo rapid HIV and syphilis testing and 3-site chlamydia and gonorrhea testing at baseline and the 12-month follow-up. Outcomes are measured before the intervention (baseline) and at the 4-, 8-, and 12-month follow-ups.

RESULTS

The study was funded in September 2018, and data collection began in May 2019. The last participant follow-up was in January 2024. Currently, the data analyst is cleaning data sets in preparation for data analyses, which are scheduled to begin in April 2024. Data analysis meetings are scheduled regularly to establish timelines and examine the results as analyses are gradually being conducted. Upon completion, a list of manuscripts will be reviewed and prioritized, and the team will begin preparing them for publication.

CONCLUSIONS

This study is the first to test the efficacy of an intervention with the potential to simultaneously support the sexual, behavioral, and mental health of gay and bisexual men in Central and Eastern Europe using motivational interviewing support and sensitivity to the high-stigma context of the region. If efficacious, Comunică presents a scalable platform to provide support to gay and bisexual men living in Romania and similar high-stigma, low-resource countries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03912753; https://clinicaltrials.gov/study/NCT03912753.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52853.

Characteristics of mental health interventions in a cohort of Italian PLWH over the last five years: impact of HIV disease and outbreak of COVID-19 pandemic

Evidence accumulated during past years confirm that people living with HIV (PLWH) still have to deal with comorbidities and chronic complications that can increase physical and psychological issues and can affect daily functioning, quality of life and mental health. Moreover, during the COVID-19 pandemic PLWH proved to be a population at increased risk of psychological distress. We explored the ongoing issues and the characteristics of the mental health interventions for which a cohort of Italian PLWH interacted with a psychologist over the past five years. We analysed a dataset that included 61 PLWH who underwent a psychological intervention between 2018 and 2022. We compared different frequencies in characteristics of mental health interventions according to different demographic and clinical variables, psychopathological symptoms and time of the request for intervention. We showed that psychopathological symptoms most frequently reported by patients were anxiety (55.7%), and depression (49.2%). Furthermore, we reported that most our patients undertook occasional psychological support meetings (31%), sought an intervention after the outbreak of the COVID-19 pandemic (62.3%) and complained about disclosure issues (48.5%). Disclosure issues were mainly reported by younger PLWH (p = 0.002) with a shorter disease (p = 0.031) and treatment history (p = 0.032), and higher interpersonal sensitivity (p = 0.042). It seems fundamental to integrate psychological interventions into the care of PLWH, to give particular attention to PLWH with risky demographic, clinical and mental health factors and to pay special attention to emergency conditions (such as the COVID-19 pandemic) and the most widespread issues to create ad hoc interventions.

A randomized controlled trial of an mHealth intervention for gay and bisexual men's mental, behavioral, and sexual health in a high-stigma, low-resource context: Project Comunică protocol

Background

The World Health Organization (WHO) reported that 80% of new HIV diagnoses in 2014 in Europe occurred in Central and Eastern Europe (CEE). Romania has particularly high HIV incidence, AIDS prevalence, and AIDS-related deaths. HIV incidence today in Romania is largely attributed to sexual contact among gay and bisexual men (GBM). However, homophobic stigma in Romania keeps GBM out of reach of the scant available prevention services and serves as a risk factor for HIV. The Comunică intervention delivers motivational interviewing and cognitive-behavioral therapy skills across eight live text-based counseling sessions. Preliminary evidence suggests that Comunică possesses promise for reducing GBM's co-occurring mental (e.g., depression), behavioral (e.g., heavy alcohol use), and sexual (e.g., HIV-transmission-risk behavior) health risks in Romania and perhaps other similar high-stigma national contexts. This paper describes a randomized controlled trial (RCT) designed to test the efficacy of Comunică.

Methods

To test Comunică's efficacy, 305 GBM were randomized to receive Comunică or a content-matched education attention control condition. The control condition consists of eight time-matched educational modules that present information regarding GBM identity development, information about HIV transmission and prevention, the importance of HIV/STI testing and treatment, heavy alcohol use and its associations with HIV-transmission-risk behavior, sexual health communication, finding social support, and creating sexual health goals. Outcomes are measured pre-intervention (baseline), and at 4-, 8-, and 12-month follow-ups. The primary outcome is frequency of condomless anal sex acts with HIV-positive or unknown-status partners outside of the context of one's own adherent PrEP use or primary partner's adherent PrEP use or undetectable viral load in the past 30 days at each follow-up. Secondary outcomes include depression, anxiety, suicidal thoughts, heavy alcohol use, and HIV/STI testing; motivational and stigma-related mechanisms of intervention efficacy will also be examined.

Discussion

If found to be efficacious, Comunică presents a scalable platform to provide mental, behavioral, and sexual health support to GBM living in Romania and similar high-stigma, low-resource areas within the CEE region and beyond.

Trial registration

Registered April 11, 2019 to ClinicalTrials.gov Identifier: NCT03912753.

Long-term effects of a social media-based intervention, Run4Love, on depressive symptoms of people living with HIV: Three-year follow-up of a randomized controlled trial (Preprint)

Background

Emerging studies have shown the effectiveness of mobile health (mHealth) interventions in reducing depressive symptoms among people living with HIV. Most of these studies included only short-term follow-up, with limited data on long-term effects.

Objective

The purpose of this study is to assess the long-term effects of a randomized controlled trial called Run4Love on depressive symptoms among people living with HIV at 1-year and 3-year follow-ups.

Methods

A total of 300 people living with HIV with depressive symptoms were recruited and randomized to an intervention or a control group in Guangzhou, China, from September 2017 to January 2018. The intervention group received a 3-month Run4Love program, including adapted evidence-based cognitive behavioral stress management courses and exercise promotion via WeChat (Tencent), a popular social media app. The control group received usual care and a brochure on nutrition. The primary outcome was reduction in depressive symptoms, measured using the Center for Epidemiological Studies–Depression (CES-D) scale. Data used in this study were collected at baseline and at the 1-year and 3-year follow-ups. Generalized estimating equations were used to examine the group differences at 1-year and 3-year follow-ups.

Results

Approximately half of the participants completed the assessment at 1-year (149/300, 49.7%) and 3-year (177/300, 59%) follow-ups. At 1-year follow-up, participants in the intervention group reported significant reduction in depressive symptoms compared with the control group (CES-D: from 23.9 to 18.1 in the intervention group vs from 24.3 to 23.3 in the control group; mean −4.79, SD 13.56; 95% CI −7.78 to −1.81; P=.002). At 3-year follow-up, between-group difference in CES-D remained statistically significant (from 23.9 to 20.5 in the intervention group vs from 24.3 to 24.4 in the control group; mean −3.63, SD 13.35; 95% CI −6.71 to −0.54; P=.02). No adverse events were reported during the 3-year follow-up period.

Conclusions

The mHealth intervention, Run4Love, significantly reduced depressive symptoms among people living with HIV, and the intervention effects were sustained at 1-year and 3-year follow-ups. Further research is needed to explore the mechanisms of the long-term effects of mHealth interventions such as Run4Love and to implement these effective interventions among people living with HIV.

Trial Registration

Chinese Clinical Trial Registry ChiCTR-IPR-17012606; https://trialsearch.who.int/Trial2.aspx?TrialID=ChiCTR-IPR-17012606

International Registered Report Identifier (IRRID)

RR2-10.2196/10274

Efficacy of Psychological Interventions Towards the Reduction of High-Risk Sexual Behaviors Among People Living with HIV: A Systematic Review and Meta-analysis, 2010-2020

People living with HIV/AIDS (PLWH) may be vulnerable to mental illness. As sexual transmission is the leading cause of HIV infection, evidence-based study for the effect of psychological interventions on the change of sexual is needed. To estimate the efficacy of psychological interventions towards reducing unprotected sex and increasing condom use among PLWH. We systematically searched PubMed, Web of Science, EMBASE (OVID), and PsycINFO (OVID) for studies reporting psychological intervention effects on the outcomes of condom use and/or unprotected sex from 2010 to 2020. This review is registered with PROSPERO, CRD42020193640. Of 949 studies, 17 studies were included in this systematic review. Overall, participants in the intervention group reduced sexual risk or condomless sex relative to control groups. The effect was higher for people having sex with HIV-positive partners comparing with those who had sex with HIV-negative or unknown status partners. Psychological interventions might positively affect the condom use of PLWH and should be prioritized and regularly.

Syndemics and preexposure prophylaxis are independently associated with rectal immune dysregulation in sexual minority men

OBJECTIVE

Syndemic conditions have been linked to engagement in receptive condomless anal sex (CAS) and HIV seroconversion. However, little is known about the biological pathways whereby syndemics could amplify vulnerability to HIV and other sexually transmitted infections (STIs).

DESIGN

HIV-negative sexual minority men (i.e. gay, bisexual and other MSM) were recruited from four STI clinics in South Florida for a cross-sectional study.

METHODS

Participants completed assessments for four syndemic conditions: depression, posttraumatic stress disorder, hazardous alcohol use and any stimulant use (i.e. any self-reported use or reactive urine toxicology results). Cytokine and chemokine levels were measured using LEGENDplex from the rectal swabs of 92 participants reporting receptive CAS and no antibiotic use in the past three months.

RESULTS

After controlling for age, race/ethnicity, preexposure prophylaxis (PrEP) use and number of receptive CAS partners, a greater number of syndemic conditions was associated with higher levels of rectal cytokines/chemokines relevant to immune activation, inflammation and the expansion and maintenance of T-helper 17 target cells, including rectal interferon-gamma (β = 0.22; P = 0.047), CXCL-8 (β = 0.24; P = 0.025) and interleukin-23 (β = 0.22; P = 0.049). Elevations in rectal cytokine or chemokine levels were most pronounced among participants experiencing two or more syndemic conditions compared with those experiencing no syndemic conditions. PrEP use was independently associated with elevations in multiple rectal cytokines/chemokines.

CONCLUSION

Syndemic conditions could increase biological vulnerability to HIV and other STIs in sexual minority men by potentiating rectal immune dysregulation.

Latent Class Analysis of Syndemic Factors Associated with Sustained Viral Suppression among Ryan White HIV/AIDS Program Clients in Miami, 2017

The study's objective was to identify the association between sustained viral suppression (all viral load tests < 200 copies/ml per year) and patterns of co-occurring risk factors including, mental health, substance use, sexual risk behavior, and adverse social conditions for people with HIV (PWH). Latent class analysis followed by multivariable logistic regression was conducted for 6554 PWH in the Miami-Dade County Ryan White Program during 2017, and a five-class model was selected. Compared to Class 1 (no risk factors), the odds of achieving sustained viral suppression was significantly lower for Class 2 (mental health) (aOR: 0.67; 95% CI 0.54-0.83), Class 3 (substance use and multiple sexual partners) (0.60; 0.47-0.76), Class 4 (substance use, multiple sexual partners, and domestic violence) (0.71; 0.55-0.93), and Class 5 (mental health, substance use, multiple sexual partners, domestic violence, and homelessness) (0.26; 0.19-0.35). Findings indicate the need for targeted interventions that address these syndemic factors.

Mental health in HIV prevention and care: A qualitative study of challenges and facilitators to integration in Vietnam

INTRODUCTION

Globally, men who have sex with men (MSM) experience a disproportionate burden of mental health issues. While HIV service providers may possess the skills and relationships to provision mental health and psychosocial support (MHPSS) to this population, task-sharing models that integrate MHPSS into HIV contexts remain limited. The aim of this study was to explore the sociodemographic, psychological, and structural factors operant at the client and HIV service provider levels that shape MHPSS access and burden among MSM and opportunities for integration in Vietnam.

METHODS

Between June and August 2018, semi-structured interviews were conducted with 20 MSM and 13 service providers at out-patient clinics (OPCs) and community-based organizations (CBOs) in Hanoi, Vietnam. Interviews explored participants' understandings of and experiences with the signs, causes, and appropriate treatments for mental health concerns; and perceived barriers to MHPSS integration in HIV contexts. Data were coded thematically and analyzed in MAXQDA.

RESULTS

Most MSM did not view their mental distress as constituting illness or as warranting clinical attention. Specifically, terms like "mental illness" were often associated with being "crazy" or immoral, while symptoms of distress were interpreted as having to do with everyday difficulties associated with being MSM and/or HIV-positive. Due to mental health stigma, MSM were reluctant to access services while service providers were similarly reluctant to query about needs. Few service providers knew where to refer patients for MHPSS, and none had done so previously. Most service providers reported lacking the human capital, expertise, and funding to address MHPSS needs.

CONCLUSIONS

Our findings suggest that aside from mental health stigma, future integration strategies must address competing demands and incentivization structures, limitations in existing mental health infrastructure and funding, misperceptions around MHPSS needs and symptoms, and opportunities to streamline MHPSS with existing CBO activities to strengthen community wellbeing.

Cumulative Burden of Mental Health Factors and Engagement in HIV Care in Argentina

BACKGROUND

Cumulative burden of multiple mental health conditions may worsen physical health outcomes in vulnerable populations. Accordingly, identifying cumulative burdens of mental health conditions that may affect HIV treatment and care can guide public health strategies to reduce their impact on HIV-related health outcomes. This study examined the relationship between the cumulative burden of mental health conditions and factors associated with engagement in HIV care in Argentina.

METHOD

Data for this study was obtained at baseline from Conexiones y Opciones Positivas en la Argentina 2 (COPA2). Participants (N = 360) were cisgender patients living with HIV who were lost to care, recruited from seven clinics serving people living with HIV in four Argentine urban centers. Cumulative burden of mental health conditions (i.e., depressive symptoms, problematic substance use, unhealthy alcohol use, and psychotic symptoms) was assessed.

RESULTS

Every one-point increase in the number of mental health conditions present was associated with a decrement in patient-provider communication (b = - 0.22, p < .001), self-efficacy (b = - 0.13, p = .012), and motivation for adherence (b = - 0.11, p = .039).

CONCLUSION

This study found cumulative burden of depression, problematic substance use, unhealthy alcohol use, and psychotic symptoms to be negatively associated with factors related to engagement in HIV care. Results highlight the importance of identification and treatment of challenges to mental health, in order to ameliorate their influence on engagement in HIV care.

Spatial analysis and risk factors of suicide among people living with HIV/AIDS who committed suicide

Poor mental health may confer worse health outcomes among people living with HIV/AIDS (PLWH). Suicidal behaviors are symptoms of a depressive episode. The goal was to explore characteristics for spatial distribution and risk factors for suicide among PLWH. This study was conducted in Mainland China with the annual newly reported data of PLWH from 2013 to 2018. We compared the spatial distribution differences between the HIV epidemic and suicide mortality and analyzed the global and local spatial analysis of suicide. Further, we explored the possible risk factors of suicide in PLWH by multivariate regression and a decision tree model. High suicide mortality regions in PLWH in China were inconsistent with that of the high prevalence of PLWH, which showed that there was distribution discordance between the HIV epidemic and suicide mortality. Multivariate regression showed that the possible risk factors of PLWH who committed suicide were younger age, with Han nationality, single, having a higher educational level, and homosexual infection route. The decision tree model showed that age was the primary factor. In conclusion, there was a discordance between HIV prevalence and suicide mortality; lower HIV prevalence regions might have higher mortality due to suicide. Concern is merited amongst PLWH with poor mental health.

Missed opportunities within healthcare for an earlier diagnosis of HIV

Despite guidelines, many individuals are not routinely tested for HIV within healthcare settings. Our objective was to quantify and characterize preceding clinical encounters by newly-diagnosed persons living with HIV in southern Alberta, Canada. We discuss the clinical impact of missed HIV testing, and options for remediation. Clinical encounters prior to HIV diagnosis including the discharge diagnosis were collected between 1 April 2011 and 1 April 2016. We followed the HIV Indicator Diseases across Europe Study criteria to identify HIV Clinical Indicator Conditions (HCICs) present at clinical encounters. Patients accessing prior care were compared to those who had not previously accessed care. Of 393 individuals, 231 (58.7%) had ≥1 encounter prior to diagnosis; 224 (57%) of encounters occurred in outpatient clinics, 130 (33.1%) in emergency departments, and 39 (9.9%) in urgent care clinics. Approximately 25% (n = 57) of patients who engaged healthcare had ≥ 1 recognized HCIC but did not receive HIV testing. The most frequent HCICs were infection (n = 34; 60%) and hematological disorders (n = 12; 21%). The median CD4 cell count at HIV diagnosis for patients with an HCIC was 127 cells/mm³. In this population, three of five patients had accessed healthcare prior to diagnosis with one of four presenting with HCICs but were not offered HIV testing. Protocols beyond the current recommendations are urgently required to address missed HIV diagnostic opportunities who engaged healthcare.

Mortality After Cryptococcal Infection in the Modern Antiretroviral Therapy Era

BACKGROUND

The prevalence of cryptococcosis in people living with HIV (PLWH) in the developed world has decreased considerably in the modern antiretroviral therapy (ART) era. Although early mortality of PLWH with opportunistic infections is well understood, overall mortality has not been previously evaluated.

METHODS

We conducted a retrospective cohort study of cryptococcosis in PLWH from January 1, 2002, to July 1, 2017. Data were also evaluated before and after 2008 to evaluate the possible effect of modern ART on outcomes. Death date was obtained from the hospital's medical informatics database and the Social Security Death Index. Participants were grouped as survivors, early-mortality (death <90 days), and late-mortality (death ≥90 days) individuals.

RESULTS

We reviewed 105 PLWH with cryptococcosis, with 55 survivors (52.4%), 17 early-mortality (16.2%), and 33 late-mortality individuals (31.4%). Overall, mortality was 47.6% (n = 50) with a median follow-up of 3.7 years (interquartile range 1.1, 8.1 years). Late-mortality individuals were less likely to be virally suppressed at the last observation compared with survivors (24% vs 62%, P < 0.001). Individuals diagnosed in the modern ART era had significantly lower mortality (hazard ratio 0.5, confidence interval: 0.2 to 0.8) and were more likely to be virally suppressed at the last observation (57% vs 29%, P = 0.003). Individuals with government-provided insurance had a higher mortality compared to those with private insurance (hazard ratio 2.8, confidence interval: 1.1 to 7.2, P = 0.013).

CONCLUSIONS

Despite improvements in ART, PLWH have high mortality after cryptococcal infection that persists beyond their initial hospitalization. Lower mortality was associated with increased HIV viral suppression and private insurance in the modern ART era.

Audit of patient retention in pre-exposure prophylaxis (PrEP) services in an integrated sexual reproductive health service setting

Pre-exposure prophylaxis (PrEP) for HIV in Wales was launched in July 2017. We set up a PrEP service delivered via our integrated sexual reproductive health service in Aneurin Bevan University Health Board (ABUHB), south east Wales. Public Health Wales (PHW) data show a 22% ‘lost to follow-up’ rate amongst Welsh PrEP patients. Over 18 months, 278 patients booked into ABUHB PrEP clinics. Of these, 275 were men who have sex with men (MSM). One hundred and ninety-three patients commenced PrEP, 5 were diagnosed with HIV at baseline, 42 did not attend their first appointment. The remainder declined PrEP. Of those commenced on PrEP, 51.7% had reduced clinic attendances; all were MSM. Patients with reduced attendances were more likely to be younger (mean age 33 vs. 37 years), reside outside ABUHB catchment area (56.4% vs. 49.6%) and have mental health issues (28.6% vs. 18.8%), but were less likely to disclose substance misuse (24.2% vs. 27.1%) than those attending in line with operational guidance. Of the 63 patients who stopped attending the PrEP clinic, 32.3% (21) had documented reasons, the most common being reduced self-perceived risk. This is the first evaluation of reasons why patients stop attending as well as risk factors associated with those lost to follow-up in PrEP services in Wales.

Effect of a WeChat-Based Intervention (Run4Love) on Depressive Symptoms Among People Living With HIV in China: A Randomized Controlled Trial

BACKGROUND

People living with HIV (PLWH) have high rates of depressive symptoms. However, only a few effective mental health interventions exist for this vulnerable population.

OBJECTIVE

The aim of this study was to assess the efficacy of a WeChat-based intervention, Run4Love, with a randomized controlled trial among 300 people living with HIV and depression (PLWHD) in China.

METHODS

We recruited PLWH from the HIV outpatient clinic in South China. Participants were screened based on the Center for Epidemiologic Studies-Depression (CES-D) scale. Those who scored 16 or higher were eligible to participate. A total of 300 eligible patients were enrolled. After obtaining informed consent from the participants, completion of a baseline survey, and collection of participants' hair samples for measuring cortisol, the participants were randomly assigned to an intervention or a control group in a 1:1 ratio. The intervention group received the Run4Love program, delivered via the popular social media app WeChat. Cognitive behavioral stress management courses and weekly reminders of exercise were delivered in a multimedia format. Participants' progress was monitored with timely and tailored feedback. The control group received usual care and a brochure on nutrition for PLWH. Data were collected at 3, 6, and 9 months. The primary outcome was depression, which was measured by a validated instrument.

RESULTS

Participants in the intervention and control groups were comparable at baseline; about 91.3% (139/150), 88.3% (132/150), and 86.7% (130/150) participants completed the 3-, 6-, and 9-month follow-ups, respectively. At the 3-month follow-up, a significant reduction in CES-D score was observed in the intervention group (from 23.9 to 17.7 vs from 24.3 to 23.8; mean difference=-5.77, 95% CI -7.82 to -3.71; P<.001; standard effect size d=0.66). The mean changes in CES-D score from baseline to the 6- and 9-month follow-ups between the two groups remained statistically significant. No adverse events were reported.

CONCLUSIONS

The WeChat-based mobile health (mHealth) intervention Run4Love significantly reduced depressive symptoms among PLWHD, and the effect was sustained. An app-based mHealth intervention could provide a feasible therapeutic option for many PLWHD in resource-limited settings. Further research is needed to assess generalizability and cost-effectiveness of this intervention.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-IPR-17012606; http://www.chictr.org.cn/showproj.aspx?proj=21019 (Archived by WebCite at https://www.webcitation.org/78Bw2vouF).

Substance Use Screening in HIV Care Settings: a Review and Critique of the Literature

PURPOSE OF REVIEW

People living with human immunodeficiency virus/AIDS (PLWHA) experience high prevalence of substance use disorders (SUD). HIV care settings represent a unique opportunity to identify possible SUD, to provide SUD interventions, and to improve linkage to SUD treatment. The aims of this paper are to (a) review and critique the extant literature examining substance use screening approaches among PLWHA in HIV care settings and (b) provide recommendations for future clinical practice.

RECENT FINDINGS

Twenty-one peer-reviewed articles that examined substance screening approaches employed in HIV and other primary care settings were included in the review. There was limited literature reporting on the implementation and evaluation of substance use screening practices within HIV care settings, and methodological rigor varied across studies. Further, the use of validated substance use screening measures or incorporation of other substance use screening approaches (e.g., use of urine drug testing) within routine HIV care practice is limited. Strategies to implement routine substance use screening within HIV care and incorporate additional substance use assessment, brief interventions, and referral to specialty substance use treatment are discussed. Use of self-report substance use screening measures using web- or computer-delivered approaches that can be integrated within electronic health record systems is particularly promising. HIV care practices should consider potential models to optimally screen and treat SUD. Co-location of HIV and SUD treatment services may be optimal; when co-located services are not possible, strategies to consistently provide brief intervention approaches and referrals to specialty SUD treatment are needed.

A systematic review of comprehensive interventions for substance abuse: Focus on victimization

Violence victimization is common among men and women who use substances and is associated with co-occurring health issues such as PTSD, depression and HIV. Substance use interventions, therefore, should include integrated components that are designed to address co-occurring health issues among victimized substance-using individuals. This systematic review synthesized the evidence on efficacy of comprehensive, integrated, multicomponent interventions for victimized substance-using individuals. The efficacy of integrated multicomponent intervention strategies was assessed for the following syndemic conditions: mental health, substance misuse, violence, and HIV risk. Seventeen studies were identified. Examples of effective components were empowerment strategies for violence, mindfulness-based stress reduction for mental health, social cognitive skill building for addressing HIV risk and psychoeducation for substance misuse. Although in this review, some components were found to be effective, we identified methodological limitations of included studies which calls for more rigorous research in this area. Further, there is lack of evidence base for multicomponent interventions for victimized substance-using individuals in developing countries. Additional studies are needed to establish rigorous evidence base for multicomponent interventions for victimized substance using individuals that help them cope effectively with their trauma of violence and address their needs.

Identifying missed clinical opportunities for the earlier diagnosis of HIV in Australia, a retrospective cohort data linkage study

Background

Treatment as prevention approaches for HIV require optimal HIV testing strategies to reduce undiagnosed HIV infections. In most settings, HIV testing strategies still result in unacceptably high rates of missed and late diagnoses. This study aimed to identify clinical opportunities for targeted HIV testing in persons at risk to facilitate earlier HIV diagnosis in New South Wales, Australia; and to assess the duration between the diagnosis of specific conditions and HIV diagnosis.

Methods

The Australian National HIV registry was linked to cancer diagnoses, notifiable condition diagnoses, emergency department presentations and hospital admissions for all HIV diagnoses between 1993 and 2012 in NSW. Date of HIV acquisition was estimated from back-projection models and people with a likely duration from infection to diagnosis of less than 180 days were excluded. Risk factors associated with clinical opportunities for the earlier diagnosis of HIV were identified.

Results

Sexually transmitted infection diagnoses (particularly gonorrhoea and syphilis) and some hospital admissions (mental health and drug-related diagnoses, and non-infective digestive disorder diagnoses) were prominent among people estimated to be living with undiagnosed HIV. The length of time between a clinical opportunity for the earlier HIV diagnosis and actual HIV diagnosis was 13.3 months for notifiable conditions, and 15.2 months for hospital admissions. People with lower CD4+ cell count at diagnosis, and older people were significantly less likely to have a missed opportunity for earlier HIV diagnosis.

Conclusions

Additional targeted clinical HIV testing strategies are warranted for people with gonorrhoea and syphilis; and hospital presentations or admissions for mental health, drug-related and gastrointestinal diagnoses.

Run4Love, a mHealth (WeChat-based) intervention to improve mental health of people living with HIV: a randomized controlled trial protocol

BACKGROUND

People living with HIV (PLWH) suffer from high rates of mental illness; but targeted effective interventions are limited, especially in developing countries. High penetration of smartphone usage and widespread acceptance of social media applications provide an unprecedented opportunity for mobile-based health interventions (mHealth interventions) in resource-limited settings like China. The current report describes the design and sample characteristics of the Run4Love randomized controlled trial (RCT) aimed at improving mental health in PLWH in China.

METHODS

A total of 300 PLWH with elevated depressive symptoms were recruited and randomized into either the intervention or control group. Participants in the intervention group received an adapted cognitive-behavioral stress management (CBSM) course delivered by the enhanced WeChat platform (for 3 months) and were motivated to engage in physical activities. Progress of the participants was automatically tracked and monitored with timely feedback and rewards. The control group received a brochure on nutrition for PLWH in addition to standard care. The outcome assessments are conducted at baseline, 3, 6, and 9 months using tablets. The primary outcome is depressive symptoms measured by the scale of the Center for Epidemiology Studies Depression (CES-D). Secondary outcomes include quality of life, chronic stress measured with biomarker of hair cortisol, and other measures of stress and depression, self-efficacy, coping, HIV-related stigma, physical activity, and patient satisfaction. Mixed effects model with repeated measures (MMRM) will be used to analyze the intervention effects.

DISCUSSION

The Run4Love study is among the first efforts to develop and evaluate a multicomponent and integrated mHealth intervention to improve the mental health and quality of life of PLWH. Once proven effective, Run4Love could be scaled up and potentially integrated into the routine case management of PLWH and adapted to other populations with chronic diseases.

TRIAL REGISTRATION

Chinese Clinical Trial Registry - ChiCTR-IPR-17012606 , registered on 07 September 2017.

Gender Moderates the Association of Depressive Symptoms to Sexual Risk Behavior Among HIV-Positive African-American Outpatients

Previous research has reported an association between depressive symptoms and sexual risk behavior. The purpose of this study was to explore whether gender moderates this association in a sample of HIV-positive African-Americans. Participants (N = 93) self-reported depressive symptoms (Center for Epidemiological Studies-Depression Scale; CES-D), and sexual risk behavior for the past 4 months. Analyses revealed that the depressive symptoms-by-gender interaction was associated with condomless sex and substance use proximal to sex. When analyses were stratified by gender, depressive symptoms were associated with condomless sex and frequency of substance use only for women. We conclude that depressive symptoms may be a more powerful sexual risk factor among women relative to men.

Association between Perceived Discrimination in Healthcare Settings and HIV Medication Adherence: Mediating Psychosocial Mechanisms

There is insufficient research on the impact of perceived discrimination in healthcare settings on adherence to antiretroviral therapy (ART), particularly among women living with HIV, and even less is known about psychosocial mechanisms that may mediate this association. Cross-sectional analyses were conducted in a sample of 1356 diverse women living with HIV enrolled in the Women's Interagency HIV Study (WIHS), a multi-center cohort study. Indirect effects analysis with bootstrapping was used to examine the potential mediating roles of internalized stigma and depressive symptoms in the association between perceived discrimination in healthcare settings and ART adherence. Perceived discrimination in healthcare settings was negatively associated with optimal (95% or better) ART adherence (adjusted odds ratio (AOR) = 0.81, p = 0.02, 95% confidence interval (CI) [0.68, 0.97]). Furthermore, internalization of stigma and depressive symptoms mediated the perceived discrimination-adherence association: Serial mediation analyses revealed a significant indirect effect of perceived discrimination in healthcare settings on ART adherence, first through internalized HIV stigma, and then through depressive symptoms (B = - 0.08, SE = 0.02, 95% CI [- 0.12, - 0.04]). Perceiving discrimination in healthcare settings may contribute to internalization of HIV-related stigma, which in turn may lead to depressive symptoms, with downstream adverse effects on ART adherence among women. These findings can guide the design of interventions to reduce discrimination in healthcare settings, as well as interventions targeting psychosocial mechanisms that may impact the ability of women living with HIV to adhere to ART regimens.

Substance Use Disorders, Violence, Mental Health, and HIV: Differentiating a Syndemic Factor by Gender and Sexuality

This paper measures syndemic substance use disorder, violence, and mental health and compares the syndemic among HIV-infected heterosexual men, heterosexual women, and men who have sex with men (MSM). Data were from a sample of high needs substance-using, HIV-infected people in South Florida between 2010 and 2012 (n = 481). We used confirmatory factor analysis to measure a syndemic latent variable and applied measurement invariance models to identify group differences in the data structure of syndemic co-morbidities among heterosexual men, heterosexual women, and MSM. We found that variables used to measure the syndemic fit each sub-group, supporting that substance use disorder, violence, and mental health coincide in HIV-infected individuals. Heterosexual men and MSM demonstrated similar syndemic latent variable factor loadings, but significantly different item intercepts, indicating that heterosexual men had larger mean values on substance use disorder, anxiety, and depression than MSM. Heterosexual men and heterosexual women demonstrated significantly different syndemic variable factor loadings, indicating that anxiety and depression contribute more (and substance use contributes less) to the syndemic in heterosexual men compared to heterosexual women. MSM and heterosexual women demonstrated similar syndemic latent variable factor loadings and intercepts, but had significantly different factor residual variances indicating more variance in violent victimization and depression for MSM and more variance in stress for heterosexual women than what is captured by the observed syndemic indicators. Furthermore, heterosexual women had a larger syndemic factor mean than MSM, indicating that the syndemic burden is greater among heterosexual women than MSM. Our findings support that measurement invariance can elucidate differences in the syndemic to tailor interventions to sub-group needs.

Addressing Structural Barriers to HIV Care among Triply Diagnosed Adults: Project Bridge Oakland

People who are "triply diagnosed" with HIV, mental health issues, and substance-related disorders face tremendous barriers connecting to and remaining in HIV care. Authors of this article implemented Project Bridge Oakland (PBO), an intervention based on harm reduction and trauma-informed care, to help maintain continuity of care for triply diagnosed adults through cycles of criminal justice involvement. From August 2011 to December 2014, a clinical social worker and an HIV physician provided intensive case management for 19 clients living in Oakland, California. By working with clients across a multitude of community, clinic, and correctional spaces while maintaining a low threshold for services, the social worker was able to engage a severely marginalized population in HIV care. This article details the PBO strategies for assisting with a wide range of services needed for community stabilization, navigating criminal justice involvement, and establishing a therapeutic relationship through mundane practices such as eating and waiting for appointments. This article illustrates how programs aimed at stabilizing triply diagnosed clients in the community and connecting them to HIV care require coordination among providers, outreach to engage clients, ample time to work with them, and flexibility to account for the complexities of their day-to-day lives and experiences.

Using Syndemics Theory to Investigate Risk and Protective Factors Associated with Condomless Sex Among Youth Living with HIV in 17 U.S. Cities

Identifying risk and protective factors associated with condomless sex among youth living with HIV is imperative for developing effective HIV prevention strategies. A cross-sectional sample of 1728 participants, 12-26 years of age, recruited from adolescent medicine clinics in 17 U.S. cities completed an audio-computer assisted self-interview with questions about their substance use, psychosocial factors, and attitudinal and behavioral factors. Guided by syndemics theory, a path analysis was used to assess the interrelations of these factors. Analyses of model fit statistics indicated statistically significant direct pathways between substance use, psychosocial factors, self-efficacy for risk-reduction, alternative risk-reduction attitudes and behaviors and condomless sex. The total indirect effect of self-efficacy for risk-reduction on condomless sex through alternative risk-reduction attitudes and behaviors was also significant. Multi-faceted, tailored interventions that address individual risk and protective factors and their combined synergistic effects are urgently needed to prevent condomless sex among this population.

"Life-Steps" for PrEP Adherence: Demonstration of a CBT-Based Intervention to Increase Adherence to Preexposure Prophylaxis (PrEP) Medication Among Sexual-Minority Men at High Risk for HIV Acquisition

One dramatic advance in human immunodeficiency virus (HIV) prevention efforts has been the prescription of medications typically used for HIV treatment as prophylaxis against acquiring HIV. As a preventative agent, this practice is referred to as "preexposure prophylaxis" (PrEP). The U.S. Federal Drug Administration approved daily PrEP for adults at risk for HIV who do not consistently use condoms during sex with HIV-infected or unknown-status partners. In this paper, we describe a cognitive-behavioral therapy (CBT) PrEP adherence intervention developed for use in high-risk sexual-minority men in the United States, adapted from "Life-Steps," an evidence-based CBT intervention to promote adherence to HIV treatment. Modules include creating a PrEP dosing schedule, adhering to daily PrEP, problem solving barriers to adherence, and sexual risk-reduction techniques. Supplemented with practical video vignettes, this novel intervention may help to enhance the clinical practice of health care providers in outpatient settings to increase PrEP adherence in sexual-minority men.

Contextualizing Psychosocial Determinants of Alcohol Use by Age Cohorts of Adults Living With HIV, Ages 50 and Older

We examined the influence of age on associations between affective states, social support, and alcohol use by age cohorts. We recruited 96 older Black adults living with HIV from the southeastern United States in 2013 and 2014. Participants completed questionnaires assessing demographics, psychological function, and substance use. Hierarchical regression analyses assessed the relationship between psychosocial factors and alcohol use in a 50- to 59-year-old group, and a 60-years-and-older age group. After controlling for covariates, trait anger, state anger, and life stress were positively associated with alcohol consumption in the younger group, while social support was negatively associated with alcohol consumption in the older group. Interventions should target negative affective states in 50- to 59-year-old adults with HIV, and preserve social support for adults with HIV as they age, as such interventions will likely have an impact on these individuals' alcohol consumption and longstanding quality of life.

Genetic factor common to schizophrenia and HIV infection is associated with risky sexual behavior: antagonistic vs. synergistic pleiotropic SNPs enriched for distinctly different biological functions

Schizophrenia (SZ) and HIV infection are serious disorders with a complex phenotypic relationship. Observational studies have described their comorbidity; their genetic correlation is not well studied. We performed extensive analysis in search of common genetic factors for SZ and HIV, and their relationship with risky sexual behavior (RSB). Summary statistics from genome-wide association studies of HIV infection and schizophrenia were obtained and 2379 European Americans were genotyped and assessed for RSB score. Genetic relationships between traits were analyzed in three ways: linkage disequilibrium (LD) score regression to estimate genetic correlation; GPA (Genetic analysis incorporating Pleiotropy and Annotation) to test pleiotropy and identify pleiotropic loci; polygenic risk scores (PRS) of SZ and HIV to predict RSB using linear regression. We found significant pleiotropy (p = 5.31E - 28) and a positive genetic correlation (cor = 0.17, p = 0.002) for SZ and HIV infection. Pleiotropic SNPs with opposite effect directions (antagonistic) and SNPs with the same effect direction (synergistic) were enriched for distinctly different biological functions. SZ PRS computed with antagonistically pleiotropic SNPs consistently predicted RSB score with nominal significance, but SZ PRS based on either synergistically pleiotropic SNPs or all SNPs did not predict RSB. The epidemiologic correlation between schizophrenia and HIV can partly be explained by overlapping genetic risk factors, which are related to risky sexual behavior.

Knowledge about HIV in a Community Sample of Urban African Americans in the South

PURPOSE

Race and HIV are intertwined in complex ways. African Americans, particularly those residing in the southern United States, are at great risk for contracting and subsequently transmitting HIV. Research on the extent to which members of this population understand the risks associated with engaging in specific behaviors is limited. This paper examines HIV knowledge among at-risk adult African American men and women and the factors associated with levels of HIV knowledge.

METHODS

Based on a conceptual model derived from Social Disorganization Theory and Syndemics Theory, interviews were conducted between 2009 and 2011. Questionnaire-based interviews were conducted with 1,864 respondents from 80 strategically-chosen census block groups in Atlanta, Georgia. An innovative approach to assessing amount of HIV knowledge was implemented, to derive better estimates of the extent of knowledge.

RESULTS

Overall, HIV knowledge was low (average=43.5% correct answers). Seven factors were identified as contributing uniquely to having higher levels of knowledge about HIV transmission: (1) younger age, (2) being educated beyond the high school level, (3) being gay, lesbian or bisexual, (4) experiencing sexual abuse during childhood and/or adolescence, (5) drinking alcohol less frequently, (6) knowing a larger number of HIV-infected persons and (7) knowing anyone currently living with "full blown" AIDS.

CONCLUSION

HIV educational and intervention programs targeting at-risk African American adults need to develop effective ways of bolstering a solid understanding of how HIV is/not transmitted. In particular, efforts need to be targeted toward older adults, those with lower levels of educational attainment and persons who are not acquainted with anyone who is HIV-infected.

Alcohol Use and Human Immunodeficiency Virus (HIV) Infection: Current Knowledge, Implications, and Future Directions

Alcohol use is common among people living with human immunodeficiency virus (HIV). In this narrative review, we describe literature regarding alcohol's impact on transmission, care, coinfections, and comorbidities that are common among people living with HIV (PLWH), as well as literature regarding interventions to address alcohol use and its influences among PLWH. This narrative review identifies alcohol use as a risk factor for HIV transmission, as well as a factor impacting the clinical manifestations and management of HIV. Alcohol use appears to have additive and potentially synergistic effects on common HIV-related comorbidities. We find that interventions to modify drinking and improve HIV-related risks and outcomes have had limited success to date, and we recommend research in several areas. Consistent with Office of AIDS Research/National Institutes of Health priorities, we suggest research to better understand how and at what levels alcohol influences comorbid conditions among PLWH, to elucidate the mechanisms by which alcohol use is impacting comorbidities, and to understand whether decreases in alcohol use improve HIV-relevant outcomes. This should include studies regarding whether state-of-the-art medications used to treat common coinfections are safe for PLWH who drink alcohol. We recommend that future research among PLWH include validated self-report measures of alcohol use and/or biological measurements, ideally both. Additionally, subgroup variation in associations should be identified to ensure that the risks of particularly vulnerable populations are understood. This body of research should serve as a foundation for a next generation of intervention studies to address alcohol use from transmission to treatment of HIV. Intervention studies should inform implementation efforts to improve provision of alcohol-related interventions and treatments for PLWH in healthcare settings. By making further progress on understanding how alcohol use affects PLWH in the era of HIV as a chronic condition, this research should inform how we can mitigate transmission, achieve viral suppression, and avoid exacerbating common comorbidities of HIV and alcohol use and make progress toward the 90-90-90 goals for engagement in the HIV treatment cascade.

Triangulating Syndemic Services and Drug Treatment Policy: Improving Drug Treatment Portal Locations in Baltimore City

THE PROBLEM

The prevalence of injection drug use (IDU) and incidence of human immunodeficiency virus (HIV) remain high in Baltimore, where IDU is a primary HIV risk factor. Substance use disorders and HIV are related syndemically--their causes and consequences interact synergistically. Baltimore is increasingly considering the syndemic relationship of substance use disorders, IDU, and HIV in making decisions about drug treatment funding and location.

PURPOSE OF ARTICLE

Our goal was to empirically identify the optimal location of new drug treatment programs through the development and application of a novel, practical tool.

KEY POINTS

Syndemic triangles were constructed to measure and visualize unmet need for drug treatment services. These data were used to determine priority zones for new treatment centers.

CONCLUSIONS

The application of this tool helped inform strategies for locating drug treatment services in Baltimore, and its successful use suggests its potential value in other metropolitan areas.

Determining the Cost-Savings Threshold for HIV Adherence Intervention Studies for Persons with Serious Mental Illness and HIV

Persons with serious mental illnesses are at increased risk for contracting and transmitting HIV and often have poor adherence to medication regimens. Determining the economic feasibility of different HIV adherence interventions among individuals with HIV and serious mental illness is important for program planners who must make resource allocation decisions. The goal of this study was to provide a methodology to estimate potential cost savings from an HIV medication adherence intervention program for a new study population, using data from prior published studies. The novelty of this approach is the way CD4 count data was used as a biological marker to estimate costs averted by greater adherence to anti-retroviral treatment. Our approach is meant to be used in other adherence intervention studies requiring cost modeling.

Importance of substance use and violence in psychosocial syndemics among women with and at-risk for HIV

Women in the US continue to be affected by HIV through heterosexual contact. Sexual risk behaviors among women have been associated with a syndemic, or a mutually reinforcing set of conditions, including childhood sexual abuse (CSA), depression, substance use, violence, and financial hardship. Baseline data from a cohort of women with and at-risk for HIV (N = 620; 52% HIV+) were analyzed with Poisson regression to assess evidence for additive, independent and interactive effects among syndemic conditions in relation to reported sexual risk behaviors (e.g., unprotected and transactional sex) over the past 6 months, controlling for age and HIV status. The number of syndemic conditions was incrementally associated with more types of sexual risk behaviors. For example, women with all five syndemic conditions reported 72% more types of risk behaviors over 6 months, as compared to women without any syndemic conditions. Compared to women with no syndemic conditions, women with three syndemic conditions reported 34% more and women with one syndemic condition reported 13% more types of risk behaviors. Endorsing substance use in the past 6 months, reporting CSA, and experiencing violence as an adult were independently associated with 49%, 12%, and 8% more types of risk behaviors, respectively compared to women without these conditions. Endorsing both substance use and violence was associated with 27% more types of risk behaviors. These associations were not moderated by HIV status. Understanding specific relationships and interactions are needed to more effectively prioritize limited resources in addressing the psychosocial syndemic associated with sexual risk behavior among women with and at-risk for HIV. Our results identify interrelated psychosocial factors that could be targeted by intervention studies aiming to reduce high-risk sex in this population.

Human Immunodeficiency Virus Prevention

Human immunodeficiency virus (HIV) is the virus that causes AIDS. Surveillance data from 2012 indicate an estimated 1.2 million people aged 13 years and older were living with HIV infection in the United States, and 12.8% do not know their status. There are approximately 50,000 new HIV infections annually. With no available cure for HIV, primary prevention to reduce incident cases of HIV is essential. Strategies to prevent HIV transmission include reducing sexual risk behavior and needle sharing. The Centers for Disease Control and Prevention has multiple resources available for primary and secondary prevention to reduce disease transmission and severity.

Prediction of HIV Sexual Risk Behaviors Among Disadvantaged African American Adults Using a Syndemic Conceptual Framework

The focus of this paper is on HIV sexual risk taking among a community-based sample of disadvantaged African American adults. The objective is to examine multiple factors associated with sexual HIV risk behaviors within a syndemic conceptual framework. Face-to-face, computer-assisted, structured interviews were conducted with 1535 individuals in Atlanta, Georgia. Bivariate analyses indicated a high level of relationships among the HIV sexual risks and other factors. Results from multivariate models indicated that gender, sexual orientation, relationship status, self-esteem, condom use self-efficacy, sex while the respondent was high, and sex while the partner was high were significant predictors of condomless sex. Additionally, a multivariate additive model of risk behaviors indicated that the number of health risks significantly increased the risk of condomless sex. This intersection of HIV sexual risk behaviors and their associations with various other behavioral, socio-demographic, and psychological functioning factors help explain HIV risk-taking among this sample of African American adults and highlights the need for research and practice that accounts for multiple health behaviors and problems.

A transdiagnostic minority stress treatment approach for gay and bisexual men's syndemic health conditions

Developing and deploying separate treatments for separate conditions seems ill-suited to intervening upon the co-occurring, and possibly functionally similar, psychosocial conditions facing gay and bisexual men. This article argues for the need to create transdiagnostic interventions that reduce multiple syndemic conditions facing gay and bisexual men at the level of their shared source in minority stress pathways. This article first reviews psychosocial syndemic conditions affecting gay and bisexual men, then suggests pathways that might link minority stress to psychosocial syndemics based on recent advancements in emotion science, psychiatric nosology, and cognitive-affective neuroscience, and finally suggests cross-cutting psychosocial treatment principles to reduce minority stress-syndemic pathways among gay and bisexual men. Because minority stress serves as a common basis of all psychosocial syndemic conditions reviewed here, locating the pathways through which minority stress generates psychosocial syndemics and employing overarching treatment principles capable of simultaneously alleviating these pathways will ultimately create a transdiagnostic approach to improving gay and bisexual men's health. Clinical research and training approaches are suggested to further validate the pathways suggested here, establish the efficacy of treatment approaches tied to those pathways, and generate effective methods for disseminating a transdiagnostic minority stress treatment approach for gay and bisexual men's psychosocial syndemic health.

Health Outcomes of HIV-Infected People with Mental Illness

Improving outcomes for people with HIV and mental illness will be critical to meeting the goals of the US National HIV/AIDS Strategy. In a retrospective analysis of the 2008-2010 cycles of the locally representative Philadelphia Medical Monitoring Project, we compared the proportions of HIV-infected adults with and without mental illness: (1) retained in care (≥2 primary HIV visits separated by ≥90 days in a 12-month period); (2) prescribed antiretroviral therapy (ART) at any point in a 12-month period; and (3) virally suppressed (HIV-1 RNA ≤200 copies/mL at the last measure in the 12-month period). Multivariable regression assessed associations between mental illness and the outcomes, adjusting for age, gender, race/ethnicity, insurance, alcohol abuse, injection drug use, CD4 count, and calendar year. Of 730 HIV-infected persons, representative of 9409 persons in care for HIV in Philadelphia, 49.0 % had mental illness. In adjusted analyses, there were no significant differences in retention (91.3 vs. 90.3 %; AOR 1.30, 95 % CI 0.63-2.56) and prescription of ART (83.2 vs. 88.7 %; AOR 0.79, 95 % CI 0.49-1.25) between those with and without mental illness. However, mentally ill patients were less likely to achieve viral suppression than those without mental illness (65.9 vs. 74.4 %; AOR 0.64, 95 % CI 0.46-0.90). These findings argue for the need to optimize ART adherence in this population.

Methods to Obtain a Representative Sample of Ryan White-Funded Patients for a Needs Assessment in Los Angeles County: Results from a Replicable Approach

The Health Resources and Services Administration requires that jurisdictions receiving Ryan White (RW) funding justify need, set priorities, and provide allocations using evidence-based methods. Methods and results from the 2011 Los Angeles Coordinated HIV/AIDS Needs Assessment-Care (LACHNA-Care) study are presented. Individual-level weights were applied to expand the sample from 400 to 18 912 persons, consistent with the 19 915 clients in the system. Awareness, need, and utilization for medical outpatient care were high (>90%). Other services (eg, child care) had limited awareness (21%). Majority of participants reported at least 1 service gap (81%). Lack of insurance (risk ratio [RR] = 3.0, 95% confidence interval [CI]: 1.5-6.2), substance use (RR = 2.9, 95% CI: 1.3-6.4), and past lapses in medical care (RR = 2.8, 95% CI: 1.3-5.9) were associated with gaps. Within clusters, past incarceration was associated with gaps for housing (RR = 13.5, 95% CI: 3.5-52.1), transportation (RR = 3.2, 95% CI: 1.2-8.4), and case management (RR = 4.0, 95% CI: 1.3-12.2). Applied methods resulted in representative data instrumental to RW program planning efforts.

Syndemics of psychosocial problems and HIV risk: A systematic review of empirical tests of the disease interaction concept

In the theory of syndemics, diseases co-occur in particular temporal or geographical contexts due to harmful social conditions (disease concentration) and interact at the level of populations and individuals, with mutually enhancing deleterious consequences for health (disease interaction). This theory has widespread adherents in the field, but the extent to which there is empirical support for the concept of disease interaction remains unclear. In January 2015 we systematically searched 7 bibliographic databases and tracked citations to highly cited publications associated with the theory of syndemics. Of the 783 records, we ultimately included 34 published journal articles, 5 dissertations, and 1 conference abstract. Most studies were based on a cross-sectional design (32 [80%]), were conducted in the U.S. (32 [80%]), and focused on men who have sex with men (21 [53%]). The most frequently studied psychosocial problems were related to mental health (33 [83%]), substance abuse (36 [90%]), and violence (27 [68%]); while the most frequently studied outcome variables were HIV transmission risk behaviors (29 [73%]) or HIV infection (9 [23%]). To test the disease interaction concept, 11 (28%) studies used some variation of a product term, with less than half of these (5/11 [45%]) providing sufficient information to interpret interaction both on an additive and on a multiplicative scale. The most frequently used specification (31 [78%]) to test the disease interaction concept was the sum score corresponding to the total count of psychosocial problems. Although the count variable approach does not test hypotheses about interactions between psychosocial problems, these studies were much more likely than others (14/31 [45%] vs. 0/9 [0%]; χ2 = 6.25, P = 0.01) to incorporate language about "synergy" or "interaction" that was inconsistent with the statistical models used. Therefore, more evidence is needed to assess the extent to which diseases interact, either at the level of populations or individuals, to amplify HIV risk.

Neighborhood-level and individual-level correlates of cannabis use among young persons living with HIV/AIDS

INTRODUCTION

In addition to individual characteristics, there may be a wide range of environmental or neighborhood stressors that contribute to elevated cannabis use in groups of youth living with HIV/AIDS (YLHIV); however, the effects of social disorganization on cannabis use in YLHIV to date have not been studied.

METHODS

We examined the effects of individual-level and neighborhood-level factors by developing hierarchical generalized linear models estimating odds of current cannabis use (any use during the past 3 months) and daily cannabis use among a sample of YLHIV (N = 1921) currently receiving medical care.

RESULTS

The final model for daily cannabis use in the past 3 months included significant positive effects associated with hostility (O.R. = 1.08, 95% C.I.: 1.05, 1.11), being older (O.R. = 1.12, 95% C.I.: 1.05, 1.20), being a bisexual male (O.R. = 1.72, 95% C.I.: 1.10, 2.70), and residing in a community with a murder rate in the highest quartile (O.R. = 1.91, 95% C.I.: 1.27, 2.87), second highest quartile (O.R. = 1.62, 95% C.I.: 1.06, 2.46), or third highest quartile (O.R. = 1.52, 95% C.I.: 1.01, 2.30).

DISCUSSION

This paper advances our knowledge of the multilevel factors associated with elevated cannabis use among groups of YLHIV and furthers our understanding of social and structural determinants of health in this population. Future research into cannabis use among YLHIV should consider, not only cannabis use within the context of the adjustment of living with HIV/AIDS, but also the stressors that characterize the environments in which groups of YLHIV live.

Medication adherence in people dually treated for HIV infection and mental health conditions: test of the medications beliefs framework

Beliefs about medication necessity and concerns predict treatment adherence in people with a wide-array of medical conditions, including HIV infection. However, medication beliefs have not been examined in people dually treated with psychotropic medications and antiretroviral therapy. In the current study, we used a prospective design to investigate the factors associated with adherence to psychotropic medications and antiretrovirals among 123 dually treated persons living with HIV. We used unannounced phone-based pill counts to monitor adherence to psychiatric and antiretroviral medications over a 6-week period. Hierarchical regression models included demographic, health and psychosocial characteristics as predictors of adherence followed by medication necessity and concerns beliefs. Results showed that medication necessity beliefs predicted both antiretroviral and psychiatric medication adherence over and above established predictors of adherence. Medication concerns also predicted psychotropic adherence, but not antiretroviral adherence. These models accounted for 31 and 22 % of the variance in antiretroviral and psychotropic adherence, respectively. Findings suggest that the necessity-concerns medication beliefs framework has utility in understanding adherence to multiple medications and addressing these beliefs should be integrated into adherence interventions.

HIV testing among adults with mental illness in the United States

Nationally representative data from the 2007 National Health Interview Survey (NHIS) were used to compare HIV testing prevalence among US adults with mental illness (schizophrenia spectrum disorder, bipolar disorder, depression, and/or anxiety) to those without, providing an update of prior work using 1999 and 2002 NHIS data. Logistic regression modeling was used to estimate the probability of ever being tested for HIV by mental illness status, adjusting for age, sex, race/ethnicity, marital status, substance abuse, excessive alcohol or tobacco use, and HIV risk factors. Based on data from 21,785 respondents, 15% of adults had a psychiatric disorder and 37% ever had an HIV test. Persons with schizophrenia (64%), bipolar disorder (63%), and depression and/or anxiety (47%) were more likely to report ever being tested for HIV than those without mental illness (35%). In multivariable models, individuals reporting schizophrenia (adjusted prevalence ratio=1.68, 95% confidence interval=1.33-2.13), bipolar disease (1.58, 1.39-1.81), and depression and/or anxiety (1.31, 1.25-1.38) were more likely to be tested for HIV than persons without these diagnoses. Similar to previous analyses, persons with mental illness were more likely to have been tested than those without mental illness. However, the elevated prevalence of HIV in populations with mental illness suggests that high levels of testing along with other prevention efforts are needed.

Psychosocial health conditions and HIV prevalence and incidence in a cohort of men who have sex with men in Bangkok, Thailand: evidence of a syndemic effect

Men who have sex with men (MSM) in Bangkok may experience multiple psychosocial health conditions, such as substance use, suicidality, and a history of sexual abuse. These factors may contribute to HIV vulnerability in a syndemic way. A syndemic is defined as a number of synergistically interacting health conditions producing excess disease in a population. The objective of this study is to examine whether psychosocial health conditions among MSM have a syndemic association with HIV prevalence and HIV incidence. To do this, we evaluated psychosocial health conditions and their associations with unprotected sex, HIV prevalence and HIV incidence in a cohort of Thai MSM (N = 1,292). There was a positive and significant association between the number of psychosocial health conditions and increased levels of unprotected sex and HIV prevalence at study baseline. The number of psychosocial health conditions at baseline was also associated with increased HIV incidence during follow-up (no conditions, HIV incidence = 15.3 %; one to three conditions, 23.7 %; four to five conditions, 33.2 %). The number of psychosocial health conditions was positively associated with HIV risk behavior and HIV prevalence and incidence. Prevention efforts among MSM need to address the existence of multiple psychosocial health conditions and their synergy to effectively decrease the spread of HIV infection.

Factors Associated with Symptoms of Depression among Injection Drug Users Receiving Antiretroviral Treatment in Indonesia

OBJECTIVE

Few studies have examined psychiatric comorbidity among HIV positive injection drug users (IDUs) in resource-limiting settings. We sought to identify key factors associated with symptoms of depression among IDUs receiving antiretroviral (ARV) treatment in Jakarta and Denpasar, Indonesia.

METHODS

The cross-sectional study was conducted at five ARV delivery sites in Indonesia. Former IDUs aged 18 years or older having received ARV treatment for at least three months (n=117) were recruited and interviewed face-to-face. A 9-item version of the Center for Epidemiologic Studies Depression Scale was used to measure symptoms of depression. A structured questionnaire measured participants' demographic characteristics, social support and services received, current substance use, and treatment for drug dependency and HIV. Multiple logistic regression was used to calculate adjusted odds ratios (AOR) and 95% confidence intervals (CI).

RESULTS

Of the 117 participants, 33% (39) exhibited symptoms of depression, 24% (28) reported using an illicit substance in the past month, and 29% (34) were in methadone treatment. Depressive symptoms were significantly associated with recent substance use in the last 30 days (AOR, 95% CI: 5.3, 1.9 to 15.4) and being on methadone (3.5, 1.2 to 10). Older age (per year 0.9, 0.8 to 1), full-time employment (0.2, 0.1 to 0.7), and living with parents (0.2, 0.1 to 0.6) appeared to be protective.

CONCLUSION

The results suggest that depression is common among Indonesian IDUs, even among patients enrolled in methadone treatment. HIV clinics and drug treatment programs need to recognize the risk/protective factors and also provide services to address this common comorbidity.

Relationship between psychiatric disorders and sexually transmitted diseases in a nationally representative sample

OBJECTIVE

Sexually transmitted diseases (STDs) are a significant public health concern. Numerous internalizing and externalizing psychiatric disorders have been found to be related to STD risk. However, to date, no studies have examined several psychiatric disorders simultaneously to account for STD risk. Given that psychiatric disorders often co-occur and can be explained by a limited number of latent dimensions of psychopathology, it is important to examine whether the relationship between STDs and psychiatric disorders is best explained by broad dimensions of psychopathology.

METHODS

The current study examined the associations between a range of Axis I and II psychiatric disorders at baseline and rates of STDs at a three-year follow-up in a large, nationally representative sample of adults in the United States (n=34,434). A confirmatory factor analysis (CFA) was conducted to fit three factors, two internalizing and one externalizing. Structural equation modeling (SEM) was used to assess the relationships between and among the factors and STD status and to test for mediation.

RESULTS

In bivariate analyses, most Axis I and Axis II disorders were associated with STD diagnosis at Wave 2, whereas the results of the structural model showed that only the externalizing factor was significantly associated with STD diagnosis at Wave 2. Further, the externalizing factor mediated the relationship between one of the internalizing factors and STD diagnosis.

CONCLUSION

Findings suggest the unique contribution of externalizing psychopathology to STD risk and the importance of examining latent dimensions of disorders when understanding this relationship between psychiatric disorders and STDs.

Increasing quality of life and reducing HIV burden: the PATH+ intervention

The heightened risk of persons with serious mental illness (SMI) to contract and transmit human immunodeficiency virus (HIV) is a public health problem. Our objective was test the effectiveness of a community-based advanced practice nurse intervention to promote adherence to HIV and psychiatric treatment regimens call Preventing AIDS Through Health for Positives (PATH+). We enrolled 238 HIV-positive subjects with SMI who were in treatment at community HIV provider agencies from 2004 to 2009. Participants in the intervention group were assigned an advanced practice nurse who provided community-based care management at a minimum of one visit/week and coordinated their medical and mental healthcare for 12 months. A parallel process latent growth curve model using three data points for biomarkers (baseline, 12 and 24 months) and five data points for health related quality of life (baseline, 3, 6, 12, and 24 months) showed moderate to excellent fit for modeling changes in CD4, viral load, and mental and physical SF-12 subscales. Results suggest that positive effects for PATH+ persisted at 24 months; 12 months after the intervention ended. This project demonstrates the effectiveness of a nurse-led, community-based, individually tailored adherence intervention. We demonstrated improved outcomes in individuals with HIV/SMI and regarding health-related quality of life and reductions in disease burden.

Treatment considerations for HIV-infected individuals with severe mental illness

There has been a general recognition of a syndemic that includes HIV/AIDS and serve mental illnesses including schizophrenia, major depression, bipolar disorder, post-traumatic stress disorder, and others. The pathophysiology and direction of effects between severe mental illness and HIV infection is less clear however, and relatively little work has been done on prevention and treatment for people with these complex, co-occurring conditions. Here we present the most recent work that has been published on HIV and mental illness. Further, we describe the need for better treatments for "triply diagnosed persons"; those with HIV, mental illness, and substance abuse and dependence. Finally, we describe the potential drug-drug interactions between psychotropic medications and anti-retrovirals, and the need for better treatment guidelines in this area. We describe one example of an individually tailored intervention for persons with serious mental illness and HIV (PATH+) that shows that integrated community-based treatments using advanced practice nurses (APNs) as health navigators can be successful in improving health-related quality of life and reducing the burden of disease in these persons.

Depression and HIV Risk Taking among Men Who Have Sex with Other Men (MSM) and Who Use the Internet to Find Partners for Unprotected Sex

PURPOSE

This study examines the prevalence of depression in a sample of MSM who are at high risk for HIV. It examines the relationship between depressive symptomatology and involvement in HIV risk behaviors, and the factors associated with greater depressive symptomatology.

METHODS

The data come from a national random sample of 332 MSM who used any of 16 websites to identify men with whom they could engage in unprotected sex. Data were collected via telephone interviews.

RESULTS

Depression was more prevalent in this population (26.7%) than among men in the general population. Depression was not related directly to any of the HIV risk behaviors examined, but it was related to men's attitudes toward condom use, which was the strongest predictor of their involvement in risky behaviors. Five factors were identified as being associated with greater depression: lower educational attainment, greater discrimination based on sexual orientation, greater eroticizing of ejaculatory fluids, experiencing more substance abuse problems, and greater childhood maltreatment.

CONCLUSIONS

Depression is a consequential problem in this population. Although depression does not appear to be related directly to HIV risk practices in this population, its influence cannot be discounted because of its effects on other key predictors of risk involvement.

Documentation of psychiatric disorders and related factors in a large sample population of HIV-positive patients in California

This retrospective cohort study examined electronic medical records of HIV-positive patients in California (N = 7,834) to find the prevalence of any psychiatric condition and the associations between several factors and the likelihood of these disorders. Approximately 53 % of the patients in this study had a documented psychiatric condition, including 23 % who had a mood disorder, 19 % who had a substance-related disorder, and 16 % who had an anxiety disorder. After controlling for potential confounders, significant positive associations (p < 0.001) were found between female gender and the presence of any mood disorder (adjusted odds ratio [95 % confidence interval, 95 %CI] = 1.58 [1.26-1.99]) or anxiety disorder (AOR = 1.54 [1.18-2.02]) and between homosexual orientation and the presence of any psychiatric condition (AOR = 1.33 [1.15-1.55]), mood disorder (AOR = 1.71 [1.42-2.07]), or anxiety disorder (AOR = 1.41 [1.22-1.88]). There were also significant negative associations between African-American race and the presence of any psychiatric condition (AOR = 0.68 [0.60-0.77]), mood disorder (AOR = 0.74 [0.64-0.86]), anxiety disorder (AOR = 0.43 [0.36-0.52]), or substance-related disorder (AOR = 0.78 [0.67-0.91]) and between state/federal insurance and the presence of any psychiatric condition (AOR = 0.70 [0.62-0.79]), mood disorder (AOR = 0.71 [0.62-0.80]), or anxiety disorder (AOR = 0.77 [0.66-0.89]).

A syndemic including cigarette smoking and sexual risk behaviors among a sample of MSM in Shanghai, China

OBJECTIVES

We explored possible correlates of cigarette smoking and their associations with levels of smoking among a sample of Chinese men who have sex with men (MSM). We also explored the syndemic associations of substance use and psychosocial problems on sexual risk behaviors.

METHODS

Cross-sectional data collection from 404 MSM in Shanghai, China.

RESULTS

MSM exhibit a high prevalence of smoking (66.3%). Both light and heavy smoking were associated with alcohol and drug use, depression, intimate partner violence, sexual attitudes, and gay identity (though the associations for light smokers were moderate compared to those for heavy smokers).

CONCLUSIONS

Our findings indicate the presence of a health syndemic among MSM, and suggest that smoking prevention and cessation and other substance abuse interventions should be integrated into efforts preventing sexual risk behaviors among MSM.

Condom use self-efficacy and HIV risk practices among men who use the internet to find male partners for unprotected sex

This research examines the levels of condom use self-efficacy in a population of men who have sex with men who are at great risk for contracting/transmitting HIV. It focuses on the relationship between condom use self-efficacy and risk involvement, and examines the factors associated with greater/lower levels of condom use self-efficacy. The data come from a national sample of men, randomly chosen, who used any of 16 websites specifically to identify other men with whom they could engage in unprotected sex. Data were collected between January 2008 and May 2009 from 332 men, via telephone interviews. Multivariate analyses and structural equation modeling were used to test a conceptual model based on syndemics theory. Overall levels of condom use self-efficacy were fairly high, and self-efficacy was related inversely to involvement in HIV risk practices. Six factors were found to be indicative of levels of condom use self-efficacy: the number of drug problems experienced, sexual role identity as a "bottom," not caring about the HIV serostatus of potential sex partners, experiencing childhood maltreatment, having confidence in HIV-related information provided in other men's online profiles, and level of HIV knowledge. Condom use self-efficacy plays an integral role in HIV risk practices among high-risk men who have sex with men. This is true despite the fact that, overall, condom use self-efficacy levels were fairly high in this population.