Sex isn't that simple: culture and context in HIV prevention interventions for gay and bisexual male adolescents

Gay and bisexual male adolescents and young adults in the United States have been disproportionately impacted by the HIV pandemic. Despite the steadily increasing rise in their HIV infection rates, there has not been a commensurate increase in HIV prevention programs targeted to the unique social and sexual lives of these youths. Programs that address cultural and contextual factors that influence sexual risk and protective behaviors need to be developed, implemented, and rigorously evaluated. These interventions should address the potential influences of sexual and gay culture on the HIV risk/protective behaviors of gay and bisexual adolescents, as well as the influence of more traditional cultural factors related to ethnicity. The influence of contextual developmental factors should also be addressed. This may include an incorporation into prevention programs of the societal-level influences of heterosexism and masculinity ideology and the individual-level influences of sexual identity and ethnic identity development. Researchers and interventionists need to be creative and innovative in their HIV prevention approaches and ensure that programs are grounded in the lives and realities of gay and bisexual adolescents and young adults.     

Development and Implementation of Health and Wellness CBT for Individuals With Depression and HIV

Rates of depression are reported to be between 22% to 33% in adults with HIV, which is double that of the general population. Depression negatively affects treatment adherence and health outcomes of those with medical illnesses. Further, it has been shown in adults that reducing depression may improve both adherence and health outcomes. To address the issues of depression and nonadherence, Health and Wellness (H&W) cognitive behavioral therapy (CBT) and medication management (MM) treatment strategies have been developed specifically for youth living with both HIV and depression. H&W CBT is based on other studies with uninfected youth and upon research on adults with HIV. H&W CBT uses problem solving, motivational interviewing, and cognitive-behavioral strategies to decrease adherence obstacles and increase wellness. The intervention is delivered in 14 planned sessions over a 6-month period, with three different stages of CBT. This paper summarizes the feasibility and acceptability data from an open depression trial with 8 participants, 16 to 24 years of age, diagnosed with HIV and with a Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnosis of depression, conducted at two treatment sites in the Adolescent Trials Network (ATN). Both therapists and subjects completed a Session Evaluation Form (SEF) after each session, and results were strongly favorable. Results from The Quick Inventory of Depressive Symptomatology–Clinician (QIDS-C) also showed noteworthy improvement in depression severity. A clinical case vignette illustrates treatment response. Further research will examine the use of H&W CBT in a larger trial of youth diagnosed with both HIV and depression.     

Family‐Based HIV and Sexually Transmitted Infection Risk Reduction for Drug‐Involved Young Offenders: 42‐Month Outcomes

This study tested a family‐based human immunodeficiency virus (HIV)/sexually transmitted infection (STI) prevention approach integrated within an empirically supported treatment for drug‐involved young offenders, Multidimensional Family Therapy (MDFT). A randomized, controlled, two‐site community‐based trial was conducted with 154 youth and their parents. Drug‐involved adolescents were recruited in detention, randomly assigned to either MDFT or Enhanced Services as Usual (ESAU), and assessed at intake, 3, 6, 9, 18, 24, 36, and 42‐month follow‐ups. Youth in both conditions received structured HIV/STI prevention in detention and those in MDFT also received family‐based HIV/STI prevention as part of ongoing treatment following detention release. Youth in both conditions and sites significantly reduced rates of unprotected sex acts and STI incidence from intake to 9 months. They remained below baseline levels of STI incidence (10%) over the 42‐month follow‐up period. At Site A, adolescents who were sexually active at intake and received MDFT showed greater reduction in overall frequency of sexual acts and number of unprotected sexual acts than youth in ESAU between intake and 9‐month follow‐ups. These intervention differences were evident through the 42‐month follow‐up. Intervention effects were not found for STI incidence or unprotected sex acts at Site B. Intensive group‐based and family intervention in detention and following release may reduce sexual risk among substance‐involved young offenders, and a family‐based approach may enhance effects among those at highest risk. Site differences in intervention effects, study limitations, clinical implications, and future research directions are discussed.     

A Novel Technology-Enhanced Internalized Stigma and Shame Intervention for HIV-Positive Persons With Substance Use Disorders

Internalized stigma, shame, and other negative self-conscious emotions are inadequately addressed barriers to HIV-related self-care, particularly among people actively using substances. Innovative approaches are needed to optimize antiretroviral treatment (ART) adherence as well as engagement in HIV care among people living with HIV and substance use disorders. Based on qualitative feedback from providers and patients, we iteratively developed and conducted a proof-of-concept study of a relatively brief transdiagnostic emotion regulation intervention designed to improve ART adherence and engagement in HIV care by addressing behavioral and psychological barriers, including internalized stigma and shame, among people living with HIV and active substance use disorders. The final intervention included 5 individual sessions focused on metacognitive awareness of emotions and thoughts, cognitive reframing of dysfunctional thoughts about the self using concepts such as self-compassion, and identifying and reaching the participants’ personalized HIV-self-care goal(s). All participants received daily texts querying current emotion and weekly texts querying ART adherence and substance use. To extend the effects of the intervention, we developed a personalized bidirectional text component through which participants received their personalized compassionate self-statements, informed by the intervention content, in response to their answers to emotion queries for 8 weeks after the 5 sessions. The texts modeled using compassionate self-statements as a form of cognitive reframing, consistent with cognitive restructuring of distorted core beliefs. We consented 10 participants living with HIV and active substance use disorders in the proof-of-concept pilot. Of the 8 participants who completed all intervention sessions, participants replied to 70% of all text messages sent. All 8 reported strong acceptability of the intervention content. This emotion-focused, technology-enhanced intervention demonstrated proof-of-concept, in that this patient population would participate in this intervention. A larger randomized controlled pilot is needed to determine feasibility and acceptability among people living with HIV and substance use disorders, a hard-to-reach and underserved population.     

Another dragon in the kitchen: Psychological experiences of hepatitis C treatment among HIV‐hepatitis C co‐infected gay men

Background: Increasing numbers of HIV‐infected gay men acquire hepatitis C virus (HCV) co‐infection, which causes serious medical consequences. Treatment for HCV is associated with many severe side effects, in some cases psychological, and many patients subsequently fail to adhere, even when psychological services are utilised, to improve treatment adherence. Objective: This qualitative study aimed to explore the experiences of HIV‐infected gay men undergoing treatment for HCV in order to inform psychological services to better meet specific treatment needs of this population. Methods: Thirteen HIV‐infected gay men who had undergone HCV treatment were interviewed and a qualitative analysis was conducted. Participants described HCV and its treatments in the context of their relationships and lifestyles. Findings: Four domains emerged: HCV diagnosis and treatment; HCV treatment education; change in sense of self; and sexual risk‐taking. Adhering to treatment was a significant challenge for all participants and emerged across all domains. Discussion: Psychological services for this population of co‐infected gay men should assist this clinical population not only with adherence to hepatitis C treatment but should also be available at an earlier stage in the process to help patients make informed choices about whether or not to begin a course of treatment. Assessing factors such as coping strategies, treatment readiness and knowledge, self‐awareness, and level of risk‐taking, can guide clinicians in tailoring treatment and adherence planning for HIV/HCV‐co‐infected gay men.     

A Cognitive Behavioral Adherence Intervention for Adolescents with Type 1 Diabetes

This study examined the impact of a cognitive behavioral intervention for nonadherent adolescents with type 1 diabetes. Six youths having problems following the diabetes regimen received training in cognitive restructuring and problem solving during individual sessions. A multiple baseline design across participants was used. Treatment effectiveness was assessed through 24-hr recall adherence interviews with adolescents and frequency of testing data was downloaded from glucose meters. Data was also collected for diabetes-specific stress. Five youths displayed improvement on at least one self-care behavior. Furthermore, the results suggest that the cognitive behavioral intervention was effective in diminishing diabetes-related stress in two participants. Cognitive behavioral interventions show promise for increasing self-care behaviors among nonadherent youths with type 1 diabetes. However, individual youths varied in their response to treatment. Further research is needed in developing procedures to better meet the needs of youths, improve youth participation, and enhance treatment effectiveness.     

Homeless youths and HIV infection.

Risk of human immunodeficiency virus (HIV) infection exacerbates the already difficult lives of 1.5 million homeless adolescents in the United States. Homeless youths engage in sexual and substance-abuse behaviors that place them at increased risk of contracting HIV, and they demonstrate other problem behaviors that reduce their coping responses. Model HIV prevention programs and interventions for HIV-positive youths, implemented for homeless adolescents, need to be disseminated on a national level. Social policies must recognize adolescents' rights to satisfaction of basic survival needs; comprehensively address the needs of dysfunctional, disenfranchised, and single-parent families; and provide continuity of care for adolescents to facilitate independent living. Special provisions must be made when designing programs for gay, sexually abused, and substance-abusing youths.     

Brief Behavioral Activation Treatment for Depressed Adolescents Delivered by Nonspecialist Clinicians: A Case Illustration

Behavioral activation (BA) can be as effective as cognitive-behavioral therapy for the treatment of depression in adults, but to date there is little research with adolescents. This is problematic given the recognized need to increase access to evidence-based interventions for depression in young people. We have developed a new adaptation of brief Behavioral Activation (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011) specifically for young people: Brief BA for depressed adolescents. In this paper, we use a case example with session-by-session measurement to show how a nonspecialist clinician can deliver this intervention successfully. We discuss the key themes arising from this training case, challenges the clinician faced, and how these were managed through training and supervision.     

Two strategies to increase adherence to HIV antiretroviral medication: life-steps and medication monitoring

Advances in the medical treatment of HIV have made it clear that adherence to highly active antiretroviral treatment is a crucial feature for treatment success. The present paper had two goals: (1) to examine psychosocial predictors of adherence in persons receiving HIV antiretroviral therapy; (2) to compared two minimal-treatment interventions to increase HIV medication adherence in a subset of persons who self-reported less than perfect adherence. One of the interventions, Life-Steps, is a single-session intervention utilizing cognitive-behavioral, motivational interviewing, and problem-solving techniques. The other intervention, self-monitoring, utilizes a pill-diary and an adherence questionnaire alone. Significant correlates of adherence included depression, social support, adherence self-efficacy, and punishment beliefs about HIV. Depression was a significant unique predictor of adherence over and above the other variables. Both interventions yielded improvement in adherence from baseline, and the Life-Steps intervention showed faster improvements in adherence for persons with extant adherence problems.     

Application of a modified health belief model to hiv preventive behavioral intentions among gay and bisexual men

Abstract

The utility of a modified health belief model (Janz and Becker, 1984) for predicting the intention to use condoms was tested in a study among gay and bisexual men. The model explained a reasonable amount of variance. It was found that younger men's decision to have safe sex was guided by factors other than those that influenced older men. Among younger men, the intention to use a condom was positively related to the relative number of persons with AIDS in their social environment (cues to action) and to the perceived benefits of HIV preventive behavior. Among older men, this behavioral intention was much more determined by their perception of the prevalence of HIV and by their perception of their vulnerability to HIV infection. These findings are important because they may partly explain the recent increase in AIDS-risk behavior among young gay and bisexual men. The discussion focuses on these findings and on the implications for interventions aimed at promoting safe sex.     

Cognitive-behavioural health-promotion intervention increases fruit and vegetable consumption and physical activity among South African adolescents: a cluster-randomised controlled trial

Rates of chronic diseases are high among Black South Africans but few studies have tested cognitive-behavioural health-promotion interventions to reduce this problem. We tested the efficacy of such an intervention among adolescents in a cluster-randomised controlled trial. We randomly selected 9 of 17 matched pairs of schools and randomised one school in each pair to the cognitive-behavioural health-promotion intervention designed to encourage health-related behaviours and the other to a human immunodeficiency virus (HIV)/sexually transmitted disease (STD) risk-reduction intervention that served as the control. Interventions were based on social cognitive theory, the theory of planned behaviour and qualitative data from the target population. Data collectors, blind to participants' intervention, administered confidential assessments at baseline and 3, 6 and 12 months post-intervention. Primary outcomes were fruit and vegetable consumption and physical activity. Participants were 1057 grade 6 learners (mean age = 12.4 years), with 96.7% retained at 12-month follow-up. Generalised estimating equations revealed that averaged over the follow-ups, a greater percentage of health-promotion intervention participants than HIV/STD control participants met 5-a-Day fruit and vegetable and physical activity guidelines. The intervention also increased health-promotion knowledge, attitude and intention, but did not decrease substance use or substance-use attitude and intention. The findings suggest that theory based and contextually appropriate interventions may increase health behaviours among young adolescents in sub-Saharan Africa.     

A Task-Shifting Problem-Solving Therapy Intervention for Depression and Barriers to Antiretroviral Therapy Adherence for People Living With HIV in Zimbabwe: Case Series

HIV is prevalent in Sub-Saharan Africa, and depression frequently co-occurs. Depression is one of the most important predictors of poor adherence to antiretroviral therapy (ART). Little has been done to develop integrated interventions that are feasible and appropriate for task-shifting to nonspecialists that seek to address both depression and barriers to ART adherence in Sub-Saharan Africa.This case series describes an integrated intervention for depression and ART adherence delivered by a lay adherence counselor and supervised by a local psychologist. The 6-session intervention was based on problem-solving therapy for depression and for barriers to adherence (PST-AD), with stepped care for those whose depression did not recover with PST-AD. Primary outcomes were acceptability and depression. Acceptability was measured by participant attendance to the 6 sessions.Three case studies illustrate the structured intervention, solutions identified to adherence barriers and to problems underlying low mood, and changes seen in the participant's psychological symptoms. Acceptability of the intervention was high and common mental disorder symptoms scores measured using the SRQ-8 decreased overall.An integrated intervention for depression and adherence to ART appeared feasible in this low-income setting. An RCT of the intervention versus an appropriate comparison condition is needed to evaluate clinical and cost-effectiveness.     

HIV/AIDS in South Africa: a review of sexual behavior among adolescents

South Africa has a fast-growing HIV/AIDS rate, with the highest prevalence among young people (15 to 24 years), especially females. This paper is a comprehensive analytical review of available research concerning the sexual behavior of adolescents in South Africa. It offers insight into HIV infection among adolescents and provides an important base for educational interventions aimed at behavior change and reducing further transmission. The most important conclusion is that, despite the research (however limited) that has been done, there has been no significant change in the rate of infection among adolescents in South Africa. A new generation of behavioral interventions, involving both factual knowledge and life skills to promote behavioral risk reduction, is recommended.     

Multidimensional Family Therapy HIV/STD Risk-Reduction Intervention: An Integrative Family-Based Model for Drug-Involved Juvenile Offenders

Drug and juvenile justice involved youths show remarkably high rates of human immunodeficiency virus (HIV)/sexually transmitted disease (STD) risk behaviors. However, existing interventions aimed at reducing adolescent HIV risk behavior have rarely targeted these vulnerable young adolescents, and many approaches focus on individual-level change without attention to family or contextual influences. We describe a new, family-based HIV/STD prevention model that embeds HIV/STD focused multifamily groups within an adolescent drug abuse and delinquency evidence-based treatment, Multidimensional Family Therapy (MDFT). The approach has been evaluated in a multisite randomized clinical trial with juvenile justice involved youths in the National Institute on Drug Abuse Criminal Justice Drug Abuse Treatment Studies ( http://www.cjdats.org ). Preliminary baseline to 6-month outcomes are promising. We describe research on family risk and protective factors for adolescent problem behaviors, and offer a rationale for family-based approaches to reduce HIV/STD risk in this population. We describe the development and implementation of the Multidimensional Family Therapy HIV/STD risk-reduction intervention (MDFT-HIV/STD) in terms of using multifamily groups and their integration in standard MDFT and also offers a clinical vignette. The potential significance of this empirically based intervention development work is high; MDFT-HIV/STD is the first model to address largely unmet HIV/STD prevention and sexual health needs of substance abusing juvenile offenders within the context of a family-oriented evidence-based intervention.     

The National Institutes of Health (NIH) State-Of-the-Science Conference on Preventing Violence and Related Health-Risking Social Behaviors in Adolescents — A Commentary

Although youth in the United States remain substantially more violent than adolescents and young adults in most industrial countries, the National Institutes of Health's (NIH) State-of-the-Science Conference on Preventing Violence and Related Health-Risking Social Behaviors in Adolescents identified many reasons for optimism about our capacity to develop effective prevention and intervention responses. The research is getting better and contrary to popular opinion we do know a lot about what does work. Future advances will depend upon our insistence on the use of effectiveness evidence and the development of a taxonomy which will facilitate cross disciplinary communication.     

Older Adolescents’ Self-Determined Motivations to Disclose Their HIV Status

Disclosure of HIV status is an important topic for youth living with HIV/AIDS, yet theoretical frameworks for understanding HIV disclosure motivations have been poorly applied. Self-determination theory (SDT) proposes that people are at optimal functioning when they are engaging in activities that are interesting and enlivening. This study utilized SDT to understand young adults’ motivations to disclose their HIV status. Interviews and observations were conducted with nine youth aged 17–19 and two adult staff. Results indicate that SDT is useful for understanding types of motivation (i.e., amotivation, controlled, and autonomous motivation) to disclose. Amotivation was the most common type of motivation, and came from two recursive sources: fear of stigma and previous experiences of others disclosing without their consent. Controlled motivation to disclose occurred when participants were motivated to disclose because of reasons related to other people, rather than internal or personal reasons, and included the reasons of wanting to gain a closer relationship, reciprocate a shared secret, for psychological or emotional relief, and for attention. Autonomous motivation included two themes: the life perspective that “Having HIV is just part of who I am,” and valuing educating others because education was perceived as important and beneficial to others. This study extends SDT into the domain of HIV disclosure in older adolescents. People providing guidance and support to older adolescents with HIV/AIDS can use SDT to understand different motivations to disclose.     

Evidence for a Comprehensive Sexuality Education Intervention that Enhances Chinese Adolescents’ Sexual Knowledge and Gender Awareness and Empowers Young Women

While Chinese adolescents become more sexually active, their sexual attitudes are profoundly influenced by traditional gender and sexual norms. The tensions between the rapid transition in youth sexuality and lags in sex education call for a paradigm shift of sexuality education in China. The present study examined the effectiveness of a school-based empowerment comprehensive sexuality education (CSE) intervention in changing adolescents’ sexual knowledge, gender and sexual attitudes, and sexual self-efficacy. We used data from a quasi-experimental intervention study with self-administered pretest and posttest surveys conducted among 1131 10th grade high school students in Lanzhou, northwest China. Whereas 583 participants in two intervention schools attended 12 45-min CSE sessions focusing on gender, rights, and critical thinking skills across 4–7 months, 548 participants in two comparison schools received no or limited conventional sex education. After controlling for differences in sociodemographics and in the influence of family, peers, and internet use between the two groups, female and male adolescents exhibited significantly more accurate sexual knowledge, stronger endorsement of nontraditional gender roles, and greater rejection of sexual double standards immediately after the intervention. Additionally, young women reported significantly higher sexual self-efficacy following the intervention. The findings suggest that the school-based empowerment CSE intervention is helpful in creating an environment in which both young men and young women benefit in sexual knowledge and gender awareness and young women increase their sexual decision-making skills, thereby lending support to the theory and practice of an empowerment CSE approach.

     

Acceptability and feasibility of a brief substance use intervention for adolescents in Cape Town,South Africa: A pilot study

Substance use is prevalent among South African adolescents, but few interventions exist to reduce risk of harm. This study assesses the feasibility, acceptability and preliminary effects of a brief intervention for reducing adolescent substance use and other risk behaviours. This single-arm feasibility test recruited 30 substance-using adolescents and their primary caregiver. Participants received separate interventions (2 sessions for adolescents, 1 session for caregivers), with a subsample randomly selected for post-intervention interviews. Feasibility was measured by the proportion of eligible adolescents who were enrolled and retained in the study. Interviews explored acceptability, and changes in outcomes from baseline to 1-month follow-up assessed preliminary effects of the intervention. Thirty of 43 (69.8%) eligible adolescents and their caregivers were enrolled, with 29 adolescents (96.7%) and 28 caregivers (93.3%) completing the intervention. Twenty-eight adolescents (93.3%) and 29 caregivers (96.7%) were retained at follow-up. Frequency of alcohol, cannabis use and delinquent-type behaviours decreased significantly from baseline to follow-up. Participants appreciated the intervention content and delivery and felt that it facilitated behaviour change. Suggestions for improving the intervention were provided. This study found that the intervention is feasible, acceptable and had promising effects on adolescent behaviour. Efficacy must be established with a randomised controlled trial.