A longitudinal evaluation of a social support model of medication adherence among HIV-positive men and women on antiretroviral therapy.

Nonadherence in the management of chronic illness is a pervasive clinical challenge. Although researchers have identified multiple correlates of adherence, the field remains relatively atheoretical. The authors propose a cognitive-affective model of medication adherence based on social support theory and research. Structural equation modeling of longitudinal survey data from 136 mainly African American and Puerto Rican men and women with HIV/AIDS provided preliminary support for a modified model. Specifically, baseline data indicated social support was associated with less negative affect and greater spirituality, which, in turn, were associated with self-efficacy to adhere. Self-efficacy to adhere at baseline predicted self-reported adherence at 3 months, which predicted chart-extracted viral load at 6 months. The findings have relevance for theory building, intervention development, and clinical practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Randomized controlled trial of an intervention to prevent adherence failure among HIV-infected patients initiating antiretroviral therapy.

Objective: Compare the efficacy of a multicomponent social support intervention to standard-of-care counseling on medication adherence among HIV-infected patients initiating antiretroviral therapy. Design: Randomized controlled trial. Generalized estimating equations tested for differences in the percentage of participants achieving 90% adherence. Main Outcome Measures: Pill-taking, electronically monitored over 6 consecutive months; plasma viral load (VL), assessed at 3 and 6 months following initiation of therapy. Results: Of 226 participants who were randomized and began the trial, 87 (38%) were lost to the study by 6 months. The proportion of adherent participants declined steadily over time, with no time by group interaction. Sustained adherence was associated with increased odds of achieving an undetectable VL (OR = 1.78; 95% CI = 1.01, 3.13). In intention-to-treat analyses, a larger proportion of the intervention group than the control group was adherent (40.15% vs. 27.59%, p = .02) and achieved an undetectable VL p = .04). However, the majority of participants who remained on study experienced some reduction in VL (≥ 1-log drop or undetectable), regardless of experimental condition. Conclusion: The multicomponent social support intervention significantly improved medication adherence over standard-of-care counseling; evidence for improved virologic outcomes was inconsistent. Early discontinuation of care and treatment may be a greater threat to the health of HIV patients than imperfect medication-taking. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An information-motivation-behavioral skills model of adherence to antiretroviral therapy.

HIV-positive persons who do not maintain consistently high levels of adherence to often complex and toxic highly active antiretroviral therapy (HAART) regimens may experience therapeutic failure and deterioration of health status and may develop multidrug-resistant HIV that can be transmitted to uninfected others. The current analysis conceptualizes social and psychological determinants of adherence to HAART among HIV-positive individuals. The authors propose an information-motivation-behavioral skills (IMB) model of HAART adherence that assumes that adherence-related information, motivation, and behavioral skills are fundamental determinants of adherence to HAART. According to the model, adherence-related information and motivation work through adherence-related behavioral skills to affect adherence to HAART. Empirical support for the IMB model of adherence is presented, and its application in adherence-promotion intervention efforts is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Age-associated predictors of medication adherence in HIV-positive adults: Health beliefs, self-efficacy, and neurocognitive status.

Objective: Although most agree that poor adherence to antiretrovirals is a common problem, relatively few factors have been shown to consistently predict treatment failure. In this study, a theoretical framework encompassing demographic characteristics, health beliefs/attitudes, treatment self-efficacy, and neurocognitive status was examined in relationship to highly active antiretroviral therapy adherence. Design: Prospective, cross-sectional observational design. Main Outcome Measures: Neuropsychological test performance, health beliefs and attitudes, and medication adherence tracked over a 1-month period using electronic monitoring technology (Medication Event Monitoring System caps). Results: The rate of poor adherence was twice as high among younger participants than with older participants (68% and 33%, respectively). Results of binary logistic regression revealed that low self-efficacy and lack of perceived treatment utility predicted poor adherence among younger individuals, whereas decreased levels of neurocognitive functioning remained the sole predictor of poor adherence among older participants. Conclusion: These data support components of the health beliefs model in predicting medication adherence among younger HIV-positive individuals. However, risk of adherence failure in those ages 50 years and older appears most related to neurocognitive status. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected individuals.

Objective: To evaluate cognitive-behavioral therapy to enhance medication adherence and reduce depression (CBT-AD) in individuals with HIV. Design: A two arm, randomized, controlled, cross-over trial comparing CBT-AD to enhanced treatment as usual only (ETAU). ETAU, which both groups received, included a single-session intervention for adherence and a letter to the patient's provider documenting her or his continued depression. The intervention group also received 10 to 12 sessions of CBT-AD. Main Outcome Measures: Adherence to antiretroviral therapy as assessed by Medication Event Monitoring Systems (MEMs) and depression as assessed by blinded structured evaluation. Results: At the acute outcome assessment (3-months), those who received CBT-AD evidenced significantly greater improvements in medication adherence and depression relative to the comparison group. Those who were originally assigned to the comparison group who chose to cross over to CBT-AD showed similar improvements in both depression and adherence outcomes. Treatment gains for those in the intervention group were generally maintained at 6- and 12-month follow-up assessments. By the end of the follow-up period, those originally assigned CBT-AD demonstrated improvements in plasma HIV RNA concentrations, though these differences did not emerge before the cross-over, and hence there were not between-groups differences. Conclusions: CBT-AD is a potentially efficacious approach for individuals with HIV struggling with depression and adherence. Replication and extension in larger efficacy trials are needed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Adherence to antiretroviral medications in HIV: Differences in data collected via self-report and electronic monitoring.

Controversy remains regarding the reliability of methods used to determine adherence to antiretroviral medication in HIV. In this study the authors compared adherence rates of 119 HIV-positive participants during a 6-month study, as estimated via electronic monitoring (EM) and self-report (SR). Adherence for both short (4-day) and long (4-week, or intervisit) periods was examined, as well as factors that underlie discrepancies between EM and SR. Results showed that intervisit EM estimates were consistently lower than those of SR. SR estimates based on shorter periods (4 days) were closer to those of EM. Higher discrepancies between EM and SR estimates were associated with lower cognitive functioning and externalized locus of control. These findings lend support for using both EM and SR methods; however, study design (e.g., length) and other factors (e.g., cognitive status, cost) should be considered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Electronic monitoring-based counseling to enhance adherence among HIV-infected patients: A randomized controlled trial.

Objective: To investigated the effectiveness of an adherence intervention (AIMS) designed to fit HIV-clinics' routine care procedures. Design: Through block randomization, patients were allocated to the intervention or control group. The study included 2 months baseline measurement, 3 months intervention, and 4 months follow-up. HIV-nurses delivered a minimal intervention (“adherence sustaining”) to patients scoring >95% adherence at baseline, and an intensive intervention (“adherence improving”) to patients with     

A randomized clinical trial of a manual-guided risk reduction intervention for HIV-positive injection drug users.

This study randomized 90 HIV-seropositive, methadone-maintained injection drug users (IDUs) to an HIV Harm Reduction Program (HHRP+) or to an active control that included harm reduction components recommended by the National AIDS Demonstration Research Project. The treatment phase lasted 6 months, with follow-ups at 6 and 9 months after treatment entry. Patients in both treatments showed reductions in risk behaviors. However, patients assigned to HHRP+ were less likely to use illicit opiates and were more likely to adhere to antiretroviral medications during treatment; at follow-up, they had lower addiction severity scores and were less likely to have engaged in high risk behavior. Findings suggest that enhancing methadone maintenance with an intervention targeting HIV-seropositive IDUs increases both harm reduction and health promotion behaviors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Internalized heterosexism among HIV-positive, gay-identified men: Implications for HIV prevention and care.

Internalized heterosexism (IH), or the internalization of societal antihomosexual attitudes, has been consistently linked to depression and low self-esteem among gay men, and it has been inconclusively associated with substance use and sexual risk in gay and bisexual men. Using structural equation modeling, the authors tested a model framed in social action theory (C. K. Ewart, 1991, 2004) in which IH is associated with HIV transmission risk and poor adherence to HIV antiretroviral therapy (ART) through the mechanisms of negative affect and stimulant use. Data from a sample of 465 gay-identified men interviewed as part of an HIV risk reduction behavioral trial were used to test the fit of the model. Results support the hypothesized model in which IH was associated with unprotected receptive (but not insertive) anal intercourse with HIV-negative or unknown HIV status partners, and with ART nonadherence indirectly via increased negative affect and more regular stimulant use. The model accounted for 15% of the variance in unprotected receptive anal intercourse and 17% of the variance in ART nonadherence. Findings support the potential utility of addressing IH in HIV prevention and treatment with HIV-positive gay men. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Treatment Advocacy Program: A randomized controlled trial of a peer-led safer sex intervention for HIV-infected men who have sex with men.

Objective: Primary care may be an effective venue for delivering behavioral interventions for sexual safety among HIV-positive men who have sex with men (MSM); however, few studies show efficacy for such an approach. We tested the efficacy of the Treatment Advocacy Program (TAP), a 4-session, primary-care-based, individual counseling intervention led by HIV-positive MSM “peer advocates” in reducing unprotected sex with HIV-negative or unknown partners (HIV transmission risk). Method: We randomized 313 HIV-positive MSM to TAP or standard care. HIV transmission risk was assessed at baseline, 6 months, and 12 months (251 participants completed all study waves). We conducted intent-to-treat analyses using general estimating equations to test the interaction of group (TAP vs. standard care) by follow-up period. Results: At study completion, TAP participants reported greater transmission risk reduction than did those receiving standard care, χ2(2, N = 249) = 6.6, p = .04. Transmission risk among TAP participants decreased from 34% at baseline to about 20% at both 6 and 12 months: Transmission risk ranged from 23% to 25% among comparison participants. Conclusions: TAP reduced transmission risk among HIV-positive MSM, although results are modest. Many participants and peer advocates commented favorably on the computer structure of the program. We feel that the key elements of TAP—computer-based and individually tailored session content, delivered by peers, in the primary care setting—warrant further exploration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The dose effect of a group intervention for bereaved HIV-positive individuals.

Group interventions for health-related issues such as cancer and HIV infection have demonstrated effectiveness and are widely used, yet the question of dosage for group interventions has received little attention. This study examined the longitudinal effect of varying doses of a group intervention for coping with AIDS-related loss in 158 HIV-positive women and men. Grief and psychiatric distress were assessed at baseline, postintervention, and at 4-, 8-, and 12-month follow-ups. Longitudinal data analyses using mixed models were conducted to examine differences in outcome by dosage. Results show that both grief and psychiatric distress were inversely related to dosage across time, indicating that the higher the intervention exposure, the greater the reduction in distress and grief. The clinical significance of change by dosage was also considered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Social Support, Positive States of Mind, and HIV Treatment Adherence in Men and Women Living With HIV/AIDS.

Numerous studies have linked social support to better medication adherence among illness groups, but few have examined potential mechanisms for this relationship. Relationships were examined between social support, depression, positive states of mind (PSOM), and medication adherence among HIV positive men who have sex with men (n = 61) and women (n = 29) on highly active antiretroviral therapy. Depression and PSOM were evaluated as potential mediators of the relationship between support and adherence. Cross-sectional data showed that greater social support and PSOM related to better adherence whereas higher depression scores related to nonadherence. PSOM partially mediated the relationship between social support and adherence. PSOM may be an important mechanism through which social support is related to better medication adherence in this population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A social problem-solving model of adherence to HIV medications.

HIV medication adherence remains a challenge and limits the degree to which treatment benefit can be maximized. This study tested an explanatory model of HIV medication adherence using a social problem-solving (SPS) framework. Associations of SPS with adherence are hypothesized to be direct and/or indirect via psychological health. HIV+ adults were interviewed using validated measures of SPS, psychological health, and antiretroviral therapy (ART) medication adherence. Structural equation modeling (SEM) techniques were used to test hypothesized relationships and to evaluate overall fit of the model to the data. SEM supported an indirect association (but not direct) of SPS on adherence via psychological health among the 545 HIV+ adults included in the analyses. Overall, the findings resulted in a model of adherence that offered very good fit to the data and correctly classified 97% of the cases as adherent versus nonadherent. Results support the use of SPS as a conceptual framework for understanding adherence to ART. Findings offer rationale and direction for SPS interventions to enhance adherence by improving psychological health. Such approaches, if effective, have the potential to positively impact psychological well being and adherence, thereby maximizing clinical benefit from treatment, which is linked to lower mortality from AIDS. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized controlled trial of goal choice interventions for alcohol use disorders among men who have sex with men.

This study tested the efficacy of behavioral treatments for alcohol use disorders (AUD) among men who have sex with men (MSM) and who are at risk for HIV transmission. HIV-negative MSM with current AUD (N = 198) were recruited, offered treatment focused on reducing drinking and HIV risk, and followed during treatment and 12 months posttreatment. Participants (n = 89) accepted treatment and were randomized to either 4 sessions of motivational interviewing (MI) or 12 sessions of combined MI and coping skills training (MI + CBT). Other participants (n = 109) declined treatment but were followed, forming a non-help-seeking group (NHS). MI yielded significantly better drinking outcomes during the 12-week treatment period than MI + CBT, but posttreatment outcomes were equivalent. NHS participants significantly reduced their drinking as well. Service delivery and treatment research implications are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reducing STD and HIV risk behavior of substance-dependent adolescents: A randomized controlled trial.

A randomized controlled trial assessed 3 interventions designed to increase safer sex behaviors of substance-dependent adolescents. Participants (N = 161) received 12 sessions of either a health information intervention (I only), information plus skills-based safer sex training (I + B), or the same experimental condition plus a risk-sensitization manipulation (I + M + B). The I + B and I + M + B conditions, as compared with the I only condition, (a) produced more favorable attitudes toward condoms; (b) reduced the frequency of unprotected vaginal sex; and (c) increased behavioral skill performance, frequency of condom-protected sex, percentage of intercourse occasions that were condom protected, and number of adolescents who abstained from sex. The intervention that included the risk-sensitization procedures was more resistant to decay. An unexpected finding was that the I + B and I + M + B conditions produced substantial increased in sexual abstinence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The prevention of depressive symptoms in rural school children: A randomized controlled trial.

A controlled trial was conducted to evaluate a prevention program aimed at reducing depressive and anxious symptoms in rural school children. Seventh-grade children with elevated depression were selected. Nine primary schools (n=90) were randomly assigned to receive the program, and 9 control schools (n=99) received their usual health education classes. Children completed questionnaires on depression, anxiety, explanatory style, and social skills. Parents completed the Child Behavior Checklist (T. M. Achenbach, 1991). No intervention effects were found for depression. Intervention group children reported less anxiety than the control group after the program and at 6-month follow-up and more optimistic explanations at postintervention. Intervention group parents reported fewer child internalizing and externalizing symptoms at postintervention only. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized controlled trial of a coping group intervention for adults with HIV who are AIDS bereaved: Longitudinal effects on grief.

The authors sought to study the longitudinal effects of a cognitive-behavioral group intervention for coping with AIDS bereavement among a diverse sample of adults who were HIV positive. Participants (N = 267) were randomly assigned to receive the 12-week intervention or individual therapy upon request. Measures were administered at baseline, postintervention, and 4-, 8-, and 12-month follow-ups. Longitudinal data were analyzed with linear mixed models to examine change in grief by condition across the study period and the effect of the intervention on grief through its interaction with psychiatric distress. The authors used the Grief Reaction Index to assess grief and the Symptom Checklist-90-Revised to assess global psychiatric distress. Participants in both conditions reported decreases in grief severity. However, among those with higher levels of psychiatric distress, participants in the group intervention had significantly lower grief severity scores compared with participants in the individual therapy condition. The long-term effectiveness of this AIDS-bereavement intervention for psychiatrically distressed people with HIV/AIDS supports the need for tailored interventions among those at risk for complicated grief responses. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Health-related quality of life in bereaved HIV-positive adults: Relationships between HIV symptoms, grief, social support, and Axis II indication.

Objective: This study evaluated a model of the impact of borderline and antisocial personality disorder indications on HIV symptoms and health-related quality of life (HRQoL) in AIDS-bereaved adults, accounting for grief severity, social support, and years since HIV diagnosis. Design: Structural equation modeling was used to test the proposed model in a sample of 268 HIV-seropositive adults enrolled in an intervention for coping with AIDS-related bereavement. Main Outcome Measures: Functional assessment of HIV infection, HIV symptoms. Results: The proposed model demonstrated excellent fit with study data and all hypothesized paths were supported. Personality disorder indication was directly related to HIV symptoms and HRQoL and indirectly related through both social support and grief severity. Social support was negatively related to HIV symptoms and positively related to HRQoL, while grief severity was positively related to HIV symptoms and negatively related to HRQoL. Finally, HIV symptoms had a direct negative relationship with HRQoL. Conclusion: Personality disorders have a direct negative effect on HIV symptoms and HRQoL and indirect effects through grief severity and social support. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Hopelessness as a mediator of the association between social support and depressive symptoms: Findings of a study of men with HIV.

Data from a prospective longitudinal study were used to investigate whether hopelessness mediates the association between social support and depression, as hypothesized by L. Y. Abramson, G. I. Metalsky, and L. B. Alloy (1989). Measures of hopelessness, social support, and depression were administered to 103 HIV-infected men and readministered 6 months later. Findings indicated that low baseline social support predicted increases in hopelessness and depression. Increases in hopelessness predicted increases in depression after controlling for baseline social support. Low baseline social support did not predict increased depression when hopelessness was controlled statistically. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A Stress and Coping Model of Medication Adherence and Viral Load in HIV-Positive Men and Women on Highly Active Antiretroviral Therapy (HAART).

The authors tested a structural model that incorporated age, time since diagnosis, social support, coping, and negative mood as predictors of medication adherence and HIV viral load on 188 men and 134 women on highly active antiretroviral therapy (HAART). The authors used psychosocial latent factors formed from baseline measures to predict latent factors of adherence, as assessed by electronic monitoring and self-report, and viral load defined by indicators assessed over a 15-month period. Results from the model indicate that greater negative mood and lower social support are related to greater use of avoidance-oriented coping strategies. Use of these coping strategies by patients on HAART is related to poorer medication adherence and, subsequently, higher viral load. This model advances researchers' understanding of the contribution of psychosocial variables in predicting treatment adherence and disease progression in HIV-positive men and women. (PsycINFO Database Record (c) 2010 APA, all rights reserved)