mental health AIDS

Summer 2006 Newsletter / Volume 7, Issue 4

HIV Treatment News

Psychiatric/Psychological/
Psychosocial/Spiritual Care

Neuropsychological Impairment

Marcotte et al. (2006) administered neuropsychological (NP) testing as well as the Useful Field of View (UFOV), a computerized measure of visual attention, to 42 HIV-positive and 21 HIV-negative study participants. The investigators found that "HIV+ participants performed significantly worse than the HIV- participants on the UFOV, particularly on the Divided Attention subtest. Poor UFOV performance was associated with higher accident rates in the past year, with a trend for NP impairment to also predict more accidents. The highest number of accidents occurred in the group with a 'high risk' UFOV designation and NP impairment; this category correctly classified 93% of HIV+ participants as to who did, and did not, have an accident" (p. 13).

The findings ... suggest that a subset of HIV+ individuals may have visual attentional impairments that put them at high risk for driving accidents. HIV+ participants performed significantly worse than control participants on the UFOV, a measure with demonstrated sensitivity to impaired driving performance. There was a trend for worse performance across all subsets, with the greatest differences seen on the measure of divided attention. Declines in visual attention were not solely the result of advancing disease nor high levels of general cognitive impairment – individuals impaired on the UFOV covered the spectrum of disease stages and severity of cognitive impairment, suggesting a process occurring at least partially independent of disease progression, as well as a cognitive deficit not entirely captured by common NP tests. (p. 23)

Marcotte and colleagues urge clinicians to "attend to visual attention as well as general cognitive status in estimating which patients are at risk for impaired driving" (p. 13). They further speculate that "many individuals could potentially benefit from behavioral treatment for deficient driving skills. Recent evidence indicates that ... speed of processing training may improve performance on the UFOV, and this may transfer to on-road driving performance ... . While it remains to be seen whether the attentional impairments seen in an HIV-infected cohort could be remediated with training, it does offer the hope that perhaps some HIV+ patients could reacquire safe driving skills" (p. 25).

Carey et al. (2006) examined prospective memory (ProM)3 among 42 individuals living with HIV, as well as 29 demographically similar comparison individuals who were not HIV-infected. "The HIV-1 sample demonstrated deficits in time- and event-based ProM, as well as more frequent 24-hour delay ProM failures and task substitution errors4 relative to the ... [comparison] group. In contrast, there were no significant differences in recognition performance, indicating that the HIV-1 group was able to accurately retain and recognize the ProM intention when retrieval demands were minimized" (pp. 536-537).

In light of the prevalence of Task Substitution errors in HIV-1, it might be prudent to incorporate highly explicit and specific task reminders (e.g., a text messaging system that gives explicit instructions, including the name of the particular medication, recommended dosage, and any conditions under which the medication should be taken) when designing remedial medication adherence strategies. Medication adherence efforts might also be enhanced by minimizing the ProM 'load' (e.g., keeping to a minimum the number and complexity of tasks to be completed) for persons with HIV-1. (p. 546)

Adherence to Treatment

As suggested in this issue's Tool Box, "[w]hereas prior research has emphasized individual-level factors associated with HAART [highly active antiretroviral therapy] adherence, recent studies suggest the need to examine interpersonal, social, and structural environmental factors that may affect vulnerable populations' effective HAART use" (Knowlton et al., 2006, p. 486).

To this end, Knowlton and colleagues drew data from a community sample of 466 heterosexually active IDUs living with HIV in four U.S. cities and taking recommended HAART at the time of the study. Within this sample (66% male, 69% African American, 26% recently homeless; median age 43 years), 28% had an undetectable viral load. Furthermore, "[r]esults indicated that among participants on recommended HAART, adjusted odds of viral suppression were at least 3 times higher among those with high emotional support, stable housing, and CD4 > 200; viral suppression was approximately 60% higher among those with better patient-provider communication" (p. 489). On this latter point, "[i]n item-by-item analyses of a scale on engagement with one's healthcare provider, questions most highly associated with undetectable viral load were those pertaining to patient-provider communication and joint decision making, eg, 'My doctor listens to me, answers my questions, involves me in decisions'" (p. 490). Finally, "[o]utpatient drug treatment and ... [African American] race and an interaction between current drug use and social support were marginally negatively significant. Among those with high perceived support, noncurrent drug users compared with current drug users had a greater likelihood of [undetectable viral load]; current drug use was not associated with [undetectable viral load] among those with low support" (p. 486). In short, these results "suggest the major role of social support in facilitating effective HAART use in this population and suggest that active drug use may interfere with HAART use by adversely affecting social support" (p. 486). To promote the effective use of HAART, these findings move Knowlton and colleagues to conclude that

interpersonal support and communication skill building interventions are needed, targeting patients with a recent history of IDU (especially African Americans), their main supportive ties, and their healthcare providers. The results also suggest the need for policies and programs that improve their access to stable housing and to outpatient drug abuse treatment. Such multisectoral interventions may help address the structural and social environmental influences impacting the population's ability to effectively incorporate medication taking into their everyday lives, relationships, and routines. ... (p. 491)

How do positive interactions with health care providers and adherence self-efficacy (i.e., an individual's confidence in his or her ability to adhere) relate to one another and, ultimately, to antiretroviral adherence? Johnson, Chesney, et al. (2006) "hypothesize[d] that positive provider interactions are linked to greater self-efficacy for adherence, which in turn is associated with better [antiretroviral] adherence; specifically, that higher adherence self-efficacy explains the association between provider interaction and adherence" (p. 259). To explore this hypothesis, the investigators utilized a mixture of "[c]omputerized self-administered and interviewer-administered self reported measures of medication adherence, demographic and treatment variables, provider interactions, and adherence self-efficacy" (p. 258) with a convenience sample of 2,765 adults receiving antiretroviral therapy.

Analyzing these data, Johnson and colleagues did, indeed, find that

adherence self-efficacy mediated the relationship between positive provider interactions and medication adherence. This indicates that, statistically, the relationship of provider interactions and adherence can be explained by adherence self-efficacy, suggesting that self-efficacy may be the mechanism of the relationship between the other two variables. The pattern of this relationship was the same regardless of gender, race/ethnicity, [IDU], and site of usual HIV care, suggesting substantial support for this model of adherence. Furthermore, this relationship is maintained when controlling for important demographic variables (age, gender, education), treatment variables (CD4 count, usual source of care), and other factors often linked to adherence (depression, social support, IDU).

These findings have implications for improving adherence self-efficacy such that fostering positive interactions between providers and patients may lead to better medication adherence. ... For example, helping providers create an environment in which the patient feels respected and understood may lead to greater confidence in the patient's ability to stick to a treatment regimen. ... Physician training to increase collaborative negotiation in setting treatment goals and strategies is also likely to bolster adherence self-efficacy. ... Because patient perceptions of stress may undermine self-efficacy for antiretroviral adherence, ... it may also be beneficial to improve patient-physician communication about managing stressful life circumstances that influence medication adherence. Likewise, patient-focused interventions that enhance skills may improve provider/patient visits ... and lead to greater self-efficacy for medication adherence. For example, assertive communication skills, in which the patient is able to respectfully make specific requests of the provider, may facilitate positive interactions. Other strategies by which the patient can influence the interaction with the provider (e.g., making lists of questions for the provider) may have a beneficial impact on the patient-provider interaction and thereby improve adherence self-efficacy. (pp. 263, 265)

Canadian investigators (Veinot et al., 2006) conducted interviews with 34 young people (ages 12-24 years) living with HIV in Ontario to assess their views on, and experience with, antiretroviral treatment.

Four major themes emerged: Treatment knowledge: confusion and skepticism. Many participants did not understand, or believe in, antiretroviral treatment. Some youth on treatment did not understand why they were taking medications. Treatment decision-making: lack of choice and feeling emotionally unprepared. Some youth did not feel that they had choices about treatment, and others did not feel ready to make treatment decisions. Difficulties taking medications. Youth had problems with social routine disruption, feeling "different" and side effects. Many viewed costs of medications as a barrier to treatment. Inconsistent treatment adherence and treatment interruptions, which were common amongst participants. (p. 261)

Drawing on these themes and exercising caution in generalizing these findings to a wider population of youth living with HIV, Veinot and colleagues nonetheless observe that "[d]evelopmentally appropriate education about HIV treatment and youth-specific outreach for social programs may be helpful in facilitating HIV-positive youths' treatment access. Providers may also wish to consider delivering resiliency-based interventions and using empowerment-based approaches to assist youth in becoming involved in treatment decisions. Finally, youth may need specific support for managing adherence and difficulties with treatment" (p. 266).

Serostatus Disclosure

Peretti-Watel et al. (2006) conducted a cross-sectional survey with a nationally representative sample of 2,932 adults receiving outpatient HIV care at French hospitals. The purpose of the survey was to investigate serodisclosure patterns and their relationship to experiences of HIV-related stigma and to HAART adherence. Peretti-Watel and colleagues found that

HIV disclosure patterns were both selective and cumulative: disclosure was more frequent for friends and siblings, while concealment prevailed concerning children, other relatives, and colleagues; but patients who disclosed their seropositivity to one significant other were also more likely to disclose it to other significant others. Patients reporting experiences of discrimination from sexual partners were less likely to be highly adherent [to HAART], and ... [the investigators] also found a significant relationship between uncontrolled disclosure and non-adherence. (p. 254)

Peretti-Watel and colleagues observe that "[p]atients who have opted for concealment probably consider non-adherence and uncontrolled disclosure as competing risks, but among them a significant minority loses on both counts. Counselling provided to HIV-infected people should not separate the adherence and disclosure issues, and adherence interventions should seek to help patients to manage concurrently disclosure/concealment of their seropositivity and its consequences" (p. 254).

In an exploratory study, Wiener and Battles (2006) examined the relationship between serostatus disclosure and interpersonal relationships, psychological functioning, and HIV prevention behavior among 40 perinatally infected youth (ages 13 to 24) living with HIV.

No link was found between the age the participant learned the diagnosis and later psychological distress or degree of romantic disclosure ... [but] greater disclosure ... [was] associated with better psychosocial outcomes, fewer posttraumatic stress symptoms, … and higher peer self-competence. Although preliminary, this study is the first that explored the psychosocial effects of an adolescent's HIV diagnosis disclosure. The web of disclosure is complex and delicate, each disclosure encumbered with consequences. As clinicians, we need to help adolescents build the communication, health care, and general life skills that correspond with their increased survival rates. (p. 309)

Stress Management

Continuing research on a trial introduced in the Spring 2006 issue of mental health AIDS 5, Carrico et al. (2006) randomized 130 MSM living with HIV and receiving HAART to one of two conditions: either a 10-week, cognitive behavioral stress management (CBSM) group offered in conjunction with individualized antiretroviral medication adherence training (MAT) from a clinical pharmacist (CBSM + MAT; n = 76) or a MAT-only condition (n = 54). "Measures of self-reported adherence, active cognitive coping (i.e., acceptance and positive reinterpretation), avoidant coping (i.e., denial and behavioral disengagement), and depressed mood were examined over the 10-week intervention period" (p. 155). "The results … provide support for the efficacy of CBSM + MAT for decreasing depressed mood and avoidant … coping … in HIV-positive gay and bisexual men treated with HAART. However, this intervention did not influence the use of active cognitive coping strategies or adherence over the 10-week intervention period" (p. 161). As Carrico and colleagues see it, "[a]lthough denial may be an effective means of distress reduction in the short term, reliance on this coping strategy may result in a decreased capacity to effectively manage a variety of disease-related stressors in the long term. CBSM+MAT addresses this potentially detrimental pattern by teaching stress reduction skills that may decrease depressed mood via reduced reliance on denial coping" (p. 155).

Coping, Social Support, & Quality of Life

Belanoff et al. (2005) conducted a pilot study in which they matched and randomly assigned an ethnically diverse and predominantly low-income sample of 59 men and women living with HIV to one of two conditions. In the experimental condition, participants received weekly sessions of supportive-expressive group therapy plus educational materials on HIV/AIDS, while those in the control condition received the educational materials alone. CD4 cell counts and viral load were assessed at baseline and again 12 weeks later. The investigators found that "individuals who were randomized to group therapy showed a statistically significant increase in CD4 count and decrease in HIV viral load. Among individuals randomized to the education only condition, no significant change occurred in CD4 count or viral load" (p. 349).

The overall results of this study provide preliminary data which suggest that supportive-expressive group therapy may be effective in modulating important biological markers of HIV disease progression, particularly that of CD4 count. For viral load, the within-group analysis showed statistically significant improvement in the group therapy condition over time. However, in the between groups comparison of the two treatment arms, the difference in viral load was not statistically significant. Therefore, further research with larger samples is warranted by these preliminary results. (p. 357)

To evaluate the benefits of expressive writing among people living with HIV, Rivkin, Gustafson, Weingarten, and Chin (2006) interviewed and then randomized an ethnically diverse sample of 79 men and women living with HIV to one of two conditions. In the expressive writing condition, participants were asked to write for 20 minutes about "their deepest thoughts and feelings about living with HIV" (p. 13), while in the control condition, participants were asked to describe their activities during the preceding 24 hours. Participants in each condition were asked to repeat the exercise once weekly over the subsequent 3-week period. Immunological functioning was assessed at baseline and again at 2-month (n = 62) and 6-month (n = 50) follow-up interviews.

This study provides mixed support for the benefits of expressive writing for people living with HIV. Although there were no effects of expressive writing on depression immune function, or the number of positive or negative changes described at the 2-month or 6-month follow-ups, the ways that participants wrote about their experiences influenced benefits from expressive writing. Expressive writing participants who showed increased cognitive processing and discussion of social themes in their writing had better immune function and described more positive changes at follow-up than those who did not. ... The results in the current study suggest that cognitive processing is critical to the benefits of expressive writing. The cognitive processing that takes place during writing may improve adjustment by facilitating changes in how individuals think about the events and helps individuals find meaning in the stressful experiences ... . The current study also suggests that increases in expression of social themes may be important in the benefits of writing. However, the nature of the social themes expressed in the writing, and the extent to which they reflect social support, conflict, or burdens could not be captured by ... [computerized text analysis]. It is possible that those, for whom writing prompted changes in social interactions, may have experienced greater health benefits and positive changes from the writing. (pp. 20-21)

Rivkin and colleagues conclude that these findings, together with those from earlier studies, "suggest that cognitive processing of emotions and concerns about HIV can facilitate better emotional and physical adjustment. An intervention such as expressive writing that can help people confront and process their disease has the potential to improve the lives of people living with HIV. ... For people living with HIV, this writing intervention may be more effective when it is incorporated into a more intensive counseling approach that facilitates greater cognitive processing and emotion-regulation" (p. 24).

Tarakeshwar, Khan, and Sikkema (2006) conducted comprehensive, in-depth interviews about spirituality with 10 men and 10 women living with HIV.

Interview themes suggest that the HIV diagnosis facilitated a relationship-based framework of spirituality. Relationships that formed this framework were: relationship with God/Higher Power, renewed engagement with life, and relationship with family. Within "relationship with God/Higher Power," subthemes included gratitude for God's benevolent influence, spiritual struggles, and building connections with their Higher Power. Self care, transformation of life goals, and accepting mortality were subthemes for "renewed engagement with life." Subthemes within "relationship with family" included finding a sense of purpose, finding support through families, and families as a source of strain. (p. 59)

To integrate spirituality into coping interventions, Tarakeshwar and colleagues offer several suggestions:

First, it would be important to allow men and women with HIV to define what spirituality means to them, how spirituality has "evolved" in their lives, and examine their experience of spiritual struggles (shame, guilt, and anger at God-Higher Power). ... [E]xpressions of these struggles can be critical during the months/years following the HIV diagnosis. Second, the themes highlight the notion that spirituality can be practiced in a variety of ways, not all of which include organized religion. ... [T]here are other ways (prayer, meditation, Bible reading) through which ... [people] can observe their spirituality. Thus, individuals with HIV can be encouraged to seek appropriate resources (e.g., meditation groups) to help them connect with their Higher Power. Third, "spirituality" is not all about the "higher" realm. For ... [study] participants, strengthening family ties was an inextricable component of spirituality. Hence, interventions can include discussions on re-building family connections, finding support from family members, and balancing personal and familial needs. The latter is particularly salient for women. (pp. 68-69)

End-of-Life Issues

Continuing this focus on spirituality, Williams et al. (2005) randomly assigned 58 residents of an AIDS-dedicated skilled nursing facility to one of four month-long conditions: Metta meditation6 (instruction, followed by daily self-administration via audiocassette), massage (30 minutes per day, 5 days per week), a combination of meditation and massage, or standard care. "This study showed significant improvement in overall and spiritual quality of life in patients with AIDS near the end-of-life who received the combined meditation and massage intervention. ... The groups receiving single interventions (meditation-only or massage-only) showed less of a decline than standard care in overall and transcendent quality of life scores, although these differences were not significant" (p. 947). Notably, "[i]nfluence on quality of life appears to be sustainable, as the improvement in scores appreciated by the combined intervention group … [was] evident at 8 weeks (1-month postintervention phase) and remained at 68 weeks, the last assessment time point" (p. 948). With regard to the impact of the combined intervention, Williams and colleagues conjecture that "physical touch is a valuable component of end-of-life care for patients with AIDS. Possibly, among this population, where the stigma of disease engenders a sense of physical isolation and alienation, ... massage may be essential for the spiritual effects of meditation to be appreciated" (p. 950). They conclude that "[t]his pilot study is unique in addressing the spiritual needs of late-stage patients with AIDS from two modalities, meditation and massage. While the interventions are spiritual, they are nondenominational, and are therefore readily generalizable" (p. 950).

– Compiled by Abraham Feingold, Psy.D.

__________

1 "Of the conditions summarized in ... [this] review, 70% had expert sources. Of these expert sources, 25% were public health educators; 25% were psychologists[,] … counselors or masters level professionals; 13% were physicians; 11% were staff from clinics or from the research team; 9% were nurses; 16% were teachers, social workers, or outreach workers; and 1% were not specified but worked at health centers. Of the nonexpert sources, 88% were community leaders, peer opinion leaders, and community peers (including classmates and family members); 10% were artists (rap teams and actors); and 2% religious leaders" (p. 222).

 2 In the AIDS risk reduction model (ARRM), "risk behavior change is a three-stage process. First, people come to perceive their behavior as a possible source of HIV infection. Second, they develop a conscious commitment to behavior change; and, third, they act on this commitment. Progress through the three stages depends upon other psychosocial factors. For example, AIDS knowledge regarding virus transmission routes, symptoms, etc., is posited as a factor that influences perceived infection risk (stage 1). Self-efficacy, or confidence in one's ability to perform risk-reducing behaviors, is a predictor of both commitment to behavior change (stage 2) and actual behavior change (stage 3). Behavior change can be analyzed as an end-point (such as condom use) or a series of incremental steps (such as raising the idea of condom use with a sexual partner) leading to the end-point. Finally, some factors in the ARRM are not stage-specific but instead are hypothetically relevant as motivators of movement across stages. These include social factors such as peer norms regarding risk behavior and cues to action such as information received from an HIV education program" (pp. 93-94).

 3 "A form of episodic memory, ProM involves the complex processes of forming, monitoring, and executing future intentions vis-à-vis ongoing distractions" (p. 536). "Practical, everyday examples of ProM include remembering to take medications at a particular time or remembering to turn off the stove after preparing a meal" (p. 537).

 4 One example of a task substitution error is repeating a task from an earlier trial, perhaps reflecting some interference with the retrieval of intentions for the task at hand.

 5 Antoni, M.H., Carrico, A.W., Durán, R.E., Spitzer, S., Penedo, F., Ironson, G., Fletcher, M.A., Klimas, N., & Schneiderman, N. (2006). Randomized clinical trial of cognitive behavioral stress management on human immunodeficiency virus viral load in gay men treated with highly active antiretroviral therapy. Psychosomatic Medicine, 68(1), 143-151.

 6 "Metta meditation ... [p]ractitioners cultivate a personal state of 'metta' [i.e., 'loving-kindness' in Pāli] by gently repeating phrases that are meaningful in terms of what they wish, first for themselves and then for others. Classically there are four phrases used:

May I be free from danger.
May I have mental happiness.
May I have physical happiness.
May I have ease of well-being. ...

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