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1.  Quality of life, psychosocial health, and antiretroviral therapy among HIV-positive women in Zimbabwe 
AIDS care  2009;21(12):1517-1527.
Little is known about the psychosocial impact of antiretroviral therapy (ART) among women in sub-Saharan Africa. Therefore, we conducted a cross-sectional study in Zimbabwe to assess the impact of ART on HIV-positive women’s health-related quality of life, using the Medical Outcomes Study-HIV Quality of Life (QOL) questionnaire. Additionally, we assessed socio-demographics, reproductive and sexual health, HIV-related history, disclosure, social stigma, self-esteem, and depression. Structured interviews were conducted with 200 HIV-positive women and categorized into three groups by treatment: (1) Group 1 (n = 31) did not meet clinical or laboratory criteria to begin treatment; (2) Group 2 (n = 73) was eligible to begin treatment but awaiting initiation of treatment; and (3) Group 3 (n = 96) was on ART for a median of 13 months. The women had similar sociodemographic characteristics but varied significantly in clinical characteristics. Women on ART reported fewer AIDS-related symptoms in the last week and year and had higher current and lower baseline CD4 counts compared to women not on ART. On most QOL domains women on ART reported higher mean scores as compared to women not on ART ( p<0.01). Additionally, women on ART reported less depression compared to women not on ART ( p<0.001). Between the two groups of women not on ART, unexpectedly, there were no significant differences in their scores for QOL or depression. Thus, Zimbabwean women living with HIV experience better overall QOL and lower depression on ART. Altogether, our findings suggest that ART delivery in resource-poor communities can enhance overall QOL as well as psychosocial functioning, which has wide-ranging public health implications.
PMCID: PMC4431539  PMID: 20024731
quality of life; depression; HIV treatment; sub-Saharan Africa; Zimbabwe
2.  HIV-Related Stigma: Implications for Symptoms of Anxiety and Depression among Malawian Women 
An estimated 11% of the adult population in Malawi, Africa, is living with HIV/AIDS. The disease has taken a toll on communities, resulting in high morbidity and mortality. Malawian women carry the burden of being caretakers for individuals infected with HIV while also worrying about their own health; however, little is known about how HIV/AIDS affects psychological functioning among Malawian women in areas hit hardest by the epidemic. To that end, this paper examined the influence of HIV-related stigma on symptoms of anxiety and depression among 59 women 17-46 years old who were recruited from the Namitete area of Malawi. Women who reported greater worry about being infected with HIV and greater HIV-related stigma were significantly more likely to report greater symptoms of anxiety and depression. These findings suggest that interventions that reduce HIV-related stigma are likely to enhance psychological functioning among Malawian women, which in turn will improve the women's quality of life and well-being.
PMCID: PMC4416225  PMID: 25920985
HIV/AIDS; stigma; Malawi; women; depression; anxiety
3.  Alcohol Use and Sexual Risk Behavior among College Students: Understanding Gender and Ethnic Differences 
The purpose of the current study was to assess the role of gender and ethnicity in the relationship between alcohol use and risky sexual behavior.
Sexually active college students (n = 425) reported on alcohol expectancies, perceived risk of HIV, and drinking and sexual behavior in the context of a larger health behavior survey.
Approximately one-third of participants reported binge drinking 3 or more times in the past two weeks. African American women reported less drinking and less positive alcohol expectancies than other women. Older men engaged more often than younger men in binge drinking and reported more sexual partners in the past year. Younger age and greater perceived risk for HIV were positively associated with condom use for both women and men.
Collectively, these findings suggest that alcohol abuse and HIV prevention efforts among young adults need to consider gender, ethnicity, and age.
PMCID: PMC4370335  PMID: 19253158
substance use; sexual risk; HIV risk; gender; ethnicity
4.  The Relationship between Sexual Trauma, Peritraumatic Dissociation, PTSD, and HIV-Related Health in HIV-Positive Men 
This study tested a novel extension of Schnurr and Green’s (2004) model of the relationships between trauma symptoms and health outcomes, with the specific application to HIV-positive men. A diverse sample of 167 HIV-positive men recruited from San Francisco Bay Area HIV Clinics completed demographic, medical, trauma history and symptom questionnaires. Mediation analyses were conducted using the method proposed by Baron and Kenny (1986). Regression analyses found sexual revictimization (SR) significantly mediated the relationship between child sexual abuse (CSA) and peritraumatic dissociation (PD) and PD mediated the relationship between SR and current posttraumatic stress (PTS) symptom severity. PTS symptoms partially mediated the relationship between SR and current HIV symptom severity. The findings indicate that among HIV-positive men, sexually revictimized men constitute a vulnerable group that is prone to peritraumatic dissociation, which places them at risk for posttraumatic stress disorder and worsened HIV-related health. Furthermore, traumatic stress symptoms were associated with worse HIV-related symptoms, suggesting that PTS symptoms mediate the link between trauma and health outcomes. This study highlights the need for future research to identify the bio-behavioral mediators of the PTSD-health relationship in HIV-positive individuals.
PMCID: PMC4119469  PMID: 24354509
HIV; Sexual Abuse of Males; Child Sexual Abuse; Revictimization; Dissociation; Posttraumatic Stress Disorder
5.  The Impact of Childhood Bullying among HIV-Positive Men: Psychosocial Correlates and Risk Factors 
Child abuse & neglect  2013;37(4):273-281.
While some studies have examined the deleterious effects of childhood bullying on adults, no studies to date have focused on the effects of bullying on Persons Living with HIV (PLH), a particularly at-risk population. PLH experience higher rates of childhood and adulthood physical and sexual abuse than the population at large, and experience of childhood abuse appears to be predictive of sexual and other risk behaviors in this population. Thus it remains critical to examine rates of childhood bullying and correlates of bullying in adult PLH.
A sample of 171 HIV-positive men over 18 years of age were recruited from the San Francisco Bay Area. All participants reported experiencing symptoms of traumatic stress. The participants were recruited as part of a larger study assessing a group intervention for individuals with HIV and symptoms of trauma. Self-report questionnaires were administered to assess participants’ exposure to bullying in childhood and trauma symptoms in adulthood.
Bullying was commonly reported by men in the current sample, with 91% of the sample endorsing having experienced some level of bullying before age 18. Having been bullied in childhood was significantly (p < .05) associated with methamphetamine use in adulthood, difficulties with mood, and with symptoms of trauma. Results of a hierarchical regression equation found that report of bullying in childhood predicted additional, unique variance in trauma symptoms in adulthood above and beyond the effect of exposure to other forms of trauma, resulting in a better-fitting model.
The current study highlights the association between rate of childhood bullying and symptoms of trauma in adulthood, accounting for the effect of exposure to other forms of trauma. Given the impact of trauma symptoms on disease progression in PLH, exposure to bullying must be considered in any intervention aiming to reduce trauma symptoms or improve mental or physical health among HIV-positive populations.
PMCID: PMC3622771  PMID: 23294606
HIV/AIDS; bullying; trauma; risk behavior; men
6.  Socio-Contextual Factors: Moving Beyond Individual Determinants of Sexual Risk Behavior among Gay and Bisexual Adolescent Males 
Journal of LGBT youth  2013;10(3):10.1080/19361653.2013.799000.
This study investigated factors associated with sexual behavior that confers the greatest risk for HIV transmission (i.e., unprotected anal intercourse; UAI) among 52 sexually active gay and bisexual adolescent males in a Midwestern city ages 15-19. A logistic regression model found that ethnicity other than African American, more sexual partners in the past year, greater stigma towards homosexuality, and greater perceived peer sexual norms for risky behavior were significantly associated with UAI (x2=27.96, df=5, p<.001; Nagelkerke R2 = 0.56). Implications for prevention interventions are discussed.
PMCID: PMC3810983  PMID: 24187600
Adolescents; African American; at risk behavior; bisexual; ethnicity; gay; HIV/AIDS; male; race; sexual behavior; stigma
7.  HIV disclosure patterns, predictors, and psychosocial correlates among HIV-positive women in Zimbabwe 
AIDS Care  2011;24(3):358-368.
Disclosure of positive HIV status in Sub-Saharan Africa has been associated with safer sexual practices and better antiretroviral therapy (ART) adherence, but associations with psychosocial function are unclear. We examined patterns and psychosocial correlates of disclosure in a Zimbabwean community. Two hundred HIV positive women at different stages of initiating ART participated in a cross-sectional study examining actual disclosures, disclosure beliefs, perceived stigma, self-esteem, depression, and quality of life. Ninety-seven percent of the women disclosed to at least one person, 78% disclosed to their current husband/partner, with an average disclosure of 4.0 persons per woman. The majority (85–98%) of disclosures occurred in a positive manner and 72–95% of the individuals reacted positively. Factors significantly correlated with HIV disclosure to partners included being married, later age at menses, longer duration of HIV since diagnosis, being on ART, being more symptomatic at baseline, ever having used condoms, and greater number of partners in the last year. In multivariate analysis, being married and age at menses predicted disclosure to partners. Positive disclosure beliefs, but not the total number of disclosures, significantly correlated with lower perceived stigma (rho=0.44 for personalized subscale and rho=0.51 for public subscale, both p<0.0001), higher self-esteem (rho=0.15, p=0.04), and fewer depressive symptoms (rho=−0.14, p=0.05). In conclusion, disclosure of positive HIV status among Zimbabwean women is common and is frequently met with positive reactions. Moreover, positive disclosure beliefs correlate significantly with psychosocial measures, including lower perceived stigma, higher self-esteem, and lower depression.
PMCID: PMC3243809  PMID: 21902570
disclosure; stigma; depression; HIV; antiretroviral therapy; Zimbabwe; Sub-Saharan Africa
8.  Relationships among Childhood Trauma, Posttraumatic Stress Disorder and Dissociation in Men Living with HIV/AIDS 
This study examined the relationships among dissociation, childhood trauma and sexual abuse, and posttraumatic stress disorder (PTSD) symptoms in HIV-positive men. Data was collected from 167 men enrolled in a randomized clinical trial (Project RISE) that examined a group therapy intervention to decrease HIV-related risk behavior and trauma-related stress symptoms. Participants completed the Trauma History Questionnaire, the Impact of Event Scale - Revised, and the Stanford Acute Stress Reaction Questionnaire. Overall, 35.3% of the participants reported having experienced childhood sexual abuse (CSA). A total of 55.7% of the sample met diagnostic criteria for PTSD. The intensity of dissociative symptoms that participants endorsed was positively associated with experience of childhood sexual abuse (r = .20, p < .01). Dissociative symptoms were also positively associated with specific PTSD symptoms, notably hyperarousal (r = .69, p < .001). Hierarchical regression indicated that hyperarousal symptoms account for more of the variance in dissociation than childhood sexual abuse. These results suggest that childhood sexual abuse may be involved in the development of dissociative symptoms in the context of adulthood stress reactions. Furthermore, the pattern of the association between dissociation and PTSD is consistent with the possibility of a dissociative PTSD subtype among HIV-positive men.
PMCID: PMC3298730  PMID: 22211444
HIV/AIDS; dissociation; child abuse; sexual abuse; physical abuse; posttraumatic stress disorder
9.  Trauma, Dissociation, and Antiretroviral Adherence among Persons Living with HIV/AIDS 
Journal of psychiatric research  2011;45(7):942-948.
There are approximately 1,000,000 persons living with HIV/AIDS (PLH) in the United States; to reduce rates of new infection and curb disease progression, adherence to HIV medication among PLH is critical. Despite elevated trauma rates in PLH, no studies to date have investigated the relationship between dissociation, a specific symptom of trauma, and HIV medication adherence. We hypothesized that Post-Traumatic Stress Disorder (PTSD) symptoms would be associated with lower adherence, and that dissociation would moderate this relationship.
Forty-three individuals with HIV were recruited from community-based clinics to participate in a cross-sectional study. The relationship of trauma, dissociation, and their interaction to the probability of antiretroviral adherence was assessed using a hierarchical binary logistic regression analysis.
Among 38 eligible participants, greater PTSD was associated with lower odds of adherence (OR = .92, p < .05). Dissociation moderated the effect of PTSD on adherence, resulting in lower odds of adherence (OR = .95, p < .05). PTSD symptoms were significantly associated with lower odds of adherence in individuals reporting high levels of dissociation (OR = .86, p < .05) but not in those reporting low levels of dissociation (OR = 1.02, p > .05).
This is the first study to demonstrate a relationship between dissociation and medication adherence. Findings are discussed in the context of clinical management of PLH with trauma histories and the need for interventions targeting dissociative symptomatology to optimize adherence.
PMCID: PMC3118254  PMID: 21636097
dissociation; posttraumatic stress disorder; depression; HIV/AIDS; adherence; medication
10.  Reactions of Heterosexual African-American Men to Women’s Condom Negotiation Strategies 
Journal of sex research  2010;47(6):539-551.
This study describes responses of 172 single heterosexual African American men, ages 18–35, to condom negotiation attempts. Strategies used included reward, coercive, legitimate, expert, referent, and informational strategies, based on Raven’s (1992) influence model. The purpose was: 1) to identify strategies influencing participant acquiescence to request, and 2) to identify predictors of participant compliance/refusal to comply with negotiation attempts. Participants viewed six videotape segments showing an actress, portrayed in silhouette, speaking to the viewer as a ‘steady partner’. After each segment, participants completed measures of: request compliance, positive and negative affect, and attributions concerning the model and themselves. No significant differences were found in men’s ratings across all vignettes. However, differences in response existed across subgroups of individuals, suggesting that while the strategy used had little impact on participant response, the act of suggesting condom use produced responses that differed across participant subgroups. Subgroups differed on levels of AIDS risk knowledge, STD history, and experience with sexual coercion. Also, the “least-willing-to-use” subgroup was highest in anger/rejection and least likely to make attributions of caring for partner. Effective negotiation of condom use with a male sexual partner may not be determined as much by specific strategy used as by partner characteristics.
PMCID: PMC2888974  PMID: 19760529
11.  A Review of Efficacious Technology-Based Weight-Loss Interventions: Five Key Components 
Telemedicine Journal and e-Health  2010;16(9):931-938.
A qualitative review focusing on articles published in the last 10 years that used an experimental or pre/post-test design and used a technology-based intervention for weight loss was conducted. Five technology-based components—self-monitoring, counselor feedback and communication, social support, use of a structured program, and use of an individually tailored program—were reviewed from 21 studies. Although short-term results have been promising, long-term results have been mixed. The interface of technology and behavior change is an effective foundation of a successful, short-term weight-loss program and may prove to be the basis of long-term weight loss.
Objective: Obesity is highly prevalent among American adults and has negative health and psychosocial consequences. The purpose of this article was to qualitatively review studies that used technology-based interventions for weight loss and to identify specific components of these interventions that are effective in facilitating weight loss. Materials and Methods: We conducted a narrow, qualitative review, focusing on articles published in the last 10 years that used an experimental or pre/posttest design and used a technology-based intervention for weight loss. Results: Among the 21 studies reviewed, we identified the following five components that we consider to be crucial in technology-based weight-loss interventions that are successful in facilitating weight loss: self monitoring, counselor feedback and communication, social support, use of a structured program, and use of an individually tailored program. Conclusions: Short-term results of technologically driven weight-loss interventions using these components have been promising, but long-term results have been mixed. Although more longitudinal studies are needed for interventions implementing these five components, the interface of technology and behavior change is an effective foundation of a successful, short-term weight-loss program and may prove to be the basis of long-term weight loss.
PMCID: PMC3000900  PMID: 21091286
obesity; weight loss; technology
12.  Condom Use Negotiation in Heterosexual African-American Adults: Responses to Types of Social Power-Based Strategies 
Journal of sex research  2008;45(2):150-163.
Little research has been performed on how people respond to different strategies to negotiate condom use in sexual situations, and whether certain strategies tend to be perceived as more or less effective in condom use negotiation. This study examined gender differences and preferences in the use of and response to six different styles of condom use negotiation with a hypothetical sexual partner of the opposite gender. Participants were 51 heterosexually-active African-American men and women between the ages of 18 and 35, attending an inner-city community center. Study participants completed a semi-structured qualitative interview in which they were presented with six negotiation strategies —coercive, reward, legitimate, expert, referent, and informational--based on Raven’s 1992 Power/Interaction Model of Interpersonal Influence. Results showed that women participants responded best to referent, reward, and legitimate strategies, and worst to informational tactics. Men participants responded best to reward strategies, and worst to coercion to use condoms. Further, responses given by a subset of both women—and, to a greater extent, men--indicated that use of negotiation tactics involving coercion to use condoms may result in negative or angry reactions. Finally, response to strategies may vary with the value of the relationship as viewed by the target of negotiation. Implications for HIV prevention programs and media campaigns are discussed.
PMCID: PMC2753393  PMID: 18569536
American annals of the deaf  2008;153(1):48-54.
In Contrast with the nearly 30 years of HIV/AIDS research with the hearing community, data on HIV infection among persons who are deaf and hard of hearing is primarily anecdotal. Although the few available estimates suggest that deaf and hard of hearing persons are disproportionately affected by HIV infection, no surveillance systems are in place to Identify either frequency or mode of HIV infection within this population. Moreover, to date, all empirically validated HIV prevention interventions have relied on communication strategies developed for persons who hear. Therefore, understanding and developing-effective prevention methods is crucial for persons who are deaf or hard of hearing. The authors explore (a) factors among this population that may contribute to HIV-related behaviors, (b) four key concepts consistently included in successful interventions, and (c) practical ways in which to use this information to tailor effective intervention strategies for this population.
PMCID: PMC2728086  PMID: 18619068
14.  Influence of Coping, Social Support, and Depression on Subjective Health Status Among HIV-Positive Adults With Different Sexual Identities 
The authors examined associations between psychosocial variables (coping self-efficacy, social support, and cognitive depression) and subjective health status among a large national sample (N = 3,670) of human immunodeficiency virus (HIV)-positive persons with different sexual identities. After controlling for ethnicity, heterosexual men reported fewer symptoms than did either bisexual or gay men and heterosexual women reported fewer symptoms than did bisexual women. Heterosexual and bisexual women reported greater symptom intrusiveness than did heterosexual or gay men. Coping self-efficacy and cognitive depression independently explained symptom reports and symptom intrusiveness for heterosexual, gay, and bisexual men. Coping self-efficacy and cognitive depression explained symptom intrusiveness among heterosexual women. Cognitive depression significantly contributed to the number of symptom reports for heterosexual and bisexual women and to symptom intrusiveness for lesbian and bisexual women. Individuals likely experience HIV differently on the basis of sociocultural realities associated with sexual identity. Further, symptom intrusiveness may be a more sensitive measure of subjective health status for these groups.
PMCID: PMC2653049  PMID: 19064372
coping; depression; HIV; sexual identity; symptoms; social support
15.  Positive provider interactions, adherence self-efficacy, and adherence to antiretroviral medications among HIV infected adults: A mediation model 
AIDS patient care and STDs  2006;20(4):258-268.
Adherence to antiretroviral (ARV) therapy for HIV infection is critical for maximum benefit from treatment and for the prevention of HIV-related complications. There is evidence that many factors determine medication adherence, including adherence self-efficacy (confidence in one's ability to adhere) and relations with health care providers. However, there are no studies that examine how these two factors relate to each other and their subsequent influence on HIV medication adherence. The goal of the current analysis was to explore a model of medication adherence in which the relationship between positive provider interactions and adherence is mediated by adherence self-efficacy. Computerized self administered and interviewer administered self reported measures of medication adherence, demographic and treatment variables, provider interactions, and adherence self-efficacy were administered to 2765 HIV infected adults on ARV. Criteria for mediation were met, supporting a model in which adherence self-efficacy is the mechanism for the relationship between positive provider interactions and adherence. The finding was consistent when the sample was stratified by gender, race, injection drug use history, and whether the participant reported receipt of HIV specialty care. Positive provider interactions may foster greater adherence self-efficacy, which is associated with better adherence to medications. Results suggest implications for improving provider interactions in clinical care, and future directions for clarifying inter-relationships among provider interactions, adherence self-efficacy, and medication adherence are supported.
PMCID: PMC2432422  PMID: 16623624
HIV/AIDS; Provider Relations; Adherence/Compliance

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