Viewpoint on Human Immunodeficiency Virus Medical Care Retention Guidelines in the Coronavirus 2019 Pandemic Era and Beyond: Lessons Learned From Electronic Health Record Screening and Outreach.

In this viewpoint, we discuss retention in care for people with human immunodeficiency virus (HIV) and call into question the methodology used to characterize retention, as well as the definitions themselves. Optimal retention for people with HIV (PWH) is defined in multiple ways by major healthcare leaders in the United States, typically focusing on appointment attendance or laboratory work. Yet, these definitions rely on in-person encounters, an approach to care that is becoming less common due to the rise of telehealth visits, particularly in light of the coronavirus disease 2019 pandemic. Our recent work showed that relying on electronic health records to identify PWH who were not retained in care not only failed to capture the nuances of modern HIV medical treatment engagement, but also led to misidentification of patients' retention status due to limitations in the record system. As such, we recommend a reevaluation of how HIV medical care retention is defined and reported.

Characterizing Social Connectedness and Associated Mental Health Symptoms among Sexual Minority Men Enrolled in a Substance Use Recovery Support Program.

BACKGROUND: Sexual minority men (SMM; gay, bisexual, and other men who have sex with men) report higher rates of substance use compared to other populations. Social connectedness is a critical component for promoting and maintaining recovery from substance use disorders. However, the degree of social connectedness among SMM who report substance use is largely unknown. OBJECTIVES: We examined substance use, social connectedness (past 30-d participation in formal recovery support, past 30-d interaction with supportive family/friends, relationship satisfaction, and types of support) and mental health among SMM at the time of their enrollment in a behavioral substance use program from September 2019 to October 2021. RESULTS: Of the107 SMM, 80% of the sample reported past 30-d illicit substance use, with methamphetamine representing the most commonly reported drug used (53%). Participants used a variety of social connections for support, including self-help groups (44% voluntary; 5% religious-affiliated; 20% other) and family/friends (81%). Importantly, 15% reported they had no one to turn to when having trouble and 36% were either dissatisfied or very dissatisfied with their relationships. Participants who endorsed significant depressive (58%) and anxiety (70%) symptoms were more likely to endorse relationship dissatisfaction than participants who did not endorse symptoms (p < 0.01). CONCLUSIONS: One-third of SMM enrolled in a substance use recovery program expressed relationship dissatisfaction, particularly those struggling with depression or anxiety. Future research and programming should examine ways of leveraging existing social connectedness or forging new social supports to enhance mental health and substance use recovery for SMM using substances.

Strategies Used to Manage Chronic Pain in HIV-Disease: Comparing Persons Prescribed Opioids Versus Persons not Receiving Opioids.

Chronic pain is common in people living with HIV (PLWH), causes substantial disability and is associated with limitations in daily activities. Opioids are commonly prescribed for pain treatment among PLWH, but evidence of sustained efficacy is mixed. There is little information available on how PLWH who have chronic pain use multimodal strategies in pain management. The current cross-sectional study examined background characteristics, self-reported pain, and the use of other pain treatments among 187 PLWH with chronic pain and depressive symptoms who were and were not prescribed opioids. Approximately 20.9% of participants reported using prescription opioids at the time of the study interview. These individuals were significantly more likely to report having engaged in physical therapy or stretching, strengthening or aerobic exercises in the previous 3 months, recent benzodiazepine use, and receiving disability payments. There were no significant differences in pain characteristics (pain-related interference, average pain severity, and worst pain severity) between the two groups. Those not prescribed opioids were more likely to report better concurrent physical functioning and general health, and fewer physical role limitations, but higher depression symptom severity. Our findings suggest that many PLWH with chronic pain and depressive symptoms express high levels of pain with deficits in physical function or quality of life despite their use of opioids. The high rate of co-use of opioids and benzodiazepines (30.8%) is a concern because it may increase risk of overdose. An integrated care approach that includes a variety of effective non-pharmacologic treatment strategies such as physical therapy may be beneficial in reducing the reliance on opioids for pain management.

HIV-PASS (Pain and Sadness Support): Randomized Controlled Trial of a Behavioral Health Intervention for Interference Due to Pain in People Living With HIV, Chronic Pain, and Depression.

OBJECTIVE: This study aimed to determine whether HIV-Pain and Sadness Support (HIV-PASS), a collaborative behavioral health intervention based on behavioral activation, is associated with decreased pain-related interference with daily activities, depression, and other outcomes in people living with HIV. METHODS: We conducted a three-site clinical trial ( n = 187) in which we randomly assigned participants to receive either HIV-PASS or health education control condition. In both conditions, participants received seven intervention sessions, comprising an initial in-person joint meeting with the participant, their HIV primary care provider and a behavioral health specialist, and six, primarily telephone-based, meetings with the behavioral health specialist and participant. The intervention period lasted 3 months, and follow-up assessments were conducted for an additional 9 months. RESULTS: Compared with health education, HIV-PASS was associated with significantly lower pain-related interference with daily activities at the end of month 3 (our primary outcome; b = -1.31, 95% confidence interval = -2.28 to -0.34). We did not observe other differences between groups at 3 months in secondary outcomes that included worst or average pain in the past week, depression symptoms, anxiety, and perceived overall mental and physical health. There were no differences between groups on any outcomes at 12 months after enrollment. CONCLUSIONS: A targeted intervention can have positive effects on pain interference. At the end of intervention, effects we found were in a clinically significant range. However, effects diminished once the intervention period ended. TRIAL REGISTRATION: ClinicalTrials.gov NCT02766751.

The relationship between substance use and physical activity among people living with HIV, chronic pain, and symptoms of depression: a cross-sectional analysis.

ABSTRACTChronic pain, depression, and substance use are common among people living with HIV (PLWH). Physical activity can improve pain and mental health. Some substances such as cannabis may alleviate pain, which may allow PLWH to participate in more physical activity. However, risks of substance use include poorer mental health and HIV clinical outcomes. This cross-sectional analysis examined the relationships of self-reported substance use (alcohol, cannabis, and nicotine use), gender, and age with self-reports of walking, moderate physical activity, and vigorous physical activity, converted to Metabolic Equivalent of Task Units (METs), among 187 adults living with HIV, chronic pain, and depressive symptoms in the United States. Women reported less walking, vigorous activity, and total physical activity compared to men. Individuals who used cannabis reported more vigorous physical activity relative to those who did not use cannabis. These findings were partially accounted for by substance use*gender interactions: men using cannabis reported more vigorous activity than all other groups, and women with alcohol use reported less walking than men with and without alcohol use. Research is needed to increase physical activity among women who use substances and to evaluate reasons for the relationship between substance use and physical activity among men.

Anger and substance use in HIV-positive patients with chronic pain.

Chronic pain increases the risk of substance use in people living with HIV (PLWH). Depression and anxiety have also been identified as risk factors for substance use among PLWH. Relatedly, other negative mood states, such as anger, may influence chronic pain among PLWH. The current cross-sectional study examined whether the distinct negative mood state of anger is associated with substance use among 187 PLWH who report chronic pain. Using negative binomial regression analyses, we found higher levels of anger were positively associated with alcohol use. Higher levels of anger were inversely associated with benzodiazepine use. No association was found between anger and marijuana use, and there were no significant interactions between anger and pain severity on substance use. Our findings suggest that anger is an independent risk factor for substance use among PLWH and chronic pain. Addressing anger may be useful when adapting behavioral therapies in the treatment of pain among PLWH.

Improving functioning in HIV+ patients with chronic pain and comorbid depression: Protocol for a randomized clinical trial testing a collaborative behavioral health intervention based on behavioral activation.

OBJECTIVE: Persons living with HIV (PWH) experience a disproportionate level of comorbid chronic pain and depression compared to individuals who do not have a diagnosis of HIV. Many PWH report pain that impairs daily function, is severe, and requires medical management. Depression alone is associated with HIV disease progression, medication non-adherence, and increased mortality. Given that numerous studies show that PWHs have chronic pain and depression despite pharmacologic treatment, there is a clear need for additional treatment modalities to address these conditions. DESIGN: In this paper, we describe our protocol for a multisite, randomized controlled trial of the effectiveness of a collaborative behavioral intervention, called HIV-Pain and Sadness Support (HIVPASS), designed for PWH who endorse chronic pain and depressive symptoms, as compared to an attention matched Health Education (HE) condition. The HIVPASS intervention is based on Behavioral Activation and designed to target both pain and depression using an integrated model that promotes collaboration between HIV medical and psychological providers. SETTING AND METHODS: We plan to (1) recruit PWH who endorse chronic pain and depression in three sites located in New England and the Midwestern United States and (2) compare our HIVPASS intervention to a full attention matched HE intervention with the primary outcome of pain interference, and secondary outcomes of depression, physical activity, HIV medication adherence, and health-related quality of life. Follow-up assessments will occur monthly for three months during the intervention phase and then during the post-intervention phase at months four, six, nine and twelve. CONCLUSIONS: We provide descriptions of our protocol and interventions of our randomized controlled trial for comorbid chronic pain and depression in PWH. TRIAL REGISTRATION: http://ClinicalTrials.govNCT02766751 https://clinicaltrials.gov/ct2/show/NCT02766751?term=stein%2C+michael&draw=2&rank=5.

Acceptance of chronic pain in depressed patients with HIV: correlations with activity, functioning, and emotional distress.

Chronic pain is highly prevalent among persons with HIV (PWH), as is depression. Both comorbidities might contribute to, as well as be maintained by, avoidance-based coping. A promising alternative to avoidance-based coping is acceptance. Acceptance of pain is associated with improved functioning and quality of life in chronic pain patients, but this relationship has not been substantially explored among PWH. Cross-sectional data from 187 adult outpatients enrolled in a randomized trial for depressed PWH with chronic pain were analyzed. Controlling for pain severity and demographics, the relationships among pain acceptance and indicators of activity, functioning, and emotional distress (i.e., anxiety and anger) were assessed in seven regression models. No significant relationships were found between self-reported physical activity or objective measurement of mean steps/day with pain acceptance. Results revealed an inverse relationship between chronic pain acceptance and pain-related functional interference (by.x = -.52, p < .01) and a positive relationship with self-reported functioning (by.x = 7.80, p < .01). A significant inverse relationship with anxiety symptoms (by.x = -1.79, p < .01) and pain acceptance was also found. Acceptance of chronic pain can facilitate decreased emotional distress, improved well-being, and better functioning and quality of life. Further investigation of chronic pain acceptance among PWH could inform the development of acceptance-based interventions.

Cross-sectional evaluation of perceived health care provider engagement, self-efficacy, and ART adherence in people living with HIV/AIDS.

Despite advancements in the treatment and prevention of HIV/AIDS, adherence to antiretroviral therapy (ART) remains suboptimal. Research indicates that health care provider (HCP) engagement is related to adherence, yet little is known about the specific pathways that underlie this relation. This cross-sectional study examined the relation between perceived HCP engagement and ART adherence in people living with HIV/AIDS (PLWHA), as well as the role of adherence self-efficacy in this relation. Participants (N = 207) completed self-report measures assessing monthly ART adherence, perceived ability to take ART as prescribed, and perceptions of HCP engagement. Results of a path analysis revealed a direct positive relation between perceived HCP engagement and ART adherence, and a significant indirect relation of perceived HCP engagement to ART adherence through adherence self-efficacy. Higher perceived HCP engagement was related to greater adherence self-efficacy, which, in turn was related to higher ART adherence. Findings are consistent with research demonstrating that HCP support leads to increased motivation to engage in treatment and extends past work on the importance of positive patient-provider relationships. Notably, results suggest that increasing patient perceptions of HCP engagement may be one way to boost adherence self-efficacy and improve ART adherence in PLWHA.

A Randomized Trial Comparing Brief Advice and Motivational Interviewing for Persons with HIV-HCV Co-infection Who Drink Alcohol.

Alcohol use contributes to the progression of liver disease in HIV-HCV co-infected persons, but alcohol interventions have never addressed low levels of alcohol use in this population. We enrolled 110 persons consuming at least 4 alcoholic drinks weekly in a clinical trial comparing two active 18-month long interventions, delivered every 3 months by phone, brief advice about drinking versus a motivational intervention. Final assessment was at 24 months. MI had larger reductions in alcohol use days than the BA arm at all follow-up assessments. The treatment by time effect was not significant for days of drinking (p = 0.470), mean drinks per day (p = 0.155), or for the continuous FIB-4 index (p = 0.175). Drinking declined in both conditions from baseline, but given the small sample, we do not have sufficient data to make any conclusion that one treatment is superior to the other.Trial Registry Trial registered at clinicaltrials.gov; Clinical Trial NCT02316184.

Sustained Sobriety: A Qualitative Study of Persons with HIV and Chronic Hepatitis C Coinfection and a History of Problematic Drinking.

For persons diagnosed with HIV and who are coinfected with hepatitis C virus (HCV), chronic liver disease is a leading cause of death and excessive consumption of alcohol can be a contributing factor. Little is known about the factors these individuals identify as key to achieving sustained sobriety. In this qualitative study, fourteen HIV/HCV coinfected persons who endorsed past problematic drinking were interviewed about their path to sustained sobriety. In open-ended interviews, participants often described their drinking in the context of polysubstance use and their decision to become sober as a singular response to a transcendent moment or a traumatic event. All articulated specific, concrete strategies for maintaining sobriety. The perceived effect of the HIV or HCV diagnosis on sobriety was inconsistent, and medical care as an influence on sobriety was rarely mentioned. Qualitative interviews may offer new insights on interventions and support strategies for heavy-drinking persons with HIV/HCV coinfection.

Examination of using alcohol to cope, depressive symptoms, and perceived social support in persons with HIV and Hepatitis C.

Depression is common among people living with HIV (PLWH) and some likely turn to alcohol to cope with this emotional distress. Using alcohol to cope is associated with increased alcohol use, persistent longitudinal alcohol use, and alcohol-related problems. This association is particularly concerning among PLWH who are co-infected with Hepatitis C (HCV) because alcohol adds to the damage already caused by HCV. Despite data showing the associated risks of using alcohol to cope, scant research has examined factors that might contribute to coping-based alcohol use in HIV-HCV patients, such as limited social support. Baseline data from a randomized trial of strategies to reduce alcohol use in co-infected HIV and HCV adult patients (n=110) were analyzed. Multiple linear regression models were used to estimate the association between using alcohol to cope, depression, and four aspects of social support, controlling for demographic variables. Results showed that using alcohol to cope was not significantly correlated with social support but was significantly correlated with depressive symptoms. In fact, depressive symptoms and severity of alcohol consumption accounted for nearly 45% of the variance related to coping-based alcohol use. These data highlight the central role of depression in the coping motives-alcohol use relationship among co-infected patients.

Using behavioral psychotherapy techniques to address HIV patients' pain, depression, and well-being.

For persons with HIV (PWH), aims of psychotherapy can extend beyond HIV-related topics. Issues such as HIV stigmatization and disclosure and HIV-related self-care including treatment adherence might be ongoing concerns, but patients often need support to develop skills to manage other problems, whether functional or psychiatric. In the context of an ongoing randomized clinical trial, we delivered an individual, behavioral activation-based intervention to PWH with comorbid chronic pain and depression. Our primary treatment target was to reduce pain-related interference in physical and psychosocial functioning. Throughout the course of the 7-session intervention, clinicians used 4 core strategies to help patients improve a variety of domains related to their health and well-being: (a) teaching value-based goal setting, (b) developing skills to be an activated and informed patient, (c) focusing on changing behavior despite discomfort, and, (d) facilitating access to care (e.g., flexible scheduling and primarily phone sessions). The application of these strategies to HIV-related and non-HIV-related problems are presented to illustrate how and when clinicians can utilize these strategies. These practical lessons will inform a flexible approach to helping PWH address a myriad of health and functional issues related to their overall well-being. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Perceptions of Alcohol Risk Among HIV/Hepatitis C Coinfected Patients.

OBJECTIVES: We examined how patient perceptions of alcohol risk, provider discussions about alcohol, and treatment of hepatitis C virus (HCV) differed among HIV-HCV coinfected patients in primary care. METHODS: Between April, 2016 and April, 2017, we conducted a screening survey with patients in an HIV primary care clinic in Seattle, Washington, who had chronic HCV coinfection or a history of chronic HCV infection who had successfully cleared their infection with treatment. RESULTS: Of 225 participants, 84 (37%) were active drinkers (drank ≥2-4 times/mo in past 3 months). Of those with little to no use for ≥3 months, 65 (29%) were former drinkers with a history of alcohol use and 76 were abstainers with no such history. Former drinkers and abstainers were more likely than active drinkers to perceive that any drinking was unsafe (69% vs 58% vs 31%; P < 0.001). Former drinkers were more likely to report a physician's recommendation to stop drinking than active drinkers (63% vs 47%; P = 0.05). The great majority (87%) of former drinkers decided to stop or reduce drinking on their own (most often in response to a nonhealth life event) and only 13% acknowledged doing so on their doctor's prompting. HCV treatment was not associated with former or active drinking status. CONCLUSIONS: Our findings underscore the importance of educating not only HIV-HCV patients about the effects of alcohol use but also HIV clinicians about delivering consistent counseling about alcohol avoidance. Understanding the reasons that HIV-HCV coinfected persons make changes in their alcohol use could drive novel interventions that reduce the negative consequences of drinking.

"Being diagnosed with HIV was the icing on the cake of my life": A case study of fostering resiliency through flexible interventions along the stigma-sickness slope.

The experiences of transgender individuals have been reflected in the stigma-sickness slope in which early stigma leads to marginalization and discrimination, placing an individual at risk for poverty and engagement in higher risk behaviors, eventually leading to sickness, such as HIV infection. For instance, the prevalence of HIV infection among transwomen is 49 times greater than among the general population. Traditional models of care provision for transgender individuals with HIV do not consider the burdens of multiple comorbidities and fear of discrimination impacting access and engagement in HIV medical care and psychotherapy. The present case study will describe how evidence- and strengths-based treatments can be flexibly integrated to promote sustained engagement in psychotherapy and improve patient outcomes. Our patient, a Latina transwoman, presented to psychotherapy at the time of her HIV diagnosis with mental and physical health concerns representative of marginalized populations. Nearly 3 years of treatment with 2 therapists in a medical setting are detailed, illustrating the realistic delivery of evidence-based care to promote minority resilience and disrupt the stigma-sickness slope. Through this case study, we present recommendations to address barriers to care. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Motivation to Quit Drinking in Individuals Coinfected with HIV and Hepatitis C.

Alcohol consumption is common among individuals coinfected with HIV and hepatitis C (HCV) despite the uniquely harmful effects in this population. Limited research has examined factors that could influence drinking reduction or cessation among HIV/HCV coinfected persons; this study investigates motivation to quit. Participants were 110 alcohol-consuming HIV/HCV coinfected patients recruited from medical clinics. Participants self-reported 90-day drinking frequency and intensity; alcohol-related problems; reasons to quit drinking; reasons to drink; and motivation to quit drinking. Participants consumed alcohol on 54.1 (± 26.9) of the past 90 days. In a multivariate model that controlled for demographic variables, motivation to quit drinking was directly associated with alcohol-related problems (ßy·x = 0.35, p = .007) and reasons to quit drinking (ßy·x = 0.23, p = .021), and inversely associated with drinking for enhancement (ßy·x = - 0.36, p = .004). This study identified several factors associated with motivation to quit drinking in a sample of alcohol-consuming HIV/HCV patients.

Pathways to Health: an Examination of HIV-Related Stigma, Life Stressors, Depression, and Substance Use.

BACKGROUND: Despite antiretroviral treatment (ART) being an efficacious treatment for HIV, essentially making it a chronic non-terminal illness, two related and frequent concerns for many people living with HIV/AIDS (PLWHA) continue to be HIV-related stigma and life stress. These two variables are frequently associated with depression, substance use, and poorer functional health. Studies to date have not fully examined the degree to which these constructs may be associated within one model, which could reveal a more nuanced understanding of how HIV-related stigma and life stress affect functional health in PLWHA. METHODS: The current study employed hybrid structural equation modeling to examine the interconnectedness and potential indirect relationships of HIV-related stigma and life stress to worse health through substance use and depression, controlling for ART adherence and age. Participants were 240 HIV-infected individuals who completed a biopsychosocial assessment battery upon screening for an RCT on treating depression in those infected with HIV. RESULTS: Both HIV-related stigma and stressful life events were directly related to depression, and depression was directly related to health. There were significant indirect effects from stigma and stress to health via depression. There were no significant effects involving substance use. CONCLUSION: It is important to continue to develop ways to address stigma, stressful life events, and their effects on distress in those living with HIV. Expanding our knowledge of disease progression risk factors beyond ART adherence is important to be able to design adjuvant interventions, particularly because treatment means that people living with HIV have markedly improved life expectancy and that successful treatment means that HIV is not transmittable to others.

Direct and Indirect Effects of Heavy Alcohol Use on Clinical Outcomes in a Longitudinal Study of HIV Patients on ART.

In a cohort of patients receiving care for HIV, we examined longitudinally the impact of past 30-day frequency of heavy drinking (consuming 5+ drinks on one occasion) on HIV-related (detectable viral load and CD4+ T cell count) and non-HIV-related (hemoglobin and biomarkers of kidney function and liver fibrosis) clinical outcomes and the extent to which these effects were due to reduced antiretroviral therapy (ART) adherence. Data came from the Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy. Between March 2004 and June 2006, 533 individuals receiving ART were recruited and followed every 6 months for six years. Using longitudinal mediation analysis, we estimated natural direct effects (NDE) of heavy drinking frequency (never, 1-3 times, or 4+ times in the past 30 days) on clinical outcomes and natural indirect effects (NIE) mediated via ART adherence. A one-level increase in heavy drinking frequency had a significant negative NDE on CD4+ T-cell counts (-10.61 cells/mm3; 95 % CI [-17.10, -4.12]) and a significant NIE through reduced ART adherence of -0.72 cells/mm3 (95 % CI [-1.28, -0.15]), as well as a significant NIE on risk of detectable viral load (risk ratio = 1.03; 95 % CI [1.00, 1.05]). Heavy drinking had a significant detrimental NIE on a combined index of 5-year mortality risk and detrimental NDE and total effect on a biomarker of liver fibrosis. Heavy drinking has deleterious effects on multiple clinical outcomes in people living with HIV, some of which are mediated through reduced ART adherence.

Cognitive behavioural therapy for adherence and depression in patients with HIV: a three-arm randomised controlled trial.

BACKGROUND: Depression is highly prevalent in people with HIV and has consistently been associated with poor antiretroviral therapy (ART) adherence. Integrating cognitive behavioural therapy (CBT) for depression with adherence counselling using the Life-Steps approach (CBT-AD) has an emerging evidence base. The aim of this study was to test the efficacy of CBT-AD. METHODS: In this three-arm randomised controlled trial in HIV-positive adults with depression, we compared CBT-AD with information and supportive psychotherapy plus adherence counselling using the Life-Steps approach (ISP-AD), and with enhanced treatment as usual (ETAU) including Life-Steps adherence counselling only. Participants were recruited from three sites in New England, USA (two hospital settings and one community health centre). Patients were randomly assigned (2:2:1) to receive CBT-AD (one Life-Steps session plus 11 weekly integrated sessions lasting up to 1 h each), ISP-AD (one Life-Steps session plus 11 weekly integrated sessions lasting up to 1 h each), or ETAU (one Life-Steps session and five assessment visits roughly every 2 weeks), randomisation was done with allocation software, in pairs, and stratified by three variables: study site, whether or not participants had been prescribed antidepressant medication, and whether or not participants had a history of injection drug use. The primary outcome was ART adherence at the end of treatment (4 month assessment) assessed via electronic pill caps (Medication Event Monitoring System [MEMS]) with correction for pocketed doses, analysed by intention to treat. FINDINGS: Patients were recruited from Feb 26, 2009, to June 21, 2012. Patients who were assigned to CBT-AD (94 randomly assigned, 83 completed assessment) had greater improvements in adherence (estimated difference 1·00 percentage point per visit, 95% CI 0·34 to 1·66, p=0·003) and depression (Center for Epidemiological Studies depression [CESD] score estimated difference -0·41, -0·66 to -0·16, p=0·001; Montgomery-Asberg depression rating scale [MADRS] score -4·69, -8·09 to -1·28, p=0·007; clinical global impression [CGI] score -0·66, -1·11 to -0·21, p=0·005) than did patients who had ETAU (49 assigned, 46 completed assessment) after treatment (4 months). No significant differences in adherence were noted between CBT-AD and ISP-AD (97 assigned, 87 completed assessment). No study-related adverse events were reported. INTERPRETATION: Integrating evidenced-based treatment for depression with evidenced-based adherence counselling is helpful for individuals living with HIV/AIDS and depression. Future efforts should examine how to best disseminate effective psychosocial depression treatments such as CBT-AD to people living with HIV/AIDS and examine the cost-effectiveness of such approaches. FUNDING: National Institute of Mental Health, National Institute of Allergy and Infectious Diseases.

Description and Demonstration of Cognitive Behavioral Therapy to Enhance Antiretroviral Therapy Adherence and Treat Depression in HIV-Infected Adults.

There are an estimated 1.1 million individuals living with HIV/AIDS in the United States. In addition to the various medical comorbidities of HIV infection, depression is one of the most frequently co-occurring psychiatric conditions among HIV-infected individuals. Furthermore, depression has been found to be associated with nonadherence to antiretroviral therapy (ART), as well as HIV disease progression. Cognitive behavioral therapy (CBT) has repeatedly been found to effectively treat depression in adult populations, and CBT for adherence and depression (CBT-AD) is an effective treatment for improving depressive symptoms and medication adherence in the context of various chronic health conditions, including diabetes and HIV-infection. This paper provides a description of the CBT-AD approach to treat depression and ART adherence in HIV-infected adults, which we have developed and tested in our clinic, and for which detailed therapist and client guides exist. To augment the description of treatment, the present article provides video component demonstrations of several core modules that highlight important aspects of this treatment, including Life-Steps for medication adherence, orientation to CBT-AD and psychoeducation, and suggestions for adaptation of core CBT modules for HIV-infected adults. Discussion of video demonstrations highlights differences in patient presentations and course of treatment between HIV-infected adults receiving CBT-AD and HIV-uninfected adults receiving traditional CBT for depression. This description and the accompanying demonstrations are intended as a practical guide to assist therapists wishing to conduct such a treatment in the outpatient setting.