Assessment of the efficacy of a cognitive-behavioural group psychotherapy programme for HIV-infected patients referred to a consultation-liaison psychiatry department

Behavioral interventions to promote condom use among women living with HIV

BACKGROUND

High rates of HIV infection among women of reproductive age have dramatic consequences for personal and public health. Prophylaxis during sexual intercourse in the form of condoms has been the most effective way to prevent both STI and HIV transmission among people living with HIV.

OBJECTIVES

To investigate the effectiveness of behavioral interventions in promoting condom use among women living with HIV.

SEARCH STRATEGY

We conducted a comprehensive literature search in several scientific databases, clinical trials databases, conference proceedings, and conference websites to identify studies produced between 1980 and May 2010 that met our selection criteria.

SELECTION CRITERIA

Studies were included in the analysis if they conducted a randomized controlled trial that examined the effects of behavioral interventions on condom use among HIV-positive women; considered at least one HIV-related behavioral outcome (e.g., reported protected anal, vaginal, or oral sex) or biological outcome (e.g., acquisition of STIs); and one follow-up assessment three months or more after the intervention. Studies were assessed irregardless of langauge or publication status.

DATA COLLECTION AND ANALYSIS

We used random effects models to summarize odds ratios (ORs) that compared intervention and control groups with respect to a dichotomous outcome (consistent versus inconsistent condom use). We used funnel plots to examine publication bias and a χ(2) statistic to test for heterogeneity. The methodological and evidence quality was evaluated through risk of bias criteria and the GRADE system, respectively.

MAIN RESULTS

Five primary studies that collectively researched a total of 725 women living with HIV were analysed. When compared to standard care or minimal HIV support intervention, meta-analysis showed that behavioral interventions had no effect on increasing condom use among HIV-positive women. This finding was consistent at various follow-up meetings (3, 6, and 12-months) as well as over the entire 12-month follow-up period (OR= 0.82; 95% CI 0.65-1.04; p=0.11). Only one study presented adequate data to analyze the relationship between behavioral interventions and STI incidence. Studies included in this analysis demonstrated low risk of bias based on the risk of bias criteria. However, sample size was considered inadequate across all studies.

AUTHORS' CONCLUSIONS

Meta-analysis shows that behavioral interventions have little effect on increasing condom use among HIV-positive women. However, these findings should be used with caution since results were based on a few small trials that were targeted specifically towards HIV-positive women. To decrease sexual transmission of HIV among this population, we recommend interventions that combine condom promotion, family planning provision and counselling, and efforts to reduce viral loads among HIV-positive women and their partners (e.g., HAART treatment provision). New research is needed to address the needs of HIV-positive women, including an assessment of the impact of interventions that combine safer sexual behavior and harm reduction approaches.

HIV and depression--a systematic review of interventions

HIV-positive individuals are more likely to be diagnosed with major depressive disorder than HIV-negative individuals. Depression can precede diagnosis and be associated with risk factors for infection. The experience of illness can also exacerbate depressive episodes and depression can be a side effect to treatment. A systematic understanding of which interventions have been tested in and are effective with HIV-seropositive individuals is needed. This review aims to provide a comprehensive understanding of evaluated interventions related to HIV and depression and provide some insight on questions of prevalence and measurement. Standard systematic research methods were used to gather quality published papers on HIV and depression. From the search, 1015 articles were generated and hand searched resulting in 90 studies meeting adequacy inclusion criteria for analysis. Of these, 67 (74.4%) were implemented in North America (the US and Canada) and 14 (15.5%) in Europe, with little representation from Africa, Asia and South America. Sixty-five (65.5%) studies recruited only men or mostly men, of which 31 (35%) recruited gay or bisexual men. Prevalence rates of depression ranged from 0 to 80%; measures were diverse and rarely adopted the same cut-off points. Twenty-one standardized instruments were used to measure depression. Ninety-nine interventions were investigated. The interventions were diverse and could broadly be categorized into psychological, psychotropic, psychosocial, physical, HIV-specific health psychology interventions and HIV treatment-related interventions. Psychological interventions were particularly effective and in particular interventions that incorporated a cognitive-behavioural component. Psychotropic and HIV-specific health psychology interventions were generally effective. Evidence is not clear-cut regarding the effectiveness of physical therapies and psychosocial interventions were generally ineffective. Interventions that investigated the effects of treatments for HIV and HIV-associated conditions on depression generally found that these treatments did not increase but often decreased depression. Interventions are both effective and available, although further research into enhancing efficacy would be valuable. Depression needs to be routinely logged in those with HIV infection during the course of their disease. Specific data on women, young people, heterosexual men, drug users and those indiverse geographic areas are needed. Measurement of depression needs to be harmonized and management into care protocols incorporated.

Measuring depression levels in HIV-infected patients as part of routine clinical care using the nine-item Patient Health Questionnaire (PHQ-9)

Little is known about the psychometric properties of depression instruments among persons infected with HIV. We analyzed data from a large sample of patients in usual care in two US cities (n=1467) using the nine-item Patient Health Questionnaire (PHQ-9) from the PRIME-MD. The PHQ-9 had curvilinear scaling properties and varying levels of measurement precision along the continuum of depression measured by the instrument. In our cohort, the scale showed a prominent floor effect and a distribution of scores across depression severity levels. Three items had differential item functioning (DIF) with respect to race (African-American vs. white); two had DIF with respect to sex; and one had DIF with respect to age. There was minimal individual-level DIF impact. Twenty percent of the difference in mean depression levels between African-Americans and whites was due to DIF. While standard scores for the PHQ-9 may be appropriate for use with individual HIV-infected patients in cross-sectional settings, these results suggest that investigations of depression across groups and within patients across time may require a more sophisticated analytic framework.

Major depression in patients with HIV/AIDS and substance abuse

Previous research has been inconsistent in documenting a strong relationship between depression and HIV/AIDS, although a recent meta-analysis of studies examining this issue indicates that rates of depression are modestly higher for this population. For the current study, conducted from 2001-2004, we sought to examine rates and types of depressive symptoms in a cohort of patients receiving HIV care at two urban medical centers. These patients were participants in an intervention study examining adherence and mental health in persons triply diagnosed with psychiatric disorders, substance use disorders, and HIV/AIDS. Nearly three quarters of these participants were people of color, two thirds described their sexual orientation as heterosexual, and the vast majority were unemployed. We sought to examine the relationship of depression to patients' adherence to antiretroviral medication regimens (highly active antiretroviral therapy [HAART]). Results obtained from structured clinical interviews and self-report questionnaires indicated that study participants experienced high rates of depressive symptoms, and that 72.9% of participants met criteria for major depressive disorder (MDD). The results of this study offer a detailed view of the incidence and nature of MDDs and depressive symptoms for an urban sample of substance-abusing adults with HIV/AIDS. Given the degree to which depressive symptoms and MDD appear to be prevalent for this group, as well as the observation that these symptoms are amenable to treatment, future research should focus on identifying helpful strategies and interventions for treating these symptoms, effective ways of providing linkages to care, and ways in which standardized assessment and treatment protocols might be adapted to better suit this population.

Improvement of psychosocial adjustment to HIV-1 infection through a cognitive-behavioral oriented group psychotherapy program: a pilot study

The present study evaluated the efficacy of a group therapy program in improving psychosocial adjustment to HIV infection, and tried to identify variables predictive of greater improvement. The outcome of 47 completing patients was analyzed, comparing the measures between T1 (1 month before therapy), and T2 (first session), and between T2 and T3 (last session) using the Wilcoxon matched-pairs signed-ranks test for each dimension of the Psychosocial Adjustment to Illness Scale (PAIS). The therapy consisted of 16 weekly 2-hour sessions following a structured time-limited cognitive-behavioral group psychotherapy program. During the intervention (between T2 and T3) a significant improvement was observed in health care orientation, vocational environment, domestic environment, sexual relation, extended family relationships, social environment, and total PAIS. There were no changes during baseline (between T1 and T2) in any of the PAIS subscales, or in the total PAIS score. Sexual route of transmission was independently associated with an improvement in health care orientation (beta = 2.525). Time since HIV diagnosis (beta = 0.022) and being employed (beta = 2.548) were independently associated with an improvement in adjustment to vocational environment. Men who have sex with men showed a poorer improvement in adjusting to family relations after the intervention (beta = -2.548). Finally, a lower CD4 count (beta = -0.005) and being employed (beta = 3.054) were independently associated with an improvement in adjustment to social environment. Our psychotherapy program improved psychosocial functioning in a heterogeneous sample of HIV-1-infected patients referred to a consultation-liaison psychiatry unit.

Personality profile of HIV outpatients: preliminary results and remarks on clinical management

BACKGROUND

Currently, HIV is one of the most widely spread epidemics in the world. The specificity of the mode of transmission, the well-known severity of the prognosis, and the kind of therapies used are peculiarities of this illness. Personality traits of individuals with HIV may influence conditions for the infection itself. On the other hand, it is possible that personality traits may influence the course of the illness and the willingness of the patients to adhere to treatment. The present study assessed the personality traits of a heterogeneous group of seropositive subjects compared with healthy controls to determine specific temperament and character traits of this population.

METHODS

The Temperament and Character Inventory (TCI) was administered to 126 HIV-positive outpatients belonging to different risk categories for HIV infection and to a sample of healthy individuals matched for sex, age, and socioeconomic parameters.

RESULTS

Drug-dependent HIV-positive patients displayed higher scores in novelty seeking and harm avoidance and lower scores in self-directedness compared with healthy controls. Non-drug-dependent HIV-positive subjects scored significantly higher in self-transcendence.

CONCLUSIONS

Temperament and character features significantly differentiate the HIV-positive subjects from controls and those belonging to the different risk categories for HIV infection. Drug-dependent subjects with HIV display more impulsiveness, which possibly predates the HIV infection. They are also more fearful and lack self-directedness. Non-drug-dependent subjects express higher self-transcendence resources, possibly to overcome their difficulties. Both the temperament and character features may influence compliance with treatment and require specific interventions considering these subgroups.

Depression in HIV-infected patients: allopathic, complementary, and alternative treatments

OBJECTIVES

The purpose of this review article is to synthesize the current knowledge related to depression and HIV disease.

METHODS

The research literature was critically evaluated for several selected therapies that are prescribed for HIV-infected persons to treat depression. These therapies included pharmacotherapy, psychotherapy, alternative, and complementary therapies.

RESULTS

Several therapies are currently available for the treatment of depression in HIV disease. When prescribing treatments, clinicians should be aware of problems associated with diagnoses, drug-drug interactions, and the benefits of some of the new therapies that are now available. Treatment regimes should be carefully designed to meet the individual needs of the patient and will optimally include a combination of approaches including psychotherapy, pharmacotherapy, education, and/or complementary therapies.

CONCLUSIONS

Although HIV is now a treatable disease, the prevalence of depression in the HIV population remains high and should be continually addressed.

Symptom Management in HIV-Infected Patients

Symptom management has always been a focus of nursing care. Assessing and managing symptoms is an important component of HIV nursing practice. When effective, interventions to relieve symptoms may improve quality of life (QoL), potentially increase adherence to highly active antiretroviral therapy, and improve other outcomes such as functional status. Common underrecognized and/or undertreated symptoms that may influence the QoL of persons living with HIV include fatigue, pain, anxiety/depression, and sleep disturbances. These symptoms may also contribute to the difficulty of adhering to HAART When evaluating a patient's symptoms, the nurse attempts to understand the symptom experience from the patient's perspective because symptoms are subjective experiences. Together, the nurse and patient work to determine feasible interventions. Symptom management plans are evaluated frequently. Fundamentally, symptom management aims to decrease the frequency, intensity, and distress of symptoms, with the ultimate goal of improving QoL.

Zur Bedeutung depressiver Störungen für die somatische Medizin/ The importance of depressive disorders in somatic medicine

Depressive disorders--including mild and subthreshold forms--are frequent in medical patients, although often not recognized. Over the past decades accumulating scientific evidence has demonstrated their clinical relevance. Depressive disorders and also elevated scores on self-rating scales for depressive symptoms are clearly related to disease behavior and quality of life. In many physical conditions they also predict adverse outcome, including premature death. This paper gives an overview of the literature on the relevance and treatment of comorbid depression in patients with HIV infection, cancer and coronary heart disease. It shows that the subjective effects of depression are rather similar in different somatic conditions. In addition, depression also interacts with the physical course of different diseases. However, the specific physiological mediators involved vary among different somatic diseases and have not yet been completely understood. Despite this uncertainty an improved recognition and treatment of comorbid depression can be recommended. Supportive interventions focussing on coping demands as well as regular psychotherapy and in some cases antidepressant medication may be indicated. While it still appears premature to establish generally applicable treatment guidelines, an individualized approach with regard to the different treatment alternatives for individual patients should be advocated.