David W. Pantalone

Self-Report Measures of Antiretroviral Therapy Adherence: A Review with Recommendations for HIV Research and Clinical Management

A review of 77 studies employing self-report measures of antiretroviral adherence published 1/1996 through 8/2004 revealed great variety in adherence assessment item content, format, and response options. Recall periods ranged from 2 to 365 days (mode=7 days). The most common cutoff for optimal adherence was 100% (21/48 studies, or 44%). In 27 of 34 recall periods (79%), self-reported adherence was associated with adherence as assessed with other indirect measures. Data from 57 of 67 recall periods (84%) indicated self-reported adherence was significantly associated with HIV-1 RNA viral load; in 16 of 26 (62%), it was associated with CD4 count. Clearly, the field would benefit from item standardization and a priori definitions and operationalizations of adherence. We conclude that even brief self-report measures of antiretroviral adherence can be robust, and recommend items and strategies for HIV research and clinical management.

Efficacy of interventions in improving highly active antiretroviral therapy adherence and HIV-1 RNA viral load. A meta-analytic review of randomized controlled trials.

Summary:Adherence to highly active antiretroviral therapy (HAART) is generally suboptimal, limiting the effectiveness of HAART. This meta-analytic review examined whether behavioral interventions addressing HAART adherence are successful in increasing the likelihood of a patient attaining 95% adherence or an undetectable HIV-1 RNA viral load (VL). We searched electronic databases from January 1996 to September 2005, consulted with experts in the field, and hand searched reference sections from relevant articles. Nineteen studies (with a total of 1839 participants) met the selection criteria of describing a randomized controlled trial among adults evaluating a behavioral intervention with HAART adherence or VL as an outcome. Random-effects models indicated that across studies, participants in the intervention arm were more likely than those in the control arm to achieve 95% adherence (odds ratio [OR] = 1.50, 95% confidence interval [CI]: 1.16 to 1.94); the effect was nearly significant for undetectable VL (OR = 1.25; 95% CI: 0.99 to 1.59). The intervention effect for 95% adherence was significantly stronger in studies that used recall periods of 2 weeks or 1 month (vs. ≤7 days). No other stratification variables (ie, study, sample, measurement, methodologic quality, intervention characteristics) moderated the intervention effect, but some potentially important factors were observed. In sum, various HAART adherence intervention strategies were shown to be successful, but more research is needed to identify the most efficacious intervention components and the best methods for implementing them in real-world settings with limited resources.

A randomized controlled trial of a peer support intervention targeting antiretroviral medication adherence and depressive symptomatology in HIV-positive men and women.

OBJECTIVEnTo determine the efficacy of a peer-led social support intervention involving support groups and telephone contacts compared with standard clinical care to enhance antiretroviral medication adherence.nnnDESIGNnRandomized controlled trial with follow-up. Participants were 136 HIV-positive indigent mainly African American and Puerto Rican men and women recruited from an outpatient clinic in the Bronx, New York. The 3-month intervention was delivered by other HIV-positive clinic patients trained in addressing barriers to adherence and sensitively providing appraisal, spiritual, emotional, and informational adherence-related social support.nnnMAIN OUTCOME MEASURESnMedical chart-abstracted HIV-1 RNA viral load, antiretroviral adherence according to electronic drug monitoring and participant self-report, and social support and depressive symptomatology. All assessments conducted at baseline, 3 months, and 6 months.nnnRESULTSnIntent-to-treat and as-treated analyses indicated no between-conditions intervention effects on the primary outcome of HIV-1 RNA viral load or any of the secondary outcomes at immediate postintervention or follow-up. Post hoc analyses within the intervention condition indicated greater intervention exposure was associated with higher self-reported adherence, higher social support, and lower depressive symptomatology at follow-up, even after controlling for baseline adherence.nnnCONCLUSIONnNull findings, consistent with the limited literature on efficacious highly active antiretroviral therapy (HAART) adherence interventions, may be due to insufficient exposure to the intervention, its low intensity, or the nature of the sample-a heterogeneous HAART-experienced group of patients with high levels of substance use and multiple other competing stressors. Overall, findings highlight the need for more comprehensive and intensive efforts to battle nonadherence.

Predictors of Suicidal Ideation in a Statewide Sample of Transgender Individuals

Transgender individuals experience violence and discrimination, which, in addition to gender transitioning, are established correlates of psychological distress. In a statewide sample of 350 transgender adults, we investigated whether a history of violence and discrimination increased the odds of reporting lifetime suicidal ideation (SI) and whether differences in SI were predicted by gender transition status. Violence, discrimination, and transition status significantly predicted SI. Compared with individuals with no plans to transition, individuals with plans or who were living as their identified gender reported greater odds of lifetime SI. We discuss implications for SI disparities using Meyers minority stress model.

HIV Disclosure and Safer Sex

“It is difficult to identify a more charged issue in AIDS prevention than that of nondisclosure of positiveHIV status to sexual partners.” (Ciccarone et al., 2003; p. 949) Jenenne is a 38-year-old African American woman in Harlem who contracted HIV 10 years ago from her ex-husband, a heroin user. She uses crack cocaine sporadically and is recurrently depressed. Financially, her situation is precarious. Jenenne at first concealed her HIV status from her current boyfriend, Darrell, out of fear he would reject her. Although they began their sexual relationshipalwaysusing condoms,Darrel later refused. Suspicious of Jenenne’s worsening physical condition, Darrell finally confronted her and discovered the truth. Furious, he promptly abandoned her. Eventually, though, he returned and they resumed their relationship, practicing exclusively safer sex. However, Darrell soon began complaining about how condoms were inhibiting his sexual functioning and began pressuring Jenenne to have unprotected intercourse. Miguel is a 25-year-old Mexican American gay man in Los Angeles who was diagnosed HIV-positive two years ago. He has never used drugs and has stopped drinking since his diagnosis. He works full-time as a waiter. Since his diagnosis, he has had multiple anonymous sexual encounters and a few short relationships. Miguel never revealed his serostatus to any of these partners; however, he scrupulously practiced safer sex, feeling a moral responsibility to protect others. Currently, he is in a committed relationship with another Mexican American man, Jose, who has never been tested for HIV. Miguel has been very open with Jose about his

A Systematic Review of the Frequency and Correlates of Partner Abuse in HIV-Infected Women and Men Who Partner With Men

&NA; Partner abuse (PA) is a highly prevalent and devastating social phenomenon, extracting an economic toll of more than

Unmet Mental Health and Social Service Needs of Formerly Incarcerated Women Living with HIV in the Deep South

8 billion annually in the United States due to lost productivity alone. Many of the risk factors for PA increase vulnerability to acquiring HIV as well, yet little research has explored these overlapping epidemics. In this systematic review, we examine the frequency of PA victimization from male partners among persons living with HIV—both men who have sex with men (MSM) and women. We located 31 manuscripts reporting data from 24 unique samples, indicating a high lifetime frequency (but large range) of estimates for women/MSM, respectively, for physical (26–62%/15–39%), sexual (22–44%/8–33%), and psychological abuse (55%/22–73%). Data indicate strong and consistent associations of PA with poor mental health, engagement in health risk behaviors, and nonadherence to HIV medication for both groups. We discuss implications for clinical practice as well as future research directions.

Distinct Coping Profiles Are Associated With Mental Health Differences in Transgender and Gender Nonconforming Adults

&NA; Due to the disproportionate burden of HIV among incarcerated women in the United States, jails and prisons have been identified as key sites for health service delivery. Recidivism remains high, potentially reflecting unmet mental health and social service needs of incarcerated women, especially during the postrelease adjustment period. However, little published research has investigated this possibility directly. We conducted semi‐structured, in‐depth interviews with previously incarcerated women living with HIV, and other key informants, and completed service‐availability mapping in two Alabama cities. Key findings were: (a) discharge planning and postrelease support services to manage risky environments were absent, (b) postrelease services were concentrated in a few community‐based organizations, (c) mental health and substance abuse treatment during re‐entry was essential to prevent relapse, and (d) social support was crucial for postrelease adjustment. We propose a novel conceptual model with key steps to establish continuous care for previously incarcerated women living with HIV.

Antiretroviral Adherence Interventions: A Review of Current Literature and Ongoing Studies

OBJECTIVEnThis study assessed the unique coping strategies of transgender and gender nonconforming (TGNC) individuals in the United States used to manage gender-related stress, and examined associations between specific coping profiles and mental health.nnnMETHODSnData were from 316 participants in the 2014-2015 Transgender Stress and Health Study, an online study of TGNC mental and sexual health. A factor analysis of the coping measure (Brief COPE) was followed by a k-means cluster analysis to evaluate distinct profiles of coping with gender-related stress. Proportional odds models and logistic regression models indicated how coping profiles related to levels of self-reported depressive symptoms and suicidality.nnnRESULTSnA 4-factor structure was identified with three distinct profiles of coping with gender-related stress, each representative of the frequency (high or low) in which participants used functional and dysfunctional coping strategies: (a) high-functional/low-dysfunctional, (b) high-functional/high-dysfunctional, and (c) low-functional/low-dysfunctional. There were significant differences in depressive symptoms and suicidality based on distinct gender-related coping profiles. The high-functional/high-dysfunctional group reported significantly poorer mental health compared with the high-functional/low-dysfunctional group.nnnCONCLUSIONnTo improve mental health outcomes in TGNC individuals, health providers and researchers should strive to not only promote functional coping strategies for managing gender-related stress but also decrease dysfunctional coping strategies.