mental health AIDS

Fall 2007 Newsletter / Volume 9, Issue 1

HIV Treatment News

Psychiatric/Psychological/
Psychosocial/Spiritual Care

Adherence to Treatment

In a prospective, longitudinal study, British investigators (Horne, Cooper, Gellaitry, Date, & Fisher, 2007) tested the utility of the necessity-concerns framework11 in predicting acceptance of and adherence to HAART. A total of 136 study participants, predominantly white gay men, were given a recommendation by their physicians to initiate HAART. Of these men, 38 (28%) declined the offer of treatment, and 98 (72%) accepted the treatment that was offered. Study participants were reassessed 12 months after joining the study. Horne and colleagues found that "[u]ptake of HAART was associated with perceptions of personal necessity for treatment ... and concerns about potential adverse effects ... . There was a significant decline in adherence over time. Perceived necessity ... and concerns about adverse effects ..., elicited before initiating HAART, predicted subsequent adherence. These associations were independent of clinical variables and depression" (p. 334). The investigators conclude that

[t]he necessity-concerns framework may be used to inform interventions facilitating informed choice and supporting optimal adherence to HAART. Patients' perceptions of necessity and concerns about HAART should be elicited and addressed after a clinically indicated treatment recommendation. Interventions to support informed decision making and adherence should ensure that all patients have an accurate description of the medical model of HIV, including the ways in which the CD4 cell count is used as a marker of disease progression and the action of anti-HIV medication. Clinicians and researchers should also be sensitive to the fact that many patients have experienced earlier treatments for HIV that were later found to be ineffective or have seen others experience problems with antiretroviral treatment and, as a result, may be suspicious of current medical advice. ... In the current study, having previously stopped therapy was associated with low adherence. Many patients stop therapy because of side effects, ... indicating that adherence in this group may be enhanced by more proactive management of side effects. (p. 339)

Similarly, in Sweden, Södergård et al. (2007) analyzed data for a nationwide, cross-sectional survey of 828 adults who were prescribed antiretrovirals. The purpose of this study was to assess the role of readiness in maintaining antiretroviral adherence. Using a structural equation modeling approach, the investigators identified "readiness as a distinct factor that influences adherence and hence treatment outcome" (p. 108). Although this approach "could not rule out that other models might also fit the data equally well" (p. 108), "[b]ased on ... [these] results, ... it seems appropriate to shift focus from adherence to readiness, especially in conditions where treatment can be postponed such as antiretroviral treatment. The benefits of readiness compared to adherence are that readiness might be measured prior to treatment initiation and could, as a result, predict if a patient is ready to become adherent and hence predict future treatment outcome" (p. 114).12

Support for adherence may also be derived from finding meaning in one's life. Westling, Garcia, and Mann (2007) asked 41 low-income women living with HIV to participate in a writing task twice weekly over a period of 1 month. Participants were randomly assigned to either "write about the best future they could imagine" (p. 629), or to write about a neutral topic (i.e., not about their expectations regarding the future). Antiretroviral adherence was self-reported at baseline (Time 1) and again at the conclusion of the intervention (Time 2). Westling and colleagues

found that individuals who were able to discover meaning in their lives reported better adherence to their HIV medications than individuals who were not able to discover meaning in their lives. Nineteen of 40 participants13 were coded as having at least one discovery of meaning statement in their writing, and these individuals were significantly better at following their HIV medication regimens at Time 2. The size of these effects is small to moderate, but ... finding meaning was associated with adhering to medications 'most' of the time, while failing to find meaning was associated with adhering only 'some' of the time. (p. 633)

Additionally,

participants who were engaged in cognitive processing were more likely to demonstrate discovery of meaning than participants who were not engaged in cognitive processing. All of the participants who were coded as having discovered meaning also showed cognitive processing. In addition, ... [the investigators] predicted that optimistic individuals would be more likely to find meaning during the writing task, and ... this [was also found] to be true. Higher situation-specific optimism and higher dispositional optimism at baseline were related to participants' discovery of meaning during the writing task. (p. 634)

Westling and colleagues conclude that the "[d]iscovery of meaning may result in positive health outcomes by leading individuals to engage in healthier behaviors" (p. 627).

Access to Care

Gardner et al. (2007) "examine[d] psychological and behavioral variables as predictors of … [visiting] an HIV medical care provider among [273] persons recently diagnosed with HIV" (p. 418) in four U.S. cities. Data analysis revealed that "seeing a care provider was significantly more likely among participants diagnosed with HIV within 6 months of [study] enrollment ..., those in the preparation versus precontemplation stages at baseline ..., those who reported at baseline that someone (friend, family member, social worker, other) was helping them get into care ..., and those who received a case manager intervention ..." (p. 418).

For HIV case management professionals, ... [these] findings indicate that cognitive state of readiness, time since HIV diagnosis, ... and interpersonal helping relationships are all important to assess when working with people with HIV. Most of these variables are susceptible to intervention. The data also indicate a need to reach HIV positive persons soon after they learn they are infected and assist them in getting into care. Furthermore, assessing the person's readiness to enter care is an important first step in establishing a client plan. ... Clients who are assessed as low on readiness should be asked questions to elicit underlying attitudes and motivational states, as well as knowledge about HIV and its treatment that may influence their state of readiness. This information can be turned into an action plan. Similarly, some of the behaviors that deter getting into care can be intervened on if case managers are available. ... [For example,] family or friends can be enlisted to assist clients in obtaining care ... by ... providing brief strengths-based case management to persons recently diagnosed with HIV. (pp. 423-424)

Tobias et al. (2007) interviewed a geographically diverse sample of 1,000 people living with HIV, not newly diagnosed and not fully engaged in medical care. "The sample was predominantly non-white (86%), male (59%), and unstably housed (61%), with a past history of cocaine use (68%). Twelve percent had received no HIV medical care in the 6 months prior to the interview" (p. 426).

The investigators found that "[t]hose with no care were similar to those who received some HIV care in sociodemographic characteristics, but in multivariate analysis were less likely to have a case manager ... or use mental health services ..., had lower mental health status scores ..., were more likely to be active drug users ..., had greater unmet support service needs ... and reported that health beliefs were a barrier to care ..." (p. 426).

Tobias and colleagues conclude that "interventions may need to provide more intensive case management and address barriers to the receipt of mental health care and support services. Furthermore, ... interventions to engage the unengaged need to address people's health beliefs about HIV care by delivering information about the benefits of care and treatment in such a manner that this information can be received, processed, trusted, and acted upon" (p. 433).

Coping, Social Support, & Quality of Life

In their continuing effort to clarify the association between various clinical and psychosocial factors and health-related quality of life (HRQOL) at different points in time, Jia et al. (2007) have reported once again on their analysis of data elicited at baseline and 12 months later from a cohort of 197 men receiving HIV medical care in north Florida. The investigators

found that increased active coping and social support remained strong predictors of multiple dimensions of HRQOL improvement; more comorbid conditions and longer HIV infection duration were predictive of decreases in multiple dimensions of HRQOL over time. CD4 cell count was significantly associated with emotional well-being at baseline and 12 months. In addition, the association between CD4 cell count and five HRQOL dimensions was negative at baseline but positive at 12 months. These results suggest that to improve the HRQOL of men with HIV infection over time in the HAART era, continuous effort is important in enhancing active coping strategies and social support, improving the management of comorbid conditions of HIV/AIDS, and in assessing ... HIV diagnosis duration. The results also suggest that patients' CD4 cell count has a differential effect on HRQOL depending on the patients' frame of reference and the patients' current goals. Clinicians cannot assume that low CD4 cell count will automatically lead to poorer HRQOL. Rather, clinicians should explore the meaning that patients attach to various levels of CD4 cells and recognize the importance of the patients' psychosocial characteristics and other clinical factors when making clinical decisions and initiating treatments. (p. 967)

One factor receiving greater attention in HIV care is the smoking of tobacco. Webb, Vanable, Carey, and Blair (2007) examined the self-reported prevalence and correlates of cigarette smoking among 212 adult men and women receiving care in an HIV clinic. The investigators found that

74% of the sample smoked at least one cigarette per day; using standard definitions, 23% of the sample were light smokers, 22% were moderate smokers, and 29% smoked heavily. Smoking was associated with more HIV-related symptoms, greater alcohol and marijuana use, and less social support. Light smoking was related to minority race/ethnicity and less income; moderate smoking was associated with less education; and heavy smoking was related to less education and younger age. Viral load, CD4 count, and depression14 were not associated with smoking status. (p. 371)

Webb and colleagues acknowledge that

[t]he findings from this study need to be tested longitudinally before definitive clinical practice recommendations can be made. Until that time, these results have initial implications for smoking cessation interventions. First, clinicians should assess HIV+ patients for the presence of multiple factors that may place them at increased risk for smoking ... [and] educate HIV+ patients on the consequences of tobacco use. The present research also suggests that targeting heavy alcohol use and marijuana smoking may be an important intervention component. Finally, healthcare providers ... should encourage patients to seek social support, which could help heavy smokers manage their response to diagnosis. ... Future research should ... work towards developing biopsychosocial interventions that consider the unique needs of this underserved group. (p. 380)

On this point, French investigators (Bénard et al., 2007) collected self-report data on tobacco/other drug use, nicotine dependence, motivation to stop smoking, and depressive symptoms from a cohort of men and women receiving outpatient HIV care.

Among 509 patients included, mean age was 44 years, 74% were men, 19% were infected through injection drug use, and 257 (51%) were regular smokers (at least one cigarette per day). Among them, 60% had a medium or strong nicotine dependence ..., 40% were motivated to quit smoking and 70% had already tried at least once. ... [A medium or strong nicotine dependence] was more frequently reported in the 146 smokers (62%) with depressive symptoms compared to other smokers (70% versus 48%). Fifty-five regular smokers (23%) were codependent on cannabis and 31 (12%) ... [on] alcohol. Overall, only 35 (14%) regular smokers were motivated, non-codependent, without depressive symptoms, and could be proposed a standard tobacco cessation program. (p. 458)

On the basis of these findings, the investigators conclude that "HIV-infected regular smokers can be dispatched in three main categories: those who could benefit from standard tobacco cessation programs, with a management of depressive symptoms if needed, those who need a treatment of codependencies prior to smoking cessation and those who first need motivational interventions" (p. 467).

Bénard and colleagues take particular note that "[d]epressive symptoms were highly prevalent in this representative population of HIV-infected patients. To be successful, smoking cessation interventions should be specifically built to take into account depression and codependencies in addition to nicotine dependence and motivation" (p. 458).

McKee et al. (2007) "examine[d] interactions between psychosocial risk (i.e., maternal depressive symptoms) and protective (i.e., child coping skills and mother-child relationship quality) correlates of depressive symptoms" (p. 259) among 108 African American children between the ages of 9 and 11 whose mothers were either living with HIV (n = 46) or were not HIV infected (n = 65). The investigators found

that the risk and resource factors ... studied do [appear to] operate differently in the families in which mothers are and are not HIV infected. Specifically, the mother-child relationship was a buffer when maternal depressive symptoms were elevated, but only when mothers were HIV infected. Furthermore the combination of a better mother-child relationship and more active child coping skills was associated with fewer child depressive symptoms, but again only when mothers were HIV infected. These findings suggest that a family-based approach that targets children whose mothers are infected with HIV/AIDS could include enhancing the mother-child relationship (e.g., teaching attending, praising, and positive communication skills), promoting child coping skills (e.g., use of distraction, positive thinking, and acceptance) to handle uncontrollable stressors (e.g., maternal HIV infection), and ameliorating maternal depressive symptoms (e.g., through the scheduling of pleasant activities and completion of thought records). More important, none of these strategies necessarily require[s] maternal disclosure of the mother's HIV/AIDS to her child; rather, for example, activities involving the child could be conducted with a more general focus, such as how to cope with a mother's depressive symptoms and the changes in parenting behavior that may occur over time. The aim of such a general approach would be to enhance overall parenting skills, coping skills, and child and maternal adjustment to help a child adjust to the short- and long-term consequences of maternal HIV infection. (p. 265)

Speaking to a key consequence of infection, Chenard (2007) identified ways in which stigma affects the self-care behaviors15 of gay men living with HIV by examining data drawn from 15 individual interviews and a focus group with five men. According to Chenard, "[t]hese men responded to HIV/AIDS stigma by using various stigma management strategies. Striving for normalcy emerged as the central theme. Participants saw HIV status disclosure as the main route to an affirming social support system and ultimately as a way to resolve any incongruence between self-view and reflected appraisals" (p. 23). In Chenard's view, clinicians

can play a key role in evaluating clients' emotional responses to HIV/AIDS and their use of effective coping strategies. Asking the person to "tell me how you are dealing with the social pressures of being a gay man with HIV" acknowledges the presence of stigma in the client's life and encourages him to talk about how stigma affects his ability to self-manage the illness. Given that HIV/AIDS stigma is such an integral part of the illness experience, it may be helpful to think of stigma as a symptom of HIV/AIDS. As such, strategies for managing stigma should be included when teaching clients about self-management skills.

Strong and stable social support networks are important for ameliorating the untoward effects of HIV/AIDS stigma. ... [Clinicians] are well-positioned to facilitate discussion with their HIV-positive gay male clients about the availability of both formal and informal social support networks and to suggest avenues for finding support. ...

[Therapists working with] HIV-positive gay men can help them make informed decisions about the risks and benefits of status disclosure. HIV-positive gay men who feel heavily stigmatized and use more hiding strategies will likely experience increased stress and risk[,] closing off access to the social support needed to facilitate adaptation to the illness. The model presented here can be used to frame a discussion with clients about how stigma management is integrally related to the goal of having a life of normalcy. (p. 31)

Lastly, previous studies have associated a number of psychosocial factors (e.g., depression, life stress, avoidant coping) with HIV disease progression. O'Cleirigh, Ironson, Weiss, and Costa (2007) "examined the relationship between the Big Five Conscientiousness factor16 and HIV disease progression (CD4 cell and viral load) over 1 year in 119 seropositive participants" (p. 473) who were diverse with regard to gender, ethnicity, sexual orientation, and socioeconomic status. The investigators "also examined whether Conscientiousness effects were mediated by adherence, perceived stress, depression, or coping measures" (p. 473). "[C]ontrolling for demographic variables, initial disease status, and antiretroviral medications[,] ... Conscientiousness predicted significant increases in CD4 number and significant decreases in viral load at 1 year. Conscientiousness was related positively to medication adherence and active coping and negatively to depression and perceived stress. Only perceived stress emerged as a possible mediator" (p. 473).

On the basis of these findings, O'Cleirigh and colleagues speculate that "lower Conscientiousness may be a risk factor for accelerated disease progression in people living with HIV" (p. 478) and

suggest that measuring Conscientiousness in people with HIV could help to identify those who may be ... in need of additional support in the management of HIV. The observed relationship of Conscientiousness with perceived stress particularly, but also with medication adherence, depression, and coping, may also suggest appropriate targets for psychosocial interventions. As the Conscientiousness assessment in this study is brief, it could easily be incorporated in primary medical care and other outpatient clinical settings.17 Although Conscientiousness is not generally conceptualized as a modifiable trait, coping, stress appraisal, depressive symptoms, and adherence have each been shown to be responsive to cognitive-behavioral interventions specifically designed for people facing the challenges of living with HIV ... and may be good targets for intervention among patients with HIV who are low in Conscientiousness. (pp. 478-479)

– Compiled by Abraham Feingold, Psy.D.

 11 "Research in a variety of chronic illnesses suggests that the salient beliefs relating to patients' medication decisions can be grouped under 2 categories: perceptions of necessity or personal need for treatment and concerns about potential adverse effects. ... [T]his 'necessity-concerns' framework ... [may be used by] clinicians to elicit and address key beliefs underpinning patients' attitudes and decisions about treatment" (p. 335).

 12 In a recent article, Highstein, Willey, and Mundy (2006) describe the development of Stage of Readiness and decisional balance instruments that are based on the Transtheoretical Model of Behavior Change. "Use of these instruments can give a provider added objective data on which to base a decision to either prescribe [antiretroviral therapy] immediately or to first implement an intervention tailored to enhance this patient's readiness to adhere" (p. 563). Readers are also referred to the Tool Box entitled "Emerging Methods for Motivating Effective Medication Practice" in the Summer 2006 issue of mental health AIDS for a discussion of approaches that may enhance treatment readiness.

 13 One participant in the control condition did not turn in her writing assignments for analysis.

 14 "Symptoms of depression were substantial, despite the exclusion of somatic items to eliminate the overlap with HIV symptoms. With the focus on cognitive-affective depression, there was a high prevalence of depressive symptoms in ... [this] sample[.] ... Thus, the high rates of depression might have obscured the actual influence of depression on smoking rates (i.e., creating a restricted range)" (pp. 379-380).

 15 "For the purpose of this study, self-care was defined as any independent, self-determined behavior that had a direct or indirect impact on physical or mental health, such as health maintenance, health promotion, or disease prevention behaviors (primary or secondary); self-treatment behaviors; adherence to prescribed or recommended treatment interventions; and any behaviors that … [militate against] negative health sequelae or those that enhance health status ..." (p. 25).

 16 "The Five-Factor Model (FFM) of personality is the predominant model of personality traits, positing that five domains – Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness – summarize most individual differences in personality[.] ... Within the Conscientiousness domain, six facets have been operationalized ..., which include competence, order, dutifulness, achievement striving, self-discipline, and deliberation. ... Conscientiousness has both proactive (e.g., need for achievement) and inhibitive (e.g., cautiousness) aspects ... . On the basis of this conceptualization, ... [the investigators] hypothesized that Conscientiousness may be related to slower disease progression through both aspects, with the inhibitive facets of Conscientiousness protecting the individual from engaging in risky or health-damaging behaviors and [the] proactive … [factors helping] through the practice of health-promoting behaviors (e.g., medication adherence), through more favorable coping profiles (e.g., more active and less avoidant coping), and through greater resilience to distress (e.g., less catastrophic disease-related stressor appraisals and lower levels of depressive symptomatology)" (pp. 473-474).

 17 "Conscientiousness was assessed using the self-report version of the 12-item Conscientiousness scale of the NEO-FFI ([NEO Five-Factor Inventory]; Costa & McCrae, 1992)" (O'Cleirigh et al., 2007, p. 475).

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