Noelle R. Leonard

Four-year behavioral outcomes of an intervention for parents living with HIV and their adolescent children.

Objective: The adjustment of parents living with HIV (PLH) and their adolescent children was examined over 4 years in response to an intervention. Outcomes at 2 years had been previously published. Methods: A randomized controlled trial was conducted, with a representative sample from New York City. Results: In the intervention condition, fewer adolescents became teenage parents, and conduct problems tended to be lower over 4 years than in the standard care condition. Fewer parents were drug dependent and tended to relapse into substance use or use passive coping styles compared with the standard care condition over 4 years. The time-trend analysis showed that the significant reductions in problem behaviors and emotional distress previously observed over 15–24 months in the intervention condition, then eroded over time and were non-significant at 48 months. Conclusions: Ongoing support and skills are needed to maintain intervention effects over longer periods.

Mindfulness training improves attentional task performance in incarcerated youth: a group randomized controlled intervention trial

We investigated the impact of cognitive behavioral therapy and mindfulness training (CBT/MT) on attentional task performance in incarcerated adolescents. Attention is a cognitive system necessary for managing cognitive demands and regulating emotions. Yet persistent and intensive demands, such as those experienced during high-stress intervals like incarceration and the events leading to incarceration, may deplete attention resulting in cognitive failures, emotional disturbances, and impulsive behavior. We hypothesized that CBT/MT may mitigate these deleterious effects of high stress and protect against degradation in attention over the high-stress interval of incarceration. Using a quasi-experimental, group randomized controlled trial design, we randomly assigned dormitories of incarcerated youth, ages 16–18, to a CBT/MT intervention (youth n = 147) or an active control intervention (youth n = 117). Both arms received approximately 750 min of intervention in a small-group setting over a 3–5 week period. Youth in the CBT/MT arm also logged the amount of out-of-session time spent practicing MT exercises. The Attention Network Test was used to index attentional task performance at baseline and 4 months post-baseline. Overall, task performance degraded over time in all participants. The magnitude of performance degradation was significantly less in the CBT/MT vs. control arm. Further, within the CBT/MT arm, performance degraded over time in those with no outside-of-class practice time, but remained stable over time in those who practiced mindfulness exercises outside of the session meetings. Thus, these findings suggest that sufficient CBT/MT practice may protect against functional attentional impairments associated with high-stress intervals.

Picking up the pieces: Caregivers of adolescents bereaved by parental AIDS

This study describes caregivers of adolescents whose parents died of AIDS and examines how caregivers perceive the impact of raising bereaved adolescents. For adolescents bereaved by AIDS, 65 non-parental caregivers were recruited and assessed twice over 6 months. Most caregivers (89%) were female members of the extended family, 49% were married and 29% were employed. Caregivers were older and more likely to be employed than parents with HIV (PWH), but were similar in ethnicity, partnership and financial status, and religiosity. Caregivers had generally been selected by the parent prior to death (66%) and most caregivers (75%) had at least moderate involvement in the care of the youth prior to parental death. Caregiver–youth relationships were stable (91%) over a 6-month period. Caregivers were significantly less emotionally distressed than PWH had been. Caregiver burden was rated as moderate; the number of positive caregiver–youth relationships decreased significantly over 6 months. Family caregiving is a common, ongoing and stable relationship in families coping with AIDS.

Increasing and supporting the participation of persons of color living with HIV/AIDS in AIDS clinical trials.

Persons living with HIV/AIDS (PLHA) of color are under-represented in AIDS clinical trials (ACTs), which may limit the generalizability of research findings and denies many individuals access to high levels of care and new treatments available through ACTs. Disproportionately low rates of recruitment in health care settings and by providers are a major barrier to ACTs for this group. Moreover, PLHA of color are more likely than their white peers to decline to participate, mainly due to fear and mistrust (although willingness is also high), negative social norms about ACTs, and difficulty navigating the unfamiliar ACT system. We describe a small number of successful behavioral and structural interventions to increase the participation of PLHA of color in screening for and enrollment into ACTs. HIV care settings, clinical trials sites, and trial sponsors are uniquely positioned to develop procedures, supports, and trials to increase the proportion of PLHA of color in ACTs.

The Effect of Peer-Driven Intervention on Rates of Screening for AIDS Clinical Trials Among African Americans and Hispanics

OBJECTIVES We examined the efficacy of a peer-driven intervention to increase rates of screening for AIDS clinical trials among African Americans and Hispanics living with HIV/AIDS. METHODS We used a randomized controlled trial design to examine the efficacy of peer-driven intervention (6 hours of structured sessions and the opportunity to educate 3 peers) compared with a time-matched control intervention. Participants were recruited using respondent-driven sampling (n = 342; 43.9% female; 64.9% African American, 26.6% Hispanic). Most participants (93.3%) completed intervention sessions and 64.9% recruited or educated peers. Baseline and post-baseline interviews (94.4% completed) were computer-assisted. A mixed model was used to examine intervention effects on screening. RESULTS Screening was much more likely in the peer-driven intervention than in the control arm (adjusted odds ratio [AOR] = 55.0; z = 5.49, P < .001); about half of the participants in the intervention arm (46.0%) were screened compared with 1.6% of controls. The experience of recruiting and educating each peer also increased screening odds among those who were themselves recruited and educated by peers (AOR = 1.4; z = 2.06, P < .05). CONCLUSIONS Peer-driven intervention was highly efficacious in increasing AIDS clinical trial screening rates among African Americans and Hispanics living with HIV/AIDS.

Gender differences in attitudes toward AIDS clinical trials among urban HIV-infected individuals from racial and ethnic minority backgrounds

Abstract Racial/ethnic minorities and women are under-represented in AIDS clinical trials (ACTs). We examined gender differences in willingness to participate in ACTs among urban HIV-infected individuals (N=286). Sixty percent of participants were male, and most were from racial/ethnic minority backgrounds (55% African-American, 34% Latino/Hispanic, 11% White/other). Knowledge of ACTs was poor. Males and females did not differ substantially in their distrust of AIDS scientists, or in barriers to ACTs. Almost all (87%) were somewhat or very willing to join ACTs. Females were less willing than males to join, including trials testing new medications or new medication combinations. Males and females differed in correlates of willingness to participate in ACTs. Despite long-standing barriers to medical research among minorities and women, willingness to participate was substantial, particularly for men, although the factors that might motivate them to join differed by gender. Women appeared more averse to trials involving new anti-retroviral regimens than men. Gender-specific outreach, behavioural intervention, and social marketing efforts are needed.

Intergenerational benefits of family-based HIV interventions.

The longitudinal impact of a family-based intervention on grandchildren of parents with HIV (PWH) is evaluated. Because PWH and their daughters demonstrated gains over 6 years when randomized to a coping skills intervention compared with a control condition, the adjustment of the PWHs grandchildren was also compared across conditions. Grandchildren in the intervention condition reported significantly fewer internalizing and externalizing behavioral symptoms compared with grandchildren in the control condition. There is weak evidence that grandchildren in the intervention condition had higher scores on measures of cognitive development and more positive home environments. These results suggest that there are possibly long-term, intergenerational benefits of an intervention for families coping with HIV.

An Exploratory Behavioral Intervention Trial to Improve Rates of Screening for AIDS Clinical Trials Among Racial/Ethnic Minority and Female Persons Living with HIV/AIDS

Individuals from racial/ethnic minority backgrounds and women have not been proportionately represented in AIDS clinical trials (ACTs). There have been few intervention efforts to eliminate this health disparity. This paper reports on a brief behavioral intervention to increase rates of screening for ACTs in these groups. The study was exploratory and used a single-group pre/posttest design. A total of 580 persons living with HIV/AIDS (PLHA) were recruited (39% female; 56% African-American, 32% Latino/Hispanic). The intervention was efficacious: 25% attended screening. We identified the primary junctures where PLHA are lost in the screening process. Both group intervention sessions and an individual contact were associated with screening. Findings provide preliminary support for the intervention’s efficacy and the utility of combining group and individual intervention formats. Interventions of greater duration and intensity, and which address multiple levels of influence (e.g., social, structural), may be needed to increase screening rates further.

A multi-method exploratory study of stress, coping, and substance use among high school youth in private schools.

There is growing awareness that students’ experiences of stress may impede academic success, compromise mental health, and promote substance use. We examined these factors in an under-studied population, private/independent high school students, using a multi-method (qualitative and quantitative), iterative data collection and analytic process. We first conducted qualitative interviews with faculty and staff at a number of highly competitive private schools, followed by an anonymous quantitative survey with 128 11th grade students from two of these settings. We then conducted a qualitative exploration of the quantitative results with a subset of students. Next, a set of Expert Panel members participated in qualitative interviews to reflect on and interpret study findings. Overall, we found students experienced high levels of chronic stress, particularly in relation to academic performance and the college admissions process. While students described a range of effective, adaptive coping strategies, they also commonly internalized these serious pressures and turned to alcohol and drugs to cope with chronic stress, although not typically at problematic levels. We discuss study implications for both schools and families derived from the Expert Panel.

HIV-infected individuals who delay, decline, or discontinue antiretroviral therapy: comparing clinic- and peer-recruited cohorts

A substantial proportion of persons living with HIV/AIDS (PLHA) delay, decline, or discontinue antiretroviral therapy (ART) when it is medically indicated (40–45%), largely African-Americans and Latinos/Hispanics. This study explores the feasibility of locating PLHA, who are not on ART (PLHA-NOA) through clinics and peer-referral; compares the two cohorts on multi-level barriers to ART; and examines readiness to initiate/reinitiate ART, a predictor of treatment outcomes. We recruited adult HIV-infected African-American and Latino/Hispanic PLHA-NOA through HIV hospital clinics and peer-referral in 2012–2013. Participants were engaged in structured 1-h assessments with reliable/valid measures on barriers to ART. We found that recruitment through peers (63.2%, 60/95) was more feasible than in clinics (36.8%, 35/90). Participants were 48.0 years old and had lived with HIV for 14.7 years on average, and 56.8% had taken ART previously. Most (61.1%) were male and African-American (76.8%), and 23.2% were Latino/Hispanic. Peer-recruited participants were older, had lived with HIV longer, were less engaged in HIV care, and were more likely to have taken ART previously. The cohorts differed in reasons for discontinuing ART. Levels of ART knowledge were comparable between cohorts (68.5% correct), and there were no differences in attitudes toward ART (e.g., mistrust), which were in the neutral range. In bivariate linear regression, readiness for ART was negatively associated with physician mistrust (B = −10.4) and positively associated with self-efficacy (B = 5.5), positive outcome expectancies (B = 6.3), beliefs about personal necessity of ART (B = 17.5), and positive internal norms (B = 7.9). This study demonstrates the feasibility of engaging this vulnerable population through peer-referral. Peer-recruited PLHA evidence particularly high rates of risk factors compared to those in hospital clinics. Interventions to support ART initiation and continuation are sorely needed for both subgroups.