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.

Detecting Depression in People Living with HIV in South Africa: The Factor Structure and Convergent Validity of the South African Depression Scale (SADS).

Screening measures for depression developed in high-income countries have not always demonstrated strong psychometric properties in South Africa and with people living with HIV (PLWH). The present study explored the psychometric properties of the 16-item South African Depression Scale (SADS) comprised of idioms of distress specific to isiXhosa culture in PLWH. The SADS was administered to 137 Xhosa-speaking PLWH who met diagnostic criteria for major depressive disorder (MDD) together with the Hamilton Depression Scale (HAM-D) and the Center for Epidemiological Studies Depression Scale (CES-D). We conducted exploratory factor analysis, correlation, and reliability statistics. Four factors of the SADS emerged: Sadness, lethargy/burdened, anhedonia/withdrawal, and cognitive/somatic. All factors correlated significantly with the HAM-D and CES-D. Internal consistency of the overall measure was high (α = .89). The SADS promises to be a robust measure of depression in isiXhosa-speaking PLWH in South Africa likely due to the inclusion of local idioms of distress.

Connecting the dots: a comparison of network analysis and exploratory factor analysis to examine psychosocial syndemic indicators among HIV-negative sexual minority men.

Syndemics, or comorbid and mutually reinforcing psychosocial problems, are associated with increased HIV risk among men who have sex with men (MSM). Although the dynamic interplay among syndemic indicators is theorized to be crucial for increasing risk of HIV acquisition, novel approaches are needed to understand how these syndemic problems interrelate. This study examined the associations between nine self-reported syndemic indicators in 194 MSM at high risk of HIV acquisition. We compared exploratory factor analyses (EFA) to a network analysis. In the present study, network analysis consisted of edges representing bidirectional partial polychoric correlations between nodes, which represent psychosocial syndemic indicators. EFA yielded a 1-factor solution including suicidal ideation (SI), injection drug use (IDU), depression, social anxiety, intimate partner violence, substance use, and sexual compulsivity, and excluded heavy drinking and childhood sexual abuse. Network analysis yielded a pattern of interconnectedness with the most central nodes being SI, IDU, substance use, and depression. Statistically significant relationships (absolute edge weights) were found between SI and depression, social anxiety, and IDU, and IDU and substance use. These results suggest that depression and substance use, especially more severe presentations of these conditions such as SI and IDU, are prominent interconnected components of the HIV syndemic among MSM at high risk for HIV acquisition. SI, IDU, substance use, and depression may indeed be prudent targets of intervention. Future research on the inclusion of these syndemic indicators in analytical models involving interaction terms may be warranted.

'I went back to being myself': acceptability of a culturally adapted task-shifted cognitive-behavioural therapy (CBT) treatment for depression (Ziphamandla) for South African HIV care settings.

There is a need for a culturally adapted, evidence-based, psychotherapy treatment that is effective, acceptable, and feasible for integration into primary care in South Africa. This qualitative study used exit interviews to examine participants' experiences of an adapted cognitive-behavioural therapy treatment for adherence and depression, task-shifted and delivered by nurses in two peri-urban HIV clinics near Cape Town. Nine semi-structured exit interviews were conducted with isiXhosa-speaking females and analysed using thematic analysis. Overall, participants responded positively to the treatment, viewing it as acceptable and beneficial and as a catalyst to returning to normalcy. Results indicated that participants viewed the treatment as being effective in ameliorating their depressive symptoms and improving their adherence to ART . Additional benefits described included improvements in subjective wellbeing and social and occupational functioning. Several began or resumed employment, an important behavioural indicator of the treatment's capacity to facilitate positive change and cost saving. Recommendations to improve the treatment included using video material and educating others about depression. These findings have positive implications regarding the acceptability and cultural applicability of the treatment for use in South Africa.

A Comparison of Adherence Timeframes Using Missed Dose Items and Their Associations with Viral Load in Routine Clinical Care: Is Longer Better?

Questions remain regarding optimal timeframes for asking about adherence in clinical care. We compared 4-, 7-, 14-, 30-, and 60-day timeframe missed dose items with viral load levels among 1099 patients on antiretroviral therapy in routine care. We conducted logistic and linear regression analyses examining associations between different timeframes and viral load using Bayesian model averaging (BMA). We conducted sensitivity analyses with subgroups at increased risk for suboptimal adherence (e.g. patients with depression, substance use). The 14-day timeframe had the largest mean difference in adherence levels among those with detectable and undetectable viral loads. BMA estimates suggested the 14-day timeframe was strongest overall and for most subgroups although findings differed somewhat for hazardous alcohol users and those with current depression. Adherence measured by all missed dose timeframes correlated with viral load. Adherence calculated from intermediate timeframes (e.g. 14-day) appeared best able to capture adherence behavior as measured by viral load.

Periconception HIV Risk Behavior Among Men and Women Reporting HIV-Serodiscordant Partners in KwaZulu-Natal, South Africa.

HIV-infected men and women who choose to conceive risk infecting their partners. To inform safer conception programs we surveyed HIV risk behavior prior to recent pregnancy amongst South African, HIV-infected women (N = 209) and men (N = 82) recruited from antenatal and antiretroviral clinics, respectively, and reporting an uninfected or unknown-HIV-serostatus pregnancy partner. All participants knew their HIV-positive serostatus prior to the referent pregnancy. Only 11 % of women and 5 % of men had planned the pregnancy; 40 % of women and 27 % of men reported serostatus disclosure to their partner before conception. Knowledge of safer conception strategies was low. Around two-thirds reported consistent condom use, 41 % of women and 88 % of men reported antiretroviral therapy, and a third of women reported male partner circumcision prior to the referent pregnancy. Seven women (3 %) and two men (2 %) reported limiting sex without condoms to peak fertility. None reported sperm washing or manual insemination. Safer conception behaviors including HIV-serostatus disclosure, condom use, and ART at the time of conception were not associated with desired pregnancy. In light of low pregnancy planning and HIV-serostatus disclosure, interventions to improve understandings of serodiscordance and motivate mutual HIV-serostatus disclosure and pregnancy planning are necessary first steps before couples or individuals can implement specific safer conception strategies.

"If I don't use a condom I would be stressed in my heart that I've done something wrong": Routine Prevention Messages Preclude Safer Conception Counseling for HIV-Infected Men and Women in South Africa.

Intended conception likely contributes to a significant proportion of new HIV infections in South Africa. Safer conception strategies require healthcare provider-client communication about fertility intentions, periconception risks, and options to modify those risks. We conducted in-depth interviews with 35 HIV-infected men and women accessing care in South Africa to explore barriers and promoters to patient-provider communication around fertility desires and intentions. Few participants had discussed personal fertility goals with providers. Discussions about pregnancy focused on maternal and child health, not sexual HIV transmission; no participants had received tailored safer conception advice. Although participants welcomed safer conception counseling, barriers to client-initiated discussions included narrowly focused prevention messages and perceptions that periconception transmission risk is not modifiable. Supporting providers to assess clients' fertility intentions and offer appropriate advice, and public health campaigns that address sexual HIV transmission in the context of conception may improve awareness of and access to safer conception strategies.

Evaluation of the single-item self-rating adherence scale for use in routine clinical care of people living with HIV.

The self-rating scale item (SRSI) is a single-item self-report adherence measure that uses adjectives in a 5-point Likert scale, from "very poor" to "excellent," to describe medication adherence over the past 4 weeks. This study investigated the SRSI in 2,399 HIV-infected patients in routine care at two outpatient primary HIV clinics. Correlations between the SRSI and four commonly used adherence items ranged from 0.37 to 0.64. Correlations of adherence barriers, such as depression and substance use, were comparable across all adherence items. General estimating equations suggested the SRSI is as good as or better than other adherence items (p's <0.001 vs. <0.001-0.99) at predicting adherence-related clinical outcomes, such as HIV viral load and CD4(+) cell count. These results and the SRSI's low patient burden suggest its routine use could be helpful for assessing adherence in clinical care and should be more widespread, particularly where more complex instruments may be impractical.

Which HIV-infected men who have sex with men in care are engaging in risky sex and acquiring sexually transmitted infections: findings from a Boston community health centre.

OBJECTIVES: The primary objective was to determine the prevalence of sexually transmitted infections (STI) in a cohort of HIV-infected men who have sex with men (MSM) in their primary care setting, and to identify the demographic and behavioural characteristics of those infected with STI and the correlates of sexual transmission risk behaviour. METHODS: At study entry, participants (n = 398) were tested for STI and their medical charts were reviewed for STI results in the previous year. Data on demographics, substance use, sexual behaviour and HIV disease characteristics were collected through a computer-assisted self-assessment and medical record extraction. Logistic regression analyses assessed characteristics of those with recent STI and recent transmission risk behaviour. RESULTS: The sample was predominantly white (74.6%) and college educated (51.7%). On average, participants were 41.5 years old (SD 8.4) and had been HIV infected for 8.6 years (SD 6.7); 9% of the sample had an STI, with 6.4% testing positive for syphilis, 3.1% for gonorrhoea and 0.25% for chlamydia. Age and years since HIV diagnosis were significantly associated with testing positive for an STI, as was engaging in transmission risk behaviour and using methamphetamine, ketamine and inhalants. Substance use, particularly methamphetamine use, and being more recently diagnosed with HIV were each uniquely associated with transmission risk behaviour in a multivariable model. CONCLUSIONS: These results underscore the need to develop more effective secondary prevention interventions for HIV-infected MSM, tailored to more recently diagnosed patients, particularly those who are younger and substance users.

Symptoms of depression prospectively predict poorer self-care in patients with Type 2 diabetes.

AIMS: To examine prospectively the association of depression symptoms with subsequent self-care and medication adherence in patients with Type 2 diabetes mellitus. METHODS: Two hundred and eight primary care patients with Type 2 diabetes completed the Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS) and the Summary of Diabetes Self-Care Activities (SDSCA) at baseline and at follow-up, an average of 9 months later. They also self-reported medication adherence at baseline and at a follow-up. RESULTS: Baseline HANDS scores ranged from 0 to 27, with a mean score of 5.15 +/- 4.99. In separate linear regression models that adjusted for baseline self-care, patients with higher levels of depressive symptoms at baseline reported significantly lower adherence to general diet recommendations and specific recommendations for consumption of fruits and vegetables and spacing of carbohydrates; less exercise; and poorer foot care at follow-up (beta ranging from -0.12 to -0.23; P < 0.05). Similarly, each one-point increase in baseline HANDS score was associated with a 1.08-fold increase in the odds of non-adherence to prescribed medication at follow-up (95% confidence interval 1.001, 1.158, P = 0.047). Increases in depression scores over time also predicted poorer adherence to aspects of diet and exercise. CONCLUSIONS: Depressive symptoms predict subsequent non-adherence to important aspects of self-care in patients with Type 2 diabetes, even after controlling for baseline self-care. Although the relationship between symptoms of depression and poorer diabetes self-care is consistent, it is not large, and interventions may need to address depression and self-care skills simultaneously in order to maximize effects on diabetes outcomes.

Study participation as a social group influencing sexual behaviours in an HIV-prevention trial for men who have sex with men.

Perceived group membership, perceptions about accompanying group norms and the degree to which a person identifies with a social group are predictive of a wide range of human behaviours. Behavioural clinical trials in general, and HIV-prevention intervention trials in particular, however, have not examined the degree to which individuals who join a large behavioural study (and hence, a group) may, in an unanticipated way, develop a sense of social identity related to the study, and how this identity or associated group norms may influence participants' behaviours and, potentially, study outcomes. Project EXPLORE was a large-scale behavioural intervention trial in six US cities to prevent HIV seroconversion among men who have sex with men (MSM) (EXPLORE Study Team, 2004). We previously found that participants (examined at one study site) were more likely to engage in high-risk sexual activities with other MSM who were EXPLORE participants than other partners. The present ancillary study (n=271) sought to examine the degree to which perceived group membership, group identity and group norms among EXPLORE study participants was associated with sexual behaviour with other EXPLORE participants, high-risk sexual behaviours with other EXPLORE participants and intentions to engage in high-risk sex with other EXPLORE participants. A principal components analysis of a 14-item scale assessing perceived group membership and norms regarding being part of EXPLORE yielded six principal components (PCs): PC1: perception that EXPLORE participants engage in safer sex; PC2: social comfort with EXPLORE participants; PC3: perceived group identity with EXPLORE; PC4: trust of other EXPLORE participants; PC5: perception that EXPLORE participants are cunning; and PC6: feeling detached from EXPLORE. Social comfort with other EXPLORE participants (OR = 1.24; p = 0.013) and trust of other EXPLORE participants (OR = 1.44; p=0.003) was significantly associated with a higher odds of having sex with another EXPLORE participant. Feeling detached from EXPLORE (OR = 0.56; p=0.020) was significantly associated with a lower odds of engaging in high-risk sexual behaviour with other EXPLORE participants. Regarding intentions to engage in high-risk sexual behaviour with other EXPLORE participants, social comfort with EXPLORE participants (OR = 1.39; p<0.001) and trust of other EXPLORE participants (OR = 1.30; p<0.027) were significantly associated with higher odds of this outcome and the perception that EXPLORE participants are cunning (OR = 0.66; p<0.004) and feeling detached from EXPLORE (OR = 0.68; p<0.007) were significantly associated with lower odds of this outcome. Final models controlled for potential confounders found to be statistically significant in the bivariate analyses. These findings suggest that large-scale studies such as EXPLORE may result in participant's perceptions about group membership, identity and norms, and that these perceptions can influence study outcomes.

Benzodiazepine discontinuation difficulties in panic disorder: conceptual model and outcome for cognitive-behavior therapy.

There is consistent support for the efficacy of cognitive-behavior therapy (CBT) to aid the successful discontinuation of benzodiazepine (BZ) medication in patients with panic disorder, and help these individuals maintain treatment gains while off medication. In this article, we provide a conceptual model for BZ discontinuation difficulties in patients with panic disorder. Outcome studies are reviewed, and are placed in the context of other evidence for the efficacy of CBT in patients with this disorder.

Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents.

In the present study, the researchers examined factors related to depression, hopelessness, and suicidality in gay, lesbian, and bisexual adolescents, compared with demographically similar heterosexual adolescents. Sexual minority adolescents reported greater depression, hopelessness, and past and present suicidality than did heterosexual adolescents. However, when controlling for other psychosocial predictors of present distress, significant differences between the 2 samples disappeared. For past suicidality scores, the effects of sexual orientation were reduced, but still significant, when accounting for the other predictor variables. These results suggest that environmental factors associated with sexual orientation, which can be targeted and changed through prevention and intervention efforts, play a major role in predicting distress in this population.

Clients' expectancies and their relationship to pretreatment symptomatology and outcome of cognitive-behavioral group treatment for social phobia.

The present study examined the expectancies of clients with social phobia that they would benefit from cognitive-behavioral group treatment. Lower expectancies for positive outcome were related to greater severity of social phobia, duration of social phobia, and depression. Lower expectancies were also reported by individuals with the generalized subtype of social phobia, but expectancies were not further influenced by the presence of other Axis I disorders. Expectancy ratings did not differ between clients who dropped out of treatment and those who did not, but, after pretreatment severity of social phobia was accounted for, expectancies significantly predicted improvement among treatment completers. Clients' expectancy beliefs may be an important factor to address in the prediction of who will benefit from a cognitive-behavioral treatment, even when that treatment has demonstrated specific efficacy.

Factor structure of the Social Interaction Anxiety Scale and the Social Phobia Scale.

In the study of social anxiety, it is common to differentiate between social interaction versus performance anxiety. The Social Interaction Anxiety Scale was designed to assess social interaction anxiety, and the Social Phobia Scale to assess fear of scrutiny by others (Mattick and Clarke, 1989). In common use, these scales are typically administered together and treated as subscales of a larger measure. However, the joint factor structure of these instruments has never been examined; therefore, it is unclear whether or not the items on these scales actually represent distinct aspects of social anxiety. In the present study, a confirmatory factor analysis of the pooled items from the SIAS and SPS failed to adequately fit the data. An exploratory factor analysis yielded three factors: (1) interaction anxiety, (2) anxiety about being observed by others, and (3) fear that others will notice anxiety symptoms. However, hierarchical factor analysis suggested that these factors all load on a single higher-order factor, social anxiety. Relationships of the first-order factors to other measures of social and performance fear and avoidance are examined, and implications of our findings for the assessment of social phobia are discussed.

Two strategies to increase adherence to HIV antiretroviral medication: life-steps and medication monitoring.

Advances in the medical treatment of HIV have made it clear that adherence to highly active antiretroviral treatment is a crucial feature for treatment success. The present paper had two goals: (1) to examine psychosocial predictors of adherence in persons receiving HIV antiretroviral therapy; (2) to compared two minimal-treatment interventions to increase HIV medication adherence in a subset of persons who self-reported less than perfect adherence. One of the interventions, Life-Steps, is a single-session intervention utilizing cognitive-behavioral, motivational interviewing, and problem-solving techniques. The other intervention, self-monitoring, utilizes a pill-diary and an adherence questionnaire alone. Significant correlates of adherence included depression, social support, adherence self-efficacy, and punishment beliefs about HIV. Depression was a significant unique predictor of adherence over and above the other variables. Both interventions yielded improvement in adherence from baseline, and the Life-Steps intervention showed faster improvements in adherence for persons with extant adherence problems.

Factor structure of social fears: The Liebowitz Social Anxiety Scale.

In the assessment of social anxiety, investigators often differentiate between social interactional anxiety and performance anxiety. The Liebowitz Social Anxiety Scale (LSAS), a clinician-administered measure of social anxiety and avoidance, was originally developed with separate subscales for the assessment of fear and avoidance of situations involving social interaction and performance/observation by others. Separate confirmatory factor analyses of the LSAS fear and avoidance ratings demonstrated that this two-factor model did not provide an adequate fit to the data, suggesting the need to further investigate the underlying structure of the LSAS. Separate exploratory common factor analyses of the fear and avoidance ratings yielded four similar factors for each: (1) social interaction, (2) public speaking, (3) observation by others, and (4) eating and drinking in public, which demonstrated convergent and discriminant validity with other measures of social anxiety. These findings suggest that there are four global categories of social fear assessed by the LSAS, and that while social interaction anxiety appears to be unifactorial, fear of performance/observation situations may be multifactorial.

Anxiety in ethnic minority youth. Methodological and conceptual issues and review of the literature.

Although current research has documented a relatively high prevalence of anxiety disorders in American youth, this research has been conducted mainly with nonminority samples. Fair treatment and increasing numbers of ethnic minority persons in the United States require that more should be known about minority youth. However, research with majority youth cannot be safely generalized to minority youth for several reasons, such as potential differences in the manifestation of anxiety, differences in style of response to assessment devices, and different life circumstances. This review is presented in two major sections. First, the authors address definition of terms and fully examine the significance of studying anxiety in ethnic minority youth. Also considered are methodological issues such as sampling and participation biases. Second, the authors review anxiety in ethnic minority children and adolescents in the United States including studies addressing fears, worries, trait anxiety, test anxiety, and anxiety disorders.

Alcohol use and HIV sexual risk among MSM in Chennai, India.

Men who have sex with men (MSM) in India are a core risk group for HIV. Heavy alcohol consumption is associated with increased sexual risk-taking behaviours in many cultures, in particular among MSM. However, no studies to date have explored alcohol use and HIV risk among MSM in India. MSM in Chennai, India (n = 210) completed an interviewer-administered behavioural and psychosocial assessment. Bivariate and multivariable logistic regression procedures examined behavioural and demographic associations with weekly alcohol consumption. Twenty-eight percent of the sample (n = 58) reported using alcohol at least weekly to the point of being buzzed/intoxicated, which was associated with older age, being married to a woman, being panthi (masculine appearing, predominantly insertive partners) versus kothi (feminine acting/appearing and predominantly receptive partners), weekly tobacco use, unprotected anal sex and unprotected vaginal sex in the three months prior to study enrollment (all P < 0.05). In a multivariable model, unprotected vaginal sex in the previous three months and being married to a women were unique variables associated with weekly alcohol use (all P < 0.01). Further investigation of alcohol use within the context of sexual risk taking is warranted among Indian MSM. Panthis and MSM who are married to women may be particularly likely to benefit from interventions to decrease alcohol intake and concurrent unsafe sex.