Travis I. Lovejoy

Patterns and Correlates of Sexual Activity and Condom Use Behavior in Persons 50-Plus Years of Age Living with HIV/AIDS

This study characterized rates of sexual activity and identified psychosocial and behavioral correlates of sexual activity and condom use in a metropolitan sample of 290 HIV-infected adults 50-plus years of age. Thirty-eight percent of participants were sexually active in the past three months, 33% of whom had at least one occasion of anal or vaginal intercourse that was not condom protected. Rates and correlates of sexual activity and condom use differed between gay/bisexual men, heterosexual men, and heterosexual women. In the past three months, 72% of heterosexual men were sexually active compared to only 36% of gay/bisexual men and 21% of heterosexual women. However, among sexually active persons, only 27% of heterosexual men reported inconsistent condom use compared to 37% of gay/bisexual men and 35% of heterosexual women. As the number of older adults living with HIV/AIDS in the U.S. continues to increase, age-appropriate secondary risk-reduction interventions are urgently needed.

Reviewing Manuscripts for Peer-Review Journals: A Primer for Novice and Seasoned Reviewers

BackgroundThe importance of peer review in the furthering of science cannot be overstated. However, most doctoral students and early career professionals receive little formal or informal training in conducting peer reviews.PurposeIn recognition of this deficit in peer reviewer training, the present article was developed to provide an overview of the peer-review process at Annals of Behavioral Medicine and describe the general and specific elements that should be included in a high-quality review for the journal.ConclusionWe conclude by offering exemplar reviews of a manuscript that was ultimately accepted for publication in the journal and provide commentary on specific aspects of these reviews.

The relationship between neuropsychological functioning and HAART adherence in HIV-positive adults: a systematic review

Combination antiretroviral therapy has helped extend the lives of persons infected with HIV; however, the efficacy of highly active antiretroviral therapy (HAART) regimens depends, in part, on the consistency with which the medications are taken. In this paper, we review 11 empirical studies conducted in Western developed nations that utilized psychometrically valid neuropsychological measures to examine the relationship between cognitive functioning and HAART adherence. In general, impaired neuropsychological functioning—particularly within the domains of executive functioning and problem solving, learning and memory, attention and working memory, and global cognitive functioning—was associated with lower medication adherence across studies. However, inconsistent operationalizations of neuropsychological impairment and medication adherence employed in these studies, as well as the paucity of longitudinal data to support temporal relationships, may attenuate these conclusions. We conclude with a set of research recommendations that may help to improve the rigor of future studies and clarify questions left unanswered due to methodological limitations of existing studies.

The Relationship between PTSD and Chronic Pain: Mediating Role of Coping Strategies and Depression

Summary We found that illness‐focused pain coping mediated the relationship between posttraumatic stress disorder and both pain interference and pain severity. Abstract People with chronic pain and comorbid posttraumatic stress disorder (PTSD) report more severe pain and poorer quality of life than those with chronic pain alone. This study evaluated the extent to which associations between PTSD and chronic pain interference and severity are mediated by pain‐related coping strategies and depressive symptoms. Veterans with chronic pain were divided into 2 groups, those with (n = 65) and those without (n = 136) concurrent PTSD. All participants completed measures of pain severity, interference, emotional functioning, and coping strategies. Those with current PTSD reported significantly greater pain severity and pain interference, had more symptoms of depression, and were more likely to meet diagnostic criteria for a current alcohol or substance use disorder (all p‐values <.01). Participants with PTSD reported more use of several coping strategies, including guarding, resting, relaxation, exercise/stretching, and coping self‐statements. Illness‐focused pain coping (i.e., guarding, resting, and asking for assistance) and depressive symptoms jointly mediated the relationship between PTSD and both pain interference (total indirect effect = 0.194, p < .001) and pain severity (total indirect effect = 0.153, p = .004). Illness‐focused pain coping also evidenced specific mediating effects, independent of depression. In summary, specific pain coping strategies and depressive symptoms partially mediated the relationship between PTSD and both pain interference and severity. Future research should examine whether changes in types of coping strategies after targeted treatments predict improvements in pain‐related function for chronic pain patients with concurrent PTSD.

Evaluation of the Psychometric Properties of the Revised Short-Form McGill Pain Questionnaire

UNLABELLED The recently revised version of the Short-Form McGill Pain Questionnaire (SF-MPQ-2) was created to assess both neuropathic and non-neuropathic pain. The current study extends prior research by testing the reliability and validity of the SF-MPQ-2 in a sample of U.S. veteran patients with a range of chronic pain diagnoses. Participants (N = 186) completed the SF-MPQ-2, a sociodemographic questionnaire, the Structured Clinical Interview for the DSM-IV, and self-report pain and psychiatric measures. Pain diagnoses were extracted from the electronic medical record. The SF-MPQ-2 total and scale scores demonstrated good-to-excellent internal consistency. Convergent and discriminant validity were supported, and SF-MPQ-2 total and scale scores increased with number of pain diagnoses and pain severity. Confirmatory factor analyses indicated that a 4-factor model fit the data better than a single-factor model. However, high intercorrelations among the 4 latent constructs were observed, and a second-order global pain construct also emerged. Overall, the SF-MPQ-2 demonstrated excellent reliability and validity in a sample of U.S. veteran patients with chronic neuropathic and non-neuropathic pain. Future psychometric studies of the SF-MPQ-2 should employ longitudinal data to evaluate the ability of scale scores to uniquely predict clinical and health service outcomes. PERSPECTIVE This article presents the psychometric properties of a revised version of the SF-MPQ-2. This measure may have great utility as a screening tool in clinical practice and as an outcome measure in clinical trials.

Advancing the practice of online psychotherapy: An application of Rogers' diffusion of innovations theory.

With the advancements of technology and its increasing use in all spheres of life, clinicians too are faced with the decision of whether to adopt or refrain from adopting certain innovations in their practice. This article discusses the process of adopting clinical innovations within a theoretical framework, namely diffusion of innovations theory (DIT; Rogers, 2003). DIT constructs are applied to the example of online therapy adoption into clinical practice. Nine adoption barriers are identified, including issues of dehumanizing the therapeutic environment, start-up cost and reimbursement, infrastructure and training, licensure and jurisdiction concerns, ethical guidelines, both client and clinician suitability factors, and professional reputation and acceptance within the field. The authors conclude with a theory-based discussion of activities that may help to accelerate the adoption of online therapy among professional psychologists. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review.

Approximately 10 million U.S. adults are prescribed long-term opioid therapy (LTOT) for chronic pain despite inadequate evidence of long-term benefit and growing evidence of harms (1, 2). No published studies have compared LTOT (>1 year) versus placebo, no opioid, or nonopioid therapies (2). In recent decades, a dramatic increase in the prescription of opioid medications has been accompanied by increases in opioid overdose (3); more than 33000 opioid overdose deaths occurred in 2015 (4). Higher prescribed opioid dose is associated with overdose risk (57) as well as incidence of opioid use disorder, depression, fracture, motor vehicle accident, and suicide (812). Dose reduction or discontinuation, or opioid tapering, may decrease these risks, and expert guidelines recommend tapering when risks outweigh benefits (13, 14). Opioid tapering can be challenging for both patients and clinicians. In routine practice, discontinuation of LTOT is uncommon, ranging from 8% to 35% in prior cohort studies (15, 16). In a survey of patients receiving high-dose opioid medications for chronic pain, nearly half reported wanting to cut down or stop, yet 80% were receiving high-dose opioids 1 year later (17). Among patients who had a nonfatal overdose while being prescribed LTOT, 91% continued use of opioid medications after the overdose (18). There is little evidence to guide clinicians in the process of opioid tapering, especially in primary care settings, where most opioid therapy is prescribed (19, 20). In addition, little is known about the risks and benefits of opioid tapering. Potential risks include withdrawal symptoms, increased pain, and loss to follow-up (20). However, some patients report improvements in function and quality of life after tapering (21). The effects of opioid tapering on patient outcomes have not been systematically reviewed. To address these gaps, we systematically reviewed the evidence on the effectiveness of strategies to reduce or discontinue LTOT prescribed for chronic pain and the effect of dose reduction or discontinuation of LTOT on important patient outcomes. Methods A multidisciplinary team of investigators with expertise in pain and opioid management developed 2 key questions to address the study objectives. These key questions assessed 1) the effectiveness of strategies to reduce or discontinue LTOT, and 2) the effect of dose reduction or discontinuation of LTOT on prespecified patient outcomes of pain severity, pain-related function, quality of life, opioid withdrawal symptoms, substance use, or adverse events. We followed the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines (22), and the protocol is registered in the PROSPERO database (CRD42015020347). Data Sources and Searches We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library from inception through 19 April 2017. We consulted with a research librarian to design a search strategy based on our key questions. We developed a MEDLINE search strategy, which was also applied to other databases, using multiple subject headings (where available) and text words for key concepts of opioids, tapering, and pain. No language or year limits were applied. Within this broader search, we identified potentially relevant systematic reviews and meta-analyses published since 2005. The full electronic search strategy for MEDLINE is presented in Appendix Table 1. We examined reference lists from all included studies and from relevant systematic reviews and published expert guidelines. We also sought input from expert contacts. Records retrieved from each search strategy were organized using the EndNote bibliographic management application (Clarivate Analytics). Appendix Table 1. Ovid MEDLINE Search Strategy Study Selection Two investigators (J.W.F. and H.R.D.) independently reviewed abstracts identified by the search strategy and, when necessary, the full text to determine inclusion. Discrepancies were resolved by consensus. We included studies that involved adults (aged 18 years) who were prescribed LTOT for chronic pain (defined as pain lasting >3 months) and that addressed at least 1 key question. Studies that did not report pain duration were included if the average duration of opioid therapy was more than 3 months. We did not require interventions to involve explicit goals or mandatory conditions of opioid dose reduction. Eligible study designs included randomized trials, cohort studies, casecontrol studies, and case series. We excluded case reports and cross-sectional studies, as well as studies that did not describe the clinical intervention or report patient-level data. We also excluded studies that were not published in English; involved nonhuman participants; addressed only acute, surgical, postoperative, obstetric, or cancer pain; involved only palliative or hospice care; evaluated only illicit or nonmedical use of opioid medications; or addressed only reduction of interventional pain techniques. Data Extraction and Quality Assessment We developed an instrument for data extraction based on prior systematic reviews conducted by the investigators. Three investigators piloted the data extraction instrument using a randomly chosen study, and the results were returned to the pool for formal review. These investigators discussed difficulties with the extraction instrument and reached consensus on minor modifications. Using the finalized instrument, 2 investigators independently extracted data on design, patient sample, setting, interventions, measures, and results from each study. When dose information was not provided by the study, we used a standard algorithm for calculating morphine-equivalent doses (MEDs) of opioid medications (23). Two reviewers independently assessed study quality (risk of bias in individual studies) using criteria developed by the U.S. Preventive Services Task Force (USPSTF), which facilitate rating of study quality as good, fair, or poor (Appendix Table 2). The investigators were blinded to each others ratings, and discrepancies were resolved by consensus or by a third reviewer, if necessary. We did not exclude studies on the basis of quality. Appendix Table 2. USPSTF Quality Rating Criteria for RCTs and Cohort Studies Data Synthesis We assessed the overall quality of the evidence using a method developed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group (24). GRADE provides explicit criteria that address study design, risk of bias, imprecision, inconsistency, indirectness, and magnitude of effect to rate the quality of evidence across studies. This method rates the quality of the evidence from high (very confident that the true effect lies close to that of the estimate of effect) to very low (very little confidence in the effect estimate) (Appendix Table 3). All authors iteratively discussed GRADE assessments to achieve consensus. We present systematic review results organized by key question. We did not attempt meta-analyses because of heterogeneity across studies and methodological limitations of the studies. Appendix Table 3. GRADE Criteria for Assessing Quality of Evidence* Role of the Funding Source The Veterans Health Administrations Substance Use Disorder Quality Enhancement Research Initiative funded the study through its Locally Initiated Projects program (QLP 59-046). The funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript. Results Database searches identified 3522 abstracts, from which 74 studies met criteria for full-text review. Seventeen additional articles were identified from reference lists and expert contacts. Of these 91 studies, 68 articles representing 67 studies met inclusion criteria (2592) (Appendix Figure). These studies included 11 randomized controlled trials, 8 controlled observational studies, and 48 uncontrolled observational studies. Studies presented data on 12546 patients (range, 5 to 1457 patients); 10 studies conducted at a single center (32, 33, 36, 4448, 70, 80) and 2 studies each at 3 centers (37, 49, 50, 52, 63, 64) may have included data on individual participants in more than 1 study. We categorized studies into 8 mutually exclusive intervention types: interdisciplinary pain programs, buprenorphine-assisted dose reduction, behavioral interventions, detoxification, ketamine-assisted dose reduction, acupuncture, other outpatient programs, and other interventional programs (Table 1). Interventions occurred in outpatient settings, inpatient settings, or both in 42, 15, and 10 studies, respectively; 5 studies were conducted in primary care settings. Among 48 studies reporting baseline opioid dose for participants receiving LTOT, the mean daily dose ranged from 29 to 556 mg MED. Study interventions had an objective of opioid discontinuation or dose reduction in 43 and 12 studies, respectively; 12 studies reported on this outcome in secondary or exploratory analyses. Table 1. Effectiveness of Strategies to Reduce or Discontinue LTOT (n= 67 studies) Appendix Figure. Study flow diagram. All included studies assessed the effectiveness of strategies to reduce or discontinue LTOT (key question 1). Study quality as assessed by the USPSTF criteria was good for 3 studies, fair for 13 studies, and poor for 51 studies. The GRADE quality of evidence to address the effectiveness of strategies to reduce or discontinue LTOT was very low (Table 2; Appendix Table 4). In the remainder of this section, we highlight results from good- and fair-quality studies. Descriptions of all included studies are available in Appendix Table 5. Table 2. Summary of Findings and Quality-of-Evidence Assessment Appendix Table 4. Derivation of GRADE Score* Appendix Table 5. Characteristics of Studies Evaluating the Effectiveness of Strategies to Reduce or Discontinue LTOT for Chronic Pain Thirty-on

Health literacy of HIV-positive individuals enrolled in an outreach intervention: results of a cross-site analysis.

This article examines health literacy among a group a HIV-positive persons at risk for receiving suboptimal health care due to histories of substance abuse, mental illness, incarceration, and unstable housing or homelessness. Participants receiving services from three outreach programs funded as part of a multisite demonstration project were screened for health literacy using the Test of Functional Health Literacy in Adults (TOFHLA) at program enrollment. The goal of this analysis was to identify demographics, risk factors, and health indicators associated with different levels of health literacy. Results indicated that although fewer than 30% of the sample scored in the marginal or inadequate range for health literacy, participants with these lower levels of health literacy were more likely to be African American or Latino/a, heterosexual, speak Spanish as their primary language, and have less than a high school education. The disparities in health literacy found in this study point to a need to assess level of health literacy and provide culturally sensitive health literacy interventions for persons with chronic diseases such as HIV. In addition to offering these services within HIV health care settings, health professionals can use other potential venues for health literacy assessment and intervention including substance abuse treatment and community-based social service, education, and training programs. Health care and support service providers also must become aware of the importance of health literacy when caring for all patients with HIV, particularly those most likely to have low health literacy.

Predicting Adherence to Antiretroviral Therapy in HIV-Infected Older Adults: The Moderating Role of Gender

This study characterized rates and correlates of ART adherence in 242 HIV-infected persons 50+ years of age. Hierarchical regressions tested a model in which depression mediated the relationships between social support and avoidance coping with ART adherence. Results indicated low rates of consistent and timely adherence in both men (48%) and women (51%). For men and women alike, social support and avoidance coping predicted depression. Although rates of adherence and predictors of depression did not differ by gender, predictors of adherence did. Avoidance coping, social support and depression predicted ART adherence in older men, but not in older women. Contrary to expectations, depression did not mediate the relationships of coping and social support with ART adherence for either gender. These findings suggest that while HIV-infected older men and women share similar paths toward depression, they diverge in predictors of adherence. Adherence interventions may be more efficacious if they are sensitive to gender differences, although more research is first needed to identify factors related to adherence in HIV-infected older women.

Telephone-Delivered Motivational Interviewing Targeting Sexual Risk Behavior Reduces Depression, Anxiety, and Stress in HIV-Positive Older Adults

BackgroundFew studies have examined the secondary benefits of HIV risk reduction interventions to improve mental health functioning.PurposeThis study aimed to examine the effectiveness of telephone-delivered motivational interviewing (MI) targeting sexual risk behavior to reduce depression, anxiety, and stress in HIV-positive older adults.MethodsParticipants were 100 HIV-positive adults 45+ years old enrolled in a sexual risk reduction pilot clinical trial of telephone-delivered MI. Participants were randomly assigned to a one-session MI, four-session MI, or standard of care control condition. Telephone interviews at baseline and 3- and 6-month follow-up assessed sexual behavior, depression, anxiety, and stress.ResultsRelative to controls, participants in the one- and four-session MI conditions reported lower levels of depression, anxiety, and stress at 6-month follow-up. No between group differences were observed at 3-month follow-up or between one- and four-session MI participants at 6-month follow-up.ConclusionsPreliminary data suggest that telephone-delivered MI to reduce sexual risk behavior may confer secondary benefits of improving mental health functioning in HIV-positive persons.