Conall O’Cleirigh

Substance Use: Impact on Adherence and HIV Medical Treatment

Substance use is highly prevalent among people living with HIV/AIDS, is often comorbid with other mental health problems, related to poor HIV medical outcomes, and, is associated with poor medication and treatment adherence. The current review reports on the recent state of the literature in terms of substance use and its relation to HIV medication and treatment adherence, and offers recommendations for advancing treatment and secondary HIV prevention efforts. Identifying substance users within HIV primary care and developing, evaluating, and refining integrative substance use-mental health-adherence interventions may be clinically important targets for effective disease management and may contribute to secondary HIV prevention efforts.

Promoting the sexual health of MSM in the context of comorbid mental health problems

Despite the moderate efficacy of HIV prevention interventions for at risk gay, bisexual, and other men who have sex with men (MSM), MSM continue to represent the largest group of new HIV infections and the largest number of individuals living with HIV in the US. Environmental factors such as sexual minority stress increase the vulnerability of MSM for mental health problems. These mental health problems can be a barrier to consistently engaging in self-care health behaviors such as sexual risk reduction. We consider the following observations critical to identifying priorities for HIV prevention among MSM: (1) gay, bisexual and other MSM have higher rates of mental health problems than general population estimates; (2) these mental health problems co-occur with each other and interact synergistically to increase HIV risk; and (3) comorbid mental health problems may compromise the impact of prevention programs, and integrating treatment of mental health issues into prevention programs may improve program efficacy. Novel prevention interventions for at risk MSM that integrate programming with the treatment of co-occurring and interfering mental health issues are the most promising avenue to increase prevention intervention efficacy and effectiveness. By addressing significant mental health issues and supporting broad based prevention efforts at the individual and community level, there is also the potential to improve the overall quality of life and public mental health of gay, bisexual, and other MSM.

Functional impairment and health care utilization among HIV-infected men who have sex with men: the relationship with depression and post-traumatic stress

This study examined the relationship of post-traumatic and depressive symptom severity with measures of health-related quality of life (HRQOL), and health care utilization in a sample of 503 HIV-infected men who have sex with men (MSM) recruited in their primary HIV care setting. Participants completed computer assisted assessments of mood and anxiety, HRQOL, and HIV treatment. Peripheral blood CD4 (T helper) lymphocyte count, plasma HIV RNA concentration, and number of medical appointments were extracted from an electronic medical record. Controlling for demographics, disease stage, and antiretroviral medication, post-traumatic stress and depression symptoms accounted for significant variation in general health estimates, and in pain, role, and work-related impairment. Additionally, in multivariable models, post-traumatic stress and depression severity accounted for significant variation in health care utilization whereas symptoms and indices of HIV disease progression did not. These results extend the current research by providing evidence of the relationship between post-traumatic stress and depression symptom severity with measures of functional impairment and health care utilization in a relatively healthy, urban cohort of HIV-infected MSM.

Patterns of Substance Use Among a Large Urban Cohort of HIV-Infected Men Who Have Sex With Men in Primary Care

The present study sought to identify characteristics of HIV-infected MSM that are associated with the use of specific substances and substance abuse in general. Participants were 503 HIV-infected MSM who were receiving primary care. A self-assessment and medical records were used to obtain information about past 3-month alcohol and drug use and abuse, and demographics, HIV-disease stage and treatment, sexual risk, and mental health. Associations of these four domains with substance use and abuse outcomes were examined using hierarchical block-stepwise multivariable logistic regression. Substance use and abuse in the sample was high. Transmission risk behavior was significantly associated with over half of the outcomes. The associations of demographic and HIV-disease stage and treatment variables varied by substance, and mental health problems contributed differentially to almost every outcome. These findings should be considered for designing, implementing, and evaluating substance use programming for HIV-infected MSM.

Optimizing Content for Pre-exposure Prophylaxis (PrEP) Counseling for Men Who Have Sex with Men: Perspectives of PrEP Users and High-Risk PrEP Naïve Men

Existing trials of antiretroviral (ARV) medication as chemoprophylaxis against HIV reveal that the degree of protection is primarily dependent on product adherence. However, there is a lack of data on targets for behavioral interventions to improve adherence to ARV as prevention. Information from individuals who have used ARV as pre-exposure prophylaxis (PrEP) can inform behavioral intervention development. Thirty-nine HIV-uninfected MSM at high risk for HIV acquisition participated in one of four semi-structured focus groups. Two of the focus groups consisted of MSM who had been prescribed and used PrEP in the context of a clinical trial; the other two consisted of high-risk MSM who had not previously used PrEP. An in-depth, within-case/across-case content analysis resulted in six descriptive themes potentially salient for a PrEP adherence behavioral intervention: (1) motivations to use PrEP, (2) barriers to PrEP use, (3) facilitators to PrEP use, (4) sexual decision-making in the context of PrEP, (5) prospective PrEP education content, and, (6) perceived effective characteristics of PrEP delivery personnel. Addressing these themes in behavioral interventions in the context of prescribing PrEP may result in the optimal “packaging” public health programs that implement PrEP for high-risk MSM.

Prevalence of Psychiatric and Substance Abuse Symptomatology Among HIV-Infected Gay and Bisexual Men in HIV Primary Care

BACKGROUND The presence of psychiatric symptoms in gay/bisexual men managing HIV are underidentified and undertreated and can interfere with optimal HIV disease management. There is a paucity of prevalence reports of these symptoms in this group, identified in the primary HIV care setting. Few studies have compared prevalence rates based on empirically supported screening tools in relation to diagnoses made in primary care. OBJECTIVE The purpose of this study was to identify the prevalence of psychiatric symptoms and substance abuse in HIV-infected gay/bisexual men and to estimate the proportion of those who had been diagnosed within their primary medical care setting. METHOD Participants (n = 503) were HIV-infected gay/bisexual men screened for participation in a HIV prevention trial and completed psychosocial assessment. Data were also extracted from patients׳ electronic medical record. RESULTS More than 47% of participants met diagnostic screen-in criteria for any anxiety disorder, of whom approximately one-third were identified in primary care. More than 22% screened in for a depressive mood disorder, approximately 50% of whom had been identified in primary care. A quarter of the sample had elevated substance abuse symptoms, 19.4% of whom were identified in primary care. Of those with symptoms of alcohol abuse (19.9%), 9.0% of those were identified in primary care. CONCLUSION These results provide some evidence suggesting that mood, anxiety, and substance abuse symptomatology are prevalent among HIV-infected gay/bisexual men and are underidentified in primary care. Increased mental health and substance use screening integrated into HIV primary care treatment settings may help to identify more gay/bisexual men in need of treatment.

Developing an HIV-Prevention Intervention for HIV-Infected Men Who Have Sex with Men in HIV Care: Project Enhance

Men who have sex with men (MSM) represent the largest group with HIV in the U.S. (CDC 2005). Interventions for prevention with HIV-infected MSM are urgently needed, and integrating prevention into HIV care represents one opportunity for this advancement. This article describes the development and results of initial pilot testing of a behavioral intervention to reduce HIV sexual risk transmission behavior for HIV-infected MSM that is integrated into HIV care. To illustrate our intervention development process, we describe the setting and population (HIV-infected MSM patients at Fenway Community Health in Boston) for the project, the initial conceptualization of the project including its guiding conceptual model (information, motivation, and behavioral skills model, IMB: Fisher and Fischer 1993), the iterative process of attaining and integrating input from stakeholders, the use of peer interventionists, the open phase pilot and participant input, an overview of the intervention content, and, finally, lessons learned. The result of this process is an example of an intervention developed with strong input from the community and other stakeholders, which is ready for further testing in a randomized controlled trial.

Domains of Life Satisfaction Among Patients Living With HIV: A Factor Analytic Study of the Quality of Life Inventory

This study sought to identify multidimensional factors of life satisfaction in individuals with HIV through a factor analysis of the Quality of Life Inventory (QOLI), and to examine the relationship of these factors to health-related quality of life, depression, and medication adherence. Four quality of life domains emerged: Achievement, Self-Expression, Environment, and Interpersonal Relationships. QOLI means were substantially lower than the normative means and were significantly related to the SF-12 mental (but not the physical) component summary. Multidimensional assessments of quality of life in HIV may help specify targets sensitive to psychosocial interventions.

Body Mass Index, Depression and Sexual Transmission Risk Behaviors Among HIV-Positive MSM

Depression has been shown to be a risk factor for serodiscordant unprotected anal intercourse (SDUAI) in some studies, but not others. Body mass index (BMI) has recently been associated with SDUAI; however, to date, no published study has investigated the interactive effect of depression and BMI on SDUAI. The current study assessed the association between depression, BMI, and SDUAI among HIV-positive MSM. Participants were 430 HIV-positive MSM recruited in a Boston community health center where they received primary care. Participants completed audio computer-assisted self interview (ACASI) measures. Objective height and weight and other clinical variables were accessed through participants’ electronic medical records. Depression was positively associated with SDUAI. This association was significantly moderated by BMI. Elevated levels of depression were only associated with SDUAI for underweight participants. These findings suggest that underweight, depressed HIV-positive MSM may be particularly likely to engage in SDUAI.ResumenLa depresión ha sido reconocida como un riesgo para las personas serodiscordantes que participan en relaciones sexuales anales sin protección (SRSASP) en algunos estudios, pero no otros. El índice de masa corporal (IMC) ha sido asociado recientemente con personas SRSASP; sin embargo, hasta este momento, ningún estudio publicado ha investigado el efecto de la interacción de la depresión y IMC en personas SRSASP. Los participantes fueron 430 hombres que tienen sexo con hombres (HSH) seropositivos que se reclutaron en un centro médico comunitario en Boston donde recibían cuidado médico primario. Los participantes completaron una audio entrevista asistida por la computadora. La altura, el peso objetivo y otras medidas clínicas se obtuvieron a través de los historiales médicos electrónicos de los participantes. La depresión fue asociada directamente con SRSASP. Esta asociación fue moderada apreciablemente por el IMC. Los niveles elevados de depresión fueron asociados solamente con SRSASP para los participantes con bajo peso corporal. Estos resultados sugieren que los HSH seropositivos, deprimidos y con bajo peso corporal pueden estar en riesgo particular de entrar en SRSASP.

Rates of mood and anxiety disorders and contributors to continued heroin use in methadone maintenance patients: A comparison by HIV status.

The frequency of mood and anxiety disorders is elevated among individuals with a history of intravenous drug abuse and among those with human immunodeficiency virus (HIV), and these disorders are associated with continued substance use despite treatment. The present study examined rates of mood and anxiety disorders, and recent heroin use, among HIV-infected and HIV-noninfected patients receiving methadone maintenance therapy. Participants were 160 (80 HIV-infected, 80 HIV-noninfected) methadone patients. Clinician-administered, semistructured interviews were used to identify unipolar and bipolar depression, and four major anxiety disorders (panic disorder with agoraphobia [PDA], generalized anxiety disorder [GAD], post-traumatic stress disorder [PTSD], and social anxiety disorder [SAD]). Toxicology screens and self-reporting were used to assess heroin, cocaine, marijuana, and alcohol use over the past month. The entire sample met criteria for at least one psychiatric disorder other than substance dependence. Substantial proportions of participants met criteria for major depressive disorder (55.6%), bipolar I, bipolar II, or cyclothymia (6.4%), PDA (34.4%), GAD (22.5%), SAD (16.9%), and PTSD (34.4%). A greater proportion of HIV-infected participants met criteria for SAD (χ2 = 5.03), and a greater proportion of HIV-noninfected participants met criteria for GAD (χ2 = 5.39, P < 0.01). About 14% of participants continued to use heroin over the past month, a significantly greater proportion of whom were HIV-infected. In adjusted analyses, none of the mood or anxiety disorders emerged as significant predictors of recent heroin use, but being HIV-infected did. This study highlights the high rate of psychopathology and continued heroin use despite substance abuse treatment, and underscores the need for interventions that help mitigate these problems among methadone patients.