Linda J. Koenig

Psychosocial and Behavioral Correlates of Depression Among HIV-Infected Pregnant Women

This study addressed two aims: (1) to assess the level of depressive symptoms among pregnant, HIV-infected racial and ethnic minority women and (2) to identify potentially modifiable factors associated with prenatal depression in order to foster proactive clinical screening and intervention for these women. Baseline interview data collected from HIV-infected women participating in the Perinatal Guidelines Evaluation Project were analyzed. Participants were from prenatal clinics in four areas representative of the U. S. HIV/AIDS epidemic among women. Of the final sample (n = 307), 280 were minorities (218 blacks [African American and Caribbean], 62 Hispanic). Standardized interviews assessed potential psychosocial factors associated with pregnancy-related depression and psychological distress (life stressors, inadequate social support, and ineffective coping skills) in a population for whom little work has been done. Depressive symptomatology was considerable, despite excluding somatic items in order to avoid confounding from prenatal or HIV-related physical symptoms. The psychosocial factors significantly predicted the level of prenatal depressive symptoms beyond the effects of demographic and health-related factors. Perceived stress, social isolation, and disengagement coping were associated with greater depression, positive partner support with lower depression. These findings demonstrate that psychosocial and behavioral factors amenable to clinical intervention are associated with prenatal depression among women of color with HIV. Routine screening to identify those currently depressed or at risk for depression should be integrated into prenatal HIV-care settings to target issues most needing intervention.

Trends in Opportunistic Infections in the Pre–and Post–Highly Active Antiretroviral Therapy Eras Among HIV-Infected Children in the Perinatal AIDS Collaborative Transmission Study, 1986–2004

OBJECTIVE. We sought to determine the impact of highly active antiretroviral therapy on the incidence and prevalence of opportunistic infections in HIV-infected children. METHODS. Children born from 1986 to 1998 were monitored until 2004 in the Perinatal AIDS Collaborative Transmission Study, sponsored by the Centers for Disease Control and Prevention. We determined the pre–highly active antiretroviral therapy and post–highly active antiretroviral therapy (before and after January 1, 1997, respectively) incidence rates of opportunistic infections among HIV-infected children and characterized the temporal decreases in percentages of CD4+ cells and the mortality rates among patients with and those without incident opportunistic infections. RESULTS. The overall opportunistic infection incidence declined from 14.4 to 1.1 cases per 100 patient-years; statistically significant reductions were seen in the incidence of the most common opportunistic infections, including Pneumocystis jiroveci pneumonia (5.8 vs 0.3 cases per 100 patient-years), recurrent bacterial infections (4.7 vs 0.2 cases per 100 patient-years), extraocular cytomegalovirus infection (1.4 vs 0.1 cases per 100 patient-years), and disseminated nontuberculous mycobacterial infection (1.3 vs 0.2 cases per 100 patient-years). Kaplan-Meier analysis of time from birth to the first opportunistic infection illustrated more-rapid acquisition of opportunistic infections by HIV-infected children born in the pre–highly active antiretroviral therapy era than by those born later. In the first 3 years of life, there was a faster decline in the percentage of CD4+ cells among children with opportunistic infections. The mortality rate was significantly higher among children with opportunistic infections. CONCLUSIONS. Reduction in the incidence of opportunistic infections and prolongation of the time to the first opportunistic infection were noted during the post–highly active antiretroviral therapy era. Children who experienced opportunistic infections had higher mortality rates than did those who did not. Younger children (<3 years) who experienced opportunistic infections had faster declines in percentages of CD4+ T cells.

Women, violence, and HIV: a critical evaluation with implications for HIV services

Objective: Violence is highly prevalent among women with HIV. Determining whether HIV is causally related to violence, and whether risk for violence is increased by certain HIV prevention practices, has been difficult. Methods: We review recent literature concerning (1) violence and HIV serostatus, including the risk for violence associated with disclosure of a positive serostatus, and (2) violence associated with requests that male sex partners use condoms. Results: Studies suggest that women with or at risk for HIV come from populations that are also at risk for violence. Violence is not statistically increased among HIV-infected women compared to demographically and behaviorally similar uninfected women. However, for a small proportion of women, violence may occur around disclosure or in response to condom negotiation. Conclusions: Integrating violence screening and referral into HIV services could help many women obtain the assistance they need while minimizing the risk for violence that may be associated with partner notification or condom requests.

Randomized Controlled Trial of an Intervention to Prevent Adherence Failure Among HIV-Infected Patients Initiating Antiretroviral Therapy

OBJECTIVE Compare the efficacy of a multicomponent social support intervention to standard-of-care counseling on medication adherence among HIV-infected patients initiating antiretroviral therapy. DESIGN Randomized controlled trial. Generalized estimating equations tested for differences in the percentage of participants achieving 90% adherence. MAIN OUTCOME MEASURES Pill-taking, electronically monitored over 6 consecutive months; plasma viral load (VL), assessed at 3 and 6 months following initiation of therapy. RESULTS Of 226 participants who were randomized and began the trial, 87 (38%) were lost to the study by 6 months. The proportion of adherent participants declined steadily over time, with no time by group interaction. Sustained adherence was associated with increased odds of achieving an undetectable VL (OR=1.78; 95% CI=1.01, 3.13). In intention-to-treat analyses, a larger proportion of the intervention group than the control group was adherent (40.15% vs. 27.59%, p=.02) and achieved an undetectable VL p=.04). However, the majority of participants who remained on study experienced some reduction in VL (>or=1-log drop or undetectable), regardless of experimental condition. CONCLUSION The multicomponent social support intervention significantly improved medication adherence over standard-of-care counseling; evidence for improved virologic outcomes was inconsistent. Early discontinuation of care and treatment may be a greater threat to the health of HIV patients than imperfect medication-taking.

Characterizing Social Support: Global and Specific Social Support Experiences of HIV-Infected Youth

This study examined the nature, type, and source of social support available to a diverse group of HIV-infected adolescents and the relationship between social support and depression. Data were obtained from the baseline assessment of Adolescent Impact, a behavioral intervention conducted in 2003-2006 involving 166 HIV-infected youth, ages 13-21, in care at four urban medical centers. Youth completed the Medical Outcomes Study Social Support Survey, Beck Depression Inventory, and questions about HIV-specific social support including locus (family and friends) and type (structural, perceived, instrumental, and satisfaction). Linear regression modeling examined the relation between HIV-specific and general perceived social support, and between social support and depression. Participants were predominately minority (72% black and 20% Hispanic); perinatally infected (60% PIY), and female (53%). Most had someone to either remind them to attend (71%) or to bring them to clinic (60%), a majority family (53%) and fewer friends (4%). More youth reported being satisfied with family (64%) social support than that from friends (51%). Behaviorally infected youth (BIY) had significantly more friends who knew their serostatus than PIY (means = 4.5 and 1.7; p < 0.001), but received significantly less help from family in accessing care (p < 0.001). Satisfaction with family social support was the best predictor of general perceived social support with general perceived social support and behavioral mode of transmission the best predictors of depression. Regular screening of HIV-positive youth for social support needs, especially BIY, and identification of sources for social support should be a regular part of care.

Sexual Transmission Risk Behavior of Adolescents With HIV Acquired Perinatally or Through Risky Behaviors

Objective: To describe the prevalence and predictors of the transmission-related behaviors of adolescents with HIV acquired perinatally (perinatal) or through risky behaviors (behavioral). Methods: HIV-positive adolescents (n = 166) aged 13-21, receiving care in 3 US cities, reported sexual behaviors, drug use, and psychosocial and demographic characteristics. HIV-related data were abstracted from medical records. Results: Of 105 sexually experienced adolescents reporting risk history (42 perinatal, 63 behavioral), 49 had engaged in unprotected sex since learning their diagnosis (12 perinatal, 37 behavioral). Of sexually experienced girls, 19 had been pregnant (5 of 24 perinatal, 14 of 31 behavioral). Risk information was provided for 115 of 132 recent sex partners, 61 of whom had unprotected sex with study participants (10 with 8 perinatal participants; 51 with 33 behavioral participants). Recent unprotected sex was associated with sexual abuse during adolescence (adjusted odds ratio = 9.61, 95% CI: 1.07 to 86.12) and greater HIV knowledge (adjusted odds ratio = 1.29, 95% CI: 1.00 to 1.66) when transmission category, age, and sexual orientation were controlled. Conclusions: To limit HIV transmission and prevent unplanned pregnancies, developmentally appropriate risk-reduction interventions, and screening and treatment referral for sexual abuse, must be integrated into the care of both perinatally and behaviorally HIV-infected adolescents.

Predictors of Antiretroviral Medication Adherence Among a Diverse Cohort of Adolescents With HIV

PURPOSE To compare prevalence and describe predictors of antiretroviral treatment adherence among adolescents with HIV acquired perinatally (PIY) or through risk behaviors (BIY). METHODS Data were obtained from the baseline assessment of Adolescent Impact, an intervention for HIV-infected adolescents receiving care in three U.S. cities. Patients self-reported missed medication doses as well as medication factors, HIV knowledge, disclosure, substance use, mental health, and social support through face-to-face or computer-assisted interviews. RESULTS Of 104 participants, 68 (65.4%) reported full adherence. Compared with BIY, PIY were younger, had greater HIV disease severity, and had more structural supports. Adjusting for transmission mode (PIY vs. BIY), nonadherence by self-report was associated with higher viral load (VL) (adjusted odds ratio [AOR] = 1.5, confidence interval [CI] = 1.03, 2.18). Nonadherent adolescents were significantly likely to have had AIDS, discussed HIV disease with providers, reported difficulty with medication routine, experienced internalizing behavior problems, and used drugs. In multivariate analyses, independent predictors of nonadherence included acquiring HIV behaviorally (AOR = 4.378, CI = 1.055, 18.165), ever having AIDS (AOR = 4.78, CI = 1.31, 17.49), perceiving difficult medication routine (AOR = 1.84, CI = 1.07, 3.16), discussing disease indicators with provider (AOR = 4.57, CI = 1.74, 11.98), and missing doses because of forgetting (AOR = 2.53, CI = 1.29, 4.96). Adjusting for transmission mode, detectable VL was associated with lower recent CD4(+) lymphocyte counts, discussing disease indicators with providers, and missing doses because of forgetting or being depressed. Low recent CD4(+) lymphocyte counts (AOR = .988, p = .024) but fewer HIV symptoms (AOR = .466, p = .032) and missing doses because of forgetting (AOR = 1.76, p = .05) were independently associated with detectable VL in multivariate analysis. CONCLUSIONS Despite differences between groups, nonadherence was associated with severity of illness, difficult medication routine, and forgetfulness. Beyond individual needs, both groups of adolescents had suboptimal adherence and would benefit from simplified medication routines and organizational skills.

Adherence to antiretroviral medications for HIV pre-exposure prophylaxis: lessons learned from trials and treatment studies.

Several recent clinical trials have shown that daily oral pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate and emtricitabine (TDF– TC) can reduce the risk for sexually acquiredHIV infecion in men and women. However, the efficacy of PrEP as varied widely across trials, and it is affected heavily y adherence to daily doses of TDF–FTC. To better unerstand the importance of medication adherence to chieving the PrEP efficacy required for public health mpact, and to provide the best guidance for supporting ptimal adherence in real-world contexts when PrEP is mplemented more broadly, the current paper reviews nd summarizes findings from (1) adherence analyses rom PrEP clinical trials and (2) the antiretroviral treatent adherence literature.

Adolescents with perinatally acquired HIV: emerging behavioral and health needs for long-term survivors.

Purpose of review Because of widespread availability of highly active antiretroviral therapy in the developed world, a large proportion of children with perinatally acquired HIV have survived to adolescence and young adulthood. Although their survival is remarkable, many now experience the long-term effects of HIV infection and its treatment. Further, as these youths have entered adolescence, more is known about the impact of normative developmental transitions on health maintenance behaviors. Recent findings Although perinatally infected adolescents are healthier than they were a decade or more ago, they are significantly experienced with antiretroviral therapy, with increased virological resistance and other consequences of extended antiretroviral use. Three behavioral health challenges have been documented in the first cohort of long-term survivors: decreased medication adherence, sexual debut and accompanying pregnancy and transmission risk, and mental health problems. These issues are consistent with a developmental press for autonomy, mature sexual relationships and future planning, but must be carefully managed to preserve health. Summary Adolescents with perinatally acquired HIV require coordinated multidisciplinary support services – including adherence support, reproductive health counseling addressing both pregnancy planning and disease transmission, and mental health and educational/vocational planning – so that they can fully benefit from treatment advances.

Coping strategies of adolescents living with HIV: disease-specific stressors and responses.

Abstract This study examined disease-specific stressors and coping responses employed by youth with HIV. Data were analyzed from Adolescent Impact, a multi-site study of 166 adolescents infected with HIV in three major US cities. Participants identified HIV-related stressors during a face-to-face interview. Coping strategies were measured using the adolescent version of the Kidcope. Emotional and behavioral functioning were assessed with the Youth or Adult Self Report symptom checklists. Medication-related stressors were most common (30%) and reported more often by perinatally infected youth, whereas youth infected through risk behaviors reported more disclosure-related stressors. Passive emotional regulation was perceived as the most used and most helpful coping strategy overall. Youth reporting medication adherence-related stressors used resignation most frequently. A two-factor model (Passive and Active Coping) emerged. The Passive Coping factor included strategies that do not directly approach the problem, whereas Active Coping included strategies that involve an active approach. Youth with moderately advanced disease (CD4 200–500 cells/mm3) used a Passive Coping style more often than healthier youth (CD4 > 500 cells/mm3). Additionally, Passive Coping was associated with greater emotional and behavioral problems. Youth infected with HIV may benefit from interventions promoting adaptive coping responses to HIV-specific stressors, particularly medication adherence.