HIV infection presents individuals with multiple challenges which may overwhelm their coping resources and impair psychosocial adjustment to the ongoing demands of managing this stigmatized, chronic illness (Heckman et al., 2004; Weaver et al., 2005). Consequently, HIV-positive persons are at substantially elevated risk for developing an affective or adjustment disorder across the disease spectrum (Bing et al., 2001). Randomized controlled trials have examined the efficacy of psychological interventions that are designed to decrease negative affect as well as enhance positive psychological resources among HIV-positive persons (Antoni, 2003; Chesney et al., 2005). Findings generally support the efficacy of interventions for improving psychosocial adjustment, but there are significant limitations to both external and internal validity in trials that have been conducted (Brown & Vanable, 2008; Carrico & Antoni, in press; Crepaz et al., 2008; Scott-Sheldon, Kalichman, Carey, & Fielder, 2008). Important, unanswered questions remain regarding the clinical utility of interventions that have been tested because the majority of trials have utilized stringent inclusion criteria and focused almost exclusively on gay men. It is also difficult to determine the active mechanism(s) of interventions that have been tested because most trials have examined group-based interventions. In these trials, it is unclear whether observed treatment effects were due to psychotherapeutic processes or social support received from group members. In fact, there is little evidence for differential efficacy of group-based interventions that have been tested to date, even compared to semi-structured social support groups (Bormann et al., 2006; Chesney, Chambers, Taylor, Johnson, & Folkman, 2003; Kelly et al., 1993; Mulder et al., 1994).
Two well-controlled trials have examined the efficacy of individually delivered, psychological interventions with diverse cohorts of depressed HIV-positive persons. Markowitz and colleagues (1998) observed that individuals randomized to interpersonal psychotherapy and supportive psychotherapy with imipramine reported reductions in depressive symptoms and improvements in physical functioning over a 16-week intervention period when compared to those in cognitive-behavioral therapy or supportive psychotherapy alone. However, there did not appear to be any significant benefits of cognitive-behavioral therapy beyond the “non-specific” treatment effects of supportive psychotherapy. In the second trial, Safren and colleagues (in press) examined the efficacy of an individual cognitive-behavioral intervention for adherence and depression among depressed men and women on anti-retroviral therapy (ART). Over the 12-week intervention period, individuals in the cognitive-behavioral intervention reported reductions in depressive symptoms and displayed increases in electronically monitored ART adherence compared to those who received a single session adherence intervention. Although these trials provide support for the efficacy of individually delivered interventions among depressed HIV-positive persons, further investigations are needed to examine the long-term efficacy in more representative samples.
The Healthy Living Project is a multi-site randomized controlled trial of a 3-module, 15-session, individually delivered cognitive-behavioral intervention that was designed primarily to reduce HIV transmission risk behavior. Of the 3 modules, the first focused on improving coping skills (5 sessions); the second, on reducing sexual risk behavior (5 sessions); and the third, on improving adherence to HIV/AIDS treatment (5 sessions). One previous investigation reported that this intervention reduced HIV transmission risk behavior over the 25-month investigation period (Healthy Living Project Team, 2007). Because improvements in psychosocial adjustment were hypothesized to mediate intervention-related reductions in HIV transmission risk behavior, one key component of this intervention focused on building the capacity of individuals to execute effective coping responses (Gore-Felton et al., 2005). In the present study, we examined the efficacy of this intervention with respect to measures of negative affect (depressive symptoms, anxiety, burnout, and perceived stress) and positive psychological resources (positive affect, positive states of mind, coping self-efficacy, and perceived social support). We conducted intent-to-treat analyses of intervention effects on psychosocial adjustment from baseline to 5 months post-randomization as well as across the 25-month investigation period. We also conducted moderation analyses to determine whether the intervention was more efficacious among those who presented with elevated symptoms of depression at baseline.