Curtis Dolezal

Couple-focused support to improve HIV medication adherence: a randomized controlled trial.

Objective:To assess the efficacy of a couple-based intervention to improve medication-taking behavior in a clinic population with demonstrated adherence problems. Design:A randomized controlled trial (SMART Couples Study) conducted between August 2000 and January 2004. Setting:Two HIV/AIDS outpatient clinics in New York City. Participants:Heterosexual and homosexual HIV-serodiscordant couples (n = 215) in which the HIV-seropositive partner had < 80% adherence at baseline. The sample was predominantly lower-income racial/ethnic minorities. Intervention:Participants were randomly assigned to a four-session couple-focused adherence intervention or usual care. The intervention consisted of education about treatment and adherence, identifying adherence barriers, developing communication and problem-solving strategies, optimizing partner support, and building confidence for optimal adherence. Outcome measures:Medication adherence at week 8 (2 weeks after the intervention) compared with baseline, assessed with a Medication Event Monitoring System cap. Results:Intervention participants showed higher mean medication adherence at post-intervention when compared with controls whether adherence was defined as proportion of prescribed doses taken (76% versus 60%) or doses taken within specified time parameters (58% versus 35%). Also, participants in the intervention arm were significantly more likely to achieve high levels of adherence (> 80%, > 90%, or > 95%) when compared with controls. However, in most cases, effects diminished with time, as seen at follow-up at 3 and 6 months. Conclusion:The SMART Couples program significantly improved medication adherence over usual care, although the level of improved adherence, for many participants, was still suboptimal and the effect was attenuated over time.

The role of HIV serostatus disclosure in antiretroviral medication adherence.

This study examined the relationship between HIV serostatus disclosure and adherence to antiretroviral therapy (ART). The study was conducted with 215 HIV-seropositive patients who demonstrated poor adherence (<80%) and who were in serodiscordant relationships. Participants completed self-report measures regarding HIV serostatus disclosure and reasons for missing ART doses, as well as electronic monitoring of ART adherence (MEMS caps). Overall, 19% of the sample reported missing medication doses in the last two months due to concerns regarding serostatus disclosure. Participants who reported greater serostatus disclosure to others demonstrated higher rates of adherence, and this relationship remained after controlling for other explanatory variables. The relationship between disclosure and adherence was not mediated by practical support for adherence from others. Interventions to improve ART adherence should address the role of serostatus disclosure by providing patients with skills to maintain adherence in contexts of non-disclosure and to make informed choices regarding selective disclosure.

The Female Sexual Function Index: A Methodological Critique and Suggestions for Improvement

The Female Sexual Function Index (FSFI) is a very well-worded sexual function screen with excellent psychometric qualities. However, some aspects of the scoring procedures pose conceptual and statistical problems, which we illustrate in part by way of an empirical example. The recommended solutions should further strengthen the utility and validity of this instrument.

Prenatal androgenization affects gender-related behavior but not gender identity in 5-12-year-old girls with congenital adrenal hyperplasia.

Gender assignment of children with intersexuality and related conditions has recently become highly controversial. On the basis of extensive animal research and a few human case reports, some authors have proposed the putative masculinization of the brain by prenatal hormones—indicated by the degree of genital masculinization—as the decisive criterion of gender assignment and have derived the recommendation that 46,XX newborns with congenital adrenal hyperplasia (CAH) and full genital masculinization should be assigned to the male gender. The purpose of this study was to test in CAH girls of middle childhood the assumption that prenatal androgens determine the development of gender identity. Fifteen girls with CAH (range of genital Prader stage, 2–4/5), 30 control girls, and 16 control boys (age range, 5–12 years) underwent 2 gender-play observation sessions, and a gender identity interview yielding scales of gender confusion/dysphoria. About half a year earlier, mothers had completed 2 questionnaires concerning their childrens gender-related behavior. The results showed that, as expected, CAH girls scored more masculine than control girls on all scales measuring gender-related behavior, with robust effect sizes. By contrast, neither conventionally significant differences nor trends were found on the 3 scales of the gender identity interview. We conclude that prenatal androgenization of 46,XX fetuses leads to marked masculinization of later gender-related behavior, but the absence of any increased gender-identity confusion/dysphoria does not indicate a direct determination of gender identity by prenatal androgens and does not, therefore, support a male gender assignment at birth of the most markedly masculinized girls.

Association between history of childhood sexual abuse and adult HIV-risk sexual behavior in Puerto Rican men who have sex with men

This study explored whether homosexually active men who were sexually abused in childhood were more likely to engage in HIV-risk sexual behavior than men who were not sexually abused. Participants were 182 adult men of Puerto Rican ancestry living in New York City who had had sex with other men or with men and women. Quantitative and qualitative methods of exploration were used. Three groups were determined: (a) Abuse group (AB), formed by men who before age 13, had sex with a partner at least 4 years their senior and who felt hurt by the experience and/or were unwilling to participate in it; (b) Willing/not hurt group (W), consisting of men who had an older sexual partner before age 13 but did not feel hurt by the experience and were willing to participate; and (c) No-older-partner group (NOP). The results showed that men in the AB group were significantly more likely than men in the NOP group to engage in receptive anal sex and to do so without protection. Men in the W group were ranked between the other two groups in terms of their unsafe behavior. Age and education were cofactors both for receptive anal sex and for unprotected receptive anal sex. It is concluded that given the need to improve HIV prevention among Puerto Rican men who have sex with men, sexual abuse in childhood may constitute a marker to identify men at increased risk.

Patterns of HIV Status Disclosure to Perinatally HIV-Infected Children and Subsequent Mental Health Outcomes

Increasing numbers of perinatally HIV-infected children are surviving into their teens and beyond. Research and clinical reports suggest that many HIV-infected children, particularly those younger than 13 years, do not know they are HIV infected owing to parental concerns about the impact on their mental health. This study examines patterns of HIV status disclosure to 77 perinatally HIV-infected ethnic minority children (aged 3–13 years), and explores the association between knowledge of HIV status and emotional and behavioral outcomes. The majority of children in this study (70%) did not know their HIV status. On average, children who knew their HIV status were older and tended to have lower CD4%. Child knowledge of HIV status was not associated with gender, ethnicity, caregiver education, parent–child relationship factors, type of placement (biological vs adoptive), or other health status indicators. As hypothesized, HIV status disclosure to infected children did not result in increased mental health problems. There was a statistical trend for children who knew their HIV status to be less depressed than children who did not know. Also, greater social disclosure (e.g. communication of child’s status to family and friends) was found when the child had an AIDS diagnosis or lower CD4%, as well as when the caregiver was HIV negative, African American and not the child’s biological parent. In conclusion, pediatric HIV infection remains a highly stigmatized issue that is difficult to discuss with the infected child and others. Yet, contrary to the beliefs of many caregivers, disclosure did not result in increased mental health problems.

Rates and types of psychiatric disorders in perinatally human immunodeficiency virus-infected youth and seroreverters.

BACKGROUND The purpose of this study was to examine 1) the prevalence of psychiatric and substance use disorders in perinatally HIV-infected (HIV+) adolescents and 2) the association between HIV infection and these mental health outcomes by comparing HIV+ youths to HIV exposed but uninfected youths (HIV-) from similar communities. METHODS Data for this paper come from the baseline interview of a longitudinal study of mental health outcomes in 9-16 year old perinatally HIV-exposed youths (61% HIV+) and their caregivers. Three hundred forty youths and their primary adult caregivers were recruited from four medical centers and participated in separate individual interviews. Youth psychiatric disorder was assessed using the caregiver and youth versions of The Diagnostic Interview Schedule for Children (DISC-IV). RESULTS According to caregiver or youth report, a high percentage of HIV+ and HIV- youths met criteria for a non-substance use psychiatric disorder, with significantly higher rates among the HIV+ youths (61% vs. 49%, OR = 1.59; CI = 1.03,2.47; p < .05). The most prevalent diagnoses in both groups were anxiety disorders (46% for total sample) which included social phobia, separation anxiety, agoraphobia, generalized anxiety disorder, panic disorder, obsessive- compulsive disorder, and specific phobias. One quarter of the sample met criteria for a behavioral disorder (ADHD, conduct disorders, and oppositional defiant disorders), with ADHD being most prevalent. HIV+ youths had significantly higher rates of ADHD (OR = 2.45; CI = 1.20, 4.99, p < .05). Only 7% of youths met criteria for a mood disorder and 4% for a substance abuse disorder. Several caregiver variables (caregiver type and HIV status) were also associated with both child HIV status and mental health outcomes. CONCLUSIONS Our data suggest that HIV+ youths are at high risk for mental health disorders. Further longitudinal research is necessary to understand the etiology, as well as potential protective factors, in order to inform efficacy-based interventions.

Substance use and sexual risk behavior: understanding their association among four ethnic groups of Latino men who have sex with men.

PURPOSE To explore the association between substance use in conjunction with sex and unprotected anal sex among Colombian, Dominican, Mexican, and Puerto Rican men who have sex with men (MSM), considering ethnicity, acculturation, and mediating variables. METHODS A New York City convenience sample of 307 men provided information on past years sexual behavior, substance use, acculturation, attendance at bars, discos, and parties, self-worth, machismo, and sensation seeking. RESULTS Alcohol use and drug use were positively associated with unprotected anal sex, particularly with casual partners. Different rates of substance use among the four ethnic groups were found, but were not significant when adjusting for acculturation. Among men who engaged in both unprotected and protected anal sex, substance use was not more common on unprotected occasions than on protected occasions. Attendance at bars, clubs, etc. was not associated with unprotected anal sex. Sensation seeking, self-worth, and machismo were related to substance use and unprotected anal sex. In multivariate analyses, the substance use/unprotected sex association remained when adjusting for ethnicity, acculturation, partner type, attendance at bars, and personality variables. IMPLICATIONS Substance use and unprotected sex are associated among these Latino MSM. However, there does not appear to be a simple causal relationship between the variables. Several other variables co-vary with these factors but did not statistically explain their association.

Psychiatric disorders in youth with perinatally acquired human immunodeficiency virus infection

Background: Clinical reports from the United States indicate substantive mental health problems in perinatally human immunodeficiency virus (HIV)-infected youth that pose substantial barriers to optimizing their health. This pilot study explores rates and types of psychiatric and substance use disorders, as well as emotional and behavioral functioning in perinatally HIV-infected children and adolescents. Methods: Forty-seven perinatally-infected youths (9–16 years of age) and their primary caregivers recruited from a pediatric HIV clinic were interviewed using standardized assessments of youth psychiatric disorders and emotional and behavioral functioning, as well as measures of health and caregiver mental health. Results: According to either the caregiver or child report, 55% of youths met criteria for a psychiatric disorder. The most prevalent diagnoses were anxiety disorders (40%), attention deficit hyperactivity disorders (21%), conduct disorders (13%), and oppositional defiant disorders (11%). However, the majority of caregivers and children scored in the normative range on the symptom questionnaires on emotional and behavioral functioning. None of the demographic or child health variables or measures of caregiver mental health was significantly associated with presence of a child psychiatric disorder. There was an association between caregiver mental health and child emotional and behavioral functioning. Conclusions: Standardized assessments of mental health identified very high rates of psychiatric disorders, primarily in the anxiety and behavioral domains, in this sample of youth with perinatal HIV infection. Mental health interventions should be integrated into medical care to help members of this highly vulnerable population optimize their health and well-being.

Will Gay and Bisexually Active Men at High Risk of Infection Use Over-the-Counter Rapid HIV Tests to Screen Sexual Partners?

The Food and Drug Administration may license OraQuick™, a rapid HIV test, for over-the-counter (OTC) sale. This study investigated whether HIV-uninfected, non-monogamous, gay and bisexual men who never or rarely use condoms would use the test with partners as a harm-reduction approach. Sixty participants responded to two computer-assisted self-interviews, underwent an in-depth interview, and chose whether to test themselves with OraQuick. Over 80% of the men said they would use the kit to test sexual partners or themselves if it became available OTC. Most participants understood that antibody tests have a window period in which the virus is undetectable, yet saw advantages to using the test to screen partners; 74% tested themselves in our offices. Participants offered several possible strategies to introduce the home-test idea to partners, frequently endorsed mutual testing, and highlighted that home testing could stimulate greater honesty in serostatus disclosure. Participants drew distinctions between testing regular versus occasional partners. Non-monogamous men who have sex with men, who never or rarely use condoms, may nevertheless seek to avoid HIV. Technologies that do not interfere with sexual pleasure are likely to be used when available. Studies are needed to evaluate the advantages and disadvantages of using OTC rapid HIV tests as one additional harm-reduction tool.