mental health AIDS

Fall 2006 Newsletter / Volume 8, Issue 1

HIV Treatment News

Psychiatric/Psychological/
Psychosocial/Spiritual Care

Adherence to Treatment

Kremer, Ironson, Schneiderman, and Hautzinger (2006) examined rationales offered by a diverse sample of 79 adults living with HIV for deciding to take or not to take antiretroviral therapy.3 Study participants learned their HIV-positive status an average of 11 years earlier. "Qualitative content analysis of semistructured interviews identified 10 criteria for the decision to take or not to take [antiretroviral therapy]: CD4/viral load counts (87%), quality of life (85%), knowledge/beliefs about resistance (66%), mind-body beliefs (65%), adverse effects of [antiretroviral therapy] (59%), easy-to-take regimen (58%), spirituality/worldview (58%), drug resistance (41%), experience of HIV/AIDS symptoms (39%), and preference for complementary/alternative medicine ([CAM;]17%)" (p. 335). In comparisons with the 73% of this sample that decided to take antiretrovirals, the 27% who decided not to take antiretroviral therapy

emphasize[d] three criteria more strongly than those deciding to take [antiretroviral therapy]: the preference for CAM, avoiding adverse effects of [antiretroviral therapy], and the perceived benefit in psychosocial quality of life through not taking [antiretroviral therapy]. All other criteria did not differ.

Another important finding ... [was] that existential issues such as mind-body beliefs and spiritual beliefs ... [were] used by approximately half of ... [those sampled] in making decisions about treatment. These beliefs can be used both in the decision to take as well as in the decision not to take treatment. Of particular note, sometimes patient's spiritual belief system or belief in a mind-body connection is in conflict with the recommendation of a physician (e.g., people feeling that they do not need [antiretroviral therapy] because they believe that the body can heal itself). (p. 344)

With regard to addressing the 10 decision-making criteria identified in this study, Kremer and colleagues offer the following suggestions:

Surrogate markers [CD4/viral load counts]
Explain the importance of surrogate markers in a manner that is not too abstract and is connected with a patient's feelings. Recognize that [people living with HIV] may prefer to start [antiretroviral therapy] later than guidelines recommend and ensure that they understand the consequences of this decision.

Better quality of life
Regular assessments of quality of life may be as important as measuring surrogate markers.

Beliefs/knowledge about resistance
Make sure that all patients understand the concept of resistance and how nonadherence is related to the development of resistance.

Mind-body belief
As many patients believe in a mind-body connection it is important to explore how this may affect their decision-making.

Adverse effects
It is important to acknowledge not only whether the patient experiences adverse effects, but also how he/she perceives them. Some people are willing to tolerate adverse effects, because they believe the medication is very necessary or the body will adjust to it. Others are inclined to stop and not to start treatment to avoid adverse effects.

Easy to take regimen
Simplify [antiretroviral therapy] as much as possible for people to whom this is important, but remember that this is not the most important issue for many [people living with HIV].

Spirituality/worldview
Take a patient's spirituality and worldview into account as it may have an impact on decision-making. Operate within the patient's spiritual belief system rather than your own. Acknowledge and support the patient's spiritual beliefs and worldviews that aid in coping in living with HIV.

Drug resistance
Offer drug resistance testing to all patients who need it.

Experience of HIV/AIDS symptoms
Assess regularly the symptoms related to HIV with checklists.

Preference for CAM

Acknowledge patients['] preference for CAM and ask (and record?) each patient[']s use of CAM, being aware of potential drug interactions. (p. 347)

Drawing on additional data from this same sample of adults living with HIV, Kremer and Ironson (2006) inquire if patients "tell their physicians whether they take antiretroviral treatment ... as prescribed and why" (p. 520). The investigators found that

[p]atients are more likely to inform physicians why they take than why they do not take [antiretroviral therapy] ... . Only half of those not taking [antiretroviral therapy] shared the reasons for their decision with their physician. The six motives [for not confiding] were: anticipation that physicians will not support the decision, cannot discuss feelings, lack of trust in physician's opinion, unable to discuss spiritual/moral issues, no need for physician to know, and not seen physician yet. Of those taking [antiretroviral therapy], 21% did not tell their physician why they missed doses. The five motives were: not viewed as important, physician not asking, not seen physician yet, rarely non-adherent, no indications in surrogate markers. (p. 520)

Kremer and Ironson conclude that "[a] significant proportion of patients are not taking their medications as prescribed and are not telling their physicians. To facilitate the chance that patients communicate with their physicians, physicians need to ask and, while giving the patients medical information, create a non-judgmental, respectful atmosphere where patients feel comfortable sharing their personal view" (p. 520). The Summer 2006 Tool Box on "Emerging Methods for Motivating Effective Medication Practice" may be of help in this regard.

As for taking medication as prescribed, Nilsson Schönnesson, Diamond, Ross, Williams, and Bratt (2006) monitored a convenience sample of 144 combination antiretroviral therapy recipients in Sweden over a 2-year period. In addition to "dose" adherence (i.e., taking the number of pills that have been prescribed), these investigators measured "schedule" adherence (i.e., following instructions related to the time interval between doses) and "dietary instructions" adherence (i.e., following instructions related to whether each medication is taken with or without food). Nilsson Schönnesson and colleagues found that

61% [of study participants] maintained consistent full-dose adherence throughout baseline and all follow-up visits[, while an] ... equivalent proportion of 100% schedule adherence was 39%. Among patients with dietary instructions, 37% retained consistent adherence at all visits. Only schedule adherence was predicted by baseline data; perceived pressures from medical staff to take HIV medications ..., life stress ..., [antiretroviral therapy] health concerns ..., and [the belief that antiretroviral therapy] prolongs one's life ... predicted reduced schedule adherence over time. Perceived medication pressures from those close to the patient ..., [PTSD] symptoms ..., and adherence self-efficacy ... predicted positive schedule adherence over time. These results clearly illustrate difficulties in sustaining [antiretroviral therapy] adherent behaviour, in particular schedule and dietary restrictions, over time and thus emphasize ... the importance of multiple periodic assessments of all three types of adherence. Interventions aimed at improving schedule adherence should in particular focus on psychological and cognitive factors. (p. 407)

On this point, Johnson, Elliott, Neilands, Morin, and Chesney (2006) interviewed a convenience sample of 545 adults living with HIV to test "an explanatory model of HIV medication adherence using a social problem-solving (SPS) framework" (p. 355). Johnson and colleagues found that "[a] constructive problem-solving style was associated with a more optimal psychological adjustment and a greater likelihood of adhering to recommended regimens. A dysfunctional problem-solving style was associated with poorer psychological adjustment, which was associated with compromised adherence. Overall, ... [this] model accurately classified 97% of the cases as adherent or nonadherent, representing a vast improvement on other attempts to predict adherence" (pp. 360-361).

According to the investigators, "SPS is an attractive model for studying adherence to HIV medications because problem-solving interventions can be effectively provided in individual ... and group formats ... . SPS interventions can also be adapted for use in brief interactions in primary care clinics ... and in ongoing telephone sessions with low-cost service providers ... . Problem-solving interventions appear to be particularly useful in promoting optimal adjustment, alleviating distress, and reducing relapse among persons with chronic health conditions ..." (p. 361). Johnson and colleagues further suggest that "SPS interventions can be modified for use with HIV+ populations to include problems specific to HIV that may contribute to psychological distress such as stigma, loss of social support, challenges of health care decision making, and fears over transmission of HIV to others. ... If effective, such interventions would offer clinicians a strategy for improving psychological well-being and medication adherence among individuals with chronic illness such as HIV" (p. 361).

Rintamaki, Davis, Skripkauskas, Bennett, and Wolf (2006) evaluated the relationship between concern over the threat of HIV-related social stigma and self-reported treatment adherence among 204 people living with HIV in two different settings: one serving an urban/suburban population in Chicago, Illinois, and the other serving a rural population in Shreveport, Louisiana. The investigators report that "[n]early one third of the patients in ... [this] sample were less than 100% adherent to their HIV medication regimen within the past 4 days, and approximately 1 in 5 patients reported high concern for stigma related to their HIV status" (p. 364). Across the two locations, "[p]eople with high HIV stigma concerns were 2.5 times less likely to define and interpret the meaning of CD4 count correctly and 3.3 times more likely to be nonadherent to their medication regimen than those with low concerns. Concern over revealing HIV status was the only statistically significant, independent predictor of adherence in multivariate analysis" (p. 359). Consequently, Rintamaki and colleagues recommend that

care providers ... address stigma-related issues when counseling patients before they are placed on an antiretroviral regimen. When possible, providers may want to consider prescribing ... inconspicuous regimens [i.e., those that require fewer dosages or that do not require medication consumption in less-than-private environments] for those most sensitive to HIV stigma[, as this] may ultimately improve the proper usage of these medications among this group. In addition, psychosocial interventions should be identified that offer stigma-afflicted patients additional social support and resiliency training to mitigate the negative treatment impact of stigma. (p. 365)

Boarts, Sledjeski, Bogart, and Delahanty (2006) assessed 57 adults living with HIV (82% male, 44% African American) for PTSD and depression symptoms and took measures of antiretroviral adherence and HIV disease markers (CD4 cell count and viral load) at baseline and again approximately 3 months later. "Symptoms of PTSD and depression were common, with almost half of the participants likely meeting diagnostic criteria for at least one of the two disorders and 36.8% potentially meeting diagnostic criteria for comorbid PTSD and depression" (p. 259). Notably, this study

is the first to prospectively examine the impact of comorbid PTSD and depression symptoms on adherence levels and HIV disease markers among [people living with HIV]. Results ... [indicated that] comorbid PTSD and depressive symptoms were related to lower adherence levels ... and a higher likelihood of having a detectable viral load. ... [B]oth PTSD and depression symptoms were associated with poor adherence, although depression symptoms were also directly predictive of lower CD4 counts and higher likelihood of having detectable viral load. These findings highlight the prevalence of PTSD and depression symptoms in [people living with HIV] and reinforce the necessity of addressing psychological symptoms in treatment and adherence interventions. Further, the high prevalence of comorbid symptomatology suggests that focusing on independent diagnoses may not adequately portray the extent to which clinical symptoms may alone and comorbidly affect disease status. (p. 260)

Similarly, the importance of addressing psychosocial needs in support of antiretroviral use and adherence cannot be overemphasized. Reif, Whetten, Lowe, and Ostermann (2006) investigated the relationship between various unmet psychosocial needs (including housing, emergency food/clothing, supplemental nutrition, support groups, counseling, legal assistance, and financial assistance/benefits) and antiretroviral use and adherence among 526 adults receiving HIV care in the southeastern United States.

Most participants (84.5%) reported at least one service need in the past year. Nearly half (47%) of participants with service needs reported that at least one need was not met. Participants with one or more unmet needs were less likely to be taking any HIV medications ... and reported poorer medication adherence ... . The specific unmet needs for benefits (including Social Security, health insurance and prescription coverage) ... and a support group ... were associated with being less likely to be taking any HIV medications. Unmet need for mental health-related counseling was associated with poorer medication adherence ... . Study findings regarding the high level of unmet need and the association of unmet need with poorer outcomes illustrate the importance of interventions to address these needs. (p. 277)

Case managers often serve as a conduit to psychosocial services. Kushel et al. (2006) monitored a probability-based community sample of 280 homeless and marginally housed adults living with HIV in San Francisco over a 15-month period. The investigators found that "having [case management] was independently associated with improved adherence to [antiretroviral therapy] and improved CD4 ... cell count. ... [Case management] was not associated with changes in health services use; it was associated neither with an increased rate of receipt of primary care nor with reductions in emergency department use or hospitalizations" (pp. 239-240). Kushel and colleagues note that, "[w]ithout a randomized trial, ... [it] cannot [be] state[d] that there was a causal association between [case management] and improved outcomes" (p. 240), but suggest, on the basis of these findings, that "case management "may be an effective way to improve health outcomes among disenfranchised HIV-infected populations" (p. 241).

In Seattle, Washington, Frick, Tapia, Grant, Novotny, and Kerzee (2006) conducted a retrospective cohort analysis involving 261 recipients of HIV primary care who were either administered the highly active antiretroviral therapy (HAART) Protocol (n = 109) or were part of a historical control group (n = 152).

Per clinic policy, once the patient and his/her provider begin the discussion to initiate antiretrovirals ..., the patient is referred to the HAART Protocol and one-on-one appointments with a pharmacist, dietician, and social worker are scheduled. During the allied health appointments, each discipline provides education, assesses patient readiness to begin HAART, and identities and offers solutions for any potential barrier to successful HAART adherence. ... Each discipline documents the content of his/her interaction with the patient on the patient's HAART Protocol routing form and recommends to the provider whether the patient is ready to begin HAART or needs additional time to resolve barriers prior to initiation. After completion of appointments, providers review the comments/suggestions from each discipline and initiate medication if deemed appropriate. (pp. 512-513)

In 12-month comparisons made between clients receiving the HAART Protocol and clients in the control group, the former continued on HAART longer than the latter (> 360 days vs. 210 days), with 55% continuing on HAART for the full year; only 43% of control group participants continued on HAART for the full year. Similarly, clients receiving the HAART Protocol experienced a greater reduction in viral load over the 12-month period than clients in the control group.

The protocol identified potential barriers, such as concern over side effects, mental health diagnosis, active alcohol or drug use, or unstable housing situations, ... offering opportunity for solution implementation prior to initiation of medications, thus potentially leading to the prevention of early discontinuation. These above effects are most evident by the large proportion (nearly 15%) of patients in the control group stopping medications after their first [pharmacy] fill, whereas this phenomenon does not occur among the protocol group ... . Implementing periodic adherence assessments over time, especially early on (e.g., first 2 to 4 months on therapy) could prove useful for expanding the utility of this intervention by addressing new adherence barriers as they present themselves and preventing further therapy discontinuation over time.

In addition, the effect of the Protocol is greatest among those patients with viral loads 100,000 copies per milliliter or more. This may suggest that patients at high risk of disease progression respond to and are more greatly motivated by the education received from allied health professionals about their disease status and the importance of medication adherence than those with lower viral loads. (pp. 517-518)

In short, according to these investigators, "[t]he effect of the intervention may be both to keep people on medication longer who would otherwise stop, and to help people at highest risk of disease progression to better adhere. ... [T]his study provides strong evidence that a multidisciplinary intervention can improve duration on therapy and reduce viral load" (pp. 520, 522).

These findings may be contrasted with findings from a pilot study conducted in Houston, Texas. Visnegarwala et al. (2006) "evaluated a novel strategy of weekly delivery of medications (Directly Delivered Therapy: DDT) for six months using an outreach worker (ORW), among [antiretroviral-]naïve indigent women starting HAART and compared the 'during intervention' and 'post-intervention' outcomes to the health care team (a nurse educator, a case worker, a pharmacist and social worker/drug addictions counsellor) based approach termed Adherence Coordination Services (ACS) and the Standard of Care (SoC) historical referent group" (p. 332). The three groups had comparable baseline characteristics and were monitored over a period of 14 months. Visnegarwala and colleagues report that "[t]he proportion of women who achieved sustained virologic suppression in [the] 4-8 month period for DDT ...[,] ACS and SoC groups were 86% (18/21) ... 54% (6/11) ... and 36% (8/22) ...; and in the 10-14 month period were 80% (12/15) ... 54% (6/11) and 45%(10/22) ... . Retention rate in the DDT was 87%, and 92% of 307 ORW visits were kept, and post-intervention satisfaction was high" (p. 332). The investigators conclude that "[s]hort-term weekly delivery of medications using a community based liaison is a feasible, acceptable and a cost-effective strategy for improving both short-term and perhaps long-term adherence among women initiating their first HAART regimen" (p. 332).

[a] 2-arm, randomized, controlled trial [to] evaluate ... the efficacy of a community-based, home-visit intervention to improve medication adherence. Participants were 171 HIV-infected adults prescribed a minimum of 3 antiretroviral agents. The majority had a past or current history of substance abuse[, often with co-occurring mental illness]. Subjects were randomly assigned to receive home visits [by a nurse and peer support worker] for 1 year or usual care. Medication adherence was assessed with Medication Event Monitoring stem caps at 3-month intervals from randomization through 3 months after the conclusion of the intervention. (p. 314)

Williams and colleagues found that a larger proportion of those receiving home visits demonstrated antiretroviral adherence greater than 90% when compared with those in usual care at each point of measurement beyond baseline. Although a statistically significant intervention effect on viral load or CD4 cell count was not noted, a statistically significant association between antiretroviral adherence greater than 90%, regardless of treatment arm, and an undetectable viral load over time was noted. The investigators point out, however, that "although a consistently larger proportion of subjects in the intervention group demonstrated greater than 90% adherence, most subjects in both groups failed to achieve this important milestone. Therefore, the intervention, although effective, was not universally so. In future studies, it will be important to determine if there are specific individuals for whom this type of intervention is more or less effective and which specific elements of the intervention exert the most powerful effect on adherence behavior" (p. 319).

On this same note, Wagner et al. (2006) conducted a three-arm, randomized, controlled trial involving 199 antiretroviral therapy recipients at five California HIV primary care clinics. The investigators developed a cognitive-behavioral adherence intervention

based on the information-motivation-behavioral skills (IMB) model of behavior change … . The intervention components include providing education about HIV, [antiretroviral therapy] and the importance of adherence, tailoring the regimen to the person's daily routine, using problem-solving skills to overcome identified adherence barriers, reframing beliefs and attitudes about treatment to increase adherence self-efficacy, and facilitating positive social support for adherence. ... [This] intervention is distinctive in including a 2-week, pre-[antiretroviral therapy] placebo practice trial that simulates the challenges of [antiretroviral therapy] adherence, with the exception of treatment side-effects. (p. 1296)

Study participants were assigned either to this five-session intervention, to a five-session intervention that substituted mental rehearsal for the placebo practice trial, or to usual care. The investigators found that either of the

cognitive-behavioral intervention[s] evaluated in this study helped patients take at least 90% of prescribed doses in the initial weeks following the completion of the intervention, and to take doses on time. Intervention patients sustained a mean adherence level of 90% or more for 24 weeks, and a large majority maintained this adherence level throughout the study. The nearly 10% difference in mean adherence between the groups at week 24 was statistically significant; however, ... [no associations with viral load or CD4 cell count] were found ... . Adherence rates generally remained high across all groups, with few group differences beyond week 4. Therefore, as in other published controlled trials of [antiretroviral therapy] adherence interventions, the effects on adherence observed in this study were modest and relatively short-term ..., and no effects were found with regard to virologic and immunologic outcomes ... . (p. 1300)

Wagner and colleagues conclude that

the front-loaded cognitive-behavioral intervention had modest, transient effects in improving antiretroviral adherence, and no effects on viral load and CD4 cell count. For effects to be more robust and durable, interventions may need to vary the amount of training, and perhaps the nature of the training strategy as well, utilizing the full armament of adherence enhancing strategies (e.g., cognitive-behavioral counseling, beeper/alarm reminders, directly observed therapy) depending on the needs of the patient. Accordingly, a practical and accurate method to assess the patients' need for adherence intervention would be of great value.4 (p. 1301)

The last word on the topic of antiretroviral adherence (for this issue of the newsletter, at least) goes to Rueda et al. (2006) of the highly respected Cochrane Collaboration, which conducted a systematic review of research literature published between January 1996 and May 2005 on the effectiveness of patient education and support to improve adherence to HAART.

This review identified 19 studies involving a total of 2,159 participants that evaluated an intervention intended to improve adherence. Ten of these studies demonstrated a beneficial effect of the intervention. We found that interventions targeting practical medication management skills, those administered to individuals vs groups, and those interventions delivered over 12 weeks or more were associated with improved adherence to antiretroviral therapy. We also found that interventions targeting marginalized populations such as women, Latinos, or patients with a past history of alcoholism were not successful at improving adherence. We did not find studies that evaluated the quality of the patient-provider relationship or the clinical setting. Most studies had several methodological shortcomings. (p. 2)

Coping, Social Support, & Quality of Life

Drawing on findings from their multi-year study of adolescent children of parents living with (or having died from) AIDS who had been randomly assigned to either a time-limited, family-based, cognitive-behavioral, skill-focused intervention or standard care, Rotheram-Borus, Stein, and Lester (2006) assessed predictors of adolescent adjustment 3 and 6 years after this intervention was originally implemented. The investigators neatly summarize the results as follows:

Protective factors: Youth in the intervention condition reported significantly less substance use three and six years later. In addition, positive parental bonds reported at baseline reduced emotional distress at three years and increased positive future expectations [in the realms of developing stable, supportive romantic partnerships and attaining academic and career goals] at six years. Risk factors: Substance use at three years predicted heightened sexual risk behaviors, continued substance use, and lower future expectations at six years. Early emotional distress and being Latino predicted increased emotional distress at three years. Parental death by three years predicted more sexual risk behavior and lowered future expectations at six years. (p. 174)

Rotheram-Borus and colleagues conclude that this time-limited intervention "demonstrated both direct and indirect benefits on adolescent adjustment that persist into early adulthood, especially in decreasing substance use over time. Youth who lose a parent to HIV illness are at greater risk for adjustment problems as they enter young adulthood, whereas the protective effect of positive parent-child bonds on youth emotional distress, sexual risk-taking, and future expectations suggests the potential role of interventions that enhance developmentally appropriate parent-child interactions" (p. 181).

demonstrated significantly fewer behavioral symptoms and tended to have better cognitive outcomes and more enriched home environments than did grandchildren in families coping with HIV who did not receive an intervention. Although current HIV policies focus primarily on antiretroviral therapies for persons living with HIV, the importance of providing preventive psychosocial interventions for families coping with HIV is highlighted by these findings. The specific mechanisms leading to better grandchild adjustment are not illuminated by this study. Even if it is generic to suggest better adjusted daughters parent better adjusted infants, the findings suggest long-term benefits for preventive interventions with families coping with HIV. Rather than HIV creating a negative spiral for families' adjustment, interventions can serve to mobilize families to improve the quality of their lives. (p. 626)

In their first longitudinal analysis of data emerging from a randomized, controlled trial of a group coping intervention for AIDS-related bereavement 5, Hansen et al. (2006) examined data drawn from a diverse sample of 267 men and women living with HIV who had lost one or more loved ones over the preceding 2-year period. These individuals were randomly assigned to one of two conditions. The intervention condition consisted of a 12-week bereavement coping group intervention conducted in 90-minute sessions and tailored to gender, ethnicity, and sexual orientation. "The group ... format combined semi-structured cognitive-behavioral and support group approaches. ... Specific strategies for dealing with problems of grief included: (a) establishing a sense of control and predictability; (b) anger expression and management; (c) resolution of guilt; (d) promoting self-mastery through empowerment; and (e) development of new relationships" (pp. 618-619). The comparison condition consisted of individual psychotherapy and psychiatric services on demand (the community standard-of-care). Measures of grief, psychiatric distress, quality of life, and coping were administered at baseline, 2 weeks following the intervention, and in 4-, 8-, and 12-month follow-up assessments.

The coping theory informing the study intervention proposes that although maladaptive coping strategies do not cause the grief and distress associated with AIDS-related bereavement, they can serve to exacerbate distress and prevent or delay adaptation to bereavement. Through the development of more adaptive coping strategies, ... [the coping] intervention aims to diminish stress, including grief and psychiatric distress. The present study had the dual aim of evaluating the longitudinal effects of active and avoidant coping on grief, psychiatric distress, and quality of life; and testing the ability of a group coping intervention to influence these longitudinal effects by enhancing the positive effects of active coping and diminishing the negative effects of avoidant coping. (pp. 626-627)

Indeed, Hansen and colleagues found that "[c]oping strategies directly impacted all outcome variables for both study conditions. Additionally, the coping intervention moderated the relationship between avoidant coping and the longitudinal course of grief and psychiatric distress, resulting in greater reductions in grief and distress for intervention participants after accounting for avoidant coping strategies" (p. 609). The investigators conclude that "cognitive-behavioral group interventions focused on coping enhancement can decrease avoidant coping strategies, thus accelerating the adaptation to grief for AIDS-bereaved people living with HIV, a group at increased risk for complicated grief" (p. 630).

Lastly, Bormann et al. (2006) "examined the efficacy of a psycho-spiritual intervention of mantram repetition – a word or phrase with spiritual associations repeated silently throughout the day – on psychological distress (intrusive thoughts, stress, anxiety, anger, depression), quality of life enjoyment and satisfaction, and existential spiritual well-being in HIV-infected adults" (p. 359). The investigators randomly assigned 93 study participants to either a mantram (n = 46) or attention control group (n = 47). Measurements were taken at baseline, week 5, week 10 (at the conclusion of the intervention), and week 22. Over this period, "the mantram group improved significantly more than the control group in reducing trait-anger and increasing spiritual faith and spiritual connectedness. Actual mantram practice measured by wrist counters was inversely associated with non-HIV related intrusive thoughts and positively associated with quality of life, total existential spiritual well-being, meaning/peace, and spiritual faith" (p. 359). Bormann and colleagues conclude that "a mantram group intervention and actual mantram practice each make unique contributions for managing psychological distress and enhancing existential spiritual well-being in adults living with HIV/AIDS" (p. 359).

– Compiled by Abraham Feingold, Psy.D.

__________

 1 Behavioral format: "The extent to which one has communicated or insisted on safer sex with a sexual partner" (p. 371). Intentional format: "The extent to which one plans on communicating about or insisting on safer sex with a sexual partner" (p. 371). Self-efficacy format: "One's perceived ability to communicate about or insist on safer sex with a sexual partner" (p. 371).

 2 Two additional papers emerging from this study are summarized under "Coping Strategies, Social Support, & Quality of Life," below.

 3 A recent review on the topic of treatment readiness (Nordqvist, Södergård, Tully, Sönnerborg, & Lindblad, 2006) is highlighted in this issue's Tool Box on "Resources."
 
 4 See Amico et al. (2006) and Simoni et al. (2006), highlighted in this issue's Tool Box on "Resources."

 5 Cross-sectional studies involving bereaved, HIV-positive men and women that were previously conducted by this research group may be found in the Summer 2003, Summer 2004, Summer 2005, and Fall 2005 issues of mental health AIDS.

Indicates this file is in Adobe PDF format and requires the Adobe Acrobat Reader program.

Disclaimer Privacy Policy Accessibility Department of Health and Human Services