mental health AIDS

Summer 2008 Newsletter / Volume 9, Issue 4

HIV Prevention News

About Women & Men

Continuing this focus on depressive symptoms, Ryan, Forehand, Solomon, and Miller (2008) examined whether barriers to care are related to depressive symptoms and, in turn, whether depressive symptoms are related to sexual risk behavior among 101 sexually active men and women living with HIV in non-urban areas of New England. "Although barriers to care have been linked to depressive symptoms ... and ... depressive symptoms have been linked to sexual risk behavior ..., depressive symptoms as a link between barriers to care and sexual risk behavior have not been examined" (p. 334). "Four barriers to care were examined: geographical barriers and distance to services; access to and quality of medical and psychological services; community stigma; and personal resources. The results indicated [that] barriers to care, and in particular those pertaining to access to and quality of medical and psychological services[,] were related to depressive symptoms, which, in turn, were related to sexual risk behavior" (p. 331). Because "[d]epressive symptoms appear to serve as a link between barriers to care and risk behavior" (p. 335) among individuals living with HIV in non-urban settings, Ryan and colleagues suggest that, "in addition to efforts to remove barriers to care through community-based interventions, individually-based interventions targeting depressive symptoms should be considered to reduce high-risk sexual behavior of HIV-infected individuals" (p. 335).

In another study that measured depressive symptoms, Bradley, Remien, and Dolezal (2008) assessed 197 HIV-serodiscordant couples (159 male/female couples, 38 male/male couples) to examine associations among depressive symptoms, sexual risk behavior, and partner satisfaction. Bradley and colleagues found that "HIV-positive individuals with more depressive symptoms may be less likely to engage in high-risk sexual behavior with their partners than those with less depressive symptoms, but more likely to have sexual partners outside the relationship" (p. 186). More specifically,

HIV-positive partners with higher depression scores were less likely to be part of couples reporting unprotected sex, and HIV-positive partners' higher depression scores were associated with less unprotected intradyadic sex acts [(i.e., unprotected sex between the primary partners)]. This decrease in intradyadic sexual risk behavior was partially explained by a decrease in any sexual behavior within the couple. On the other hand, HIV-positive subjects with moderate or higher depression were more likely to have outside partners. Adding the partner satisfaction measure to the models ... account[ed] for the relationship between the HIV-positive subjects' depression scores and outside partners, but not for that between higher depression score and reduced intradyadic sexual risk. (p. 186)

The investigators observe that

[c]linicians may assume that patients with a lower burden of psychiatric symptoms will demonstrate better health behaviors, including sexual risk reduction, than patients who are more severely symptomatic. However, ... findings that HIV-positive individuals with lower depression scores are less likely to have extradyadic sexual partners and are also more likely to engage in risky sex with their seronegative relationship partners present a mixed and complex picture regarding depressive symptoms and sexual risk. (p. 190)

For this reason, Bradley and colleagues urge clinicians to "assess sexual risk behavior across the range of depression symptom severity" (p. 186).

Continuing the presentation of findings from their study of Living in the Face of Trauma (LIFT), an intervention first introduced in the Spring 2007 issue of mental health AIDS, Sikkema et al. (2008) conducted a randomized controlled trial with a racially and ethnically diverse sample of 247 men who have sex with men (MSM) and women living with HIV who had histories of childhood sexual abuse (CSA). Study participants were randomly assigned to either a 15-session coping group intervention 1 or a 15-session therapeutic support group intervention.2 Sexual behavior was assessed at five time points: at baseline; immediately following the intervention; and at 4-, 8-, and 12-month follow-up computer-assisted personal interviews. Sikkema and colleagues found that the LIFT coping group intervention

was effective in reducing transmission risk behavior among HIV-positive men and women with extensive histories of CSA. Over a 12-month follow-up period, participants in the HIV and trauma coping group intervention had a greater reduction in frequency of unprotected intercourse with all partners, and with HIV-negative or serostatus unknown partners, in comparison to those in a therapeutic support group intervention. At the 12-month follow-up assessment, the coping intervention group had reduced unprotected anal and vaginal sex with all partners (HIV-positive, HIV-negative, and serostatus unknown) by an average of 54% compared with the support intervention group. A limited number of interventions targeting HIV-positive adults have demonstrated long-term efficacy in reducing sexual risk behavior, and this is the first trial to demonstrate behavioral effects over time after an intervention focused on coping with CSA and HIV. (p. 510)

Importantly, the investigators note that this

theoretically based coping intervention focused on psychological adjustment and the development of adaptive coping skills for confronting the combined stress and emotional sequelae of CSA and HIV rather than the behavioral risk reduction skills (... [e.g.], condom negotiation, self-regulatory skills) typical of most HIV prevention interventions. Study participants had experienced repetitive traumas and severe life stressors. Almost all participants had experienced penetrative abuse as a child or adolescent and later revictimization. They were primarily low socioeconomic status racial/ethnic minorities, and many had experienced homelessness, incarceration, and sex trade. These findings suggest that trauma-related stress and factors such as self-esteem, shame, avoidance, and relationship patterns must be addressed to reduce transmission risk behavior effectively among men and women living with HIV/AIDS and CSA and support recommendations to identify specific groups of HIV-positive individuals to determine tailored interventions that work best for them, ... including those that address multiple health and psychosocial problems. ... (pp. 510-511)

Sikkema and colleagues conclude that this "group intervention to address coping with HIV and CSA can be effective in reducing transmission risk behavior among HIV-positive men and women with histories of sexual trauma" (p. 506) and "should be incorporated into community-based mental health and prevention efforts to reduce the number of new HIV infections" (p. 512).

Finally, in an effort to draw together the wealth of quantitative research findings on sexual risk-reduction interventions, Noar (2008) systematically reviewed and synthesized 18 meta-analytic studiesof behavioral interventions designed to reduce HIV-related sexual risk behavior in defined target populations. "The median meta-analysis in the review contained ... 19 primary studies with a cumulative N = 9,423 participants" (p. 335). In Noar's words, "[o]ne of the most promising findings is that every meta-analysis in this review found significant sexual risk reduction outcomes on at least one outcome variable. In fact, every meta-analysis that tested for it found significant effects on condom use and 9 of 11 found effects on unprotected sex. Examination of effects on reduction of sex partners, however, revealed that such effects were less strong and less consistent" (p. 343). "[A]lso promising is the fact that four of six meta-analyses found significant reductions in STDs [(sexually transmitted diseases)] as a result of interventions" (p. 347). In numerical terms, this review "suggests that typical behavioral interventions increased the odds of condom use by 34%, decreased the odds of unprotected sex by 32%, … [in]creased the odds of [a reduction in number of] sex partners by 15%, decreased the odds of new STDs by 35%, and decreased the odds of risk behavior (as measured by sexual risk indices) by 28%" (p. 348). Importantly, "when considering all of the sexual risk outcomes, there was some variability by target population. For instance, interventions with MSM, people living with HIV, and Hispanics/Latinos appeared to have the strongest effects overall; more moderate effects were found in heterosexual adults and drug users; and weaker/more mixed effects were found in adolescents and STD patients" (pp. 348-349).

Noar also examined moderating analyses across these 18 meta-analytic studies of HIV prevention interventions. Although some conflicting findings were noted with regard to particular moderating factors, several general conclusions could be drawn from this review:

Evidence was found to support segmentation strategies within interventions in that a number of interventions were more efficacious when they were delivered to single (versus mixed) race or gender groups. This was presumably the case because homogeneous groups allow for intervention content to be more carefully targeted to those groups. Related to this, some meta-analyses provided evidence that interventions were more efficacious when the race of facilitators was matched to participants and one provided support for tailoring on gender/cultural norms ... . These findings are consistent with both tailoring and targeting practices ... as well as a recent meta-analysis which suggested that HIV prevention interventions were more efficacious when interventionists and recipients shared similar demographics ... .

In addition, evidence was found to support skills-training as an important component of behavioral interventions. This finding is consistent with several behavioral theories which suggest that individuals need not only the motivation to engage in safer sex, but also the skills and self-efficacy to engage in safer sexual behaviors ... . It is also consistent with the findings of a recent large meta-analysis of HIV prevention interventions across numerous target populations which found skills training to be an important intervention component ... . In the current review, evidence did not support all skills training components in all meta-analyses, however, and an important distinction to draw is what types of skills are being taught. For instance, some interventions focus on personal or self-management skills such as goal setting and self-reinforcement, others focus on communication skills such as discussing and negotiating condom use, and still others focus on technical skills such as how to correctly use a condom. The relation of these differing skill types to efficacy varied, and interventionists should carefully consider which skills might be most important for a particular target population. In addition, how such skills are taught, which has been found to vary greatly by intervention, is an important consideration and one that is worthy of further research attention ... .

Moreover, support was found for the long held notion that theory-based interventions are more efficacious than those that are not theory-based ... . (p. 349)

Speaking to the limitations of this approach, Noar points out that this review, "[l]ike any review, by necessity ... could only focus on generalizations across projects, rather than focus on the unique approach and details of each meta-analytic study. ... Readers interested in a particular meta-analysis with a particular target population should consult the original article for more complete reporting and details" (p. 350). Additionally, although "methods for meta-analysis have been studied for decades, methods for 'meta-analysis of meta-analyses' do not currently exist. Thus, ... [this] review relied on simple statistics, such as median effect size, to attempt to estimate the 'typical' effect of interventions. More sophisticated approaches that aggregate and weight effect sizes are used in meta-analysis, and perhaps in the future such methods will be applied to meta-analysis of meta-analyses" (p. 350). Finally, Noar notes that, "although HIV behavioral interventions have demonstrated widespread efficacy in research trials, it is yet to be determined whether or not they are capable of widespread effectiveness under real world conditions" (p. 351).

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1 "The intervention model integrated the cognitive theory of stress and coping ... and effective cognitive-behavioral treatment strategies for sexual trauma ... within a transactional framework for understanding sexual abuse outcomes. ... The coping framework of Lazarus and Folkman ... was used to demonstrate appraisal of stressors related to HIV infection and sexual trauma and to apply appropriate coping strategies. ... Adaptive coping included problem-focused strategies for changeable stressors (... [e.g.], problem solving, communication skills) and emotion-focused strategies for unchangeable stressors (... [e.g.], cognitive restructuring, relaxation techniques). Participants identified stressors related to CSA and HIV. Parallels between these traumatic experiences in terms of stress response and coping strategies were addressed.

Other therapeutic activities included identification of individual triggers, selection of attainable goals, skill-building exercises, and exposure. Risk reduction skills were addressed in the context of elements necessary for healthy relationships (... [e.g.], safety, intimacy, power, self-esteem), including sexual relations after sexual abuse, revictimization, and HIV infection. Although skills building and exposure are central features of the intervention, these 2 elements cannot occur adequately without a safe and cohesive environment. Thus, participants shared experiences and offered mutual support and feedback" (p. 508).

 2 "The comparison group paralleled a standard therapeutic support group and was led by experienced cotherapists not trained on the coping intervention model. The purpose of the group was to provide a supportive environment for participants to address issues of HIV and trauma. Because group leaders were skilled clinicians with substantial experience, this treatment condition resembled an interpersonal process group model more than a standard community-based support group. Additionally, participants were aware that all group members shared the common experience of CSA (as a result of study inclusion), and this experience was frequently the first time participants had discussed their early sexual trauma in a group environment. Thus, despite the open format, the group content had a predominant focus on the connections between CSA, HIV/AIDS, current relationships, and life events" (p. 508)

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