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Social support, positive states of mind, and HIV treatment adherence in men and women living with HIV/AIDS


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Numerous studies have linked social support to better medication adherence among illness groups, but few have examined potential mechanisms for this relationship. Relationships were examined between social support, depression, positive states of mind (PSOM), and medication adherence among HIV positive men who have sex with men (n = 61) and women (n = 29) on highly active antiretroviral therapy. Depression and PSOM were evaluated as potential mediators of the relationship between support and adherence. Cross-sectional data showed that greater social support and PSOM related to better adherence whereas higher depression scores related to nonadherence. PSOM partially mediated the relationship between social support and adherence. PSOM may be an important mechanism through which social support is related to better medication adherence in this population.
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Social Support, Positive States of Mind, and HIV Treatment Adherence in
Men and Women Living With HIV/AIDS
Jeffrey S. Gonzalez, Frank J. Penedo,
Michael H. Antoni, and Ron E. Dura´n
University of Miami
Maria Isabel Fernandez
University of Miami School of Medicine
Shvawn McPherson-Baker and Gail Ironson
University of Miami Nancy G. Klimas and Mary Ann Fletcher
University of Miami School of Medicine
Neil Schneiderman
University of Miami
Numerous studies have linked social support to better medication adherence among illness groups, but
few have examined potential mechanisms for this relationship. Relationships were examined between
social support, depression, positive states of mind (PSOM), and medication adherence among HIV
positive men who have sex with men (n61) and women (n29) on highly active antiretroviral
therapy. Depression and PSOM were evaluated as potential mediators of the relationship between support
and adherence. Cross-sectional data showed that greater social support and PSOM related to better
adherence whereas higher depression scores related to nonadherence. PSOM partially mediated the
relationship between social support and adherence. PSOM may be an important mechanism through
which social support is related to better medication adherence in this population.
Key words: adherence, HIV, antiretroviral therapy, HAART, social support, positive states of mind
HIV continues to be a major health problem in the United States
and worldwide. The development of successful antiretroviral ther-
apies has improved the health of HIV positive (HIV) patients
although also demanding near-perfect medication adherence to
achieve maximum benefit and avoid treatment failure (Rabkin &
Chesney, 1999). Increasing patient adherence remains an impor-
tant challenge in the control of the virus and provides a major
opportunity for behavioral scientists to improve the health and
quality of life of HIVpatients. Highly active antiretroviral treat-
ment (HAART) is a very rigorous, demanding, and unforgiving
regimen commanding up to 22 pills a day (Friedland & Williams,
1999). Research shows that even modest or occasional nonadher-
ence to HAART greatly diminishes the benefits of treatment. In an
HIV drug trial, for example, the omission of even a single dose in
28 days was strongly associated with treatment failure (Montaner
et al., 1998). Perhaps the most sobering evidence for this comes
from Paterson et al. (2000), who reported that among patients who
adhered to between 80% and 90% of their HIV treatment doses—a
rate of adherence that would be considered acceptable in many
other treatment populations—only 50% of patients achieved viral
load levels below detectable limits. Approximately 81% of patients
who adhered to more than 95% of their medications had undetect-
able viral loads. Thus, even very minor nonadherence in HIV
treatment has unparalleled consequences for treatment success.
Social and psychological variables are among the most signifi-
cant factors that influence adherence to medical therapy. Social
support, often defined as the degree of one’s satisfaction with his
or her social relationships, has consistently been found to relate to
adherence behavior among various populations with chronic ill-
ness (e.g., Levy, 1983). Studies of HIV patients on combination
therapy have shown a positive association between perceived
social support quality and HAART adherence (e.g., Catz, Kelly,
Bogart, Benotsch, & McAuliffe, 2000) and medical appointment
attendance (Catz, McClure, Jones, & Brantley, 1999). Less satis-
faction with overall social support has been shown to relate to
poorer adherence as measured by pharmacy refill count (Singh et
al., 1999). Few studies have examined the mechanisms through
which social support is related to medication adherence (for ex-
ceptions, see Gonzalez et al., 2001; Simoni, Frick, Lockhart, &
Liebovitz, 2002). In the current study, we aimed to examine how
social support may be related to better medication adherence by
considering depression and positive states of mind (PSOM) as
potential mediators of this relationship.
Jeffrey S. Gonzalez, Frank J. Penedo, Michael H. Antoni, Ron E. Dura´n,
Shvawn McPherson-Baker, Gail Ironson, and Neil Schneiderman, Depart-
ment of Psychology, University of Miami; Maria Isabel Fernandez, De-
partment of Epidemiology and Public Health, University of Miami School
of Medicine; Nancy G. Klimas and Mary Ann Fletcher, Department of
Microbiology and Immunology, University of Miami School of Medicine.
This work was supported by National Institute of Mental Health Grants
PO1 MH49548 and T32 MH18917.
Correspondence concerning this article should be addressed to Michael
H. Antoni, Department of Psychology, University of Miami, P.O. Box
248185, Coral Gables, FL 33134. E-mail:
Health Psychology Copyright 2004 by the American Psychological Association
2004, Vol. 23, No. 4, 413–418 0278-6133/04/$12.00 DOI: 10.1037/0278-6133.23.4.413
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
It is well established that increased social support is predictive
of lower levels of depression (S. Cohen & Wills, 1985). Although
numerous studies have reported a relationship between social
support and depression, on the one hand (e.g., Leserman et al.,
1994), and depression and adherence, on the other hand (in chronic
illness populations, DiMatteo, Lepper, & Croghan, 2000; in per-
sons living with HIV, Catz et al., 2000; Singh et al., 1996), few
have examined how social support may relate to positive psycho-
logical variables. Social support may influence adherence through
associated increases in positive psychological states. S. Cohen and
Syme (1985) suggested that social support results in increases in
positive affect and other positive psychological states through the
stability, predictability, and control that it provides. Indeed, the
ability to maintain PSOM such as focused attention, productivity,
responsible caretaking, relaxation, sensuous pleasure, and a sense
of sharing has been conceptualized as an important aspect of
adjustment to stressful situations (Horowitz, Adler, & Kegeles,
1988). Research on this positive pathway from social support to
positive psychological factors is limited despite the importance of
social relationships in current theoretical models of positive human
health (e.g., Ryff & Singer, 1998). Satisfaction with social support
related to HIV/AIDS has been linked to increased PSOM in a
sample of HIVmen and women (Turner-Cobb et al., 2002). The
question of whether PSOM is related to adherence or other health
behaviors has also received limited research attention. One recent
study suggests that related factorsfeeling that one has a mean-
ingful life, feeling comfortable and well cared for, using time
wisely, and taking time for important thingsresult in better
medication adherence in older HIV patients (Holzemer et al.,
1999). These findings lend support for the positive pathway, but
research has been limited.
In this study, we aimed to contribute to the understanding of
how social support is related to medication adherence in HIV
patients by considering two possible mediational paths: (a) social
supports relationship to less depressive symptoms and (b) social
supports relationship to more PSOM. Last, we hypothesized that
these paths would be independent of each other.
Participants were 90 HIVmen who have sex with men (MSM) and
women (of any sexual orientation) who were participants in a larger
longitudinal psychosocial intervention study at the University of Miami.
Only preintervention data were included in our analyses. Participants were
recruited through community newspapers, HIV support service agencies,
doctorsoffices and medical clinics, HIV conferences and community
events, and fliers placed throughout the South Florida area.
Inclusion criteria included being an HIVfemale or MSM between the
ages of 18 and 65 and currently on a prescribed regimen of antiretroviral
combination therapy. Individuals identified with cognitive impairment or
active suicidal ideation, panic attacks, psychosis, or alcohol or drug de-
pendence within the past 3 months (First, Spitzer, Gibbon, & Williams,
1997) were also excluded. Additional temporary exclusionary criteria
included use of antibiotics within the previous 2 weeks, changes in any
HAART medications within the previous month, having had an infection
within the prior month, having had surgery within the prior 3 months,
initiation of formal psychotherapy or a formal aerobic fitness training
program within the past 3 months, and intravenous drug use within the
prior 6 months. Participants meeting inclusion criteria signed an informed-
consent form, completed a psychosocial battery with a trained interviewer,
and received monetary compensation ($50).
Demographic and health-related variables. The following variables
were assessed by a brief questionnaire as potential control variables:
demographic characteristics including age, income, education, race,
months since diagnosis of HIV, HIV symptoms (in the past 2 weeks),
alcohol and drug consumption (drinks/times used in the past 30 days), and
recent stressful life events (in the past 3 months).
Social Provisions Scale. The Social Provisions Scale (Cutrona & Rus-
sell, 1987) is a 24-item scale that assesses agreement with statements
concerning relationships with other people on a scale from 1 (strongly
disagree)to4(strongly agree). The Social Provisions Scale measures six
constructs of social relationship provisions: (a) attachment, (b) social
integration, (c) opportunity for nurturance, (d) reassurance of worth, (e)
reliable alliance, and (f) guidance. The coefficient alpha for the total score
was .88.
Beck Depression Inventory (BDI). The BDI (Beck, Ward, Mendelson,
Mock, & Erbaugh, 1961) is a 21-item self-report questionnaire that mea-
sures depressive symptom severity. Subscale scores were computed to
examine the psychological (Items 114) and somatic (Items 1521) aspects
separately. Coefficient alpha for the BDI was .87. Coefficient alphas for the
psychological and somatic composites were .85 and .67, respectively.
PSOM. The PSOM Scale (Horowitz et al., 1988) is a state measure that
assesses individualscapacities to enter positive cognitive and interper-
sonal states over the past week. As a construct, PSOM is related to positive
mood but is conceptually broader as it also includes ones ability to attain
and appreciate positive experiences related to general well-being. The
positive states measured are (a) focused attention, (b) productivity, (c)
responsible caretaking, (d) restful repose, (e) sensuous nonsexual pleasure,
(f) sharing, and (g) sensuous sexual pleasure. The total score is conceptu-
alized as a measure of overall positive mood and life satisfaction. The
PSOM Scale has demonstrated divergent validity from measures of social
desirability, stress, and negative mood and has shown convergent validity
with measures of positive mood (Adler, Horowitz, Garcia, & Moyer,
1998). Internal reliability was .82 in the current study.
Medication adherence. The Adherence to Combination Therapy Guide
(Chesney et al., 2000) is a validated instrument that assesses the proportion
of antiretroviral medications taken compared with the amount of medica-
tion prescribed for the participant over the previous 4-day period. A trained
interviewer administered this measure in an interview format. For the
current study, an overall measure of adherence was computed by summing
the number of pills taken during the previous 4 days and dividing by the
number of pills prescribed for the same period. The resulting ratio repre-
sented the percentage of HAART pills taken as prescribed.
Immune measures. Viral load and CD4T-lymphocyte cell counts
were assessed from peripheral blood samples taken during the assessment
between 9 a.m. and 12 p.m. Serum HIV RNA viral load was measured by
standard laboratory analyses determining the number of HIV virions per
microliter of peripheral blood plasma by using an Amplicor assay (Model
83988, Roche Laboratories, Pleasanton, CA). The lower limit of quantifi-
cation for this assay was 50 copies/
l. CD4T-lymphocyte cell counts
were assessed by flow cytometry methods using commercially prepared
antibodies as described by Fletcher, Baron, Ashman, Fischl, and Klimas
(1987). Viral load and CD4count were assessed for descriptive purposes,
and viral load was additionally used to assess its relationship to self-report
of medication adherence.
Table 1 reports demographic and HIV-related variables. To
establish the validity of the 4-day measure of self-reported medi-
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cation adherence, we tested the relationship between adherence
and HIV viral load on study entry. For all analyses, participants
who had missed any medication over the previous 4 days (n31)
were compared with those who reported perfect medication adher-
ence (n59). Analysis of variance controlling for number of days
between viral load measure and self-report adherence indicated
that nonadherent participants had a higher mean log10 viral load
(M3.19, SD 1.50) than adherent participants (M2.50,
SD 1.29), F(1, 82) 5.51, p.02. Examination of actual mean
differences in untransformed viral load values suggested that the
differences between adherent (M12,091 copies/
l, SD
31,162) and nonadherent (M43,438 copies/
l, SD 102,160)
participants were clinically significant. After establishing that non-
adherence to HAART was associated with poorer health status, we
examined psychosocial factors in relation to nonadherence.
Of all potential demographic and health-related control vari-
ables, only age and alcohol use were related to medication adher-
ence at the p.10 level. Nonadherent participants were younger
(M36 years) than adherent participants (M41 years); t(88)
2.91, p.01, and reported more alcohol consumption in the
previous week (M3.4 drinks, SD 3.7) than adherent partic-
ipants (M1.5 drinks, SD 2.7), t(88) ⫽⫺2.55, p.01.
Because alcohol use was significantly skewed, a square-root-
transformed variable was used as the covariate in regression anal-
yses below. No significant gender differences were found in ad-
herence rates (p.10). A set of moderated logistic regression
analyses tested gender as a moderator of the relationships between
social support, depression, PSOM, and medication adherence. In-
teraction terms were tested between gender and each independent
variable in each of the regressions presented below. Analyses
revealed no significant interaction effects (all ps.40), suggest-
ing that the relationships did not vary as a function of gender.
Table 2 shows the results of three separate logistic regression
analyses controlling for age and alcohol use and testing social
support, depression, and PSOM as correlates of medication adher-
ence. Results of these regression analyses indicated that social
support and PSOM were significantly related to medication adher-
ence. An initial analysis showed that total BDI score was nega-
tively related to adherence (odds ratio [OR] 0.47; 95% confi-
dence interval [CI] 0.28, 0.89; p.01). To rule out the
confound of health on somatic symptoms of depression, we ex-
amined the psychological symptom subscale of the BDI, which
was also related to adherence, as a mediator. The ORs in Table 2
are based on standardized variables and reflect the increase in the
odds of being a member of the adherent group associated with a 1
standard deviation unit increase in the independent variable.
Table 2
Independent Logistic Regression Models Predicting Medication
Adherence Group Membership
Step and variable Model
OR 95% CI Walds
Logistic Regression 1
Step 1 14.43***
Age 1.08 1.02, 1.15 6.65**
Alcohol 0.57 0.36, 0.90 5.73*
Step 2 20.78***
SPS total score 1.89 1.12, 3.18 5.66*
Logistic Regression 2
Step 1 14.43***
Step 2 19.61***
PSYBDI 0.58 0.35, 0.94 4.98**
Logistic Regression 3
Step 1 14.43***
Step 2 25.44***
PSOM 2.32 1.35, 4.00 9.20**
Note. Medication adherence was coded as 1 100% and 0 ⫽⬍100%.
Except for age, all odds ratios (ORs) are based on standardized variables to
facilitate comparison between variables. The OR for age reflects the
increase in odds associated with each 1-year increase in age. Alcohol
square-root-transformed alcohol use; Controls age and alcohol; CI
confidence interval; SPS Social Provisions Scale; PSYBDI psycho-
logical symptom score from Beck Depression Inventory; PSOM positive
states of mind.
For Step 1, df 2; for Step 2, df 3; N90.
*p.05. ** p.01. *** p.001.
Table 1
Sociodemographic and HIV-Related Variables
Variable n%MSD
Age (years) 39.4 9.5
Months since HIV diagnosis 67.6 46.1
Years on antiretrovirals 1.9 2.1
Total HIV medications (total
pills in last 4 days) 45.8 25.7
HAART adherence
Adherent (100%) 59 66
Nonadherent (100%) 31 34
HIV RNA copies/
l 22,785.7 65,865.2
Total CD4T cells/mm
392.2 244.0
Male 68
Female 32
Hispanic 37
Non-Hispanic White 31
Black 28
Other 4
Grades 712 19
High school 19
Some college 27
Graduated college 21
At least some graduate school 14
Annual income
$10,001 47
$10,001$30,000 30
$30,001$50,000 12
$50,000 9
Unknown 2
Employment status
Full time 31
Part time 10
Student 4
Unemployed 19
Disabled 32
Unknown 4
Note. HAART highly active antiretroviral treatment.
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Mediation Analyses
Psychological symptoms of depression. Following the proce-
dures outlined by Baron and Kenny (1986), we conducted a series
of regression analyses to test depressive symptoms as a mediator
of the relationship between emotional social support and medica-
tion adherence. Age and alcohol use were controlled in all logistic
regressions for which medication adherence was the dependent
variable. First, medication adherence (nonadherent vs. adherent)
was regressed on social support (B.07, p.02). Then, in a
separate regression model, medication adherence was regressed on
the psychological symptom subscale of the BDI (B⫽⫺.09, p
.03). Subscale scores were then regressed on social support (B
.21, p.01). A final analysis was conducted in which medica-
tion adherence was regressed on the potential mediator and on
social support. In this final hierarchical logistic regression model,
neither social support (
.05, p.08) nor the BDI subscale
(B⫽⫺.07, p.15) was significantly related to medication
adherence. However, as a block, they were significant,
(2, N
90) 8.41, p.02. The failure of these variables to indepen-
dently relate with medication adherence suggests that the unique
variance of each independent variable was not associated with
medication adherence. Because of their failure to uniquely relate to
medication adherence, psychological symptoms of depression
could not be considered a mediator.
PSOM. A similar series of four regressions were used to test
PSOM as a mediator of social support. Figure 1 shows the un-
standardized regression coefficients for the analyses testing PSOM
as a mediator. In the final model including both social support and
PSOM, the relationship of support to medication adherence was
attenuated (B.04, p.13), whereas PSOM retained its rela-
tionship to adherence (B.16, p.01). Sobels variance estimate
of the mediated effect (Baron & Kenny, 1986; MacKinnon &
Dwyer, 1993) revealed that the indirect path of social support
to medication adherence, mediated by PSOM, was significant
1.99, p.05). The equation
) showed that
approximately 37.5% of the relationship between social support
and medication adherence was mediated by PSOM (MacKinnon &
Dwyer, 1993). Thus, PSOM was found to be a substantial partial
mediator of the relationship between perceived support and adher-
ence. This model accounted for 37% of the variability in medica-
tion adherence (Nagelkerke R
Independence of PSOM From Depression
We hypothesized that the relationship of PSOM to medication
adherence would be independent of the relationship of depression
and adherence. A hierarchical logistic regression model revealed
that PSOM remained significantly associated (OR 2.07, CI
1.17, 3.66; p.01) with medication adherence when the BDI
subscale score was entered into the model. Psychological symp-
toms of depression were not significantly related to medication
adherence in this model. Furthermore, when psychological symp-
toms of depression were added to the PSOM mediation model, the
pattern of relationships presented in Figure 1 remained unchanged.
These results indicate that the relationship of PSOM to medication
adherence and its partial mediation of social supports relationship
to medication adherence are independent of depression.
In this study, we examined the relationship between social
support and medication adherence among HIVMSM and
women who were prescribed a regimen of HAART. We hypoth-
esized that social support would relate to adherence through its
relationship with lower depression and greater PSOM. Our hy-
pothesis was based on research showing consistent relationships
between social support and depression (e.g., S. Cohen & Wills,
1985) and theoretical models predicting associations between so-
cial support and positive psychological factors (S. Cohen & Syme,
1985). Perceived quality of social support was significantly asso-
ciated with medication adherence even after we controlled for age
and alcohol consumption. These findings are consistent with pre-
vious research that has shown relationships between aspects of
support and medication adherence among HIVpatients on com-
bination therapy (Catz et al., 2000; Singh et al., 1999). Perceived
quality of social support was also associated with less depressive
symptomatology and higher levels of PSOM, consistent with pre-
vious research (S. Cohen & Wills, 1985; Turner-Cobb et al., 2002).
We also found that depression and PSOM were each individu-
ally related to medication adherence. Depressive symptomatology
was inversely related to medication adherence. Higher levels of
PSOM were related to successful medication adherence. The cur-
rent studys finding that higher levels of depressive symptomatol-
ogy were related to medication nonadherence is consistent with
previous reports (e.g., Catz et al., 2000; Singh et al., 1996). It is
important to note that this relationship was maintained even when
we examined only psychological symptoms of depression, thus
eliminating possible somatic confounds.
The finding that PSOM was a significant correlate of medication
adherence is, to the best of our knowledge, novel. Although other
research has reported relationships between similar positive as-
pects of quality of life and medication adherence among HIV
patients (Holzemer et al., 1999), we are unaware of research
showing a relationship between PSOM, or other similar positive
psychological state variables, and medication adherence in any
illness group. This finding deserves further replication and could
have important implications for understanding medication adher-
ence behavior and other important health outcomes among HIV-
Figure 1. Path diagram representing mediation analysis for Positive
States of Mind (PSOM) Scale and path diagram for model testing direct
and indirect effects of social support on medication adherence. Unstand-
ardized regression coefficients for factors entered in model individually are
in parentheses, and unstandardized regression coefficients with all factors
in the model entered simultaneously are outside of parentheses. N.S.
nonsignificant. *p.05. **p.01. ***p.001.
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infected persons. Our findings complement those of Simoni et al.
(2002), which showed that depression scores and self-efficacy
partially mediated the relationship between need for social support
and nonadherence. Although their analyses did not compare the
independence of the effects, self-efficacy was found to be more
strongly related to nonadherence than depressive symptoms. Inter-
estingly, the Simoni et al. measure of depressive mood, the Center
for Epidemiological StudiesDepression Scale (Radloff, 1977),
like many other measures, includes items that reflect negative
affect (e.g., I felt sad) as well as items that reflect positive affect
(e.g., I enjoyed life). Positive affect items are reverse coded and
included in the overall score of negative affect. However, it seems
plausible that positive affect may have independent relationships
to adherence and other health outcomes. In fact, a recent study
suggests that positive affect is the active ingredientin the asso-
ciation of Center for Epidemiological StudiesDepression Scale
scores and mortality in a large sample of HIVmen (Moskowitz,
in press). Our findings, together with those of Moskowitz, suggest
that there is justification for expanding our focus on negative
psychosocial predictors of health outcomes to include positive
factors as well and to consider the overlap between these con-
structs in our analyses.
The current study showed that PSOM was also a significant
mediator of the relationship between social support and medication
adherence. Moreover, the relationship of PSOM to medication
adherence was independent of depression, suggesting that PSOM
represents more than the absence of depression, as hypothesized.
These findings are partially supportive of S. Cohen and Symes
(1985) direct effect theory regarding the relationship between
social support and health behaviors. Their model suggests that
social support affects health behaviors by decreasing negative
psychological factors and also by increasing positive factors. It
appears, in the case of this HIVpopulation, that social support is
related to medication adherence more through positive psycholog-
ical processes than through negative ones.
Further research is needed to identify how positive psycholog-
ical states (i.e., PSOM) are related to medication adherence be-
havior. One study has shown that positive affect predicted better
health practices such as exercise and good nutrition in a sample of
healthy college students (Griffin, Friend, Eitel, & Lobel, 1993).
Are HIVindividuals high in PSOM more likely to adhere to their
medications because of positive moods associated with PSOM?
The broaden-and-build theory of positive emotions proposes that
the experience of positive emotion broadens ones focus of atten-
tion, thinking, and behavioral repertoires and may facilitate prob-
lem solving (Fredrickson, 2001). This flexibility in problem solv-
ing may be adaptive to managing medication adherence in the
context of other life stressors that are commonly experienced by
HIV patients. More research is needed to examine the applicability
of this theory to the context of medication adherence.
Causal inferences cannot be drawn from the current study be-
cause of its cross-sectional design. Generalizing findings to other
populations should be cautioned because of our use of a conve-
nience sample that was paid for participation. The use of a number
of exclusionary criteria (e.g., alcohol dependence in past 3 months,
intravenous drug use in past 6 months) may also limit the gener-
alizability of our findings. The current study adds to most HIV
studies of medication adherence in that it included both MSM and
primarily ethnic minority women of lower socioeconomic status.
However, generalizing findings to other HIVgroups should be
cautioned. We measured self-reported medication adherence,
which is known to produce higher estimates of medication adher-
ence than more objective measures such as electronic bottle-cap
monitoring (C. Cohen, 2000). However, even objective measures
of adherence such as electronic bottle-cap monitoring have been
criticized and may provide limited and/or distorted information
about adherence behavior (Samet, Sullivan, Traphagen, & Ickov-
ics, 2001). Additionally, dichotomization of the adherence variable
limited our analyses to comparisons between those participants
who were adherent to all of their medications and those who were
not. Because even very low levels of nonadherence have been
associated with treatment failure in HAART (e.g., Montaner et al.,
1998; Paterson et al., 2000), we do not believe that this limits the
validity of our findings. Future longitudinal research should eval-
uate these relationships by using multiple measures of medication
adherence to increase validity and reliability.
Findings from mediational analyses are consistent with our
hypothesis that social support, through the stability, predictability,
and control that it provides, may facilitate increases in PSOM in
the support receiver. These positive factors may provide psycho-
logical resources to help HIVindividuals cope successfully with
the stressful aspects of taking HIV medication and may increase
motivation to take medication as prescribed. These findings may
be useful in the development of intervention strategies aimed at
improving medication adherence among HIVindividuals.
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... Therefore, only 55 POCs were reachable at the time, resulting in 34 individuals interviewed. The discrepancy between those we attempted to contact and those interviewed can be attributed to incorrect/non-updated phone numbers (15), inability to take time off work (4), and health concerns (2) that interfered with participation. ...
... As interviews were audio recorded according to consent of participants, recordings were transcribed postinterview. The first, second and third authors divided transcriptions (15,15, and 4 respectively) to read through, double check against original recordings and interviewer notes to ensure accuracy, and further highlight themes within the lower 4 nested levels of the SEM in relation to the primary focus. Through extensive discussion, themes were cross-referenced with other transcription highlights and with key ideas from audio-recording debrief sessions. ...
... As interviews were audio recorded according to consent of participants, recordings were transcribed postinterview. The first, second and third authors divided transcriptions (15,15, and 4 respectively) to read through, double check against original recordings and interviewer notes to ensure accuracy, and further highlight themes within the lower 4 nested levels of the SEM in relation to the primary focus. Through extensive discussion, themes were cross-referenced with other transcription highlights and with key ideas from audio-recording debrief sessions. ...
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Introduction Adherence to medication regimens is essential to decrease morbidity/mortality and increase life expectancy among HIV positive persons on Highly Active Anti-retroviral Therapy (HAART). This study was born in response to the absence of information regarding access and adherence to HAART among refugee and asylum seekers in urban, irregular, transit country settings. Objectives The purpose was to understand the barriers and facilitators to HIV medication adherence among refugees and asylum seekers living with HIV and to generate novel recommendations to facilitate adherence. Methods Individual in-depth interviews were conducted with 34 refugees and asylum seeks to explore their lived experiences. Interviews were structured around the social ecological model to capture influences of multiple levels. Thematic analysis was conducted on transcripts. Results Stigma, lack of knowledge and language barriers were among the main barriers noted by refugees and asylum-seekers in relation to HIV medication adherence, whereas interpersonal relationships, improved health, and strong patient-physician relationships were seen as facilitators. Participants noted their desire for community-support groups, education, and increased use of interpreters in order to combat some of the social barriers preventing full HIV medication adherence. Conclusion A regular status shapes participants’ adherence to HIV medications. Group-based interventions to support refugees are needed.
... Further, mindfulness is correlated with PA among SMM-LWH (Gayner et al., 2012). PA has been found to buffer against stress-related negative health outcomes for people living with chronic illness (Eaton et al., 2014;Moskowitz et al., 2008;Pressman & Cohen, 2005;Pressman et al., 2019) such as decreases in reported symptoms due to illness (Pressman & Cohen, 2005), increased medication adherence, (Bassett et al, 2019;Gonzalez et al., 2004) and lower stress levels due to diagnosis (Bica et al., 2003;Eaton et al., 2014;Folkman, Content courtesy of Springer Nature, terms of use apply. Rights reserved. ...
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Studies show positive affect buffers against stress for people living with HIV, however, limited research has examined its potential health benefits for sexual minority men living with HIV (SMM-LHIV). In our proof-of-concept pilot, we adapted a Positive Affect intervention for mobile app delivery. The Positively Healthy app was designed as an ecological momentary intervention using a just-in-time adaptive intervention (JITAI) delivery format. Participants were 22 SMM-LHIV (Mage = 37.82; SD = 10.52), who completed a 90-day ecological momentary assessment (EMA). JITAI activities were triggered based on reported stress in the EMA survey. Participants completed a post-intervention assessment assessing usability, feasibility, and acceptability. On average, participants reported stress in 58.21% of the EMAs and responded to 82.1% of the intervention activities. Qualitative interview data indicated that app-based delivery was acceptable and feasible. Participant feedback also revealed our intervention would benefit from further adaptation to enhance system usability and tailored content to optimize acceptability for SMM-LWH.
... Les représentations sociales à l'égard des personnes séropositives contiennent donc des éléments de stigmatisation à l'origine de certaines formes de rejet social (voir Crandall & Moriarty, 1995). Ce rejet compromet par ailleurs le soutien social qui prédit la qualité de vie d'une personne infectée par le VIH/SIDA et son adhésion aux traitements antirétroviraux (Friedland et al., 1996 ;Gonzalez et al., 2004). ...
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La résistance aux antibiotiques est reconnue comme l'une des plus grandes menaces sanitaires du XXIe siècle par l'Organisation Mondiale de la Santé. En France, au début des années 2000, des actions de santé publique ont été menées pour enrayer le phénomène, aboutissant à la création du premier plan intersectoriel de lutte contre l'antibiorésistance et à la première campagne nationale de communication. Cependant, le grand public ne semble pas réaliser l'ampleur de la menace. Dans cette thèse, nous mobilisons la théorie des représentations sociales pour atteindre deux objectifs spécifiques : (1) comprendre par quels mécanismes psychosociaux s'opère la construction d’un risque sanitaire, et (2) communiquer sur le risque et orienter le changement des pratiques de santé. Les résultats observés démontrent la pertinence d'une approche basée sur la théorie des représentations sociales dans le domaine de la santé. Tout d’abord, cette théorie constitue un outil « diagnostic » qui permet de mettre en évidence la manière dont un risque sanitaire est assimilé par le grand public. D'autre part, elle peut être considérée comme un outil « incitatif » dans la mesure où elle permet de cibler des pistes d’intervention en fonction des caractéristiques des groupes sociaux et des situations dans lesquelles ils s’inscrivent. Nous concluons cette thèse en évoquant d'autres possibilités de recherche et d'application dans le domaine de la santé.
... Interestingly in our study , those without any social support have been adherent to their medications much more (60%) at 3 to 10 months of follow up which is contrary to many studies which showcase social support as a big factor for adherence. 14,15 Regularity with ARVs has been more amongst married people (53%) when followed up for more than 10 months. We also saw a positive relationship between marriage and adherence at less than three months of follow up (50%). ...
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Background & objective: HIV/AIDS is mostly seen in people who inject recreational drugs (PWID). Adherence has to be optimum for its treatment to be effective. Compliance to HIV medication has been problematic in PWID making HIV control difficult. Many studies in the past have validated educational activities like rehabilitation programs beneficial in maintaining regularity in medication intake. This brought us to the question of looking at such programs and its effects on our population. This study was conducted to assess the impact of other perspectives of abstinence and adherence including family support and employment status on a person's willingness for treatment continuation and avoidance of drugs. Methods: A retrospective chart review of 241 PWID was conducted to assess adherence to antiretroviral agents (ARVs) and abstinence from recreational drugs post visit to the rehabilitation center. Associations with family support, marital status, employment, income and back to work status were also assessed. Results: Adherence to ARVs had significant statistical association with marital status (p=0.025), starting work again (p=0.001), family support (p=0.009), employment status (p=0.009) and monthly income (p=0.025). While family support (p=0.033), employment status (p<0.0001), Going back to work (p<0.0001), mode of travel to Rehabilitation center (p<0.0001) and monthly income (p=0.004) were associated with abstinence from drugs. Duration of rehabilitation or age had no effect on adherence or abstinence in our patient population of PWID. Conclusion: Family and spousal support and employment promote optimal ARV compliance and should be encouraged when starting ARVs. Enrollment in a long-term complementing educational program would further enhance ARV intake and abstinence.
... A positive state of mind as a result of strong social support, is also linked to greater medication adherence, a critical concern when it comes to living with one or more chronic health conditions [17]. ...
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The COVID-19 pandemic created a globally shared stressor that saw a rise in the emphasis on mental and emotional wellbeing. However, historically, these topics were not openly discussed, leaving those struggling without professional support. One powerful tool to bridge the gap and facilitate connectedness during times of isolation is online health communities (OHCs). This study surveyed Health Union OHC members during the pandemic to determine the degree of COVID-19 concern, social isolation, and mental health distress they are facing, as well as to assess where they are receiving information about COVID-19 and what sources of support they desire. The survey was completed in six independent waves between March 2020 and April 2021, and garnered 10,177 total responses. In the United States, OHCs were utilized significantly more during peak lockdown times, and the desire for emotional and/or mental health support increased over time. Open-ended responses demonstrated a strong desire for connection and validation, which are quintessential characteristics of OHCs. Through active moderation utilizing trained moderators, OHCs can provide a powerful, intermediate and safe space where conversations about mental and emotional wellbeing can be normalized and those in need are encouraged to seek additional assistance from healthcare professionals if warranted.
Purpose: This study examined feasibility, acceptability, and preliminary effects of a pilot randomized controlled trial (BRIDGES) designed to improve HIV care outcomes among syndemic-affected women living with HIV (WLHA). Method: We enrolled and randomized adult WLHA who were out-of-care or at risk of falling out-of-care and experienced any syndemic condition(s) into BRIDGES ( n = 11) or standard of care ( n = 13). BRIDGES employed peer navigation one-on-one sessions and six weekly 2-h video psychoeducation group sessions. Feasibility and acceptability were assessed through participant quantitative and semistructured interviews. Intention-to-treat analyses were conducted to evaluate the preliminary effects of BRIDGES. Results: BRIDGES was highly feasible and acceptable. Intervention participants demonstrated improved self-reported adherence to antiretroviral therapy at 3 months, and better engagement and retention in care and viral suppression at 12 months compared to control participants. Discussion: BRIDGES is a promising program to provide syndemic-affected WLHA with the tools needed to mitigate social and structural barriers to HIV care.
Rationale In the United States, Black women are disproportionately affected by HIV, accounting for most new HIV infections diagnosed among women. Socio-structural barriers to HIV testing include stigma and discrimination but may be mitigated by resilience. Objective We aimed to examine the effect of discrimination and resilience on HIV testing behaviors among Black women. Methods Between 2016 and 2018, we conducted The ESSENCE Study, a retrospective cohort study on the role of physiological and environmental factors on the association between sexual assault and HIV risk among Black women in Baltimore, Maryland, USA. Black women aged ≥18 were recruited from public health STD clinics and completed an audio-computer-assisted self-interview survey. Hierarchical multiple negative binomial regression models were used to examine the associations of everyday discrimination (subtle and overt) and resilience on HIV testing frequency; resilience and its subscales (relational maintenance, personal fortitude, positive coping, independence and insight) were also examined as moderators. Results Among 236 Black women reporting HIV testing history, the median number of lifetime HIV tests was 4 (IQR = 2, 6). Mean everyday discrimination was 2.3 (SD = 1.2). Mean resilience was 5.3 (SD = 0.8). Everyday discrimination and its subscales (overt and subtle) were negatively associated with lifetime HIV testing frequency, while overall resilience was not associated with lifetime HIV testing frequency. Accounting for demographics, overall resilience moderated the association of subtle discrimination and lifetime HIV testing frequency. For the resilience subscales, more specifically: (1) Associations of subtle discrimination and HIV testing frequency were significant at the lowest relational maintenance and lowest positive coping resilience; and (2) the association of subtle discrimination and HIV testing frequency was significant at the highest resilience for all four subscales. Conclusions These findings highlight the need for provider- and community-level interventions addressing the deleterious effects of everyday discrimination and more specifically subtle everyday discrimination to encourage HIV testing.
Nowadays, the use of social media has increased exponentially. People show different behavior on social media depending on the kind of responses and behavior of people around them. It is important now to analyze the behavior of social media users and the way how they affect their friends. In this paper, behavioral analysis of people is done based on Twitter data. An algorithm is proposed which helps in finding the impact of text written by someone on social media and its effect on others. The impact of written text is calculated with the help of the number of retweets done for the same tweet. The severity of the used word is calculated based on AFINN dictionary. According to the proposed algorithm, the score of the dictionary is recalculated when a negative word is forwarded multiple times. This is done with the understanding that if a less severe negative word is used many times, it may affect the person in a highly negative manner. With this, Severity of words is recalculated and its impact on people is found with the help of the proposed algorithm. The impact of using negative words on social media affect 32 % of the total users (in their friend-list). Behavior change is demonstrated with the help of graphs week-wise, month-wise and year-wise analyses. The research helps in finding the impact of swear words on social media users depending on the frequency and severity score of the words.
In the U.S., Black women living with HIV/AIDS (WLHA) are affected disproportionately by interpersonal violence, which often co-occurs with adverse mental health and/or substance use, and exacerbates existing poor HIV care outcomes. Peer navigation has been successful in improving HIV care; however, HIV clinics often lack resources for sustainability and may not account for socio-structural barriers unique to Black WLHA. To address this gap, we developed LinkPositively, a culturally-tailored, trauma-informed WebApp for Black WLHA affected by interpersonal violence to improve HIV care outcomes. Using focus group data from nine Black WLHA and peer navigators, we developed LinkPositively. Core components include: virtual peer navigation to facilitate skill-building to cope with barriers and navigate care; social networking platform for peer support; educational and self-care tips; GPS-enabled resource locator for HIV care and support service agencies; and medication self-monitoring/reminder system. If efficacious, LinkPositively will shift the HIV prevention and care paradigm for Black WLHA.
Background: Extant literature has identified Major Depressive Disorder (MDD) as a comorbid disorder in individuals with seropositive human immunodeficiency disorder (HIV), and this may affect HIV-treatment efficacy. However, there is a paucity of literature evaluating the effects of antidepressant use on antiretroviral therapies (ART) in HIV-positive individuals. Herein, the following review assesses the effects of antidepressant medications on ART adherence in HIV-positive individuals with diagnosed MDD. Methods: A systematic search on PubMed, Scopus, Web of Science, and Google Scholar search engines were conducted between database inception to June 12th, 2020 using the search and MeSH terms: (HIV) AND (antiretroviral or treatment) AND (depress*) AND (antidepressants) AND (adherence). Results: We identified nine articles that evaluated ART adherence in HIV-positive individuals using antidepressants. Of the nine included articles, eight articles evaluated participants undergoing ART, and one article evaluated participants undergoing highly active antiretroviral therapy (HAART). Our primary findings suggest that patients who took antidepressant treatment for depression demonstrated greater adherence to HIV treatments and a reduction in missed HIV medication dosage. Limitations: The heterogeneity of study design between the included studies was high. Conclusion: The current review suggests that response to antidepressant medication may improve adherence to HIV treatments in HIV-positive individuals with comorbid depression. Further studies should expand the findings to explore the effects of disparate psychotropic agents on adherence behaviors among patients with HIV to identify the benefits of these agents on long-term health outcomes in this vulnerable clinical population.
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In this article, we attempt to distinguish between the properties of moderator and mediator variables at a number of levels. First, we seek to make theorists and researchers aware of the importance of not using the terms moderator and mediator interchangeably by carefully elaborating, both conceptually and strategically, the many ways in which moderators and mediators differ. We then go beyond this largely pedagogical function and delineate the conceptual and strategic implications of making use of such distinctions with regard to a wide range of phenomena, including control and stress, attitudes, and personality traits. We also provide a specific compendium of analytic procedures appropriate for making the most effective use of the moderator and mediator distinction, both separately and in terms of a broader causal system that includes both moderators and mediators. (46 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Bumper stickers reading "Friends can be good medicine!" were distributed by the California Department of Mental Health in 1981 as part of a statewide health promotion initiative (California Department of Mental Health, 1981). The objectives of the initiative were to increase awareness of the health-promoting influence of supportive relationships and to encourage personal involvement providing support to others. Although the ultimate success of this project is unknown, its implementation reflects the degree to which a link between social support and health has become part of our belief system. Correlations between social support and health outcomes have been found in a range of contexts and using a variety of methods (for recent reviews, see Broadhead et al. Although links between social support and health are consistently found, our understanding of the nature of this relation remains limited. A problem in past research was that social support was conceptualized unidimensionally, although it was operationalized in many different ways (e.g., marital status, community involvement, availability of confidants). More recent efforts have analyzed social support into component functions. Theorists differ somewhat with respect to the specific functions served by social support, but most conceptualizations include emotional sustenance, self-esteem building, provision of information and feedback, and tangible assistance (e.g.. Once support is defined in terms of its functions, it is possible to generate hypotheses concerning the psychological processes through which social support has its effects. Although clear theoretical formulations of the helping functions served by relationships arc crucial in the generation of hypotheses, these predictions cannot be empirically tested without appropriate assessment instruments. As described in House and Kahn's (1985) recent review, a number of social support measures have been developed. The measures differ widely in their implicit models of social support, some assessing number of supporters, others tapping frequency of supportive acts, and still others measuring degree of satisfaction with support. A number of problems have plagued these measurement efforts. At the theoretical level, the authors of social support measures have rarely articulated the assumptions underlying their instruments. For example, if a measure assesses the number of supportive individuals, the assumption is that better outcomes are associated with the quantity of support sources. If a measure taps satisfaction with support, the assumption is that better outcomes are associated with the perception that support is adequate for one's needs, regardless of tile number of supporters. Although these differences are rarely articulated, different research questions are posed and answered as a function of the manner in which social support is assessed. Inconsistencies in the literature nay be related to differences in the aspects of social support that are assessed in different studies (see Cohen & Wills, 1985).
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The purpose of this article is to describe statistical procedures to assess how prevention and intervention programs achieve their effects. The analyses require the measurement of intervening or mediating variables hypothesized to represent the causal mechanism by which the prevention program achieves its effects. Methods to estimate mediation are illustrated in the evaluation of a health promotion program designed to reduce dietary cholesterol and a school-based drug prevention program. The methods are relatively easy to apply and the information gained from such analyses should add to our understanding of prevention.
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The primary objectives of this article are (a) to put forth an explicit operational formulation of positive human health that goes beyond prevailing "absence of illness" criteria; (b) to clarify that positive human health does not derive from extant medical considerations, which are not about wellness, but necessarily require a base in philosophical accounts of the "goods" in life; (c) to provoke a change of emphasis from strong tendencies to construe human health as exclusively about the mind or the body toward an integrated and positive spiral of mind-body influences; (d) to delineate possible physiological substrates of human flourishing and offer future directions for understanding the biology of positive health; and (e) to discuss implications of positive health for diverse scientific agendas (e.g., stress, class and health, work and family life) and for practice in health fields (e.g., training, health examinations, psychotherapy, and wellness intervention programs).
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Context.— Current guidelines recommend that individuals infected with the human immunodeficiency virus type 1 (HIV-1) be treated using combinations of antiretroviral agents to achieve sustained suppression of viral replication as measured by the plasma HIV-1 RNA assay, in the hopes of achieving prolonged remission of the disease. However, until recently, many drug combinations have not led to sustained suppression of HIV-1 RNA.Objective.— To compare the virologic effects of various combinations of nevirapine, didanosine, and zidovudine.Design.— Double-blind, controlled, randomized trial.Setting.— University-affiliated ambulatory research clinics in Italy, the Netherlands, Canada, and Australia (INCAS).Patients.— Antiretroviral therapy–naive adults free of the acquired immunodeficiency syndrome with CD4 cell counts between 0.20 and 0.60×109/L (200-600/µL).Intervention.— Patients received zidovudine plus nevirapine (plus didanosine placebo), zidovudine plus didanosine (plus nevirapine placebo), or zidovudine plus didanosine plus nevirapine.Main Outcome Measure.— Plasma HIV-1 RNA.Results.— Of the 153 enrolled patients, 151 were evaluable. At week 8, plasma HIV-1 RNA levels had decreased by log 2.18, 1.55, and 0.90 in the triple drug therapy, zidovudine plus didanosine, and zidovudine plus nevirapine groups, respectively (P<.05). The proportions of patients with plasma HIV-1 RNA levels below 20 copies per milliliter at week 52 were 51%, 12%, and 0% in the triple drug therapy, zidovudine plus didanosine, and zidovudine plus nevirapine groups, respectively (P<.001). Viral amplification was attempted in 59 patients at 6 months. Viral isolation was unsuccessful in 19 (79%) of 24, 10 (53%) of 19, and 5 (31%) of 16 patients in the triple drug therapy, zidovudine plus didanosine, and zidovudine plus nevirapine groups, respectively. Among patients from whom virus could be amplified, resistance to nevirapine was found in all 11 patients receiving zidovudine plus nevirapine and in all 5 patients receiving triple drug therapy. Rates of disease progression or death were 23% (11/47), 25% (13/53), and 12% (6/51) for the zidovudine plus nevirapine, zidovudine plus didanosine, and triple drug therapy groups, respectively (P=.08).Conclusions.— Triple drug therapy with zidovudine, didanosine, and nevirapine led to a substantially greater and sustained decrease in plasma viral load than the 2-drug regimens studied. Our results also suggest that suppression of viral replication, as demonstrated by a decrease in the plasma HIV-1 RNA load below the level of quantitation of the most sensitive test available, may at least forestall the development of resistance. Figures in this Article NEVIRAPINE, a potent and selective noncompetitive inhibitor of the reverse transcriptase enzyme of human immunodeficiency virus type 1 (HIV-1), belongs to the class of antiretroviral compounds referred to as nonnucleoside reverse transcriptase inhibitors.1- 2 Nevirapine has a wide distribution throughout body tissues, including the central nervous system.3- 5 Nevirapine has at least an additive in vitro antiviral effect with zidovudine, didanosine, and lamivudine, regardless of prior zidovudine exposure.6 Early clinical experience with nevirapine monotherapy demonstrated a substantial but transient decline of serum p24 antigen levels.7- 8 The loss of nevirapine activity was temporally associated with the emergence of drug resistance.9 Similar transient benefits were demonstrated when zidovudine and nevirapine were used in an alternating schedule.10 Administration of nevirapine in combination with zidovudine alone or zidovudine plus didanosine in previously treated patients led to a substantial improvement in the magnitude and durability of the antiviral response.11- 12 Nevertheless, the responses waned over time. Of note, the response seen with the triple drug therapy regimen was more durable, remaining beyond 1 year, particularly among patients with limited prior drug exposure.12 We hypothesized that a more vigorous suppression of viral replication could prevent or delay the emergence of nevirapine resistance and ultimately prolong the effect of treatment. We therefore undertook the present study to compare the virologic and immunologic effects of various combinations of nevirapine, didanosine, and zidovudine among antiretroviral therapy–naive, HIV-1–infected patients free of the acquired immunodeficiency syndrome (AIDS).
In this article, the author describes a new theoretical perspective on positive emotions and situates this new perspective within the emerging field of positive psychology. The broaden-and-build theory posits that experiences of positive emotions broaden people's momentary thought-action repertoires, which in turn serves to build their enduring personal resources, ranging from physical and intellectual resources to social and psychological resources. Preliminary empirical evidence supporting the broaden-and-build theory is reviewed, and open empirical questions that remain to be tested are identified. The theory and findings suggest that the capacity to experience positive emotions may be a fundamental human strength central to the study of human flourishing.
Although there is an abundance of literature linking social support and mental health, less attention has been paid to the psychological effects of social conflict. In a sample of HIV-positive and HIV-negative gay men, the present study focuses on: (1) how support satisfaction and frequency of social conflict correlate with measures of depression and other aspects of mental health at study entry, and (2) whether changes in social support or social conflict are related to changes in psychological status over a 1-year period. The sample was composed of 108 asymptomatic HIV-positive and 73 HIV-negative gay men. One-year follow-up data were available on 84 HIV-positive and 63 HIV-negative men. We found that: (1) psychological disturbance was related to frequent social conflict, and to a lesser extent, dissatisfaction with social support; and (2) increased psychological disturbance over 1-year was correlated with increased social conflict, and to a lesser extent, decreased support satisfaction. The pattern of relationships over time between changes in social interaction and changes in psychological health was slightly different far the serostatus groups. Social conflict and support satisfaction may have relevance far the psychological health of gay men. Depression 2:189—199 (1994/1995). © 1995 Wiley-Liss, Inc.
The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The new scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of de pression.
The measurement of adherence to antiretroviral medications has become a major focus of HIV research. Accurate means of assessing adherence is critical. The HIV epidemic has provided unique challenges in the quest to accurately determine adherence to medications. The strengths and weaknesses of the most common means for assessing adherence are briefly reviewed. Case studies from a research study assessing adherence in alcohol abusing patients with HIV are presented to illustrate the actual use of the Medication Events Monitoring System (MEMS) and patient self-report in a clinical research setting. Practical recommendations for optimizing measurement of adherence are provided. In research studies examining adherence to HIV medications, MEMS's potential to provide detailed accurate adherence information may be quite limited because of the complexity of the regimen, patient lifestyle factors, and the use of adherence aids such as pill boxes. Innovative measurement of medication adherence remains a critical research priority.