mental health AIDS

Spring 2008 Newsletter / Volume 9, Issue 3

HIV Treatment News

Psychiatric/Psychological/
Psychosocial/Spiritual Care

Adherence to Treatment

Cruess, Minor, Antoni, and Millon (2007) "examined the association of psychosocial and behavioral characteristics using the Millon Behavioral Medicine Diagnostic (MBMD; Millon, Antoni, Millon, Meagher, & Grossman, 2001) 7 and adherence to highly active antiretroviral therapy (HAART) among 117 HIV-positive individuals on HAART regimens" (p. 277). The investigators found that

particular MBMD indexes, especially the Medication Abuse scale, could perhaps help identify medical patients with adherence problems early in the course of treatment. There was also some evidence that the MBMD could identify patients who were less responsive to standard medication counseling, perhaps suggesting the need for more intensive interventions for these subsets of individuals. In addition, the Medication Abuse scale was able to predict HAART adherence behaviors by asking more general medication usage questions (i.e., "Sometimes I can't remember what medication to take or when to take them"; and "If I don't get relief from medicine, I may increase the dosage on my own."). Thus, the MBMD might be used in clinical settings in which it is important to identify medication-taking tendencies at the inception of a new antiretroviral regimen. (p. 288)

Drawing on cross-sectional survey data from a diverse sample of 779 men and women receiving HIV care at one of four clinics in London and southeast England, Sherr et al. (2007) examined the experience of switching antiretroviral treatment regimens and the effect of such switches on a range of psychological parameters. Sherr and colleagues found that

[t]reatment naïve, non-switchers and single switchers generally reported lower symptom burden and higher quality of life. Multiple switchers reported higher physical symptom burden and higher global symptom distress scores. Those who had stopped treatment had significantly lower quality-of-life scores than all other groups. Suicidal ideation was high across the groups and nearly a fifth of all respondents had not disclosed their HIV status to anyone. Reported adherence was suboptimal – 79% of subjects were at least 95% adherent on self-report measures of doses taken over the preceding week. (p. 700)

In all, nearly half of this clinic sample switched regimens since initiating antiretroviral treatment. The investigators urge clinicians to attend to

any changes to treatment regimen and in particular to the psychological impact of moving through successive treatment switches. ... A holistic approach to treatment switching is important, as is an understanding of the impact of side-effects and the future management of disease. ... [Additionally], the level of psychological and global symptom burden was associated with adherence, and if clinicians can improve their assessment and management of treatment and disease-related symptoms, then adherence may be improved. (p. 703)

Cohn et al. (2008) examined antiretroviral adherence and health behaviors both during and after pregnancy among 149 women living with HIV and participating in a multi-site study. In this study, adherence was defined as self-reporting not missing any doses during a 3-month period. The investigators found that women with a history of illicit drug use and those who were nonadherent to prenatal vitamins were also nonadherent to antiretroviral therapy. "By targeting women with prior illicit drug use or non-adherence to prenatal vitamins for adherence counseling, more women will get the help they need to benefit optimally from antiretroviral therapy and prevent their offspring from acquiring HIV perinatally and from being exposed to toxic effects of alcohol, tobacco, and drugs" (p. 38).

Johnson et al. (2007) conducted a randomized, controlled trial involving 204 men and women in four U.S. cities – Los Angeles, Milwaukee, New York, and San Francisco – with self-reported adherence to antiretroviral therapy of < 85%. Participants were assigned to either a 15-session, individually delivered, cognitive behavioral intervention 8 or to a control condition, in which no active psychosocial interventions were delivered until the trial had concluded. Both groups participated in follow-up assessments at 5, 10, 15, 20, and 25 months following randomization, and self-reported adherence to antiretrovirals was measured by a 3-day computerized assessment. According to Johnson and colleagues,

[t]he Healthy Living Project intervention was successful in improving [antiretroviral therapy] adherence among participants with lower initial [antiretroviral therapy] adherence; however, the effect was only present at 2 of 5 time points, dissipating over time. At the 5- and 15-month assessments, the intervention and control groups reported substantial increases in their adherence rates, with the intervention group reporting a relative 10% to 13% improvement over the control group. ... There is evidence that, depending on specific regimen characteristics and baseline level of adherence, a 10% increase in mean adherence may be associated with as much as a halving of viral load ... and a 20% to 30% decreased risk of progression to AIDS, ... suggesting that the magnitude of the current effect is potentially clinically meaningful. (pp. 578-579)

Because "[t]he relative improvements among the intervention group compared with the control group dissipated at follow-up" (p. 574), the investigators conclude that "[c]ognitive behavioral intervention programs may effectively improve [antiretroviral therapy] adherence, but the effects … may be short-lived" (p. 574).

Similarly, Parsons, Golub, Rosof, and Holder (2007) randomly assigned 143 men and women on HAART who met criteria for hazardous drinking 9 to either Project PLUS, an 8-session intervention integrating MI and cognitive-behavioral skills training (CBST), 10 or a time- and content-equivalent educational condition. "Viral load, CD4 cell count, and self-reported adherence and drinking behavior were assessed at baseline and at 3- and 6-month follow-ups" (p. 443).

The investigators found that,"[r]elative to the education condition, participants in the intervention demonstrated significant decreases in viral load and increases in CD4 cell count at the 3-month follow-up and significantly greater improvement in percent dose adherence and percent day adherence. There were no significant intervention effects for alcohol use, however, and effects on viral load, CD4 cell count, and adherence were not sustained at 6 months" (p. 443). Parsons and colleagues point out that "Project PLUS is the first behavioral adherence intervention to demonstrate such improvements in all 3 measures (viral load, CD4 cell count, and percent adherence) and is the first intervention for HIV-positive individuals with alcohol-related problems to demonstrate any significant effects" (p. 448).

Although "[t]he study failed to maintain significant interaction effects at the 6-month visit, most likely because participants were no longer receiving the intervention content" (p. 448),

[m]ean scores at the 6-month follow-up are all in the hypothesized direction (... [i.e.], the intervention group demonstrating better clinical outcomes, higher levels of adherence, and less drinking compared with the education group. It is possible that the Project PLUS intervention would benefit from "booster visits" to reinforce the intervention components and to help participants sustain the positive effects impact on adherence and virologic and immunologic functioning. Future studies should consider the inclusion of booster sessions to examine their impact on long-term outcomes.

Because of its flexibility in tailoring intervention components to the specific needs of individual patients, the Project PLUS intervention is a perfect model for integration into HIV clinical care settings. Although an "intensive" intervention by some standards, the success of Project PLUS in improving clinical outcomes suggests that it might be a cost-effective investment, especially if delivered to the patients at highest risk for nonadherence. The intervention could be delivered by many different clinic professionals, including nurses, social workers, or case managers. If integrated within an HIV clinic setting, individual CBST modules could be delivered as "booster" sessions during routine care visits or when a client presented with treatment failure because of nonadherence. (p. 449)

What factors other than adherence appear to contribute to health outcomes? Surveying a diverse sample of 275 men and women with alcohol use disorders who were living with HIV, Parsons, Rosof, and Mustanski (2008) examined "the relationship between negative consequences of alcohol use, adherence self-efficacy, medication adherence, and biological markers of HIV health (CD4 count and viral load)" (p. 95). "The construct of self-efficacy, or confidence, hinges on a belief in oneself, a self-belief that one can accomplish even the most difficult ... of tasks, such as taking the often complex regimens of HAART" (p. 100). Interestingly, the investigators found that

adherence self-efficacy predicted viral load, while alcohol [use problems] did not. Further analysis found that self-efficacy had direct effects on viral load, but not on CD4 counts. ... [The investigators] next sought to determine whether the relationship between self-efficacy and viral load was mediated by adherence to medication and found that adherence significantly, but only partially, mediated the relationship. In other words, self-efficacy for adherence to HIV medications had a direct effect on viral load that was not explained by self-reported medication adherence. However, ... [the investigators] found that adherence did not mediate the relationship between self-efficacy and CD4 counts, which was explained by the fact that none of the paths to CD4 counts were significant. (p. 100)

Although Parsons and colleagues could not explain "why adherence self-efficacy did not directly impact CD4 count in the way it affects viral load" (p. 100), their findings do

reveal that factors other than adherence to medication can predict variability in HIV health. ... Thus, future interventions should include enhancing self-efficacy and strengthening beliefs in the benefits of taking medication and maintaining good health. Clearly, cognitive interventions, which emphasize boosting confidence in one's ability to take medication and confidence in the effects of medication, are implicated. Motivational therapies can address self-efficacy directly by simply asking patients about their level of confidence. Health care providers could engage their patients in a brief conversation about [their] confidence to adhere to their HAART medications that could be highly motivational and lead to higher confidence levels. Similarly, [physical health] providers could partner with behavioral health clinicians to deliver adherence interventions that include motivational components. ... Health professionals should use motivational techniques to also explore ambivalence about medication taking and attempt to assist the patient in resolving this ambivalence.11 Additionally, cognitive behavioral therapy could offer a way to improve self-efficacy by setting goals that are accomplishable and challenging thinking that interferes with confidence. (p. 101)

Serostatus Disclosure

Tompkins (2007) explored the process of HIV status disclosure between 23 mothers living with HIV and one of their children (ages 9 to 16 years) who was not infected with HIV. Within this group of mothers, 61% disclosed their positive serostatus to the child who participated in the study. "Consistent with previous research, disclosure was not related to child functioning. However, children sworn to secrecy demonstrated lower social competence and more externalizing problems. Differential disclosure, which occurred in one-third of the families, was associated with higher levels of depressive and anxiety symptoms. Finally, knowing more than mothers had themselves disclosed was related to child maladjustment across multiple domains" (p. 773). Speaking to their

positive feelings about the disclosure, both children and mothers most frequently cited increased child involvement and decreased maternal stress. Disclosure regrets, which were few, most frequently concerned fear of increased child stress and worry.

Interviews with mothers who had not yet disclosed suggested that all of these mothers would tell their children in the future. Concerns about child protection, developmental inappropriateness, and stigma were cited by these mothers as reasons for not having told. In considering future disclosure, mothers endorsed open communication and avoidance of inadvertent disclosure as reasons for disclosing [their] diagnostic status to [their] children. In light of results suggesting that children's negative emotional reactions decrease over time while hope increases following initial disclosure, such information may prove useful in preparing mothers who are contemplating disclosure to expect a wide range of initial emotional reactions from their children. Additionally, for mothers who are not yet ready to tell their children, it may be comforting to know that others share their concerns and have also made a choice to delay disclosure. Similarly, being able to normalize both mother and child reactions to disclosure may be helpful in assisting individual families [to] cope with the stress associated with disclosure-related decisions. (p. 782)

Tompkins outlines several steps that can be taken to assist mothers who are considering the disclosure of their diagnosis to their children. These steps include

contemplating and preparing for all possible reactions; honestly considering what the child may already know; learning about the typical ways in which children cope with and process stressful situations (including developmental differences and the ways in which children continue to seek information as they mature and develop); thinking about the effects such news may have on the child and the relationship; practicing developmentally appropriate ways to impart the information; deciding how to handle issues around telling others; and developing and implementing a plan to keep the topic open for discussion over time.

If the current findings should survive replication, professionals may want to inform mothers about ... the complex advantages and disadvantages of swearing a child to secrecy; of disclosing to some, but not all, family members; and of not being fully honest about what the child "knows" and sees ... . For example, if children are of drastically different ages, it may be difficult, if not impossible, to withhold disclosure from an older child before informing a younger sibling. However, considering the strain that secrets can place on family openness and communication, as well as on the individual child who must withhold information from a younger sibling, a mother who has carefully considered such factors may make different decisions. She may decide to tell the younger child sooner than if s/he was an only child and/or she may discuss the situation with the older child in order to explain the reason for differential disclosure. Similarly, a mother who honestly acknowledges that a child already knows that "something" is wrong may feel empowered to open up the lines of communication after considering some of the possible disadvantages associated with continued withholding of information (e.g., maternal guilt over concealment; avoidance of closeness with the child to prevent questions; child confusion, mistrust, anger). (p. 786)

Coping, Social Support, & Quality of Life

In another study involving mothers living with HIV, Burns, Feaster, Mitrani, Ow, and Szapocznik (2008) "examined the mechanism by which stressors, dissatisfaction with family, perceived control, social support, and coping were related to psychological distress in a [convenience] sample of [206 urban, low-income,] HIV-positive African American mothers. Additional analyses explored whether women who had a history of a drug abuse or dependence diagnosis differed either on levels of the study variables or the model pathways" (p. 95). Burns and colleagues found that "HIV-positive African American mothers who had higher levels of stressors perceived their stressors as a whole to be less controllable. Coping resources, available social support and perceived control … were positively associated with active coping and negatively associated with psychological distress. Avoidant coping was the most important predictor of psychological distress. Furthermore, the effect of avoidant coping on psychological distress was stronger for mothers with a history of drug [use] diagnosis" (p. 95). In the view of the investigators,

these results point to several promising avenues for interventions. First, working directly on the reported family dissatisfaction and building skills to enhance perceived control would potentially decrease ... psychological distress. Second, working on recruitment, maintenance and utilization of available social support would have beneficial effects on the constellation of coping responses. Having supportive and positive persons in one's network could increase supportive coping and coping strategies such as planning and taking action, while decreasing the use of avoidant coping strategies such as disengagement, distraction and suppression of thoughts as a coping response. Finally, for substance abusing HIV-positive women, encouraging and demonstrating the utility of more active and less avoidant coping responses should have direct benefits on psychological distress. (p. 113)

Fife, Scott, Fineberg, and Zwickl (2008)

evaluated an intervention to facilitate adaptive coping by persons living with HIV ..., with the participation of their cohabiting partners as a dimension of the intervention. An experimental design with randomization was used, and 84 [persons living with HIV] and their partners were recruited. The intervention 12 was based on a psychosocial educational model that incorporated four 2-hour sessions focused on communication, stress appraisal, adaptive coping strategies, and building social support. Both members of the dyad were included in each session. The comparison control included four supportive phone calls to the [person living with HIV] alone. Data were collected from both the [persons living with HIV] and their partner[s] in each of the two groups at baseline, immediately following the intervention, and 3 months and 6 months posttreatment. (p. 75)

Fife and colleagues found that "the experimental intervention involving partners was more effective in facilitating adaptive coping for [persons living with HIV] than ... supportive telephone calls to the [person living with HIV] alone" (p. 82). "The strongest effects of this intervention were changes in coping behaviors[,] ... the decrease in negative emotions and the increase in positive feelings as well as the construction of positive meaning related to the illness" (p. 82) among those who participated in the experimental intervention. Importantly, "[i]n the case of coping effectiveness and active coping, the difference between the intervention and control groups was at least partially explained by a positive change in the partner's behavior" (p. 81). Although retention was a problem in this study, particularly at the 6-month data collection point, the investigators suggest that "the design was ... feasible[, with] ... demonstrated potential for the management of stress ... [among persons living with HIV]" (p. 75).

Uphold, Holmes, Reid, Findley, and Parada (2007) "examined the relationships between health-promoting behaviors, risk behaviors, stress, and health-related quality of life (HRQOL) among 226 men with HIV infection who were [living in predominantly rural and suburban areas of the southeastern United States and] attending [one of] three infectious disease clinics" (p. 54). The investigators found that "health-promoting behaviors were positively related and stress was negatively related with most of the HRQOL dimensions ... [and h]azardous alcohol use was negatively associated with one HRQOL dimension – social functioning" (p. 54). These results "highlight the association of modifiable factors, such as health-promoting behaviors and stress, with HRQOL among men living with HIV infection" (p. 61) and suggest that

relatively simple, straightforward changes in lifestyles such as eating well, managing stress, and remaining active may result in significant improvements in HRQOL. Although there are challenges in altering one's behavior, this study highlights the importance of counseling men with HIV infection about the benefits of engaging in health-promoting behaviors and avoiding stressful life events. In addition, ... educational programs that emphasize self-care ..., coping improvement ..., and cognitive behavior ... strategies that reduce stress ... are practical and cost-effective mechanisms for empowering patients with HIV infection to take personal responsibility for improving their health and quality of life. (p. 64)

It goes without saying that improving mental health among persons living with HIV is another worthy intervention goal. To this end, McDowell and Serovich (2007) "compare[d] the ways in which perceived and actual social support affect the mental health of [139] gay men, [93] straight or bisexual men, and [125] women living with HIV/AIDS" (p. 1223). "Results of this study suggest that there are significant differences in the relationship of perceived and actual social support to mental health. Women, gay men and straight/bisexual men all experienced perceived social support versus actual social support as significantly more predictive of mental health" (pp. 1227-1228), which was measured with indices of depressive symptomatology and loneliness. McDowell and Serovich identify the value of this information to clinicians working with people living with HIV/AIDS in the following ways:

First, it suggests that individuals with small social networks can be adequately supported. Therefore, investigating the degree to which clients feel they have the resources they need would be more important than assessing the numbers of persons who can assist. Helping professionals should focus on supporting clients in recognising the many other dimensions of support offered that may not be easily recognisable such as offering material aid (i.e.[,] providing transportation) or advice. Second, therapists and other helping professionals should invest in developing or enhancing interventions that increase the value of support provided by the social network. Clinicians might consider focusing on and assisting with repairing damaged family relationships or finding ways in which friends have offered support in order to adequately buffer the effects of HIV on functioning. (p. 1228)

Lastly, Crepaz et al. (2008) conducted a meta-analysis to determine "the efficacy of cognitive-behavioral interventions (CBIs) 13 for improving the mental health and immune functioning of people living with HIV" (p. 4). The investigators included data from 15 controlled trials, published between 1991 and 2005, in their analysis, and found that "[s]ignificant intervention effects were observed for improving symptoms of depression ..., anxiety ..., anger ..., and stress ... . There is limited evidence suggesting intervention effects on CD4 cell counts ... . The aggregated effect size estimates for depression and anxiety were statistically significant in trials that provided stress management skills training and had more than 10 intervention sessions" (p. 4). Additional analyses

showed that the significant intervention effects on depression and anxiety were observed at the immediate postintervention assessment; however, there was no evidence for longer term effectiveness. It is plausible that without boosters, there would be a gradual discontinuation in the practice of skills to correctly assess irrational thoughts and improve coping and stress management skills. ... [T]he findings ... suggest that the challenge of coping with emotional issues over the course of HIV infection may require on-going behavioral reinforcement to prevent relapse. (p. 10)

Although Crepaz and colleagues correctly acknowledge a variety of limitations to this meta-analytic review, these results "suggest that CBIs can improve the mental health of [people living with HIV] ... [and that] to effectively treat [people living with HIV], mental health services must be available and accessible to [recipients of] medical care. However, it is important to recognize that the effects of CBIs may not last long term. [People living with HIV] may therefore need on-going or periodic provision of CBIs or other mental health services to ensure the sustainability of intervention effects. Certainly, more research in this area is needed" (p. 12).

---- Compiled by Abraham Feingold, Psy.D.

--------------------

 7 "The MBMD ... is a self-report inventory designed to assess a wide array of psychosocial factors that impact medical treatment and adjustment to illness. ... The main sections of the MBMD include: (a) Psychiatric Indications, (b), Coping Styles, (c) Stress Moderators, (d) Treatment Prognostics, and (e) Management Guides. The instrument contains 165 true-false items and takes approximately 20 to 25 min to complete. ... The MBMD is computer scored, generating a profile of scores that are automatically corrected for the patient's response style (i.e., overreporting or underreporting symptoms)" (p. 280).

 8 "The Healthy Living Project experimental intervention ... consisted of 15 90-minute individual counseling sessions grouped into 3 modules, each consisting of 5 sessions. Module 1 (Stress, Coping, and Adjustment), addressing quality of life, psychologic coping, and achieving positive affect and supportive social relationships, was delivered before the 5-month time point. Module 2 (Safer Behaviors), addressing self-regulatory issues, such as avoiding sexual and drug-related risk of HIV transmission or acquisition of additional sexually transmitted diseases, and disclosure of HIV status to potential partners, was delivered between the 5- and 10-month time points. Module 3 (Health Behaviors), addressing accessing health services, medication adherence, and active participation in medical care decision making, was delivered between the 10- and 15-month time points. ... Intervention sessions followed a standard structure and set of activities but were individually tailored to participants' specific life contexts, stressors, and goals" (p. 575).

9 "Because the intervention was specifically designed to target heavy or hazardous drinkers, the final requirements for enrollment included meeting criteria for hazardous drinking (> 16 standard drinks per week for men or > 12 standard drinks per week for women) ... and having alcohol problems greater than those associated with other drugs" (p. 444).

10 "The Project PLUS intervention was based on the Information-Motivation-Behavioral Skills (IMB) Model, ... which posits that information and motivation activate behavioral skills, resulting in behavior change. Two complementary techniques[, MI and CBST,] ... were integrated, allowing trained counselors to match targeted information and skill-building techniques to the particulars of each client's motivation for change. ... All sessions were delivered by master's degree-prepared counselors who completed significant training in MI and CBST and received individual and group supervision throughout the project" (p. 444).

11 See the Tool Box on "Emerging Methods for Motivating Effective Medication Practice" in the Summer 2006 issue of mental health AIDS for more information on the application of MI to antiretroviral medication taking.

12 "A manual detailing the specifics of the intervention was developed, refined, and evaluated as a part of this research; it is available upon request from the first author" (p. 76; Betsy L. Fife, Ph.D., R.N.; bfife@iupui.edu ).

13 CBIs "focus on the interaction of thoughts, feelings, and behaviors ... . Although there are various CBI techniques, the most common practices focus on altering irrational cognitions related to negative psychological states (e.g., depression, anger, anxiety), correctly appraising internal and external stressors, gaining stress management skills, and developing adaptive behavioral coping strategies. A recent systematic review of meta-analyses on CBIs ... showed that CBIs are highly effective for adult and adolescent unipolar depression, generalized anxiety disorder, panic disorder, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders. Across many disorders, including depression and anxiety, the intervention effects are maintained for substantial periods (e.g., 12 months). In cases of depression, CBIs demonstrated greater long-term effects, with relapse rates half those of pharmacotherapy ..." (pp. 4-5).

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