Addressing Syndemics and Self-care in Individuals with Uncontrolled HIV: An Open Trial of a Transdiagnostic Treatment.

Interventions addressing syndemics and ART adherence are needed for individuals with uncontrolled HIV and psychosocial problems. Twenty-seven participants with detectable HIV plasma viral load (PVL) or recent STI participated in an open trial of transdiagnostic adherence counseling and cognitive behavioral therapy. Outcomes were collected at baseline, 4-, and 8-months. Log PVL improved from baseline to 4-month (γ = - 1.13, 95% CI - 1.72, - 0.55, p < 0.001) and 8-month (γ = - 0.93, 95% CI - 1.57, - 0.30, p = 0.006), with more participants suppressed at 4- (χ2(1) = 9.09, p = 0.001) and 8-month (χ2(1) = 5.14, p = 0.016). Self-reported adherence improved across major assessments (γ = 0.87, 95% CI 0.28, 1.46, p = .005); Wisepill adherence did not. Negative affect declined during treatment (γ = - 0.28, 95% CI - 0.40, - 0.16, p < 0.001), with improvement at 4- (γ = - 4.34, 95% CI - 6.99, - 1.69, p = 0.002) but not 8-month. Positive affect trended positively during treatment and from baseline to 4-month, with significant 8-month improvement (γ = 3.84, 95% CI 0.33, 7.44, p = 0.04). Depressive symptoms did not change. In a complicated sample of participants selected for uncontrolled HIV, the intervention yielded improved PVL and self-reported adherence. Efforts to end HIV should improve upon strategies such as these, addressing syndemics. Registration: clinicaltrial.gov: NCT02696681.

Psychosocial and Neurohormonal Predictors of HIV Disease Progression (CD4 Cells and Viral Load): A 4 Year Prospective Study.

Most studies of psychosocial predictors of disease progression in HIV have not considered norepinephrine (NE), a neurohormone related to emotion and stress, even though NE has been related to accelerated viral replication in vitro and impaired response to antiretroviral therapy (ART). We therefore examined NE, cortisol, depression, hopelessness, coping, and life event stress as predictors of HIV progression in a diverse sample. Participants (n = 177) completed psychological assessment, blood draws [CD4, viral load (VL)], and a 15 h urine sample (NE, cortisol) every 6 months over 4 years. Hierarchical linear modeling (HLM) was used to model slope in CD4 and VL controlling for ART at every time point, gender, age, race, SES, and initial disease status. NE (as well as depression, hopelessness, and avoidant coping) significantly predicted a greater rate of decrease in CD4 and increase in VL. Cortisol was not significantly related to CD4, but predicted VL increase. To our knowledge, this is the first study relating NE, in vivo, to accelerated disease progression over an extended time. It also extends our previous 2 year study by relating depressed mood and coping to accelerated disease progression over 4 years.

The fork in the road: HIV as a potential positive turning point and the role of spirituality.

We interviewed 147 HIV-positive people regarding their key life-changing experiences - involving profound changes in attitudes, behaviors, beliefs (including spiritual beliefs), or self-views - to determine the prominence of HIV as the key positive/negative turning point. HIV was the key turning point, for 37% (26% positive, 11% negative), whereas for 63% of our sample it was not. Characteristics associated with perceiving HIV as the most positive turning point included having a near-death experience from HIV, increasing spirituality after HIV diagnosis, and feeling chosen by a Higher Powerto have HIV. Notably, perceived antecedents of viewing HIV as the key positive turning point were hitting rock bottom and calling on a Higher Power. Conversely, viewing HIV as the most negative turning point was associated with declining spirituality after diagnosis. Spirituality can both negatively and positively affect coping with HIV. Promoting positive spiritual coping may offer new counseling approaches. Further, for the majority of the participants, HIV is not the key turning point, which may be an indicator of the normalization of HIV with the advent of effective treatment.

Relative preservation of natural killer cell cytotoxicity and number in healthy AIDS patients with low CD4 cell counts.

OBJECTIVE: This study examines whether there may be an immune component that protects a relatively rare group of HIV-infected people with very low CD4 cell counts (< or = 50 x 10(6)/l) who have prolonged asymptomatic periods. DESIGN/METHODS: Three groups were recruited in Miami: (i) healthy low CD4 cell count patients (HLC; n = 30) who, for 9 months had < 50 x 10(6) CD4 cells/l, were asymptomatic and were not on protease inhibitors during that time; (ii) HIV comparison group (Comp; n = 60) who had CD4 cell counts predominantly 150 x 10(6) to 400 x 10(6)/l and never had AIDS Category C symptoms; this group was also followed for CD4 cell count and viral load change over 6 months; and (iii) healthy community controls (n = 33). The study was replicated at the University of California at Los Angeles (UCLA) with HLC (n = 31) versus HIV-negative laboratory controls (n = 28). RESULTS: The HLC patients were significantly higher than the Comp group on natural killer cell cytotoxicity (NKCC) and natural killer cell number (NK#) despite their lower CD4 cell numbers and higher viral loads. In fact, there was no difference between the HLC group and the healthy community control group in NK# or NKCC. The NK findings were replicated at UCLA. A retrospective analysis showing that higher NKCC was related to fewer prior symptoms in the HLC group, and prospective analysis in the Comp group showing that NK# predicted a lower increase in viral load over 6 months further supported the importance of NK# and NKCC. CONCLUSIONS: Non-specific cellular immunity may be a factor protecting the health of HIV sero-positive individuals with very low CD4 cell counts.

Disparities in psychological, neuroendocrine, and immunologic patterns in asymptomatic HIV-1 seropositive and seronegative gay men.

The present study concurrently measured psychological distress (state anxiety, depression, confusion, and intrusive thoughts), neuroendocrine (plasma cortisol concentrations), and immunologic [lymphocyte proliferative responses to phytohemagglutinin (PHA) and pokeweed mitogen (PWM)] changes in the 5-week periods preceding and following serostatus notification among asymptomatic Human Immunodeficiency Virus-type 1 (HIV-1) seropositive and seronegative gay men. Seropositives, as opposed to seronegatives, showed a disparity in predicted relationships among distress, cortisol, and immunologic measures across the prenotification to postnotification period. Individual difference analyses suggested that among seropositives, in contrast to seronegatives, plasma cortisol concentrations were negatively correlated with psychological distress and positively correlated with responses to PHA (assessed at study entry and after serostatus notification). This pattern in seropositives could not be explained by differences in prenotification perceived risk of infectivity, extraneous environmental stressors, or CD4 cell counts within the seropositive group.

Effects of anger on left ventricular ejection fraction in coronary artery disease.

This study examined the comparative potency of several psychological stressors and exercise in eliciting myocardial ischemia as measured by left ventricular (LV) ejection fraction (EF) changes using radionuclide ventriculography. Twenty-seven subjects underwent both exercise (bicycle) and psychological stressors (mental arithmetic, recall of an incident that elicited anger, giving a short speech defending oneself against a charge of shoplifting) during which EF, blood pressure, heart rate and ST segment were measured. Eighteen subjects had 1-vessel coronary artery disease (CAD), defined by greater than 50% diameter stenosis in 1 artery as assessed by arteriography. Nine subjects served as healthy control subjects. Anger recall reduced EF more than exercise and the other psychological stressors (overall F [3.51] = 2.87, p = .05). Respective changes in EF for the CAD patients were -5% during anger recall, +2% during exercise, 0% during mental arithmetic and 0% during the speech stressor. More patients with CAD had significant reduction in EF (greater than or equal to 7%) during anger (7 of 18) than during exercise (4 of 18). The difference in EF change between patients with CAD and healthy control subjects was significant for both anger (t25 = 2.23, p = 0.04) and exercise (t25 = 2.63, p = 0.01) stressors. In this group of patients with CAD, anger appeared to be a particularly potent psychological stressor.

Cognitive-behavioral stress management buffers decreases in dehydroepiandrosterone sulfate (DHEA-S) and increases in the cortisol/DHEA-S ratio and reduces mood disturbance and perceived stress among HIV-seropositive men.

This study examined the effects of a 10-week cognitive-behavioral stress management (CBSM) intervention on dehydroepiandrosterone sulfate (DHEA-S) levels and the ratio of cortisol to DHEA-S (cortisol/DHEA-S), potential surrogate adrenal markers of HIV disease progression, in relation to alterations in mood and distress. HIV-seropositive men were randomized to either a group-based CBSM intervention (n = 43) or to a wait-list control group (n = 24), with both hormonal and distress measures assessed just prior to and immediately following the 10-week period. Results showed that CBSM buffers decreases in DHEA-S and increases in the cortisol/DHEA-S ratio. Further examination also revealed that changes in the cortisol/DHEA-S ratio were significantly and positively related to changes in total mood disturbance and perceived stress over time. These findings demonstrate that a short-term CBSM intervention can buffer against decrements in DHEA-S and increments in the cortisol/DHEA-S ratio among symptomatic, HIV-positive men, and that alterations in the cortisol/DHEA-S ratio move in concert with changes in mood and distress observed during CBSM.

Blood pressure stability of normotensives and mild hypertensives in different settings.

Generalizability theory was used to examine the stability of blood pressure (BP) measurement in normotensives and mild hypertensives. Three to six readings at home or at work provided adequate reliability for the same day in each setting. Under structured laboratory conditions, two to three BP measures taken on each of 2 to 3 days for systolic and diastolic BP provided conservative estimates that were generalizable across days. Finally, generalizations across settings called for five or more measurements taken in at least two settings.

Cognitive-behavioral stress management increases free testosterone and decreases psychological distress in HIV-seropositive men.

The effects of a 10-week group-based cognitive-behavioral stress management (CBSM) intervention on psychological distress and plasma free testosterone in symptomatic, HIV-seropositive men were examined. Participants were randomized to either CBSM (n = 42) or a wait-list control group (n = 23). Men in the CBSM intervention showed significant increases in testosterone, whereas control participants showed significant decreases. Those participating in CBSM had significant distress reductions, whereas controls showed no such change. Alterations in free testosterone were inversely related to changes in distress states over time, independent of any changes in cortisol. These findings demonstrate that a short-term CBSM intervention increases free testosterone levels among symptomatic, HIV-seropositive men, and alterations in free testosterone are associated with changes in psychological distress observed during CBSM.

Concerns about breast cancer and relations to psychosocial well-being in a multiethnic sample of early-stage patients.

Much work on psychosocial sequelae of breast cancer has been guided by the assumption that body image and partner reaction issues are focal. In a tri-ethnic sample of 223 women treated for early-stage breast cancer within the prior year, the authors assessed a wider range of concerns and relations to well-being. Strongest concerns were recurrence, pain, death, harm from adjuvant treatment, and bills. Body-image concerns were moderate; concern about rejection was minimal. Younger women had stronger sexual and partner-related concerns than older women. Hispanic women had many stronger concerns and more disruption than other women. Life and pain concerns and sexuality concerns contributed uniquely to predicting emotional and psychosexual disruption; life and pain concerns and rejection concerns contributed to predicting social disruption. In sum, adaptation to breast cancer is a process bearing on several aspects of the patient's life space.

Coping self-efficacy buffers psychological and physiological disturbances in HIV-infected men following a natural disaster.

The importance of coping self-efficacy (CSE) appraisals on psychological and physiological functioning for HIV seropositive patients facing a severe environmental stressor was tested comparing 37 HIV-infected gay men and 42 healthy male control participants following Hurricane Andrew. Results suggested that greater levels of CSE were related to lower emotional distress and posttraumatic stress disorder (PTSD) symptoms in both groups. In addition, greater CSE was associated with lower norepinephrine to cortisol ratios in the HIV group but not in the healthy control group. Results are discussed in relation to the coping process for HIV-infected individuals specifically and chronically ill populations in general who face severe environmental stressors.

Endogenous depression in the elderly: prevalence and agreement among measures.

This article describes agreement among diagnoses made according to five definitions of endogenous depression in a sample of 99 depressed elders and discusses the relationship among these systems and selected demographic and clinical characteristics. Poor to fair agreement was generally demonstrated, except for Research Diagnostic Criteria (Spitzer, Endicott, & Robins, 1978) and Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., rev. (American Psychiatric Association, 1987), which demonstrated excellent agreement. Mostly, demographic and clinical variables (e.g., severity of depression) were unrelated to endogeneity diagnoses. The conclusion was reached that these criteria are not all measuring the same construct in older adults and that the relationship between depression severity and endogeneity should be discussed in terms of specific definitions rather than general terms.

Psychoneuroimmunology and HIV-1.

Recent psychoneuroimmunologic findings have suggested that it may be useful to evaluate the influence of behavioral factors on immune functioning and disease progression among human immunodeficiency virus-Type 1 (HIV-1) infected individuals. Behavioral interventions with immunomodulatory capabilities may help restore competence and thereby arrest HIV-1 disease promotion at the earliest stages of the infectious continuum. Evidence describing benefits of behavioral interventions such as aerobic exercise training on both psychological and immunological functioning among high-risk HIV-1 seronegative and very early stage seropositive gay men is presented. The HIV-1 infection is cast as a chronic disease for which early immunomodulatory behavioral interventions may have important physical and psychological impact.

Cognitive-behavioral stress management intervention buffers distress responses and immunologic changes following notification of HIV-1 seropositivity.

Forty-seven asymptomatic, healthy gay men were randomly assigned to a cognitive-behavioral stress management (CBSM) condition or an assessment-only control group 5 weeks before being notified of their HIV-1 antibody status. Seventy-two hours before and 1 week after serostatus notification, blood samples and psychometric data were collected. Control subjects showed significant increases in depression, but only slight decrements in mitogen responsivity and lymphocyte cell counts pre- to postnotification of seropositivity. Seropositive CBSM Ss did not show significant pre-post changes in depression, but did reveal significant increases in helper-inducer (CD4) and natural killer (CD56) cell counts as well as a slight increment in proliferative responses to phytohemagglutinin (PHA). Individual difference analyses suggest that the psychological buffering and immunomodulating effects of the CBSM manipulation may be attributable, in part, to relaxation skills learned and practiced or to a general willingness to comply with the intervention guidelines.

Cognitive-behavioral stress management decreases dysphoric mood and herpes simplex virus-type 2 antibody titers in symptomatic HIV-seropositive gay men.

This study tested the effects of a 10-week group cognitive-behavioral stress management (CBSM) intervention on mood and immunologic parameters in HIV-seropositive gay men whose disease had progressed to a symptomatic stage. Men were randomized to either CBSM or a modified waiting-list control group. The CBSM intervention significantly decreased self-reported dysphoria, anxiety, and total distress. Individuals who practiced relaxation more consistently had significantly greater drops in dysphoria. The intervention also decreased herpes simplex virus-Type 2 (HSV-2) immunoglobulin G antibody titers. The control group showed no significant changes in either mood or antibody titers. Individual difference analyses revealed that decreases in dysphoria significantly predicted lower HSV-2 antibody titers by the end of the 10-week period. Neither group displayed changes in HSV-Type 1 antibody titers or in CD4+ or CD8+ cell numbers.

Cognitive-behavioral stress management intervention effects on anxiety, 24-hr urinary norepinephrine output, and T-cytotoxic/suppressor cells over time among symptomatic HIV-infected gay men.

The present study tested the effects of a multimodal cognitive-behavioral stress management (CBSM) intervention on anxious mood, perceived stress, 24-hr urinary catecholamine levels, and changes in T-lymphocyte subpopulations over time in symptomatic HIV+ gay men. Seventy-three men were randomized to either a group-based CBSM intervention (n = 47) or a wait-list control (WLC) condition (n = 26). Men assigned to CBSM showed significantly lower posttreatment levels of self-reported anxiety, anger, total mood disturbance, and perceived stress and less norepinephrine (NE) output as compared with men in the WLC group. At the individual level, anxiety decreases paralleled NE reductions. Significantly greater numbers of T-cytotoxic/suppressor (CD3+CD8+) lymphocytes were found 6 to 12 months later in those assigned to CBSM. Moreover, greater decreases in NE output and a greater frequency of relaxation home practice during the 10-week CBSM intervention period predicted higher CD3+CD8+ cell counts at follow-up.

Exercise and psychoneuroimmunology.

Psychoneuroimmunology is the study of the interrelationships among psychological, neuroendocrine, and immunological parameters and is concerned with how these relationships may affect an individual's health. Substantial evidence indicates that exercise is associated with improvements in mental health, neuroendocrine, and immune functioning. We synthesize these effects of exercise and propose an "exercise and psychoneuroimmunology" model by which exercise may benefit the psychologic and immunologic sequelae of several chronic diseases. For the past several years we have been investigating exercise training interventions, based on our model, for individuals infected with the human immunodeficiency virus type 1 (HIV-1). These studies indicate that a moderate exercise training program may attenuate the adverse stressor-induced psychologic and immunologic changes for asymptomatic HIV-1 seropositive individuals. In addition, our research indicates that continued aerobic exercise training may result in increased CD4 cell counts, immune surveillance, and a potential for a slowing of disease progression. Other researchers have demonstrated similar beneficial effects of exercise for individuals infected with HIV-1 who are at more advanced stages of disease. Exercise within the context of psychoneuroimmunology appears to be a very promising approach to the treatment of illness and promotion of health.

Cardiopulmonary and CD4 cell changes in response to exercise training in early symptomatic HIV infection.

PURPOSE: The purposes of the present study were to assess the effects of a 12-wk laboratory based aerobic exercise program on cardiopulmonary function, CD4 cell count, and physician-assessed health status among symptomatic pre-AIDS HIV-infected individuals (N = 28) and to assess the degree to which ill health was associated with exercise relapse. METHODS: Responses to graded exercise test, physician-assessed health status, and CD4 cell counts were determined at baseline and 12-wk follow-up for participants randomly assigned to exercise or control conditions, and reasons for exercise noncompliance were recorded. RESULTS: Approximately 61% of exercise-assigned participants complied (> 50% attendance) with the exercise program, and analyses of exercise relapse data indicated that obesity and smoking status, but not exercise-associated illness, differentiated compliant from noncompliant exercisers. Compliant exercisers significantly improved peak oxygen consumption (VO2peak; 12%), oxygen pulse (O2pulse; 13%), tidal volume (TV; 8%), ventilation (VE; 17%), and leg power (25%) to a greater degree than control participants and noncompliant exercisers (all P < 0.05). Although no group differences in health status were found, a significant interaction effect indicated that noncompliant exercisers' CD4 cells declined (18%) significantly, whereas compliant exercisers' cell counts significantly increased (13%; P < 0.05). CONCLUSION: We conclude that although aerobic exercise can improve cardiopulmonary functioning in symptomatic HIV-infected individuals with minimal health risks, attention to factors associated with exercise adherence is warranted.

Religiosity is associated with affective and immune status in symptomatic HIV-infected gay men.

This study examines the relationship between religiosity and the affective and immune status of 106 HIV-seropositive mildly symptomatic gay men (CDC stage B). All men completed an intake interview, a set of psychosocial questionnaires, and provided a venous blood sample. Factor analysis of 12 religiously oriented response items revealed two distinct aspects to religiosity: religious coping and religious behavior. Religious coping (e.g., placing trust in God, seeking comfort in religion) was significantly associated with lower scores on the Beck Depression Inventory, but not with specific immune markers. On the other hand, religious behavior (e.g., service attendance, prayer, spiritual discussion, reading religious literature) was significantly associated with higher T-helper-inducer cell (CD4+) counts and higher CD4+ percentages, but not with depression. Regression analyses indicated that religiosity's associations with affective and immune status was not mediated by the subjects' sense of self-efficacy or ability to actively cope with their health situation. The associations between religiosity and affective and immune status also appear to be independent of symptom status. Self-efficacy, however, did appear to contribute uniquely and significantly to lower depression scores. Our results show that an examination considering both subject religiosity as well as sense of self-efficacy may predict depressive symptoms in HIV-infected gay men better than an examination that considers either variable in isolation.

Massage effects on cocaine-exposed preterm neonates.

Thirty preterm cocaine-exposed preterm neonates (mean gestational age 30 wks, mean birth weight = 1212 g, mean intensive care unit duration = 18 days) were randomly assigned to a massage therapy or a control group as soon as they were considered medically stable. Group assignment was based on a random stratification of gestational age, birth weight, intensive care unit duration, and entry weight into the study. The treatment group (N = 15) received massages for three 15-minute periods 3 consecutive hours for a 10-day period. Findings suggested that the massaged infants (1) averaged 28% greater weight gain per day (33 vs 26 g) although the groups did not differ in intake (calories or volume), (2) showed significantly fewer postnatal complications and stress behaviors than did control infants, and (3) demonstrated more mature motor behaviors on the Brazelton examination at the end of the 10-day study period.