mental health AIDS

Winter 2007 Newsletter / Volume 8, Issue 2

HIV Treatment News

Psychiatric/Psychological/
Psychosocial/Spiritual Care

Psychopharmacology

Letendre et al. (2006) conducted a 12-week, open-label pilot study "[t]o determine the effects of low-dose oral lithium on the [NP] performance of [eight] individuals diagnosed with HIV-associated neurocognitive impairment [HNCI]" (p. 1885) who had been on stable antiretroviral therapy for a minimum of 12 weeks. "Oral lithium was initiated at 300 mg daily and was titrated to maintain 12-h trough concentrations between 0.4 and 0.8 mEq/l. Global [NP] performance was assessed by the global deficit score [GDS]" (p. 1885). All participants completed the 12-week trial, at which time

treatment with lithium resulted in statistically significant improvements in [NP] performance when administered as an adjunct to stable [antiretroviral therapy]. The improvements were noted in the domains of executive functions and information processing speed, functions that are often impaired by HIV infection ... and associated with deficits in daily functioning ..., such as medication management. Six of the eight individuals improved sufficiently to reduce their GDS from the impaired ... to the normal range. These improvements were statistically significant even though the sample size was small and the lithium dosage was low. ... [In addition,] lithium was well tolerated and was not associated with changes in ... [viral load] or CD4 cell counts. (p. 1887)

Letendre and colleagues conclude that "lithium may be a useful therapeutic adjunct to [antiretroviral therapy] in individuals suffering from HNCI. These preliminary results support the performance of a larger, randomized, placebo-controlled clinical trial of lithium" (p. 1887).

Access to Care 

Drawing data from a sample of 141 adults living with HIV and participating "in a year-long substance abuse and mental health treatment programme" (p. S27) in North Carolina,3 Whetten, Whetten, et al. (2006) examined "whether distance to care predicts utilization of a substance abuse and mental health treatment programme that is regionally located and serves individuals from multiple counties when transportation is provided as part of the intervention" (p. S28).

Transportation, which included buses, taxis, and mileage reimbursement for private transportation, was provided free of charge for participants who needed this assistance. Nearly three-quarters (74%) of participants utilized the transportation services. No statistically significant differences in retention in, or utilization of, the mental health and substance abuse treatment programme were identified by distance to the treatment site. This analysis demonstrated that increased distance to care did not decrease utilization of the treatment programme when transportation was provided to the client when necessary. (p. S27)

The investigators conclude that "[t]hese results provide preliminary evidence that distance to substance abuse and mental health services need not be a barrier to care for HIV-positive individuals when transportation is provided. Such options may need to be considered when trying to treat geographically dispersed individuals so that efficiencies in treatment can be attained" (p. S27).

Sullivan et al. (2006) investigated the impact of co-locating HIV care and mental health services among 118 adults with serious mental illness and co-morbid HIV infection. Sullivan and colleagues expressed surprise tha

the great majority of ... subjects in this study were receiving regular, ongoing mental health and HIV treatment. For example, fully 93% reported taking antiretroviral medications. Neither co-location of services nor the extent to which providers located at different sites communicated with one another seems to have affected subjects' satisfaction with care or utilization of services. Although public sector care is often viewed as fractured and poorly integrated, this study suggests that consistent care for mental health and physical health problems is possible, even for persons with psychotic illnesses. Further, such consistent care does not seem to be dependent on co-locating these services. Persons with serious mental illness may have more self-care skills than expected. And it is likely that receipt of case management – sometimes from both the mental health and medical care sectors – and access to free or low-cost medication for treatment of HIV infection improved continuity of care for this group. The HIV-infected population may be benefiting from the increased attention and funding prompted by the HIV epidemic that has made possible case management services and access to medication. (pp. 358-359)

Adherence to Treatment 

In Canada, Balfour et al. (2006) conducted an RCT in which 63 antiretroviral-naïve individuals receiving HIV medical care were assigned to either a manualized psycho-educational intervention (Supportive Therapy for Adherence to Antiretroviral Treatment, or STAART) or to standard HIV clinic multidisciplinary team care (the control condition). "STAART ... consisted of four weekly individual sessions, each lasting for 75-minutes. The sessions aimed to prepare patients for the challenges of HAART, develop strategies to improve medication adherence before starting HAART, become more active in their treatment[,] ... and improve their coping skills" (p. 832). After the investigators controlled for medication readiness scores at baseline, "intervention patients (n=30) reported significantly higher mean medication readiness following the STAART intervention (four-weeks post-baseline) ... compared to controls ... . Among depressed patients (n=27), those receiving the intervention (n=15) reported significantly lower mean depression scores at four-weeks post-baseline ... compared to controls ..." (p. 830). Balfour and colleagues sum it up this way: "Overall, results indicated that the STAART intervention enhanced HIV treatment readiness compared to standard HIV clinic care by better preparing patients before initiating HAART. In addition, HIV patients who were depressed at study baseline and who were randomized to the STAART intervention condition experienced reductions in depression at four-week follow-up, whereas depressed patients who received standard clinic care had no improvements in symptoms of depression at follow-up" (p. 835).

Serostatus Disclosure

What is the relationship between HIV serostatus disclosure and adherence to antiretroviral therapy? Stirratt et al. (2006) studied 215 adults in serodiscordant relationships who were taking < 80% of their medication doses within specified time windows, assessed through an electronic monitoring device (MEMS caps). "Overall, 19% of the sample reported missing medication doses in the last two months due to concerns regarding [HIV] serostatus disclosure. Participants who reported greater serostatus disclosure to ... [family members and close personal contacts] demonstrated higher rates of adherence, and this relationship remained after controlling for other explanatory variables. The relationship between disclosure and adherence was not mediated by practical support for adherence from others" (p. 483).

Participants who cited disclosure concerns as a reason for missed doses also evidenced greater depression and negative affect, as well as lower adherence self-efficacy, adherence motivation, and expectations of detrimental outcomes from non-adherence. This may indicate that contexts of non-disclosure are more likely to compromise adherence among patients with poorer mental health, motivation, and behavioral skills (although it may alternatively be that patients with these conditions are simply more likely than others to endorse disclosure-related concerns as a reason for non-adherence). (p. 490)

Stirratt and colleagues stress that

[c]linicians working with HIV+ patients should be aware of the negative impact that lack of disclosure may have on maintaining consistent adherence. It may be important to help patients consider the potential benefits of disclosure (e.g., increased treatment support) vs. the possible negative consequences (e.g., discrimination). Blanket disclosure in all contexts and circumstances should not be advised. Instead, patients should be provided with strategies to maintain adherence in situations where disclosure of HIV serostatus is ill advised, and also taught skills to disclose in a manner that can help avoid stigma and discrimination in order to access social support for adherence. (p. 491)

A discerning approach to HIV serostatus disclosure is further reinforced by Vanable, Carey, Blair, and Littlewood (2006), who "examined the relationships among [HIV] stigma-related experiences and depression, medication adherence, serostatus disclosure, and sexual risk among 221 HIV-positive men and women" (p. 473).

In bivariate analyses that controlled for background characteristics, stigma was associated with depressive symptoms, receiving recent psychiatric care, and greater HIV-related symptoms. Stigma was also associated with poorer adherence and more frequent serostatus disclosure to people other than sexual partners, but showed no association to sexual risk behavior. In a multivariate analysis that controlled for all correlates, depression, poor adherence, and serostatus disclosure remained as independent correlates of stigma-related experiences. (p. 473) 

Coping, Social Support, & Quality of Life 

Continuing this focus on stigma, Lekas, Siegel, and Schrimshaw (2006) conducted interviews with two convenience samples of 79 women living with HIV/AIDS: one sample was interviewed prior to the introduction of HAART and a second matched sample was interviewed after HAART had become widely available. The investigators examined interview data to identify changes (if any) in the HIV-related stigma experiences of these women during different eras of the epidemic. Comparisons made between these two time periods

demonstrated that the negative stereotypes associated with infected women have remained largely unchanged and that women continue to internalize them and feel stigmatized. Women's stigma consciousness remains high, even in the HAART era, and often results in vicarious stigmatization [when witnessing or hearing about the denigration of others living with HIV], another major source of stigmatization. The … [persistence] of family members' unfounded fears of contagion that lead to ... hygienic derogatory acts [i.e., being subjected to unnecessary or excessive hygienic procedures] suggests that educational interventions continue to be significant venues of destigmatization. Finally, the fact that instances of enacted discrimination by medical and social service providers have decreased over time indicates that, as least within the AIDS field, stigmatization and discrimination against persons with HIV/AIDS are declining. (p. 1189)

In short, "[t]his analysis revealed that although enacted stigmatization has decreased slightly, felt stigma remains a primary adaptational challenge facing women with HIV/AIDS" (p. 1165).

These findings underscore the importance of designing interventions that prevent the internalization of stigma. Researchers ... have suggested that rejecting the negative connotations of one's stigmatizing status and strengthening other positive aspects of one's identity are the two primary means of preventing internalization of stigma. Given the … [persistence] of the HIV/AIDS stereotypes, ... [Lekas and colleagues] suggest that interventions focus on accentuating the positive features of these women's identity. An emphasis, for instance, on the extended survival enjoyed by many infected persons in the HAART era might cast these women as "survivors," a role that implies an accomplishment and a certain degree of resilience. In addition, intervention programs should also ... develop messages that bolster their sense of female worth by highlighting, for instance, their parenting achievements, or their peer activism around women's health issues. (pp. 1186-1187)

In another study involving these two samples, Siegel, Schrimshaw, and Lekas (2006) focused on changes (if any) in sexual activity, interest, and feelings of attractiveness among these women during different eras of the epidemic. Here again, the investigators found that

[w]omen in both the pre-HAART and HAART eras frequently discussed decreased sexual activity, a loss of sexual interest, and a diminished sense of sexual attractiveness following their HIV infection. In addition, they reported a number of reasons for why they had discontinued sexual activity or were no longer interested in sex, including anxiety about HIV transmission, a loss of freedom and spontaneity during sex, fears of emotional hurt, [and] not wanting the hassle of sexual relationships … . However, the types of changes in their sexuality women described, nor the reasons offered for these changes, did not differ … in the pre-HAART and HAART eras. (p. 437)

Siegel and colleagues observe that these findings

suggest that many HIV-infected women might benefit from counseling around their sexuality. While a certain amount of anxiety concerning infecting others or becoming reinfected can be adaptive if it motivates consistent condom use, too much anxiety may be maladaptive if it results in a fear of physical closeness and any kind of sexual intimacy, even acts that carry no risk of HIV transmission. ... The data further suggest that the women felt deeply discredited and profoundly tainted by their disease in ways that were very damaging to their self-esteem and identity as women and potential partners. ... [The investigators] believe that this is a kind of HIV-related suffering that has not been adequately studied or appreciated. These women need interventions to address these issues and to help them regain a sense of themselves as appealing, sensual women who can have gratifying, yet safe, relationships with both uninfected and infected partners. They would also likely benefit from guidance concerning how and in what circumstances to share their diagnosis with potential sexual partners to reduce the risks of painful rejection or to endure such rejection without personalizing it as much. (p. 448)

Tarakeshwar, Hansen, Kochman, Fox, and Sikkema (2006) "examined how resiliency (represented by optimism, social support, … [religiousness], and finding growth and meaning), within the context of perceived impact of sexual trauma and HIV-related stress, was linked to perspectives on addressing trauma among individuals (N = 266) with HIV and childhood sexual abuse" (p. 449). The investigators found that "individuals who reported more HIV-related stress had more negative feelings about addressing trauma symptoms while those reporting greater perceived impact of sexual trauma reported more positive feelings about addressing their trauma issues. A principal finding ... was that individuals who are more resilient are more likely to report positive feelings in addressing past trauma. In contrast, lower resiliency was associated with a greater likelihood of feeling negative about addressing past trauma" (p. 457). Tarakeshwar and colleagues suggest that

interventions that focus on instilling hope may be crucial in helping HIV-positive trauma survivors engage in treatment in at least three ways. First, hope and optimism may be buffers against the stress and anxiety associated with HIV infection. Second, those with more hope and optimism appear to be less avoidant ... . Third, optimism appears to be a component of resiliency, which is related to positive feelings about addressing trauma. Other aspects of resiliency that can be encouraged in interventions include mobilizing social support, including support that could be obtained through religious/spiritual resources ... . Finally, interventions focusing on helping participants find meaning and understanding related to traumatic experiences may be critical in promoting resiliency. (p. 458)

In their continuing longitudinal analysis of data emerging from an RCT of a group coping intervention for AIDS-related bereavement,4 Sikkema 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, cognitive-behavioral bereavement coping group intervention conducted in 90-minute sessions and tailored to gender, ethnicity, and sexual orientation.

Six primary themes were addressed over the course of treatment, including (a) development of social support and group cohesion, (b) identification and expression of emotion, (c) identification of coping difficulties specific to AIDS loss, (d) identification of current coping strategies, (e) goal setting, and (f) implementation of adaptive coping strategies to reduce psychological distress (e.g., depression, anxiety, traumatic stress). Intervention techniques included group discussion, exercises, role-plays, and assignment of tasks to practice between sessions. This bereavement coping intervention was specifically tailored to address … the complexity of both coping with AIDS-related loss and living with HIV. (p. 566)

The comparison condition consisted of individual psychotherapy and psychiatric services on demand (the community standard-of-care). Measures of grief and psychiatric distress were administered at baseline, 2 weeks following the intervention, and in 4-, 8-, and 12-month follow-up assessments.

Immediately following intervention, participants in the coping group intervention reported significantly greater reductions in grief and psychiatric distress than those who were provided individual psychotherapy on request (Sikkema et al., 2004). The results of the current analysis suggest that these differences in grief and psychiatric distress between participants in the intervention and comparison conditions declined over time, thereby eliminating group differences, probably because severity of grief significantly decreased over time in both conditions. However, among individuals who reported high levels of psychiatric distress, participants who received the bereavement coping group intervention showed significantly lower levels of grief over the 1-year follow-up compared with those in the comparison condition. This finding suggests that the intervention had a beneficial impact on persons experiencing the greatest psychiatric distress, arguably the subgroup most in need of intervention. (pp. 567-568)

Speaking to the utility of these findings, Sikkema and colleagues observe that

it may be practical, particularly in areas with limited resources, to screen for elevated distress or complicated bereavement in AIDS-bereaved individuals to identify those most likely to benefit from an intervention. A counterpoint, however, based on our pre- to postintervention findings is that those attending the coping intervention will receive a short-term benefit and those who are more distressed will do better across time, even though less distressed people tend to resolve … grief over time with or without intervention ... . Thus, for persons with HIV seeking services for AIDS-related loss, it seems justified to provide evidence-based intervention rather than only screening for distress to determine service provision. (p. 569)

Lastly, over a period of up to 5 years, Ickovics et al. (2006) monitored 773 women living with HIV in four U.S. cities and found that

psychological resources (positive affect, positive expectancy regarding health outcomes, finding meaning in challenging circumstances) ... were inversely associated with HIV-related mortality and time to death, beyond the effects of potential confounding variables such as clinical status (e.g., HIV viral load, symptoms, antiretroviral therapy), sociodemographic characteristics (e.g. age, race), and depression at study entry ... . Psychological resources also were inversely associated with CD4+ cell count decline ..., [the latter] serving as a possible mechanism linking resources to mortality. (p. 1851) 

Ickovics and colleagues conclude that "[p]sychological resources may protect against HIV-related mortality and immune system decline. Findings have implications for understanding individual variability in HIV disease progression. Moreover, because psychological resources are potentially amenable to change, results can be applied to clinical interventions aimed at improving the health of women with HIV" (p. 1851). The investigators point out, however, that 

[i]t is unclear whether clinical interventions could be designed to meaningfully enhance psychological resources. Fostering psychological resources either innate or acquired may affect treatment response and promote resilience to clinical setbacks likely as HIV disease progresses. The critical question is under what conditions, for which patients, might we have the capacity to enhance psychological resources and subsequently immune alterations and ultimately longevity ...? One needs to tread carefully, however, to insure that patients with HIV do not perceive self-blame because of natural illness progression ... . (p. 1858)

– Compiled by Abraham Feingold, Psy.D.

__________

 1 "Both interventions incorporated features of prevention case management, ... motivational interviewing, ... and harm reduction. ... The single-session intervention was based on a brief HIV-risk assessment and risk-reduction planning intervention for incarcerated men. ... It consisted of a 60- to 90-minute individual session that was conducted approximately 2 weeks before release. The interventionist assessed the participant's HIV/AIDS, hepatitis, and STI [sexually transmitted infection] knowledge and risk behavior and helped the participant develop a personal risk-reduction plan. The interventionist provided information, skills training, and referrals as required and worked with the participant to identify incremental steps toward risk reduction. The enhanced intervention consisted of 2 scheduled individual sessions before release and 4 scheduled sessions at 1, 3, 6, and 12 weeks after release. The first in-prison session was the same as the single-session intervention. The second in-prison session focused on community reentry needs and included assessment, planning, and problem solving, and facilitated referral for housing, employment, financial problems, social relationships, substance abuse and mental health treatment, legal problems, and avoiding reincarceration. The postrelease sessions involved review and updating of the plan developed during previous sessions, including discussion of facilitators of and barriers to implementing the risk-reduction plan. In-prison sessions lasted 60 to 90 minutes; the postrelease sessions were 30 to 60 minutes. Additional sessions were offered to enhanced intervention participants as needed during the intervention period" (p. 1855).

 2 "Results of this study suggest that the mental processes involved in Digits Backward are more relevant to the effects of HIV in the CNS than Digits Forward, and interpreting the two parts of this test separately should become standard practice in the assessment of the pediatric HIV population" (p. 650).

 3 For more information on this program, see Whetten, Reif, et al. (2006), highlighted in this issue's Tool Box on "Resources."
 
 4 Additional studies involving bereaved, HIV-positive men and women that were conducted by this research group may be found in the Summer 2003, Summer 2004, Summer 2005, Fall 2005, and Fall 2006 issues of mental health AIDS.

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