Arlene Kochman

Internalized stigma among people living with HIV-AIDS.

HIV is recognized as a highly stigmatized disease; however, there has been a lack of research on the internalization of this stigma by seropositive people. This study examined internalized stigma among HIV-positive men and women (N = 268) in Milwaukee and Madison, Wisconsin, and New York City. The majority of the sample experienced internalized stigma related to their HIV status. Individuals who experienced high internalized HIV stigma (IHS) had been diagnosed with HIV more recently, their families were less accepting of their illness, they were less likely to ever have attended an HIV support group, and they knew fewer people with HIV. Individuals with high IHS also worried more about spreading their infection to others. Heterosexuals and participants from Wisconsin experienced higher levels of IHS. Hierarchical regression analyses showed that IHS contributed significantly to levels of depression, anxiety, and hopelessness after controlling for the effects of key behavioral and psychosocial variables.

Outcomes from a group intervention for coping with HIV/AIDS and childhood sexual abuse: reductions in traumatic stress.

Childhood sexual abuse is common among HIV-infected persons, though few empirically supported treatments addressing sexual abuse are available for men and women with HIV/AIDS. This study reports the outcome from a randomized controlled trial of a group intervention for coping with HIV and sexual abuse. A diverse sample of 202 HIV-positive men and women who were sexually abused as children was randomly assigned to one of three conditions: a 15-session HIV and trauma coping group intervention, a 15-session support group comparison condition, or a waitlist control (later randomly assigned to an intervention condition). Traumatic stress symptoms were assessed at baseline and post-intervention, with analysis conducted for the three-condition comparison followed by analysis of the two-condition comparison between the coping and support group interventions. Participants in the coping group intervention exhibited reductions in intrusive traumatic stress symptoms compared to the waitlist condition and in avoidant traumatic stress symptoms compared to the support group condition. No differences were found between the support group intervention and waitlist conditions. Tests of clinical significance documented the meaningfulness of change in symptoms.

Effects of a coping intervention on transmission risk behavior among people living with HIV/AIDS and a history of childhood sexual abuse

Objectives:To examine the effect of a 15-session coping group intervention compared with a 15-session therapeutic support group intervention among HIV-positive men and women with a history of childhood sexual abuse (CSA) on sexual transmission risk behavior. Design:A randomized controlled behavioral intervention trial with 12-month follow-up. Methods:A diverse sample of 247 HIV-positive men and women with histories of CSA was randomized to 1 of 2 time-matched group intervention conditions. Sexual behavior was assessed at baseline; immediately after the intervention; and at 4-, 8-, and 12-month follow-up periods (5 assessments). Changes in frequency of unprotected anal and vaginal intercourse by intervention condition were examined using generalized linear mixed models for all partners, and specifically for HIV-negative or serostatus unknown partners. Results:Participants in the HIV and trauma coping intervention condition decreased their frequency of unprotected sexual intercourse more than participants in the support intervention condition for all partners (P < 0.001; d = 0.38, 0.32, and 0.38 at the 4-, 8-, and 12-month follow-up periods, respectively) and for HIV-negative and serostatus unknown partners (P < 0.001; d = 0.48, 0.39, and 0.04 at the 4-, 8-, and 12-month follow-up periods, respectively). Conclusion:A 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.

Patterns and Correlates of Sexual Activity and Condom Use Behavior in Persons 50-Plus Years of Age Living with HIV/AIDS

This study characterized rates of sexual activity and identified psychosocial and behavioral correlates of sexual activity and condom use in a metropolitan sample of 290 HIV-infected adults 50-plus years of age. Thirty-eight percent of participants were sexually active in the past three months, 33% of whom had at least one occasion of anal or vaginal intercourse that was not condom protected. Rates and correlates of sexual activity and condom use differed between gay/bisexual men, heterosexual men, and heterosexual women. In the past three months, 72% of heterosexual men were sexually active compared to only 36% of gay/bisexual men and 21% of heterosexual women. However, among sexually active persons, only 27% of heterosexual men reported inconsistent condom use compared to 37% of gay/bisexual men and 35% of heterosexual women. As the number of older adults living with HIV/AIDS in the U.S. continues to increase, age-appropriate secondary risk-reduction interventions are urgently needed.

Emotional distress in nonmetropolitan persons living with HIV disease enrolled in a telephone-delivered, coping improvement group intervention

The study delineated depressive symptoms and modeled emotional distress in persons living with HIV disease in nonmetropolitan areas of 13 U.S. states. Participants (N=329) were enrolled in a randomized clinical trial of a telephone-delivered, coping improvement group intervention, and 60% reported moderate or severe levels of depressive symptomatology on the Beck Depression Inventory. Structural equation modeling indicated that participants who experienced more severe HIV symptomatology, received less social support, and engaged in more avoidant coping also experienced more emotional distress (a latent construct comprising depressive symptoms and emotional well-being). Greater HIV-related stigma and rejection by family led to more emotional distress, with social support and avoidant coping mediating almost entirely the effects of the former 2 variables. The model accounted for 72% of the variance in emotional distress in nonmetropolitan persons living with HIV disease.

OUTCOMES FROM A RANDOMIZED CONTROLLED TRIAL OF A GROUP INTERVENTION FOR HIV POSITIVE MEN AND WOMEN COPING WITH AIDS-RELATED LOSS AND BEREAVEMENT

The purpose of this study was to examine the impact of a group coping intervention for HIV-positive men and women who have lost a loved one(s) to AIDS in the past 2 years. Two hundred thirty-five participants, diverse with respect to race/ethnicity and sexual orientation, were randomly assigned to a 12-week cognitive-behavioral group intervention or to an individual therapy on request comparison condition. Measures assessing grief and psychiatric distress were administered at baseline and 2 weeks post-intervention period. Although a strong gender effect was observed in outcome, both men and women participating in the group intervention demonstrated significantly more reduction in psychiatric distress than controls. Further, women in the group intervention demonstrated significant reductions in grief and depressive symptoms over men in both conditions and women in the comparison condition. Brief cognitive-behavioral group interventions for coping with grief have a positive impact on the psychiatric functioning of HIV-positive participants. This appears to be especially true for HIV-positive women; a group not previously focused on in clinical research related to AIDS bereavement.

Gender, ethnicity and spiritual coping among bereaved HIV-positive individuals

We examined the influence of gender and ethnicity on coping strategies of 252 bereaved, HIV-positive individuals (65.1% male; 71% ethnic minorities [African-American and Hispanic]). Factor analyses of the Ways of Coping Questionnaire and Coping with Illness Scale yielded five coping subscales: Active, Avoidant, Social Support, Self-destructive, and Spiritual. Multivariate analyses of covariance revealed significant gender and ethnic group effects on spiritual coping, after controlling for social support, education, and sexual orientation. Of all subscales, only spiritual coping was not influenced by perceived social support. Women and ethnic minorities reported greater use of spiritual coping while White men reported the least use of spiritual coping. White women reported significantly greater use of avoidant coping than White men. Further, the relationship between spiritual coping and grief varied across gender and ethnicity. These results highlight the influence of gender and ethnicity in the use of spiritual coping and the importance of integrating spirituality in psychosocial interventions.

AIDS-related grief and coping with loss among HIV-positive men and women

AIDS-related grief was examined and its association with coping among HIV-positive men and women explored. AIDS-related grief, psychological distress and coping were examined among a sample of 268 HIV-infected individuals, diverse with respect to gender, ethnicity, and sexual orientation. Participants exhibited elevated scores on measures of grief reaction and psychological distress including depressive symptoms, anxiety, and traumatic stress related to their losses. Hierarchical regression analyses revealed that severity of grief reaction was associated with escape-avoidance and self-controlling coping strategies, type of loss, depressive symptoms, and history of injection drug use. Interventions are needed to enhance coping and reduce psychological distress associated with the unique bereavement experienced by people living with HIV- and AIDS-related grief.

Reductions in alcohol and cocaine use following a group coping intervention for HIV-positive adults with childhood sexual abuse histories.

AIMS Few interventions exist to reduce alcohol and non-injection drug use among people living with HIV/AIDS. This study tested the effects of a coping group intervention for HIV-positive adults with childhood sexual abuse histories on alcohol, cocaine and marijuana use. DESIGN Participants were assigned randomly to the experimental coping group or a time-matched comparison support group. Both interventions were delivered in a group format over 15 weekly 90-minute sessions. SETTING AND PARTICIPANTS A diverse sample of 247 HIV-positive men and women with childhood sexual abuse were recruited from AIDS service organizations and community health centers in New York City. MEASUREMENTS Substance use was assessed pre- and post-intervention and every 4 months during a 12-month follow-up period. Using an intent-to-treat analysis, longitudinal changes in substance use by condition were assessed using generalized estimating equations. FINDINGS At baseline, 42% of participants drank alcohol, 26% used cocaine and 26% used marijuana. Relative to participants in the support group, those in the coping group had greater reductions in quantity of alcohol use (Wald χ²(₄)=10.77, P = 0.029) and any cocaine use (Wald χ²(₄) = 9.81, P = 0.044) overtime. CONCLUSIONS Many HIV patients, particularly those with childhood sexual abuse histories, continue to abuse substances. This group intervention that addressed coping with HIV and sexual trauma was effective in reducing alcohol and cocaine use, with effects sustained at 12-month follow-up. Integrating mental health treatment into HIV prevention may improve outcomes.

Utilization of medical treatments and adherence to antiretroviral therapy among HIV-positive adults with histories of childhood sexual abuse.

HIV is a chronic, life-threatening illness that necessitates regular and consistent medical care. Childhood sexual abuse (CSA) is a common experience among HIV-positive adults and may interfere with treatment utilization. This study examined rates and correlates of treatment utilization among HIV-positive adults with CSA enrolled in a coping intervention trial in New York City. The baseline assessment included measures of treatment utilization, mental health, substance abuse, and other psychosocial factors. In 2002-2004, participants (50% female, 69% African-American, M = 42.3 +/- 6.8 years old) were recruited. Nearly all (99%) received HIV medical care. However, 20% had no outpatient visits and 24% sought emergency services in the past 4 months. Among 184 participants receiving antiretroviral therapy (ART), 22% were less than 90% adherent in the past week. In a multivariable logistic regression model, no outpatient treatment was associated with African American race (AOR = 3.46 [1.42-8.40]), poor social support (AOR = 1.59 [1.03-2.45]), and abstinence from illicit drug use (AOR = 0.37 [0.16-0.85]). Emergency service utilization was associated with HIV symptoms (AOR = 2.30 [1.22-4.35]), binge drinking (AOR=2.92 (1.18-7.24)), and illicit drug use (AOR = 1.98 [1.02-3.85]). Poor medication adherence was associated with trauma symptoms (AOR = 2.64 [1.07-6.75]) and poor social support (AOR = 1.82 [1.09-2.97]). In sum, while participants had access to HIV medical care, a sizable minority did not adhere to recommended guidelines and thus may not be benefiting optimally from treatment. Interventions targeting HIV-positive adults with CSA histories may need to address trauma symptoms, substance abuse, and poor social support that interfere with medical treatment utilization and adherence.