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1.  Examining the Correspondence between Relationship Identity and Actual Sexual Risk Behavior among HIV-Positive Men Who Have Sex with Men 
Archives of sexual behavior  2014;43(1):129-137.
Sexual behavior of men who have sex with men (MSM), within and outside of one’s primary relationship, may contribute to increased risk of HIV transmission among those living with HIV. The current study sought to understand how HIV-infected MSM report their relationship status and the degree to which this corresponds with their sexual behavior. Further, we examined rates and psychosocial associations with sexual HIV transmission risk behavior (TRB) across relationship categories. In a sample of 503 HIV-infected MSM in HIV care, 200 (39.8%) reported having a primary partner. Of these, 115 reported that their relationship was open and 85 reported that it was monogamous. Of the 85 who reported a monogamous relationship, 23 (27%) reported more than one sexual partner in the prior three months, 53 (62%) reported only one partner, and nine did not report on the number of partners in the past 3 months. Hence, there were three categories of relationships: (1) “monogamous with one sexual partner,” (2) “monogamous with more than one sexual partner,” and (3) “open relationship.” The “monogamous with more than one sexual partner” group reported higher TRB and crystal methamphetamine use compared to the “monogamous with one sexual partner” group and different patterns of relationships with TRB emerged across the three groups. Couples-based HIV prevention interventions for MSM may be enhanced by considering that there may be different definitions of monogamy among MSM, and that the context of relationship status may require tailoring interventions to meet the needs of specific subgroups of MSM couples.
PMCID: PMC3947093  PMID: 24198170
HIV/AIDS; MSM; couples; sexual risk; monogamy; sexual orientation
2.  Body Mass Index, Immune Status and Virological Control in HIV-Infected Men who have Sex with Men 
Background & aims
Prior cross-sectional studies have found inconsistent relationships between body mass index (BMI) and disease progression in HIV-infected individuals.
Cross-sectional and longitudinal analyses were conducted on data from a sample of 864 HIV-infected men who have sex with men (MSM) obtained from a large, nationally-distributed HIV clinical cohort.
Of the 864 HIV-infected MSM, 394 (46%) were normal weight, 363 (42%) were overweight, and 107 (12%) were obese at baseline. The baseline CD4 count was 493 (SE = 9), with viral load(log10) = 2.4 (SE = .04), and 561 (65%) were virologically suppressed. Over time, controlling for viral load, HAART adherence, age, and race/ethnicity, overweight and obese HIV-infected men possessed higher CD4 counts compared to normal weight HIV-infected men. Further, overweight and obese men possessed lower viral loads compared to normal weight HIV-infected men.
For HIV-infected MSM, in this longitudinal cohort study, possessing a heavier than normal BMI is longitudinally associated with improved immunological health.
PMCID: PMC4259246  PMID: 23719237
HIV/AIDS; Body Mass Index; Obesity; CD4; Viral Load
3.  Test of a Web-Based Program to Improve Adherence to HIV Medications 
AIDS and behavior  2013;17(9):10.1007/s10461-013-0535-8.
We evaluated the effectiveness of a web-based version of the Life-Steps intervention combined with modules for stress reduction and mood management, designed to improve medication adherence among HIV infected individuals. 168 HIV+ adults were randomized into either the Life-Steps program or a waitlist control condition. All participants completed a baseline assessment and provided a 2-week electronic pill (MEMS) cap baseline reading. Follow up data collection was conducted at 3, 6 and 9 months. Patients in the web-based Life-Steps condition had significantly higher antiretroviral medication adherence rates than patients in the control group over the nine-month period as measured by the MEMS cap. In addition, analysis of viral load data indicated that the program also resulted in a significant decrease in viral load. These findings indicate that a web-based Life-Steps program can be a useful and implementable tool for helping patients living with HIV maintain medication adherence.
PMCID: PMC3812347  PMID: 23760634
Medication adherence; Web-based program; ART; Antiretroviral therapy
4.  Physical Activity and Health Outcomes among HIV-infected Men who have Sex with Men: A Longitudinal Mediational Analysis 
Low physical activity is associated with depression, which may in turn, negatively impact antiretroviral therapy (ART) adherence among HIV-infected individuals; however, prior studies have not investigated the relationships between physical inactivity and ART non-adherence.
To examine the association of physical inactivity, depression, ART non-adherence, and viral load in HIV-infected men who have sex with men.
The sample (N = 860) was from a large, multicenter cohort of HIV-infected patients engaged in clinical care.
Across time, depression mediated the relationship between physical inactivity and ART non-adherence, γ = .075, and the relationship between physical inactivity and viral load, γ = .05. ART non-adherence mediated the relationship between depression and viral load, γ = .002, and the relationship between physical inactivity and viral load, γ = .009.
Low levels of physical activity predicted increased depression and poor ART adherence over time, which subsequently predicted higher viral load.
PMCID: PMC3714319  PMID: 23483379
HIV/AIDS; physical activity; depression; adherence; viral load
5.  Does Effective Depression Treatment Alone Reduce Secondary HIV Transmission Risk? Equivocal Findings from a Randomized Controlled Trial 
AIDS and behavior  2013;17(8):2765-2772.
Depressed mood has been associated with HIV transmission risk behavior. To determine whether effective depression treatment could reduce the frequency of sexual risk behavior, we analyzed secondary outcome data from a 36-week, two-arm, parallel-design, randomized controlled trial, in which homeless and marginally housed, HIV-infected persons with comorbid depressive disorders were randomized to receive either: (a) directly observed treatment with the antidepressant medication fluoxetine, or (b) referral to a local public mental health clinic. Self-reported sexual risk outcomes, which were measured at 3, 6, and 9 months, included: total number of sexual partners, unprotected sexual intercourse, unprotected sexual intercourse with an HIV-uninfected partner or a partner of unknown serostatus, and transactional sex. Estimates from generalized estimating equations regression models did not suggest consistent reductions in sexual risk behaviors resulting from treatment. Mental health interventions may need to combine depression treatment with specific skills training in order to achieve durable impacts on HIV prevention outcomes.
PMCID: PMC3805275  PMID: 23975476
HIV; Depression; Antidepressive agents; Sexual behavior; Protected sex; Homeless persons
6.  Adult ADHD Symptoms and Five Factor Model Traits in a Clinical Sample: A Structural Equation Modeling Approach 
The Journal of nervous and mental disease  2013;201(10):10.1097/NMD.0b013e3182a5bf33.
Relationships among Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms and adult personality traits have not been examined in larger clinically diagnosed samples. We collected multi-source ADHD symptom and self-report NEO Five-Factor Inventory (Costa & McCrae, 1992a) data from 117 adults with ADHD and tested symptom-trait associations using structural equation modeling. The final model fit the data. Inattention was positively associated with Neuroticism and negatively associated with Conscientiousness. Based on ADHD expression in adulthood, hyperactivity and impulsivity were estimated as separate constructs and showed differential relationships to Extraversion and Agreeableness. A significant positive relationship between Hyperactivity and Conscientiousness arose in the context of other pathways. ADHD symptoms are reliably associated with personality traits, suggesting a complex interplay across development that warrants prospective study into adulthood.
PMCID: PMC3821966  PMID: 24080671
attention-deficit/hyperactivity disorder; ADHD; personality; Five Factor model; NEO-FFI; Neuroticism; Conscientiousness
7.  A Preliminary RCT of CBT-AD for Adherence and Depression among HIV-Positive Latinos on the U.S. –Mexico Border: The Nuevo Día Study 
AIDS and behavior  2013;17(8):2816-2829.
We conducted a preliminary RCT among 40 HIV-positive Latinos of Mexican descent on the U.S.-Mexico border who indicated imperfect adherence and depressive symptomatology. Participants were randomly assigned to culturally adapted cognitive-behavioral therapy for adherence and depression (CBT-AD) with an alarmed pillbox or usual care. Outcomes were depressive symptoms (self-report and blind clinician ratings), adherence (self-report and electronic pillbox), and biological markers. The intervention, delivered in English and Spanish, proved feasible and acceptable. Generalized estimating equations in intent-to-treat analyses showed some effects of “moderate” to “large” size, with maintenance over time. For example, intervention (vs. control) participants demonstrated at post-intervention a greater drop in BDI scores (OR = - 3.64, p = .05) and greater adherence according to the electronic pillbox (OR = 3.78, p = .03). Biological markers indicated some relative improvement for CD4 count but not VL. The promising results suggest a larger trial to determine efficacy is warranted.
PMCID: PMC3788062  PMID: 23812892
HIV/AIDS; ART adherence; depression; CBT; Latino/Hispanic
8.  HIV-infected Men Who Have Sex With Men Who Engage in Very High Levels of Transmission Risk Behaviours: Establishing a Context for Novel Prevention Interventions 
Psychology, health & medicine  2013;18(5):10.1080/13548506.2012.756537.
Men who have sex with men (MSM) comprise the largest risk group of individuals living with HIV in the United States and have the highest rates of new infections. A minority of HIV-infected MSM engage in unprotected anal intercourse after learning about their infection, potentially transmitting the virus to others. The current study sought to generate self-generated descriptive themes, from a group of HIV-infected MSM who reported high rates of sexual transmission risk behavior that may be relevant for understanding sexual risk in this group. Five descriptive themes emerged during content analysis: a) serostatus attribution, b) assumption of sexual partner’s responsibility for safer-sex, c) sexual sensation seeking, d) ongoing substance use, and e) dissatisfaction with current relationships. Traditional HIV transmission risk-reduction interventions that have been known to have only modest effects should be augmented by developing HIV prevention strategies for this subgroup of MSM to address these salient themes.
PMCID: PMC3857998  PMID: 23323526
HIV-infection; MSM; gay and bisexual men; HIV prevention; risky sexual behavior
9.  Site-nurse initiated Adherence and Symptom Support Telephone Calls for HIV-positive individuals starting antiretroviral therapy, ACTG 5031, a substudy of ACTG 384. 
HIV clinical trials  2013;14(5):235-253.
Effective and easy to implement interventions to improve adherence to antiretroviral therapy are needed.
To compare a site-nurse initiated adherence and symptom support telephone calls for HIV-positive individuals starting antiretroviral therapy compare to the study site’s standard of care.
A randomized controlled trial of site-nurse initiated adherence and symptom support telephone calls for HIV-positive individuals starting antiretrovirals. Subjects were randomized to receive site-nurse initiated telephone calls (intervention) or no additional calls above the site’s standard of care (control). Subjects received calls 1-3 days after initiating antiretrovirals, weeks 1, 2, 3, 6, 10, 14, 18, 22, 26, and every 8 weeks thereafter. Self-reported adherence was captured during study visits.
A total of 333 subjects starting antiretrovirals as part of ACTG 384 were co-enrolled into ACTG 5031. Subjects were followed for up to 160 weeks and were contacted for 74% of scheduled calls. There was no significant difference in proportion of patients with >95% mean Total Adherence, 87.9% and 91.2% (p=0.34) and mean self-reported Total Adherence, 97.9% and 98.4% in the intervention and control, respectively, or in symptom distress and clinical endpoints.
In the context of a clinical trial, where self-reported adherence was exceptionally high, the site-nurse initiated telephone calls did not further improve self-reported adherence, symptom distress or clinical outcomes.
PMCID: PMC4019013  PMID: 24144900
Adherence intervention; Nursing telephone support; Randomized Controlled Trial; Antiretroviral Therapy
10.  Psychosocial risk factors for HIV sexual risk among Indian men who have sex with men 
AIDS care  2013;25(9):1109-1113.
Indian men who have sex with men (MSM) are at increased risk for HIV compared to the general Indian population. Psychosocial factors may be uniquely associated with HIV risk among Indian MSM and may moderate the beneficial impact of standard HIV prevention approaches. Psychiatric diagnostic interviews and psychosocial and sexual risk assessments were conducted among 150 MSM in Mumbai, India. Logistic regression was employed to examine the association of psychiatric disorders and psychosocial problems to recent sexual risk behavior. Twenty-five percent of participants reported engaging in unprotected anal sex (UAS) during their last sexual contact with a man. Men who were married to a woman were more likely to have engaged in UAS during their last sexual contact with a man (35% vs. 17%, p = 0.018). In multivariable models, significant predictors of engaging in UAS were current major depression (adjusted odds ratio [AOR] = 2.61; 95% confidence interval [CI] 1.07, 6.39) and number of stressful life events (AOR = 0.91; 95% CI 0.83, 0.99). Alcohol dependence, anxiety, and self-esteem were not associated with engaging in UAS. Indian MSM with depression are at higher odds of engaging in UAS compared to MSM without depression. HIV prevention programs for Indian MSM may benefit from incorporating treatment or triage for mental health problems.
PMCID: PMC3708996  PMID: 23339580
men who have sex with men (MSM); Mumbai; India; mental health; depression; minority stress; HIV
11.  The Influence of Psychological Variables on Health Related Quality of Life among HIV Positive Individuals with a History of Intravenous Drug Use 
Journal of psychoactive drugs  2013;45(4):304-312.
Intravenous drug use (IDU) remains a prominent pathway of HIV transmission in the United States, though little is know about modifiable factors influencing quality of life among IDUs. The goal of this study was to evaluate the influence of psychological variables (e.g., depression and anxiety) on health related quality of life among HIV-positive individuals with a history of IDU who were enrolled in outpatient treatment for opioid dependence.
108 HIV-positive individuals with a history of IDU and participating in current outpatient treatment for opiate dependence who were screened for participation in a depression and adherence study reported sociodemographic data, depressive and anxiety symptoms and health-related quality of life (HRQoL; Multidimensional Health Assessment using the ACTG-SF 21).
Multiple regression models controlling for disease stage and background characteristics identified significant negative relationships between General Health Perception and Functioning without Pain for anxiety and depression, and between Role Functioning and Physical Functioning for anxiety. CD4 cell count was significantly related to Physical Functioning only.
Results indicate that distress (both depression and anxiety) contribute significantly to variation in HRQoL over and above the effects of disease variables. Effective depression and anxiety treatment may result in improved overall functioning.
PMCID: PMC3877931  PMID: 24377169
HIV; Depression; Anxiety; Health-related quality of life; intravenous drug use
12.  Psychosocial Predictors of Non-Adherence and Treatment Failure in a Large Scale Multi-National Trial of Antiretroviral Therapy for HIV: Data from the ACTG A5175/PEARLS Trial 
PLoS ONE  2014;9(8):e104178.
PEARLS, a large scale trial of antiretroviral therapy (ART) for HIV (n = 1,571, 9 countries, 4 continents), found that a once-daily protease inhibitor (PI) based regimen (ATV+DDI+FTC), but not a once-daily non-nucleoside reverse transcriptase inhibitor/nucleoside reverse transcriptase inhibitor (NNRTI/NRTI) regimen (EFV+FTC/TDF), had inferior efficacy compared to a standard of care twice-daily NNRTI/NRTI regimen (EFV+3TC/ZDV). The present study examined non-adherence in PEARLS.
Outcomes: non-adherence assessed by pill count and by self-report, and time to treatment failure. Longitudinal predictors: regimen, quality of life (general health perceptions  =  QOL-health, mental health  =  QOL-mental health), social support, substance use, binge drinking, and sexual behaviors. “Life-Steps” adherence counseling was provided.
In both pill-count and self-report multivariable models, both once-a-day regimens had lower levels of non-adherence than the twice-a-day standard of care regimen; although these associations attenuated with time in the self-report model. In both multivariable models, hard-drug use was associated with non-adherence, living in Africa and better QOL-health were associated with less non-adherence. According to pill-count, unprotected sex was associated with non-adherence. According to self-report, soft-drug use was associated with non-adherence and living in Asia was associated with less non-adherence. Both pill-count (HR = 1.55, 95% CI: 1.15, 2.09, p<.01) and self-report (HR = 1.13, 95% CI: 1.08, 1.13, p<.01) non-adherence were significant predictors of treatment failure over 72 weeks. In multivariable models (including pill-count or self-report nonadherence), worse QOL-health, age group (younger), and region were also significant predictors of treatment failure.
In the context of a large, multi-national, multi-continent, clinical trial there were variations in adherence over time, with more simplified regimens generally being associated with better adherence. Additionally, variables such as QOL-health, regimen, drug-use, and region play a role. Self-report and pill-count adherence, as well as additional psychosocial variables, such QOL-health, age, and region, were, in turn, associated with treatment failure.
PMCID: PMC4143224  PMID: 25153084
13.  South Africans with recent pregnancy rarely know partner’s HIV serostatus: implications for serodiscordant couples interventions 
BMC Public Health  2014;14(1):843.
Implementation of safer conception strategies requires knowledge of partner HIV-serostatus. We recruited women and men in a high HIV-prevalence setting for a study to assess periconception risk behavior among individuals reporting HIV-serodiscordant partnerships. We report screening data from that study with the objective of estimating the proportion of individuals who are aware that they are in an HIV-serodiscordant relationship at the time of conception.
We screened women and men attending antenatal and antiretroviral clinics in Durban, South Africa for enrollment in a study of periconception risk behavior among individuals with serodiscordant partners. Screening questionnaires assessed for study eligibility including age 18–45 years (for women) or at least 18 years of age (for men), pregnancy in past year (women) or partner pregnancy in the past 3 years (men), HIV status of partner for recent pregnancy, participant’s HIV status, and infected partner’s HIV status having been known before the referent pregnancy.
Among 2620 women screened, 2344 (90%) met age and pregnancy criteria and knew who fathered the referent pregnancy. Among those women, 963 (41%) did not know the pregnancy partner’s HIV serostatus at time of screening. Only 92 (4%) reported knowing of a serodiscordant partnership prior to pregnancy. Among 1166 men screened, 225 (19%) met age and pregnancy criteria. Among those men, 71 (32%) did not know the pregnancy partner’s HIV status and only 30 (13%) reported knowing of a serodiscordant partnership prior to pregnancy.
In an HIV-endemic setting, awareness of partner HIV serostatus is rare. Innovative strategies to increase HIV testing and disclosure are required to facilitate HIV prevention interventions for serodiscordant couples.
PMCID: PMC4246447  PMID: 25124267
HIV prevention; HIV serodiscordant couples; Safer conception; HIV serostatus disclosure
14.  Substance Use Among HIV-Infected Patients Engaged in Primary Care in the United States: Findings From the Centers for AIDS Research Network of Integrated Clinical Systems Cohort 
American journal of public health  2013;103(8):1457-1467.
The purpose of this study was to better understand substance use behaviors and deleterious health consequences among individuals with HIV.
We examined a multicenter cohort of HIV-infected patients (n = 3413) receiving care in 4 US cities (Seattle, Birmingham, San Diego, Boston) between December 2005 and April 2010 in the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS). We used generalized estimating equations to model specific substance use outcomes.
Overall, 24% of patients reported recent use of marijuana; 9% reported amphetamine use, 9% reported crack–cocaine use, 2% reported opiate use, 3.8% reported injection drug use, and 10.3% reported polydrug use. In adjusted multivariable models, those who reported unprotected anal sex had higher odds of marijuana, amphetamine, injection drug, and polydrug use. An increased number of distinct vaginal sexual partners was associated with polydrug and crack–cocaine use. Nonadherence to antiretroviral therapy was associated with the use of all substances other than marijuana.
The co-occurrence of substance use, unprotected intercourse, and medication nonadherence could attenuate the public health benefits of test, treat, and link to care strategies. Prevention programs are needed that address these coprevalent conditions.
PMCID: PMC3752382  PMID: 23763417
15.  Changes in HIV-1 Subtypes B and C Genital Tract RNA in Women and Men After Initiation of Antiretroviral Therapy 
Fiscus, Susan A. | Cu-Uvin, Susan | Eshete, Abel Tilahun | Hughes, Michael D. | Bao, Yajing | Hosseinipour, Mina | Grinsztejn, Beatriz | Badal-Faesen, Sharlaa | Dragavon, Joan | Coombs, Robert W. | Braun, Ken | Moran, Laura | Hakim, James | Flanigan, Timothy | Kumarasamy, N. | Campbell, Thomas B. | Klingman, Karin L. | Nair, Apsara | Walawander, Ann | Smeaton, Laura M. | De Gruttola, Victor | Martinez, Ana I. | Swann, Edith | Barnett, Ronald L. | Brizz, Barbara | Delph, Yvette | Gettinger, Nikki | Mitsuyasu, Ronald T. | Eshleman, Susan | Safren, Steven | Andrade, Adriana | Haas, David W. | Amod, Farida | Berthaud, Vladimir | Bollinger, Robert C. | Bryson, Yvonne | Celentano, David | Chilongozi, David | Cohen, Myron | Collier, Ann C. | Currier, Judith Silverstein | Eron, Joseph | Firnhaber, Cynthia | Flexner, Charles | Gallant, Joel E. | Gulick, Roy M. | Hammer, Scott M. | Hoffman, Irving | Kazembe, Peter | Kumwenda, Johnstone | Kumwenda, Newton | Lama, Javier R. | Lawrence, Jody | Maponga, Chiedza | Martinson, Francis | Mayer, Kenneth | Nielsen, Karin | Pendame, Richard B. | Ramratnam, Bharat | Rooney, James F. | Sanchez, Jorge | Sanne, Ian | Schooley, Robert T. | Snowden, Wendy | Solomon, Suniti | Tabet, Steve | Taha, Taha | Uy, Jonathan | van der Horst, Charles | Wanke, Christine | Gormley, Joan | Marcus, Cheryl J. | Putnam, Beverly | Ntshele, Smanga | Loeliger, Edde | Pappa, Keith A. | Webb, Nancy | Shugarts, David L. | Winters, Mark A. | Descallar, Renard S. | Sharma, Jabin | Poongulali, S. | Cardoso, Sandra Wagner | Faria, Deise Lucia | Berendes, Sima | Burke, Kelly | Kanyama, Cecelia | Kayoyo, Virginia | Samaneka, Wadzanai P. | Chisada, Anthony | Santos, Breno | La Rosa, Alberto | Infante, Rosa | Balfour, Henry H. | Mullan, Beth | Kim, Ge-Youl | Klebert, Michael K. | Mildvan, Donna | Revuelta, Manuel | Jan Geiseler, P. | Santos, Bartolo | Daar, Eric S. | Lopez, Ruben | Frarey, Laurie | Currin, David | Haas, David H. | Bailey, Vicki L. | Tebas, Pablo | Zifchak, Larisa | Sha, Beverly E. | Fritsche, Janice M.
Women with human immunodeficiency virus (HIV)–1 subtype C had significantly higher genital tract viral loads compared to women with HIV-1 subtype B and men with HIV-1 subtype C or B. Women in general were significantly less likely to have genital tract viral load below the lower limit of quantification compared to men.
Background. Combination antiretroviral therapy (cART) reduces genital tract human immunodeficiency virus type 1 (HIV-1) load and reduces the risk of sexual transmission, but little is known about the efficacy of cART for decreasing genital tract viral load (GTVL) and differences in sex or HIV-1 subtype.
Methods. HIV-1 RNA from blood plasma, seminal plasma, or cervical wicks was quantified at baseline and at weeks 48 and 96 after entry in a randomized clinical trial of 3 cART regimens.
Results. One hundred fifty-eight men and 170 women from 7 countries were studied (men: 55% subtype B and 45% subtype C; women: 24% subtype B and 76% subtype C). Despite similar baseline CD4+ cell counts and blood plasma viral loads, women with subtype C had the highest GTVL (median, 5.1 log10 copies/mL) compared to women with subtype B and men with subtype C or B (4.0, 4.0, and 3.8 log10 copies/mL, respectively; P < .001). The proportion of participants with a GTVL below the lower limit of quantification (LLQ) at week 48 (90%) and week 96 (90%) was increased compared to baseline (16%; P < .001 at both times). Women were significantly less likely to have GTVL below the LLQ compared to men (84% vs 94% at week 48, P = .006; 84% vs 97% at week 96, P = .002), despite a more sensitive assay for seminal plasma than for cervical wicks. No difference in GTVL response across the 3 cART regimens was detected.
Conclusions. The female genital tract may serve as a reservoir of persistent HIV-1 replication during cART and affect the use of cART to prevent sexual and perinatal transmission of HIV-1.
PMCID: PMC3689341  PMID: 23532477
HIV-1 genital tract RNA; HIV-1 subtypes B and C; antiretroviral drugs
16.  Moderate Levels of Depression Predict Sexual Risk in HIV-Infected MSM: A Longitudinal Analysis of Data from Six Sites involved in a “Prevention for Positives” Study 
AIDS and behavior  2013;17(5):1764-1769.
Depression is highly comorbid with HIV and may contribute to increased sexual transmission risk behavior (TRB) amongst HIV-infected MSM, the largest risk group for HIV in the U.S. However, examinations of this effect are inconsistent. The present longitudinal analyses of 746 HIV-infected MSM is from a multi-site “prevention for positives” study. A non-linear association between depression and TRB emerged. Moderate levels of depression (compared to either low or high levels) were associated with a more modest decline in the odds of sexual risk behavior over 12-month follow-up. Assessing depression in HIV primary care settings may help to identify those at risk and integrating the treatment of depression in to secondary prevention and treatment initiatives may decrease the likelihood of sexual risk and help to contain the epidemic among MSM.
PMCID: PMC3752694  PMID: 23605154
HIV prevention with positives; men who have sex with men; sexual risk; depression
17.  Validity of Medication Adherence Self-Reports in Adults With Type 2 Diabetes 
Diabetes Care  2013;36(4):831-837.
To assess the validity of self-report measures of diabetes medication adherence and evaluate the effect of depression on the validity of these reports.
Adults with type 2 diabetes, treated with oral medications, completed a set of medication adherence self-reports that varied response scales and time frames, were administered structured clinical interviews for depression, and provided blood samples for HbA1c as part of a screening for an intervention study. A subsample of participants with HbA1c ≥7.0% and clinically significant depression received Medication Event Monitoring System (MEMS) bottle caps to record adherence. Analyses examined relationships between adherence measures and HbA1c and, in the subsample, MEMS. Moderated linear regression evaluated whether depression severity modified relationships with HbA1c.
Participant (n = 170, 57% men, 81% white, mean HbA1c 8.3% [SD, 1.7]) adherence self-reports were significantly (r = −0.18 to −0.28; P < 0.03) associated with lower HbA1c. In the subsample (n = 88), all self-reports were significantly (r = 0.35 to 0.55; P ≤ 0.001) associated with MEMS-measured adherence. Depression significantly moderated the relationship between three of six self-reports and HbA1c; at high levels of depression, associations with HbA1c became nonsignificant.
Results support the validity of easily administered self-reports for diabetes medication adherence. One-month, percentage-based ratings of adherence had the strongest associations with MEMS and HbA1c; those requiring the report of missed doses had weaker associations. One-week self-ratings and measures that require respondents to record the number of missed doses appear to be vulnerable to bias from depression severity.
PMCID: PMC3609536  PMID: 23204245
18.  Project Enhance: A Randomized Controlled Trial of an Individualized HIV Prevention Intervention for HIV-Infected Men Who Have Sex With Men Conducted in a Primary Care Setting 
Men who have sex with men (MSM) are the largest group of individuals in the U.S. living with HIV and have the greatest number of new infections. This study was designed to test a brief, culturally relevant prevention intervention for HIV-infected MSM, which could be integrated into HIV care.
HIV-infected MSM who received HIV care in a community health center (N = 201), and who reported HIV sexual transmission-risk behavior (TRB) in the prior 6 months, were randomized to receive the intervention or treatment as usual. The intervention, provided by a medical social worker, included proactive case management for psychosocial problems, counseling about living with HIV, and HIV TRB risk reduction. Participants were followed every 3 months for one year.
Participants, regardless of study condition, reported reductions in HIV TRB, with no significant differential effect by condition in primary intent-to-treat analyses. When examining moderators, the intervention was differentially effective in reducing HIV TRB for those who screened in for baseline depression, but this was not the case for those who did not screen in for depression.
The similar level of reduction in HIV TRB in the intervention and control groups, consistent with other recent secondary prevention interventions, speaks to the need for new, creative designs, or more potent interventions in secondary HIV prevention trials, as the control group seemed to benefit from risk assessment, study contact, and referrals provided by study staff. The differential finding for those with depression may suggest that those without depression could reap benefits from limited interventions, but those with a comorbid psychiatric diagnosis may require additional interventions to modify their sexual risk behaviors.
PMCID: PMC3651590  PMID: 22746262
MSM; HIV prevention; AIDS/HIV; high-risk sexual behavior; depression
19.  Substance Use Predictors of Poor Medication Adherence: The Role of Substance Use Coping Among HIV-Infected Patients in Opioid Dependence Treatment 
AIDS and behavior  2013;17(1):168-173.
Many HIV-infected injection drug users (IDUs) continue to use illicit substances despite being in substance use treatment. Substance use is associated with non-adherence to HIV medications; however underlying mechanisms regarding this relation are understudied. The current investigation examined the role of substance use coping in terms of the relation between substance use and HIV medication adherence. Participants were 121 HIV-infected IDUs (41 % female, M age = 47, SD = 7.1) in opioid dependence treatment. Participants completed self-report questionnaires, were administered clinical interviews and oral toxicology screens, and used a medication-event-monitoring-system cap to assess 2 week HIV medication adherence. The use of cocaine and multiple substances were significantly related to decreased medication adherence. Substance use coping mediated these associations. Findings highlight the importance of assessing, monitoring, and targeting ongoing substance use, and ways to increase positive coping for HIV-infected IDUs in substance use treatment to aid in HIV medication adherence.
PMCID: PMC3632258  PMID: 23008124
HIV/AIDS; Medication adherence; Substance use; Coping; Cocaine
20.  Predictors of Dropout from Psychosocial Treatment in Opioid-Dependent Outpatients 
Background and Objectives
Early dropout is common in substance abuse treatment settings and may lead to poorer outcomes relative to those completing a full course of treatment. Attempts to identify predictors of dropout have yielded mixed results, highlighting the need for additional research in this area to clarify risk and protective factors to guide intervention and retention efforts. This study evaluated predictors of dropout from psychosocial treatment among opioid-dependent patients on methadone maintenance therapy.
Participants included 78 patients who had failed to respond to at least 4 months of methadone maintenance plus group counseling with clinic substance abuse counselors, and were enrolled in a study of randomized psychosocial treatment in addition to treatment-as-usual. Several factors that have been implicated in previous studies as well as two affective variables (distress intolerance and coping motives for drug use) were examined.
Results indicated that when controlling for various risk factors, age was the only significant predictor of dropout, with younger patients more likely to discontinue treatment early.
This study replicates previous findings in opioid-dependent samples that younger patients are at an increased risk of early treatment dropout.
Conclusions and Significance
Targeted intervention may be needed to retain young patients in drug abuse treatment.
PMCID: PMC3651588  PMID: 23398222
21.  Anxiety Specific Pathways to HIV Sexual Transmission Risk Behavior among Young Gay and Bisexual Men 
This study evaluated whether specific anxiety disorders increased the likelihood of sexual transmission risk behavior (TRB) in younger (ages 20–29) versus older (ages 30+) HIV positive gay and bisexual men. Participants completed screening measures for Posttraumatic Stress Disorder (PTSD), Social Phobia, and Panic Disorder, and an assessment of recent TRB Moderated regression analyses indicated that PTSD was associated with greater risk of TRB in younger but not older men, independent of HIV disease stage or treatment status. Efficacy of secondary HIV prevention efforts for younger men may be augmented by addressing the context of trauma history and consequent mental health issues.
PMCID: PMC3752916  PMID: 23997845
HIV; age; post-traumatic stress disorder; sexual transmission risk behavior
22.  Description and Demonstration of CBT for ADHD in Adults 
Cognitive and behavioral practice  2012;17(1):10.1016/j.cbpra.2009.09.002.
ADHD in adulthood is a valid, prevalent, distressing, and interfering condition. Although medications help treat this disorder, there are often residual symptoms after medication treatment, and, for some patients, they are contraindicated. Compared to other disorders, such as mood and anxiety disorders, there are few resources available for clinicians wishing to conduct cognitive-behavioral treatment for this problem. The present manuscript provides a description of our cognitive-behavioral approach to treat ADHD in adulthood, which we have developed and tested in our clinic (Safren, Otto, et al., 2005), and for which detailed therapist and client guides exist (Safren, Perlman, Sprich, & Otto, 2005; Safren, Sprich, Perlman, & Otto, 2005). To augment the description of treatment, the present article provides video component demonstrations of several core modules that highlight important aspects of this treatment. 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.
PMCID: PMC3874265  PMID: 24379644
23.  Depression and HIV/AIDS Treatment Nonadherence: A Review and Meta-analysis 
Journal of acquired immune deficiency syndromes (1999)  2011;58(2):10.1097/QAI.0b013e31822d490a.
We meta-analyzed the relationship between depression and HIV medication nonadherence to calculate the overall effect size and examine potential moderators. Overall, across 95 independent samples, depression was significantly (P < 0.0001) associated with nonadherence (r = 0.19; 95% confidence interval = 0.14 to 0.25). Studies evaluating medication adherence via interview found significantly larger effects than those using self-administered questionnaires. Studies measuring adherence along a continuum found significantly stronger effects than studies comparing dichotomies. Effect size was not significantly related to other aspects of adherence or depression measurement, assessment interval (ie, cross-sectional vs. longitudinal), sex, IV drug use, sexual orientation, or study location. The relationship between depression and HIV treatment nonadherence is consistent across samples and over time, is not limited to those with clinical depression, and is not inflated by self-report bias. Our results suggest that interventions aimed at reducing depressive symptom severity, even at subclinical levels, should be a behavioral research priority.
PMCID: PMC3858003  PMID: 21857529
adherence; compliance; depression; HIV/AIDS; meta-analysis
24.  Intimacy and Sexual Decision Making: Exploring the Perspective of HIV Positive Women Over 50 
AIDS Patient Care and STDs  2012;26(12):755-760.
Due to advances made in HIV treatment, the population of individuals with HIV over the age of 50 is growing. Aging women face many developmental challenges and some of these challenges, including having or maintaining intimate partner relationships, may be particularly pronounced for aging women living with HIV. However, research exploring the psychosocial needs of aging women with HIV is limited. Thus, the aim of this study was to explore factors that impact intimate partner relationships for older women with HIV. Nineteen women (mean age=56.79, SD=4.63 years) referred from Boston-area community organizations and hospitals completed in-depth individual interviews. Forty-seven percent of participants identified themselves as Black/African American, and 37% as White/Caucasian. Average time since diagnosis was 16.32 years (SD=5.70). Interviews continued until saturation of content was reached. Inclusion criteria included: biologically born female; aged 50 years or older; diagnosis of HIV/AIDS; and English speaking. Qualitative interviews were coded by two raters and content analyses were conducted using NVivo 9 software. The findings are described across the following three main themes: (1) stigma; (2) body image concerns; and (3) the disclosure dilemma. The themes and issues identified by this study may help guide sexual health-related interventions for older HIV-infected women.
PMCID: PMC3513978  PMID: 23199193
25.  What's Love Got to Do With It? Explaining Adherence to Oral Antiretroviral Pre-exposure Prophylaxis (PrEP) for HIV Serodiscordant Couples 
Journal of acquired immune deficiency syndromes (1999)  2012;59(5):10.1097/QAI.0b013e31824a060b.
Adherence may be the “Achilles heel” of pre-exposure prophylaxis (“PrEP”), a promising biomedical approach to HIV prevention. This paper presents an explanation of PrEP adherence for African serodiscordant couples derived from qualitative data.
Explaining quantitative findings is one way qualitative investigation contributes to research in medicine and public health. This qualitative interview study was nested in the Partners PrEP Study, a phase III randomized trial evaluating oral tenofovir and emtricitabine/tenofovir PrEP to prevent HIV acquisition by HIV-uninfected partners in serodiscordant heterosexual couples.
In-depth qualitative interviews were provided by 60 Partners PrEP Study participants in Uganda. Interviews used open-ended questions eliciting information on adherence experiences, barriers, and facilitators. An inductive approach informed by grounded theory methodology was used to analyze study data.
The proposed explanation may be summarized as follows. Serodiscordance de-stabilizes couples, as the HIV-negative partner reacts with anger, fear and sadness to the implication of infidelity represented by HIV infection. A ‘discordance dilemma’ ensues, as the desire to avoid acquiring HIV and the advantages of preserving the relationship become competing priorities. PrEP is seen as a solution – a means of safeguarding health without ending the relationship. PrEP users benefit from the support of partners, who reinforce adherence. Where discord in the relationship persists, adherence suffers.
PrEP adherence in serodiscordant couples may be understood as a function of the desire to reduce risk while preserving a partnered relationship. PrEP use in stable couples may be associated with improved adherence and thus, greater effectiveness.
PMCID: PMC3826169  PMID: 22267018
HIV prevention; Pre-exposure Prophylaxis; PrEP; Adherence; HIV Serodiscordant Couples; HIV Acquisition

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