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• People living with HIV experience "syndemics." • Transdiagnostic treatment can address multiple psychiatric and medical problems. • Developed a transdiagnostic CBT treatment to address the needs of people living with HIV. • Treatment description and case examples are provided as a guide for clinicians. People living with HIV (PLWH) experience a range of co-occurring psychosocial stressors, mental health symptoms, and structural barriers (e.g., "syndemics") that can impair their ability to adhere to medical recommendations for treatment. This has consequences for their health and the health of others as nonadherence increases the likelihood of unsuppressed HIV viral load, and therefore the ability to transmit HIV to others. Transdiagnostic treatment, or treatment not focused on a single mental health condition, can efficiently address a range of mental health problems by skills training to reduce symptoms. Additionally, cognitive behavioral and problem-solving approaches can be used to address larger, structural factors by helping individuals navigate systemic challenges using evidence-based skills. This article describes the development of a transdiagnostic treatment for PLWH and illustrates the application of the treatment through case examples. This treatment might be appropriate for integration into an HIV clinic or within an outpatient setting when working with a patient who is experiencing syndemic conditions and living with HIV. [ABSTRACT FROM AUTHOR]

Objective: Compared to non-Black women, Black women in the United States are more likely to be diagnosed with HIV, living with HIV, and have suboptimal HIV outcomes, disparities largely linked to structural and psychosocial factors that may impact mental health. Method: 151 Black women living with HIV (BWLWH) enrolled in a longitudinal cohort study completed baseline assessments between October 2019 and January 2020 in the Southeastern United States. Measures captured microaggressions (gendered-racial, HIV, and Lesbian/Gay/Bisexual/Transgender/Queer), "macro" discrimination acts (gender, race, HIV, sexual orientation), resilience factors (self-efficacy, trait resilience, posttraumatic growth, positive religious coping, and social support), and mental health (depressive symptoms, posttraumatic stress disorder (PTSD) symptoms, and posttraumatic cognitions). Four structural equation models were estimated with latent discrimination (LD), latent microaggression (LM), and latent resilience (LR) as predictors and depressive symptoms, PTSD symptoms, posttraumatic cognitions, and latent mental health (LH) as outcomes. Indirect pathways from LD and LM via LR and LR as a moderator were estimated. Results: Models fit well based on indices. There were significant direct pathways from LM and LR to depressive symptoms, posttraumatic cognitions, and LH and a significant direct pathway from LM to PTSD symptoms, but not from LD to any mental health outcome. Indirect pathways were not significant. However, LR moderated the relationships between both LM and LD with PTSD symptoms. Conclusion: Intersectional microaggressions and resilience factors may play key roles in BWLWH's mental health. Research is needed to examine these pathways overtime and provide opportunities to improve mental health and HIV outcomes among BWLWH. [ABSTRACT FROM AUTHOR]

Objective: Lesbian, gay, bisexual, and queer (LGBQ)-affirmative cognitive behavioral therapy (CBT) focused on minority stress processes can address gay and bisexual men's transdiagnostic mental and behavioral health concerns. Identifying moderators of treatment outcomes may inform the mechanisms of LGBQ-affirmative CBT and subpopulations who may derive particular benefit. Method: Data were from a clinical trial in which gay and bisexual men with mental and behavioral health concerns were randomized to receive Effective Skills to Empower Effective Men (ESTEEM; an LGBQ-affirmative transdiagnostic CBT; n = 100) or one of two control conditions (n = 154): LGBQ-affirmative community mental health treatment (CMHT) or HIV counseling and testing (HCT). The preregistered outcome was a comorbidity index of depression, anxiety, alcohol/drug problems, and human immunodeficiency virus (HIV) transmission risk behavior at 8-month follow-up (i.e., 4 months postintervention). A two-step exploratory machine learning process was employed for 20 theoretically informed baseline variables identified by study therapists as potential moderators of ESTEEM efficacy. Potential moderators included demographic factors, pretreatment comorbidities, clinical facilitators, and minority stress factors. Results: Racial/ethnic minority identification, namely as Black or Latino, was the only statistically significant moderator of treatment efficacy (B = −3.23, 95% CI [−5.03, −1.64]), t(197) = −3.88, p <.001. Racially/ethnically minoritized recipients (d = −0.71, p <.001), but not White/non-Latino recipients (d = 0.22, p =.391), had greater reductions in comorbidity index scores in ESTEEM compared to the control conditions. This moderation was driven by improvements in anxiety and alcohol/drug use problems. Discussion: Black and Latino gay and bisexual men experiencing comorbid mental and behavioral health risks might particularly benefit from a minority stress–focused LGBQ-affirmative CBT. Future research should identify mechanisms for this moderation to inform targeted treatment delivery and dissemination. What is the public health significance of this article?: In a trial of LGBQ-affirmative cognitive behavioral therapy (CBT) for gay and bisexual men with comorbid mental and behavioral health concerns, racial/ethnic identification—namely as Black or Latino—emerged as the most robust moderator of the efficacy of this treatment compared to two control conditions. Results suggest that LGBQ-affirmative CBT might represent a promising approach for Black and Latino gay and bisexual men and highlight the need to understand the mechanisms underlying this effect to inform the development of effective intersectional interventions. [ABSTRACT FROM AUTHOR]

Objective: Effective Skills to Empower Effective Men (ESTEEM) represents the first intervention to address the psychological pathways through which minority stress undermines young sexual minority men's (SMM's) mental and sexual health using transdiagnostic cognitive-behavioral therapy. This study compared the efficacy of ESTEEM against two existing interventions. Method: Participants were young HIV-negative SMM (N = 254; ages = 18–35; 67.2% racial/ethnic minority) experiencing a depression, anxiety, and/or stress-/trauma-related disorder and past-90-day HIV transmission risk behavior. After completing HIV testing and counseling, participants were randomized to receive 10-session ESTEEM (n = 100); 10-session community-based LGBQ-affirmative counseling (n = 102); or only HIV testing and counseling (n = 52). Results: For the primary outcome of any HIV transmission risk behavior at 8 months, ESTEEM was not significantly associated with greater reduction compared to HIV testing and counseling (risk ratio [RR] = 0.89, p =.52). Supportive analyses of the frequency of HIV transmission risk behavior at 8 months showed a nonsignificant difference between ESTEEM compared to HIV testing and counseling (RR = 0.69) and LGBQ-affirmative counseling (RR = 0.62). For secondary outcomes (e.g., depression, anxiety, substance use, suicidality, number of mental health diagnoses) at 8 months, ESTEEM had a larger effect size than the two comparison conditions, but these comparisons did not reach statistical significance when adjusting for the false discovery rate. Observed effect sizes for condition comparisons were smaller than the effect sizes used to power the study. In exploratory analyses, ESTEEM showed promise for reducing comorbidity. Conclusions: Because the control conditions were associated with stronger effects than anticipated, and given the heterogeneous nature of transdiagnostic outcomes, the study possessed insufficient power to statistically detect the consistently small-to-moderate benefit of ESTEEM compared to the two control conditions. What is the public health significance of this article?: As long as young sexual minority men (SMM) face minority stress, identity-affirming and effective psychological interventions are needed to address the impact that this stress has on their mental and sexual health. This study found evidence that an LGBQ-affirmative, minority-stress-focused, transdiagnostic cognitive-behavioral therapy (CBT) intervention called ESTEEM was associated with reductions across numerous mental and sexual health outcomes among young SMM experiencing co-occurring mental and sexual health concerns, though not significantly greater reductions than the two existing interventions to which ESTEEM was compared. [ABSTRACT FROM AUTHOR]

• A CBT intervention for problematic alcohol use can be adapted for lay providers. • Low motivation to change and substance-using social networks are patient challenges. • Lay provider acceptance of low patient readiness to change requires supervision. • Addressing multiple comorbidities is challenging due to session time constraints. Human immunodeficiency virus (HIV) and problematic alcohol use are two ongoing and interconnected epidemics in South Africa, with untreated problematic alcohol use associated with poorer HIV treatment outcomes and disease progression. A lack of trained mental health providers is a primary barrier to increasing access to evidence-based treatment in this setting. To address this gap, we integrated evidence-based intervention components for problematic alcohol use and antiretroviral therapy (ART) adherence, adapted for lay provider delivery in an HIV primary care setting in Cape Town, South Africa. The intervention, locally termed "Khanya" in isiXhosa, which means glow, direction, or light, comprises Life Steps adherence counseling, motivational interviewing, behavioral activation, and relapse prevention, including mindfulness-based relapse prevention components. In this case series, we present a detailed description of the intervention and provide three clinical cases of individuals who received the Khanya intervention to showcase necessary clinical adaptations and the supervision needed for optimal treatment delivery, flexibility in intervention delivery, and overall successes and challenges. We present descriptive data on alcohol use and ART adherence outcomes for the cases to supplement the narrative discussion. Successes of intervention delivery included participant uptake of mindfulness skills, reductions in alcohol use despite varying levels of motivation, and interventionist mastery over various clinical skills. Challenges included delivering the intervention within the allotted time and the strong influence of substance-using social networks. Overall, a pragmatic approach to intervention delivery was necessary, as was ongoing support for the interventionist to promote fidelity to both treatment components and therapeutic skills. Trial registration: ClinicalTrials.gov identifier: NCT03529409. Trial registered on May 18, 2018. [ABSTRACT FROM AUTHOR]

Despite the availability of HIV prevention and treatment tools, HIV disparities continue to affect Latinx sexual minority men (LSMM). Behavioral health concerns further exacerbate HIV disparities among LSMM. This study used rapid qualitative analysis to understand factors influencing LSMM's access to HIV and behavioral health services during coronavirus disease 2019 (COVID-19). Participants included LSMM with (n = 10) and without HIV (n = 10). The analysis identified 15 themes. Themes revealed that LSMM's access was disrupted by new and worsening barriers resulting from COVID-19, such as anxiety about COVID-19 exposure, confusion and disruptions to services, and new structural challenges. Other themes highlight positive changes, such as telehealth and relaxed clinic protocols, which enhanced LSMM's access to services during COVID-19. The findings suggest the need for HIV and behavioral health clinics to innovate and ensure LSMM's continued access to services during and beyond COVID-19. [ABSTRACT FROM AUTHOR]

Background Stigma is associated with poor health among sexual minority individuals. However, no studies have examined the relationship between stigma and problematic drinking among male sex workers (MSWs). This study examined the relationship between sex work stigma and problematic alcohol use among MSWs.Methods: Using baseline data from a cohort of 98 MSWs in the US Northeast enrolled between 2015 and 2016, we used logistic regression to examine associations between sex work stigma and hazardous drinking (Alcohol Use Disorders Identification Test (AUDIT) score ≥8) and sex work while drunk, and tested whether sexual orientation (gay vs non-gay identified) and social network size moderated these associations.Results: Almost half the sample (n = 46; 44%) reported hazardous drinking and 56 MSWs (57%) reported engaging in sex work while drunk. Sex work stigma was associated with hazardous drinking (adjusted odds ratio (aOR) 1.2, 95% confidence interval (CI) 1.05-1.36). Sexual orientation marginally moderated this relationship (P = 0.07), such that it was only significant among gay-identified MSWs (aOR 1.91, 95% CI 1.11-3.28), not among non-gay MSW. Similarly, sexual orientation moderated the effect of sex work stigma on sex work while drunk (P = 0.02), which was only significant among gay-identified MSWs (aOR 1.65, 95% CI 1.05-1.60). Social network size also moderated the effect of sex work stigma on sex work while drunk (P = 0.02), which was only significant among MSWs with small networks (aOR 1.26, 95% CI 1.00-1.58), suggesting large networks can be protective.Conclusions: Gay MSWs may be particularly vulnerable to alcohol-related effects of stigma. Future interventions should consider engaging social networks to curb problematic drinking among MSWs. [ABSTRACT FROM AUTHOR]

Body image disturbance is increasingly relevant as women living with HIV (WLWH) live longer. We explored body image disturbance and changes in fat distribution (lipodystrophy) in 63WLWH(mean age551 years) and evaluated associations among lipodystrophy, body image, and psychosocial variables. Eighty-one percent of participants reported one or more body parts (of six assessed) demonstrating lipodystrophy, and more than one third reported three ormore affected body parts. Increased belt/waist (58%) and increased chest/breast (39%) sizes were most common. More diffuse lipodystrophy was significantly associated with poorer body image (F[2,54] = 11.86, p < .001, partial η² = .313) and anxiety (F[2,52] = 3.82, p = .029, partial η² = .133) after controlling for age and duration of infection. Lipodystrophy was prevalent in our sample; more diffuse lipodystrophy was associated with anxiety and poor body image. Providers should assess lipodystrophy in older WLWH and provide referrals for mental health services. [ABSTRACT FROM AUTHOR]

Objective: Among men who have sex with men (MSM), HIV sexual risk and poor self-care behavior is associated with syndemics, or co-occurring psychosocial problems. Though prior research has demonstrated an additive total effect of syndemics on HIV risk behavior and infection, mostly within cross-sectional designs, it is possible that these associations are not direct but rather that syndemics disrupt relevant individual-level mediating psychological variables. One of the more common individual-level psychological variables that predicts health behavior generally, and HIV risk behavior specifically, is self-efficacy. This study sought to examine the potential effects of syndemics on condomless sex via condom-use self-efficacy as an intermediary variable. Method: In high-risk MSM (N = 197), across 3 time points (baseline, 3 months, and 6 months) we used latent growth curve modeling to test the degree to which self-efficacy mediated the relationship between syndemics (heavy alcohol use, substance use disorder, sexual compulsivity, depression, social anxiety, intimate partner violence, childhood sexual abuse) and condomless anal sex. Results: The baseline analyses were consistent with an indirect effect of the association between syndemics and condomless sex through self-efficacy. Prospective longitudinal mediation was partially supported, such that baseline syndemics were associated with lower baseline self-efficacy, which in turn predicted higher increases in condomless anal sex across time. Conclusions: These findings provide preliminary evidence (due to the partial support for the longitudinal model) that syndemics themselves may not be directly causal in their association with condomless sex, but the association may be through modifiable social-cognitive mechanisms such as condom self-efficacy. [ABSTRACT FROM AUTHOR]

In the U.S. Black women with HIV face numerous psychosocial challenges, particularly trauma, racism, HIV-related discrimination, and gender role expectations, that are associated with negative HIV health outcomes and low medical treatment adherence. Yet many of these factors are unaddressed in traditional cognitive behavioral approaches. This study presents a case series of a tailored cognitive behavioral treatment approach for Black women living with HIV. Striving Towards EmPowerment and Medication Adherence (STEP-AD) is a 10-session treatment aimed at improving medication adherence for Black women with HIV by combining established cognitive behavioral strategies for trauma symptom reduction, strategies for coping with race- and HIV-related discrimination, gender empowerment, problem-solving techniques for medication adherence, and resilient coping. A case series study of five Black women with HIV was conducted to evaluate the preliminary acceptability and feasibility of the treatment and illustrate the approach. Findings support the potential promise of this treatment in helping to improve HIV medication adherence and decrease trauma symptoms. Areas for refinement in the treatment as well as structural barriers (e.g., housing) in the lives of the women that impacted their ability to fully benefit from the treatment are also noted. [ABSTRACT FROM AUTHOR]

Objective: High rates of depression and posttraumatic stress disorder (PTSD) contribute to sexual risk, particularly in men who have sex with men (MSM) who have experienced childhood sexual abuse. The comorbidity between depression and PTSD and mechanisms by which they contribute to sexual risk in MSM remain unclear. This study sought to demonstrate the feasibility and utility of a network approach to (a) characterize symptom interconnections between depression and PTSD in MSM, (b) identify specific symptoms related to sexual risk behavior, and (c) compare symptom networks across groups at different levels of risk. Method: Cross-sectional baseline data were collected from 296 HIV-negative urban MSM as part of a multisite randomized intervention trial. Symptoms of depression and PTSD were self-reported along with sexual risk behavior. Analyses were performed in R using regularized partial correlation network modeling. Results: Network analyses revealed complex associations between depression and PTSD symptoms and in relation to sexual risk behavior. While symptoms clustered within their respective disorders, depression and PTSD were connected at key symptom nodes (e.g.. sleep, concentration). Specific symptoms (e.g., avoiding thoughts and feelings) were linked to sexual risk behavior. Network comparisons across risk groups suggested avoidant processes could be more readily activated in higher-risk individuals, whereas hyperarousal symptoms may be more salient and protective for lower-risk individuals. Conclusions: This study is one of the earliest network analyses of depression and PTSD, and first to extend this inquiry to health behavior. Symptom-level investigations may clarify mechanisms underlying psychological comorbidity and behavioral risk in MSM and refine targets for intervention/prevention. [ABSTRACT FROM AUTHOR]

Objective: Body image disturbance is a distressing and interfering problem among many sexual minority men living with HIV, and is associated with elevated depressive symptoms and poor HIV self-care (e.g., antiretroviral therapy [ART] nonadherence). The current study tested the preliminary efficacy of a newly created intervention: cognitive-behavioral therapy for body image and self-care (CBT-BISC) for this population. Method: The current study entailed a 2-arm randomized controlled trial (N = 44) comparing CBT-BISC to an enhanced treatment as usual (ETAU) condition. Analyses were conducted at 3 and 6 months after baseline. The primary outcome was body image disturbance (BDD-YBOCS), and secondary outcomes were ART adherence (electronically monitored via Wisepill), depressive symptoms (MADRS), and global functioning (GAF). Results: At 3 months, the CBT-BISC condition showed substantial improvement in BDD-YBOCS (b = -13.6, SE = 2.7, 95% CI [-19.0, -8.3], p < .001; dppc2 = 2.39); MADRS (b = -4.9, SE = 2.8, 95% CI [-10.6, .70], p = .086; dppc2 = .87); ART adherence (b = 8.8, SE = 3.3, 95% CI [2.0, 15.6], p = .01; dppc2 = .94); and GAF (b = 12.3, SE = 3.2, 95% CI [6.1, 18.6], p < .001; dppc2 = 2.91) compared with the ETAU condition. Results were generally maintained, or improved, at 6 months; although, adherence findings were mixed depending on the calculation method. Conclusions: CBT-BISC shows preliminary efficacy in the integrated treatment of body image disturbance and HIV self-care behaviors among sexual minority men living with HIV. [ABSTRACT FROM AUTHOR]

One dramatic advance in human immunodeficiency virus (HIV) prevention efforts has been the prescription of medications typically used for HIV treatment as prophylaxis against acquiring HIV. As a preventative agent, this practice is referred to as “preexposure prophylaxis” (PrEP). The U.S. Federal Drug Administration approved daily PrEP for adults at risk for HIV who do not consistently use condoms during sex with HIV-infected or unknown-status partners. In this paper, we describe a cognitive-behavioral therapy (CBT) PrEP adherence intervention developed for use in high-risk sexual-minority men in the United States, adapted from “Life-Steps,” an evidence-based CBT intervention to promote adherence to HIV treatment. Modules include creating a PrEP dosing schedule, adhering to daily PrEP, problem solving barriers to adherence, and sexual risk-reduction techniques. Supplemented with practical video vignettes, this novel intervention may help to enhance the clinical practice of health care providers in outpatient settings to increase PrEP adherence in sexual-minority men. [ABSTRACT FROM AUTHOR]

Despite continued advances in HIV prevention and treatment, gay and bisexual men and other men who have sex with men (MSM) remain the population most impacted by HIV/AIDS in the US and many other Western countries. Additionally, MSM are disproportionately affected by various psychological problems, including depression, distress, trauma and substance use. These challenges frequently co-occur, and are associated with higher rates of behaviours related to HIV acquisition and transmission, HIV infection, and, for those living with HIV/AIDS, lower levels of treatment engagement. Moreover, racial disparities exist among MSM in the US; for example, young African American MSM bear a disproportionate burden of the continuing HIV epidemic, likely related to disparate HIV prevalence in partner pools as well as long-standing structural inequities. In this review, the mental health challenges facing MSM primarily in the US, related to HIV and STI prevention and across the HIV care cascade, including HIV diagnosis, engagement and retention in care, and antiretroviral adherence, are illustrated. Disparities among MSM including racial and ethnic, age-related and structural barriers associated with HIV prevention and treatment, as well as current interventions, are also described. Moving forward towards 2020, resources will be needed to assess and implement scalable intervention strategies to address psychological and social barriers to HIV and STI risk reduction and treatment for MSM, with a particular focus on the most vulnerable subpopulations. As access to prevention and treatment strategies expand, and new breakthroughs continue to emerge, behavioural strategies will continue to be needed to reduce risk and increase uptake and engagement among MSM most at risk through 2020 and beyond. [ABSTRACT FROM AUTHOR]

Background:Practical issues, including cost, hinder implementing virologic monitoring of patients on antiretroviral therapy (ART) in resource-limited settings. We evaluated factors that might guide monitoring frequency and efforts to prevent treatment failure after initial virologic suppression. Methods:Participants were the 911 HIV-infected antiretroviral-naïve adults with CD4 count <300 cells/μL who started efavirenz-based ART in the international A5175/PEARLS trial and achieved HIV-1 RNA <1000 copies/mL at 24 weeks. Participant report of ART adherence was evaluated using a structured questionnaire in monthly interviews. Adherence and readily available clinical and laboratory measures were evaluated as predictors of late virologic failure (late VF: confirmed HIV-1 RNA ≥1000 copies/mL after 24 weeks). Results:During median follow-up of 3.5 years, 82/911 participants (9%) experienced late VF. Of 516 participants reporting missed doses during the first 24 weeks of ART, 55 (11%) experienced late VF, compared with 27 (7%) of 395 participants reporting no missed doses (hazard ratio: 1.73; 95% CI: 1.08, 2.73). This difference persisted in multivariable analysis, in which lower pre-ART hemoglobin and absence of Grade ≥3 laboratory results prior to week 24 were also associated with higher risk of late VF. Discussion:In this clinical trial, the late VF rate after successful suppression was very low. If achievable in routine clinical practice, virologic monitoring involving infrequent (e.g. annual) measurements might be considered; the implications of this for development of resistance need evaluating. Patients reporting missed doses early after ART initiation, despite achieving initial suppression, might require more frequent measurement and/or strategies for promoting adherence. [ABSTRACT FROM PUBLISHER]

Patients with prior virologic failure (VF) are at an increased risk of subsequent failure, emergence of resistance, and death. This analysis identifies outcomes and correlates of VF in a high-risk population. Methods:A5251 was designed to evaluate an enhanced adherence counseling intervention delivered by nurses from a central call site on virologic suppression. Due to slow enrollment, the study was closed prematurely and revised study endpoints were evaluated (week 24 VF (HIV-1 RNA ≥200 copies/ml) and non-perfect adherence (<100% self-reported using both the ACTG adherence questionnaire and visual analog scale (VAS)). Results:Fifty-nine participants were enrolled, 43 (73%) black non-Hispanic and 23 (39%) women. Median prior antiretroviral regimen changes were three and the co-morbidity in this population was higher than typical for HIV clinical trials. At week 24 (n = 41), 24 (59%) failed to reach virologic suppression (HIV-1 RNA <200 copies/ml) and 25 (63%) reported non-perfect adherence. Higher depression (CES-D10) and adverse illness perceptions (IPQ-B) were associated with week 24 non-adherence. Early clinical assessments (week 12 HIV-RNA ≥200 copies/mL and non-perfect adherence) as well as higher depression and adverse illness perceptions were associated with week 24 VF. Discussion:In this high-risk population, the proportion of participants with suboptimal adherence and VF was unacceptably high. Interventions to address this treatment gap are clearly needed. Depression and a higher illness perception score, failure to achieve virologic suppression by week 12, and less than perfect adherence could be used to target individuals for early interventions in treatment-experienced, high-risk individuals at high risk for VF. [ABSTRACT FROM PUBLISHER]

There are an estimated 1.1 million individuals living with HIV/AIDS in the United States. In addition to the various medical comorbidities of HIV infection, depression is one of the most frequently co-occurring psychiatric conditions among HIV-infected individuals. Furthermore, depression has been found to be associated with nonadherence to antiretroviral therapy (ART), as well as HIV disease progression. Cognitive behavioral therapy (CBT) has repeatedly been found to effectively treat depression in adult populations, and CBT for adherence and depression (CBT-AD) is an effective treatment for improving depressive symptoms and medication adherence in the context of various chronic health conditions, including diabetes and HIV-infection. This paper provides a description of the CBT-AD approach to treat depression and ART adherence in HIV-infected adults, which we have developed and tested in our clinic, and for which detailed therapist and client guides exist. To augment the description of treatment, the present article provides video component demonstrations of several core modules that highlight important aspects of this treatment, including Life-Steps for medication adherence, orientation to CBT-AD and psychoeducation, and suggestions for adaptation of core CBT modules for HIV-infected adults. Discussion of video demonstrations highlights differences in patient presentations and course of treatment between HIV-infected adults receiving CBT-AD and HIV-uninfected adults receiving traditional CBT for depression. 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. [ABSTRACT FROM AUTHOR]

Objectives: We tested the preliminary efficacy of a transdiagnostic cognitive-behavioral treatment adapted to improve depression, anxiety, and co-occurring health risks (i.e., alcohol use, sexual compulsivity, condomless sex) among young adult gay and bisexual men. Treatment adaptations focused on reducing minority stress processes that underlie sexual orientation-related mental health disparities. Method: Young gay and bisexual men (n = 63; M age = 25.94) were randomized to immediate treatment or a 3-month waitlist. At baseline, 3-month, and 6-month assessments, participants completed self-reports of mental health and minority stress and an interview of past-90-day risk behavior. Results: Compared to waitlist, treatment significantly reduced depressive symptoms (b = -2.43, 95% Cl: -4.90, 0.35, p < .001), alcohol use problems (b = -3.79, 95% Cl; -5.94, -1.64, p < .001), sexual compulsivity ( t> = -5.09, 95% Cl: -8.78, -1.40, p < .001), and past-90-day condomless sex with casual partners (b = -1.09, 95% Cl: -1.80, -0.37, p < .001), and improved condom use self-efficacy (b = 10.08, 95% Cl: 3.86, 16.30, p < .001). The treatment yielded moderate and marginally significant greater improvements than waitlist in anxiety symptoms (b = -2.14, 95% Cl: -4.61, 0.34, p = .09) and past-90-day heavy drinking (b = -0.32, 95% Cl: -0.71, 0.07, p = .09). Effects were generally maintained at follow-up. Minority stress processes showed small improvements in the expected direction. Conclusion: This study demonstrated preliminary support for the first intervention adapted to address gay and bisexual men's co-occurring health problems at their source in minority stress. If found to be efficacious compared to standard evidence-based treatments, the treatment will possess substantial potential for helping clinicians translate LGB-affirmative treatment guidelines into evidence-based practice. [ABSTRACT FROM AUTHOR]

Objective: To examine whether latent class indicators of negative affect and substance use emerged as distinct psychosocial risk profiles among HIV-infected men, and if these latent classes were associated with high-risk sexual behaviors that may transmit HIV. Methods: Data were from HIV-infected men who reported having anal intercourse in the past 6 months and received routine clinical care at 4 U.S. sites in the Centers for AIDS Research Network of Integrated Clinical Systems cohort (n = 1,210). Latent class membership was estimated using binary indicators for anxiety, depression, alcohol and/or drug use during sex, and polydrug use. Generalized estimating equations modeled whether latent class membership was associated with HIV sexual transmission risk in the past 6 months. Results: Three latent classes of psychosocial indicators emerged: (a) internalizing (15.3%; high probability of anxiety and major depression); (b) externalizing (17.8%; high probability of alcohol and/or drug use during sex and polydrug use); (c) low psychosocial distress (67.0%; low probability of all psychosocial factors examined). Internalizing and externalizing latent class membership were associated with HIV sexual transmission risk, compared to low psychosocial class membership; externalizing class membership was also associated with higher sexual transmission risk compared to internalizing class membership. Conclusions: Distinct patterns of psychosocial health characterize this sexually active HIV-infected male patient population and are strongly associated with HIV sexual transmission risk. Public Health intervention efforts targeting HIV sexual risk transmission may benefit from considering symptom clusters that share internalizing or externalizing properties. [ABSTRACT FROM AUTHOR]

Although ADHD in adolescents is an impairing and prevalent condition, with community prevalence estimates between 2% and 6%, psychosocial treatments for adolescents compared to younger children are relatively understudied. Our group has successfully developed an evidence base for cognitive-behavioral therapy (CBT) for ADHD in medication-treated adults with ADHD with clinically significant symptoms. In the current paper, we describe an adaptation of this treatment to adolescents, and provide case reports on 3 adolescents who participated in an open pilot trial. The results suggest that the treatment approach was well tolerated by the adolescents and that they experienced clinical benefit. This early report of the approach in adolescents is promising and requires further efficacy testing. [ABSTRACT FROM AUTHOR]

Objective: To better understand independent pathways linking emotional distress, medication adherence, and glycemic control in adults with Type 2 diabetes, as well as the potential mediating effects of perceived control over illness and self-efficacy. Method: Adults with Type 2 diabetes (N = 142) were recruited for an intervention study evaluating cognitive-behavioral therapy for adherence and depression. Depressive symptom severity was assessed via semistructured interview. Validated self-reports assessed diabetes-related distress, perceived control over diabetes (perceived control), self-efficacy for diabetes self-management, and medication adherence. Glycemic control was evaluated by hemoglobin A1C. Only baseline data were included in correlational and linear regression analyses. Results: Perceived control was an important mediator of emotional distress for both medication adherence and A1C outcomes. Specifically, regression analyses demonstrated that diabetes distress, but not depression severity, was significantly related to medication adherence and A1C. Self-efficacy and perceived control were also independently associated with medication adherence and A1C. Mediation analyses demonstrated a significant indirect effect for diabetes distress and medication adherence through perceived control and self-efficacy. The relationship between distress and A1C was accounted for by an indirect effect through perceived control. Conclusion: Results demonstrated that diabetes-related emotional distress is associated with poorer treatment adherence and glycemic control among adults with Type 2 diabetes; these relationships were partially mediated through perceived control over diabetes. Perceptions of one's personal ability to influence the course of diabetes may be important in understanding the pathway between emotional distress and poor diabetes-treatment outcomes. [ABSTRACT FROM AUTHOR]

Although studies consistently report high rates of comorbid posttraumatic stress disorder (PTSD) and HIV infection, development and testing of PTSD treatment interventions in HIV-infected adults is limited. As such, the purpose of this review was twofold. First, this review augments the three existing reviews of research for PTSD in HIV-infected adults conducted within the past 10 years. We found two empirically supported cognitive-behavioral therapy-based interventions for the treatment of trauma-related symptoms in HIV-infected adults. Due to the continued limited number of effective interventions for this population, a second aim of our review was to draw from the expansive field of effective PTSD interventions for the general population to propose ways that future clinical intervention research may be tailored for HIV-infected adults. Therefore, in addition to a review, we conceptualized this paper as an opportunity to generate an ideal preview of the field of intervention research in this population. [ABSTRACT FROM AUTHOR]

The consistent use of condoms is the most effective behavior for reducing the acquisition of sexually transmitted infections (STIs), and condom use self-efficacy has been shown to be a key construct related to condom use. However, the examination of modifiable psychosocial and behavioral correlates of condom use self-efficacy is lacking. Recent investigations have highlighted the association of body dissatisfaction with condom use self-efficacy, and the current study conducted a meta-analysis on all available data addressing this relationship. Eleven individual effect-size parameters from nine studies yielded a total sample of 2495 men and women participants. A random-effects model revealed an average effect-size of r = −.25, Cohen's d = −0.52, which is moderate in strength. As body dissatisfaction increases, ones’ self-efficacy regarding the use of condoms diminishes. Integrating interventions to decrease body dissatisfaction and sexual risk behaviors may prove to be an effective strategy to decrease STIs. [ABSTRACT FROM AUTHOR]

Antiretroviral therapy to treat HIV/AIDS has substantially improved clinical outcomes among patients living with HIV/AIDS, but only in the presence of very consistent adherence. One of the most prevalent and impactful individual-level predictors of poor adherence is depressive symptoms, even at subthreshold levels. Evidence-based cognitive behavioral interventions exist to address improvements in depressive symptoms and adherence in this population, yet these techniques have largely been designed and tested as individual treatments for delivery in mental health settings. This presents a significant challenge when transporting these techniques to medical settings where other formats for delivery may be more appropriate (i.e., groups, less frequent visits), and few hands-on resources exist to guide this process. As such, primary aims of this study were to adapt and implement evidence-based cognitive behavioral techniques for depression (behavioral activation; BA) and HIV medication adherence (Life-Steps) that have potential for dissemination in an outpatient community health center. The intervention incorporated feedback from health center staff and utilized a modular, group format that did not rely on sequential session attendance. Feasibility was examined over 8 weeks ( n = 13). Preliminary effects on depression, health-related quality of life, and medication adherence were examined, and exit interviews were conducted with a subset of participants ( n = 4) to inform future modifications. Treatment descriptions and recommendations for effective clinical implementation based on patient and clinician feedback are provided along with case material of two individual patients and an example group session. Current efforts are an important next step for disseminating evidence-based techniques for depression and HIV medication adherence to community health center or AIDS service organization settings. [ABSTRACT FROM AUTHOR]

Objective: Body image disturbance is a common experience for sexual minority men living with HTV, and is associated with poor self-care behaviors. However, to date, no known cohesive theoretical model has been advanced to understand the possible antecedents and outcomes of body image disturbance in this population. Thus, the goal of the current study was to test a biopsychosocial model of body image and self-care behaviors among sexual minority men living with HIV. Method: Participants were 106 gay and bisexual men living with HIV who completed a battery of self-report measures, including assessment of body image disturbance, depression, lipodystrophy, appearance orientation, condom use self-efficacy, antiretroviral therapy (ART) adherence, and HIV sexual transmission risk behaviors. Bayesian estimation was employed to assess model fit and direct and indirect pathways within the model. Results: The data fit the model well, with all theorized pathways being significant. Lipodystrophy severity and appearance orientation were associated with elevated body image disturbance. In turn, body image disturbance was related to poorer ART adherence and increased HIV sexual transmission risk behaviors, through the mechanisms of elevated depressive symptoms and poor condom use self-efficacy. Conclusions: Elevated body image disturbance among sexual minority men living with HIV is associated with important biopsychosocial variables, which in turn are related to poorer ART adherence and increased HTV sexual transmission risk behaviors. Integrative psychosocial interventions addressing co-occurring body image disturbance, depression, and HIV self-care behaviors may be a fruitful area for future clinical practice and research. [ABSTRACT FROM AUTHOR]

Background: Effective and easy to implement interventions to improve adherence to antiretroviral therapy are needed. Objective: To compare site nurse-initiated adherence and symptom support telephone calls for HIV-positive individuals starting antiretroviral therapy to the study site's standard of care. Methods: A randomized controlled trial of site nurse-initiated adherence and symptom support telephone calls for HIV-positive individuals starting antiretroviral therapy. Subjects were ran-domized to receive site nurse-initiated telephone calls (intervention) or no additional calls to the site's standard of care (control). Subjects received calls 1 to 3 days after initiating antiretrovirals, on weeks 1, 2, 3, 6,10,14,18, 22, and 26, and every 8 weeks thereafter. Self-reported adherence was captured during study visits. Results: 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 = .34) and mean self-reported total adherence (97.9% and 98.4%) in the intervention and control groups, respectively, or in symptom distress and clinical endpoints. Conclusions: 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. [ABSTRACT FROM AUTHOR]

Objective: 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. Method: 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. Results: 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. Conclusions: 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. [ABSTRACT FROM AUTHOR]

Objective: Depression and substance use, the most common comorbidities with HIV, are both associated with poor treatment adherence. Injection drug users comprise a substantial portion of individuals with HIV in the United States and globally. The present study tested cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with HIV and depression in active substance abuse treatment for injection drug use. Method: This is a 2-arm, randomized controlled trial (N = 89) comparing CBT-AD with enhanced treatment as usual (ETAU). Analyses were conducted for two time-frames: (a) baseline to post-treatment and (b) post-treatment to follow-up at 3 and 6 months after intervention discontinuation. Results: At post-treatment, the CBT-AD condition showed significantly greater improvement than ETAU in MEMS (electronic pill cap) based adherence, Yslope = 0.8873, t(86) = 2.38, p = .02; dGMA-raw = 0.64, and depression, assessed by blinded assessor: Mongomery-Asberg Depression Rating Scale, F(1, 79) = 6.52, p < .01, d = 0.55; clinical global impression, F(1, 79) = 14.77, p < .001, d = 0.85. After treatment discontinuation, depression gains were maintained, but adherence gains were not. Viral load did not differ across condition; however, the CBT-AD condition had significant improvements in CD4 cell counts over time compared with ETAU, Yslope = 2.09, t(76) = 2.20, p = .03, dGMA-raw = 0.60. Conclusions: In patients managing multiple challenges including HIV, depression, substance dependence, and adherence, CBT-AD is a useful way to integrate treatment of depression with an adherence intervention. Continued adherence counseling is likely needed, however, to maintain or augment adherence gains in this population. [ABSTRACT FROM AUTHOR]

The article discusses a study that examined the sexual behaviors and other transmission risk factors of high-risk group members who are already HIV-positive in Chennai, India. Ways in which formative data from representative individuals living with HIV can assist in developing future primary prevention interventions are explored. High-risk groups in Chennai are listed, such as men who have sex with men (MSM), female commercial sex workers, men who travel for business, and injecting drug users. Subjects germane to HIV primary prevention are considered, including the role of HIV diagnosis as the entry into HIV education and risk reduction and misconceptions about HIV transmission.

Abstract: The two most common comorbid conditions with HIV are substance use disorders and depression, and individuals with comorbid HIV, depression, and substance dependence face a more chronic and treatment-resistant course. As an example of how to adapt evidence-based approaches to a complex comorbid population, the current case study examined the integration of a combined depression and HIV medication adherence treatment. The resulting intervention, ACT HEALTHY, combines a brief behavioral activation approach specifically developed to treat depression in individuals receiving residential substance abuse treatment (LETS ACT; Daughters et al., 2008) with a brief cognitive-behavioral approach to improving HIV medication adherence (Life-Steps; Safren et al., 1999; Safren et al., 2009). The current case series demonstrates the use of ACT HEALTHY among 3 depressed HIV-positive, low-income African Americans entering residential substance abuse treatment. [Copyright &y& Elsevier]

The article presents a study which tested whether a social-cognitive model of HIV transmission risk behaviors in HIV-infected men who have sex with men (MSM) would explain recent sexual transmission risk behavior among sexually active HIV-infected men who meet or do not meet screening criteria for major depression. It is concluded that sexual transmission risk behavior (STRB) models may not generalize to HIV-infected persons with depression and risk reduction interventions should account for comorbid mental health conditions for maximum effect.

Abstract: 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. [Copyright &y& Elsevier]

Male-to-female transgender individuals who engage in sex work constitute a group at high risk for HIV infection in the United States. This mixed-methods formative study examined sexual risk among preoperative transgender male-to-female sex workers (N =11) in Boston. More than one third of the participants were HIV-infected and reported a history of sexually transmitted diseases. Participants had a mean of 36 (SD =72) transactional male sex partners in the past 12 months, and a majority reported at least one episode of unprotected anal sex. Qualitative themes included (a) sexual risk, (b) motivations for engaging in sex work, (c) consequences of sex work, (d) social networks (i.e., “trans mothers,” who played a pivotal role in initiation into sex work), and (e) potential intervention strategies. Results suggest that interventions with transgender male-to-female sex workers must be at multiple levels and address the psychosocial and environmental contexts in which sexual risk behavior occurs. [Copyright &y& Elsevier]

Objective: To evaluate cognitive-behavioral therapy to enhance medication adherence and reduce depression (CBT-AD) in individuals with HIV. Design: A two arm, randomized, controlled, cross-over trial comparing CBT-AD to enhanced treatment as usual only (ETAU). ETAU, which both groups received, included a single-session intervention for adherence and a letter to the patient's provider documenting her or his continued depression. The intervention group also received 10 to 12 sessions of CBT-AD. Main Outcome Measures: Adherence to antiretroviral therapy as assessed by Medication Event Monitoring Systems (MEMs) and depression as assessed by blinded structured evaluation. Results: At the acute outcome assessment (3-months), those who received CBT-AD evidenced significantly greater improvements in medication adherence and depression relative to the comparison group. Those who were originally assigned to the comparison group who chose to cross over to CBT-AD showed similar improvements in both depression and adherence outcomes. Treatment gains for those in the intervention group were generally maintained at 6-and 12-month follow-up assessments. By the end of the follow-up period, those originally assigned CBT-AD demonstrated improvements in plasma HIV RNA concentrations, though these differences did not emerge before the cross-over, and hence there were not between-groups differences. Conclusions: CBT-AD is a potentially efficacious approach for individuals with HIV struggling with depression and adherence. Replication and extension in larger efficacy trials are needed. [ABSTRACT FROM AUTHOR]

Abstract: Cognitive behavioral therapists may have a unique and growing role in orthopedics departments. In helping patients cope with pain, particularly where there is no specific biomedical treatment or cure, cognitive behavioral practitioners can help prevent, early on, the transition from an acute pain complaint to a costly, disabling, and interfering chronic pain syndrome (CPS; see Singh, M. K., Patel, J., & Galagher, R. (2005). Chronic pain syndrome. Physical Medicine and Rehabilitation. Retrieved April 25, 2008, from. http://www.emedicine.com/pmr/topic32.htm for a thorough description). Idiopathic hand and arm pain is a prevalent, costly, and distressing condition. It is defined as pain in the hand or arm that is vague, diffuse, with unclear pathology, or pain that is over and above what is expected based on an objective medical finding ([Ring, D., Katzielsky, J., Malhotra, L., Lee, S. G., & Jupiter, J. B. (2005). Psychological factors associated with idiopathic arm pain. Journal of Bone and Joint Surgery, 87, 374--380]). Diagnosing and treating pain in general is challenging, and it is particularly challenging when there is no clear objective pathology, as in idiopathic pain. Patients with vague, diffuse, nonspecific pain complaints often present to orthopedic departments in hope of pain relief or cure via surgical procedures, yet surgeons are poorly equipped to deal with situations where pure medical management is unwarranted. This may be detrimental to patient care and lead to chronic pain syndrome. This article reviews research and common clinical issues in patients with idiopathic hand and arm pain who present to orthopedic departments; presents a multidisciplinary team approach in coordinating and providing care for these patients; and describes two case examples of the use of cognitive and behavioral interventions as part of this team approach. Utilizing cognitive and behavioral approaches may be a way to increase the quality of life of patients presenting with idiopathic arm pain, prevent transition to chronic pain syndrome, and circumvent costly and largely ineffective surgical procedures. [Copyright &y& Elsevier]

Scott-Sheldon, Kalichman, Carey, and Fiedler (2008) present a thoughtful, important, and timely meta-analysis of randomized controlled trials of stress management interventions in HIV. They differentiate controlled effect sizes across classes of acute outcomes including psychological distress, psychosocial processes, biological processes (immune status, viral, and hormonal) and fatigue. The authors join Scott-Sheldon et al., in considering future directions for this type of clinical psychosocial intervention research in HIV. Recommendations for addressing the high prevalence of psychosocial problems including diagnosable mental health disorders comorbid with HIV are presented. Suggestions for addressing medication adherence and accommodating interventions with concomitant substance use treatment are also considered. These recommendations are presented with an emphasis on expanding both the efficacy and effectiveness of psychosocial interventions in HIV. These recommendations are presented as realistic strategies for improving the modest treatment effect sizes for psychosocial outcomes and identifying meaningful effects on distal physiological outcomes associated with traditional stress management interventions in HIV. [ABSTRACT FROM AUTHOR]