Christina S. Meade

Adherence to HAART among patients with HIV: Breakthroughs and barriers

Highly active antiretroviral therapy (HAART) has been a major breakthrough for the treatment of patients with HIV; however, adherence to treatment remains a formidable barrier. This paper evaluates the current state-of-the-science in adherence to HAART. Barriers to treatment success, determinants of adherence and interventions to improve adherence are reviewed. Overall, multifaceted interventions appear most promising. We conclude with recommendations to enhance clinical practice and improve treatment outcomes for patients with HIV. Despite substantial attention to adherence in recent years, much more remains to be done to understand and promote adherence to HAART.

The intergenerational cycle of teenage motherhood: An ecological approach.

OBJECTIVE Daughters of teenage mothers have increased risk for teenage childbearing, perpetuating intergenerational cycles. Using Ecological Systems Theory, this study prospectively examined risk factors for teenage childbearing among a national sample of adolescent girls. DESIGN Data came from the National Longitudinal Survey of Youth 1997. Participants (N = 1,430) were recruited in early adolescence and interviewed yearly for 6 years. Survival analysis was used to examine the rate of childbirth across the teenage years by maternal age at first birth. Hierarchical Cox regression was used to identify multivariate predictors of teenage childbearing and to test whether risk factors differed between daughters of teenage versus older mothers. PRIMARY OUTCOME MEASURE Age at first childbirth was based on cumulative information collected at yearly interviews. RESULTS Daughters of teenage mothers were 66% more likely to become teenage mothers, after accounting for other risks. Individual (school performance), family (maternal education, marital status, number of children), peer (dating history), and environmental (race, enrichment) factors predicted teenage childbearing. Risks unique to daughters of teenage mothers were deviant peer norms, low parental monitoring, Hispanic race, and poverty. CONCLUSION Results support multidimensional approaches to pregnancy prevention, and targeted interventions addressing unique risk factors among daughters of teenage mothers.

Urban Teens: Trauma, Posttraumatic Growth, and Emotional Distress among Female Adolescents.

Urban teens face many traumas, with implications for potential growth and distress. This study examined traumatic events, posttraumatic growth, and emotional distress over 18 months among urban adolescent girls (N = 328). Objectives were to (a) describe types of traumatic events, (b) determine how type and timing of events relate to profiles of posttraumatic growth, and (c) prospectively examine effects of event type and posttraumatic growth on short- and long-term emotional distress with controls for pre-event distress. Results indicate that type of event was related to profiles of posttraumatic growth, but not with subsequent emotional distress. When baseline emotional distress was controlled, posttraumatic growth was associated with subsequent reductions in short- and long-term emotional distress. Implications for future research and clinical practice with adolescents are addressed.

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.

Adherence to antiretroviral therapy among patients with HIV: a critical link between behavioral and biomedical sciences.

Summary: Rapid advances in biomedical science, such as pharmaceutical developments for HIV disease, must be integrated with advances in behavioral science to further our understanding of medication adherence. This article evaluates the current state of the science in adherence to antiretroviral therapy for persons with HIV. The primary objectives are to 1) identify critical determinants of adherence, and 2) describe interventions to improve adherence. Adherence is a complex dynamic behavior influenced by characteristics of the patient, treatment regimen, disease, patient‐provider relationship, and clinical setting. Therefore, the most promising interventions are multifaceted and target different locations in this matrix simultaneously. Unfortunately, nonadherence remains a formidable barrier in the management of HIV, resulting in the development of resistance and drug failure. Moreover, adherence is a public health concern, with implications for the transmission of HIV in general and the transmission of drug‐resistant strains of HIV specifically. Despite substantial attention to adherence in recent years, much more remains to be done to better understand and promote adherence to antiretroviral therapy through effective interventions. From this integration of biomedical and behavioral science, effective clinical interventions can be developed and implemented to enhance the health of patients with HIV.

Mental Health Treatment to Reduce HIV Transmission Risk Behavior: A Positive Prevention Model

Secondary HIV prevention, or “positive prevention,” is concerned with reducing HIV transmission risk behavior and optimizing the health and quality of life of people living with HIV/AIDS (PLWHA). The association between mental health and HIV transmission risk (i.e., sexual risk and poor medication adherence) is well established, although most of this evidence is observational. Further, a number of efficacious mental health treatments are available for PLWHA yet few positive prevention interventions integrate mental health treatment. We propose that mental health treatment, including behavioral and pharmacologic interventions, can lead to reductions in HIV transmission risk behavior and should be a core component of secondary HIV prevention. We present a conceptual model and recommendations to guide future research on the effect of mental health treatment on HIV transmission risk behavior among PLWHA.

Long-term correlates of childhood abuse among adults with severe mental illness: Adult victimization, substance abuse, and HIV sexual risk behavior

The prevalence of childhood sexual and physical abuse among persons with severe mental illness (SMI) is disproportionately high. Adults with SMI also engage in high rates of HIV risk behaviors. This study examined the association between childhood abuse and adult victimization, substance abuse, and lifetime HIV sexual risk in a sample of 152 adults with SMI receiving community mental health services. Structured interviews assessed psychiatric, psychosocial, and behavioral risk factors. Seventy percent reported childhood physical and/or sexual abuse, and 32% reported both types of abuse. Participants with childhood abuse were more likely to report adult victimization and greater HIV risk. A structural equation model found that childhood abuse was directly and indirectly associated with HIV risk through drug abuse and adult vicitimization. Integrated treatment approaches that address interpersonal violence and substance abuse may be necessary for HIV risk reduction in this population.

Short and long-term impact of adolescent pregnancy on postpartum contraceptive use: implications for prevention of repeat pregnancy.

PURPOSE To describe patterns and changes in contraceptive use among pregnant adolescents in early and later postpartum compared with nonpregnant adolescents. METHODS One-hundred-seventy-six pregnant and 187 nonpregnant adolescents, recruited through community clinics, were interviewed three times (baseline, 6-month follow-up, 12-month follow-up) about their condom and hormonal contraceptive practices. Changes in contraception use and patterns of consistent hormonal and/or condom use were examined. Statistical analyses included General Estimating Equations (GEE) and multinomial regression. RESULTS Pregnant adolescents increased hormonal contraceptive use from baseline to early postpartum, but decreased use from early postpartum to late postpartum. Nonpregnant adolescents did not change their hormonal contraceptive use over time. Neither group changed condom use over time. Pregnant adolescents were more likely to be consistent dual users and hormonal-only users during the 6-month follow-up compared with nonpregnant adolescents. These findings persisted at the 12-month follow-up, although there was a decline in hormonal contraception use. CONCLUSIONS Adolescents change their contraceptive use during the postpartum period. Given the slight decline in contraceptive use in late postpartum in this sample, more work is necessary to maintain motivation to continue these positive postpartum trends.

Prevalence, Course, and Predictors of Emotional Distress in Pregnant and Parenting Adolescents.

This study examines trajectories and correlates of emotional distress symptoms in pregnant adolescents (n = 203) and nulliparous adolescents (n = 188) from economically disadvantaged communities over an 18-month period. For both groups, the prevalence of significant emotional distress exceeded expectation based on adolescent norms; however, the severity of symptoms did not differ between the 2 groups. Results from growth curve modeling revealed a significant decline in symptoms during the study period for both groups, but pregnant adolescents experienced a different pattern of decline. Also, certain interpersonal factors (e.g., history of physical maltreatment, partner support) appeared to play a more important role in the emotional well-being of pregnant and parenting adolescents relative to nulliparous adolescents. Implications for early identification and intervention are discussed.

Mental health and HIV sexual risk behavior among patrons of alcohol serving venues in Cape Town, South Africa

Background:Alcohol-serving venues in South Africa provide a location for HIV prevention interventions due to risk factors of patrons in these establishments. Understanding the association between mental health and risk behaviors in these settings may inform interventions that address alcohol use and HIV prevention. Methods:Participants (n = 738) were surveyed in 6 alcohol-serving venues in Cape Town to assess post-traumatic stress disorder (PTSD) and depression symptoms, traumatic experiences, sexual behavior, and substance use. Logistic regression models examined whether traumatic experiences predicted PTSD and depression. Generalized linear models examined whether substance use, PTSD, and depressive symptoms predicted unprotected sexual intercourse. Men and women were analyzed separately. Results:Participants exhibited high rates of traumatic experiences, PTSD, depression, alcohol consumption, and HIV risk behaviors. For men, PTSD was associated with being hit by a sex partner, physical child abuse, sexual child abuse and HIV diagnosis; depression was associated with being hit by a sex partner, forced sex and physical child abuse. For women, both PTSD and depression were associated with being hit by a sex partner, forced sex, and physical child abuse. Unprotected sexual intercourse was associated with age, frequency and quantity of alcohol use, drug use, and PTSD for men and frequency and quantity of alcohol use, depression, and PTSD for women. Conclusion:Mental health in this setting was poor and was associated with sexual risk behavior. Treating mental health and substance-use problems may aid in reducing HIV infection. Sexual assault prevention and treatment after sexual assault may strengthen HIV prevention efforts.