Tailoring Cognitive Behavioral Therapy for Trauma-Exposed Persons Living With HIV

This treatment development report describes the need for evidence-based psychosocial trauma-focused treatment for people living with comorbid posttraumatic stress disorder (PTSD) and HIV. Individuals with HIV have higher rates of exposure to traumatic events and PTSD than the general public, and they also experience additional consequences of PTSD on the management of their chronic disease (e.g., established link between PTSD symptoms and lack of adherence to antiretroviral therapy [ART]). We used the empirically supported ADAPT-ITT approach to consider the initial steps in adapting evidence-based Cognitive Processing Therapy (CPT) for individuals with PTSD and HIV. This paper reviews a case example that involved various clinical issues that may arise when providing trauma-focused treatment for people living with HIV including HIV-stigma, disease management, and the need for making multicultural adaptations to psychotherapy. This case example illustrates how trauma-focused treatment may benefit from enhancement to address additional barriers that may arise over the course of PTSD treatment in this population. Feasibility of engaging and delivering a "full dose" of evidence-based PTSD treatment among individuals living with HIV is discussed. While evidence-based treatments can reduce PTSD symptom severity, issues related to chronic disease coping and HIV-related stigma management could be integrated to augment the efficacy of treatment for individuals with HIV. Adaptive intervention research targeting PTSD in persons living with HIV warrants further attention, especially given the association between PTSD and adherence to ART.     

Predictors of HIV-related stigma among young people living with HIV.

Enacted and perceived HIV stigma was examined among substance-using young people living with HIV (YPLH) in Los Angeles, San Francisco, and New York City (N = 147). Almost all YPLH (89%) reported perceived stigma, and 31% reported enacted experiences in the past 3 months; 64% reported experiences during their lifetime. The HIV stigma questions were characterized by factors of avoidance, social rejection, abuse, and shame. In multivariate models, enacted stigma was associated with gay or bisexual identity, symptomatic HIV or AIDS, and bartering sex. Perceived stigma was associated with female gender, symptomatic HIV or AIDS, bartering sex, lower injection drug use, and fewer friends and family knowing serostatus. Gay or bisexual YPLH who were also HIV symptomatic or AIDS diagnosed experienced more HIV stigma than their heterosexual peers.     

Disengagement and Engagement Coping with HIV/AIDS Stigma and Psychological Well-Being of People with HIV/AIDS

The stigma associated with HIV/AIDS poses a psychological challenge to people living with HIV/AIDS. We hypothesized that that the consequences of stigma-related stressors on psychological well-being would depend on how people cope with the stress of HIV/AIDS stigma. Two hundred participants with HIV/AIDS completed a self-report measure of enacted stigma and felt stigma, a measure of how they coped with HIV/AIDS stigma, and measures of depression and anxiety, and self-esteem. In general, increases in felt stigma (concerns with public attitudes, negative self-image, and disclosure concerns) coupled with how participants reported coping with stigma (by disengaging from or engaging with the stigma stressor) predicted self-reported depression, anxiety, and self-esteem. Increases in felt stigma were associated with increases in anxiety and depression among participants who reported relatively high levels of disengagement coping compared to participants who reported relatively low levels of disengagement coping. Increases in felt stigma were associated with decreased self-esteem, but this association was attenuated among participants who reported relatively high levels of engagement control coping. The data also suggested a trend that increases in enacted stigma predicted increases in anxiety, but not depression, among participants who reported using more disengagement coping. Mental health professionals working with people who are HIV positive should consider how their clients cope with HIV/AIDS stigma and consider tailoring current therapies to address the relationship between stigma, coping, and psychological well-being.     

ACT HEALTHY: A Combined Cognitive-Behavioral Depression and Medication Adherence Treatment for HIV-Infected Substance Users

The two most common comorbid conditions with HIV are substance use disorders and depression, and individuals with comorbid HIV, depression, and substance dependence face a more chronic and treatment-resistant course. As an example of how to adapt evidence-based approaches to a complex comorbid population, the current case study examined the integration of a combined depression and HIV medication adherence treatment. The resulting intervention, ACT HEALTHY, combines a brief behavioral activation approach specifically developed to treat depression in individuals receiving residential substance abuse treatment (LETS ACT; Daughters et al., 2008) with a brief cognitive-behavioral approach to improving HIV medication adherence (Life-Steps; Safren et al., 1999; Safren et al., 2009). The current case series demonstrates the use of ACT HEALTHY among 3 depressed HIV-positive, low-income African Americans entering residential substance abuse treatment.     

Coping with HIV Related Stigma and Well-Being

The goal of this study was to analyze the relationships to be found among stigma perception, active and avoidant coping strategies, and subjective and psychological well-being in a sample of 133 people with HIV. The results showed that stigma perception and avoidant coping strategies (venting, self-blame, denial, behavioural disengagement and substance use) were positively associated, whereas, both stigma perception and avoidant coping were negatively associated with different measures of well-being (affect balance, self-acceptance and environmental mastery). These negative relationships between stigma perception and the three well-being measures were mediated by the use of avoidant coping strategies. Results suggest that psychosocial intervention programs for people who report psychological distress arising from prejudice must be aimed at developing appropriate ways to deal with this prejudice. Intervention programs should also include strategies to directly increase well-being since from a positive psychology viewpoint certain interventions have been shown to do so, and HIV research has also shown that well-being is associated with lower mortality rates.     

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.     

Individual attitudes and perceived social norms: Reports on HIV/AIDS‐related stigma among service providers in China

This study examined HIV/AIDS‐related stigma among Chinese service providers by comparing their personal attitudes toward people living with HIV/AIDS with their perception of social norms related to people living with HIV/AIDS. We randomly selected three provincial hospitals, four city/prefecture hospitals, 10 county hospitals, 18 township health clinics, and 54 village clinics from Yunnan, China. Doctors and nurses were randomly sampled proportionally to the doctor–nurse ratio of each hospital or clinic. Lab technicians were over‐sampled in order to include an adequate representation in the analysis. A total of 1,101 service providers participated in a voluntary, anonymous survey where demographic characteristics, individual attitude and perceived social norms toward people living with HIV/AIDS, discrimination intent at work, general prejudicial attitude and knowledge on HIV/AIDS were measured. A majority of the sample demonstrated a similarity between their personal views and what they thought most people in society believe. Multiple logistic regressions revealed that participants who were younger or reported personal contact with people living with HIV/AIDS were significantly more likely to report personal attitudes toward the population that were more liberal than their perceived social norms. Holding a more liberal personal attitude toward people living with HIV/AIDS than perceived social norms was significantly and negatively related to the level of discrimination intent at work, perceived discrimination at interpersonal level and the level of general prejudicial attitude toward people living with HIV/AIDS. Results underscored the importance of understanding social norms and personal attitudes in studying HIV‐related stigma and called for the incorporation of existing human capital into future HIV stigma reduction programs.     

Overcoming Barriers to HIV Treatment Adherence: A Brief Cognitive Behavioral Intervention for HIV-Positive Adults on Antiretroviral Treatment

Maximizing HIV treatment adherence is critical in efforts to optimize health outcomes and to prevent further HIV transmission. The Balance Project intervention uses cognitive behavioral approaches to improve antiretroviral medication adherence through promoting adaptive coping with medication side effect and distress related to HIV. This 5-session intervention has been documented to prevent nonadherence among persons living with HIV who experience high levels of distress associated with their antiretroviral medication side effects. We describe the theoretical underpinnings of the intervention, provide details of the training and session protocols with a case example, and discuss implications for future applications of the intervention in both research and clinical settings.     

艾滋病污名的形成机制、负面影响与干预

艾滋病污名主要包括实际污名、感知污名和自我污名, 这些不同形式的污名给艾滋病患者带来了精神上的痛苦、社会资源的剥夺等一系列的负面影响。归因理论、社会文化理论和道德理论分别从社会心理学、社会不平等和文化道德的角度阐述了艾滋病污名的形成机制。从这些机制出发, 减少艾滋病污名可以结合接触假设、知识传播以及认知行为疗法, 并注意改变艾滋病患者的自身观念。未来的艾滋病污名研究应更多地从社会文化以及道德的角度进行跨文化的量化研究。     

Predictors of anxiety and depression among newly diagnosed people living with HIV: A longitudinal study

This longitudinal study examined whether past resilience and internalized stigma predicted anxiety and depression among newly diagnosed Spanish-speaking people living with HIV (PLWH). We also analyzed whether coping strategies mediated this relationship. Data were collected at two time points from 119 PLWH. Approximately a third of participants had scores indicative of anxiety symptoms, the same result was found for depressive symptoms. Structural equations modeling revealed that 61% of the variance of anxiety and 48% of the variance of depression 8 months after diagnosis was explained by the proposed model, which yielded a good fit to data. Anxiety and depressive symptoms were significantly and negatively predicted by positive thinking, thinking avoidance, and past resilience, and positively predicted by self-blame. Additionally, anxiety was positively predicted by internalized stigma. Past resilience negatively predicted internalized stigma, self-blame, and thinking avoidance and it positively predicted positive thinking. Internalized stigma positively predicted self-blame. Moreover, internalized stigma had a significant indirect effect on anxiety symptoms through self-blame, and past resilience had significant indirect effects on anxiety symptoms and depressive symptoms through internalized stigma and coping. The results point to the need for clinicians and policy makers to conduct systematic assessments and implement interventions to reduce internalized stigma and train people living with HIV to identify and use certain coping behaviors.     

Othering,blame and shame when working with people living with HIV

Significant advances in HIV treatment has meant that for the majority of patients with HIV, they are able to live a normal lifespan. However, HIV remains a highly stigmatizing disease with the potential to significantly impact on one’s social identity and sense of self. This paper draws on data from a qualitative study of interviews with five gay men, to explore the experiences of shame in relation to living with HIV. The paper adopts a psychoanalytic lens to highlight the mechanisms of splitting that may be involved at both a social and individual level, and the experience of shame among the participants. The paper aims to use this research data to supplement our understanding of what may be occurring ‘on the couch’ with patients who are living with HIV.     

Spirituality and Religion in Antiretroviral Therapy (ART) in Kwazulu-natal,South Africa: A Longitudinal Study

This study assesses the effects of spirituality and religion in health outcomes of patients on ART in KwaZulu-Natal, South Africa. Participants were 735 patients who attended three HIV clinics for ART over a period of 20 months as follows: 519 after 6 months on antiretroviral therapy (ART), 557 after 12 and 499 after 20 months on ART. They completed the Duke Religion Index each visit. Factors associated with spirituality/religiousness included fewer mental health problems (lower depressive symptoms, lower alcohol use), CD4 cell counts, adherence to ART, better certain health related quality of life outcomes (physical, psychological and environmental), social support and internalized HIV/AIDS stigma. Further research could examine the feasibility of including spirituality and religion in the assessment and providing support interventions for HIV patients.     

Reasons for substance use among people with psychotic disorders: method triangulation approach

Substance use disorders (SUD) are common among people with psychotic disorders and are associated with many negative consequences. Understanding the reasons for substance use in this population may allow for the development of more effective prevention and intervention strategies. We examined reasons for tobacco, alcohol, or cannabis use among people with psychotic disorders. Sixty-four participants with a diagnosed psychotic disorder completed a self-report reasons for use questionnaire. A subset of eight participants completed semi-structured qualitative interviews. Both the qualitative and quantitative data indicated that reasons for use of tobacco, alcohol, and cannabis differed considerably. Tobacco was primarily used for coping motives, alcohol for social motives, and cannabis for pleasure enhancement motives. Prevention and intervention strategies targeting coexisting psychotic disorders and SUD may improve in effectiveness if they address the perceived beneficial effects of tobacco use, the strong social pressures influencing alcohol use and if they encourage cannabis users to seek alternative pleasurable activities.     

HIV-related stigma in African and Afro-Caribbean communities in the Netherlands: manifestations, consequences and coping

HIV-related stigma in African and Afro-Caribbean diaspora communities in the Netherlands was investigated. Interviews with HIV-positive and HIV-negative community members demonstrated that HIV-related stigma manifests as social distance, physical distance, words and silence. The psychological consequences of HIV-related stigma among those diagnosed with HIV reported were emotional pain, sadness, loneliness, anger, frustration and internalised stigma. The social consequences included decreased social network size, limited social support and social isolation, and resulted from not only enacted stigma but also self-imposed social withdrawal. Also, poor treatment adherence was a health-related consequence. People living with HIV employed both problem-focused and emotion-focused coping strategies to mitigate the negative consequences of stigma. Problem-focused coping strategies included selective disclosure, disengagement, affiliating with similar others, seeking social support and, to a lesser extent, activism. Emotion-focused strategies included distraction, positive reappraisal, religious coping, external attributions, disidentification and acceptance. HIV-related stigma clearly permeates African and Afro-Caribbean communities in the Netherlands, and should be targeted for intervention.     

基于连续体信念的精神障碍污名化干预探索

以往研究尝试阐明精神障碍患者污名化的产生机制,并提出相应的干预方案。然而,不同方案的干预效果却不尽如人意,并导致了众多理论纷争。解决上述争论的关键在于揭示污名化产生的核心认知机制,即精神障碍的污名化源于人类自发性的社会分类加工。上述核心认知机制的提出将引领以连续体信念为切入点的全新污名化干预路径。该干预路径能够整合精神障碍污名化消除的理论之争,进而衍生出完整的连续体信念干预理论模型和实践模式。     

Adaptation of an HIV Medication Adherence Intervention for Adolescents and Young Adults

Rising rates of human immunodeficiency virus (HIV) infection among adolescents and young adults underscore the importance of interventions for this population. While the morbidity and mortality of HIV has greatly decreased over the years, maintaining high rates of adherence is necessary to receive optimal medication effects. Few studies have developed interventions for adolescents and young adults and none have specifically been developed for sexual minority (lesbian, gay, and bisexual; LGB) youth. Guided by an evidence-based adult intervention and adolescent qualitative interviews, we developed a multicomponent, technology-enhanced, customizable adherence intervention for adolescents and young adults for use in a clinical setting. The two cases presented in this paper illustrate the use of the five-session positive strategies to enhance problem solving (Positive STEPS) intervention, based on cognitive-behavioral techniques and motivational interviewing. We present a perinatally infected heterosexual woman and a behaviorally infected gay man to demonstrate the unique challenges faced by these youth and showcase how the intervention can be customized. Future directions include varying the number of intervention sessions based on mode of HIV infection and incorporating booster sessions.     

Positive Self-Statements: Power for Some, Peril for Others

ABSTRACT— Positive self-statements are widely believed to boost mood and self-esteem, yet their effectiveness has not been demonstrated. We examined the contrary prediction that positive self-statements can be ineffective or even harmful. A survey study confirmed that people often use positive self-statements and believe them to be effective. Two experiments showed that among participants with low self-esteem, those who repeated a positive self-statement ("I'm a lovable person") or who focused on how that statement was true felt worse than those who did not repeat the statement or who focused on how it was both true and not true. Among participants with high self-esteem, those who repeated the statement or focused on how it was true felt better than those who did not, but to a limited degree. Repeating positive self-statements may benefit certain people, but backfire for the very people who "need" them the most.     

Hazardous Alcohol Use among Persons Living with Human Immunodeficiency Virus Infection in the Eastern Cape,South Africa

The study assessed the prevalence of hazardous alcohol use among people living with HIV (PLHIV) and its correlates with socio-economic characteristics, disease variables and ART adherence in South Africa. The sample included 607 PLHIV (males =475, females =132; age range =18–61), sampled by all districts in the Eastern Cape. Participants were recruited through a health facility in the community through key informants or a support group. Results indicate that male PLHIV were more often than female PLHIV “past month” (18.9% vs. 6.1%) and hazardous alcohol drinkers (6.1% vs. 2.7%); using a cut-off score of 8 and more on the Alcohol Use Disorders Identification Test (AUDIT). Not having a disability grant for HIV/AIDS and the disability grant terminated were both related to past month alcohol use, while having the “disability grant stopped” was also related with hazardous or harmful drinking. Not having an AIDS diagnosis and not being on ART were both associated with past month alcohol use and hazardous or harmful drinking. CD4 counts and non-adherence to ART were both not significantly related with alcohol use status. Brief health provider initiated alcohol interventions for PLHIV should be promoted, with emphasis on targeting men.