Center on Stress and Health


Remien, R. H., T. M. Exner, S. F. Morin, A. A. Ehrhardt, M. O. Johnson, J. Correale, S. Marhefka, S. B. Kirshenbaum, L. S. Weinhardt, M. J. Rotheram-Borus, S. L. Catz, C. Gore-Felton, M. A. Chesney and J. Kelly (2007). "Medication adherence and sexual risk behavior among HIV-infected adults: implications for transmission of resistant virus." AIDS Behav 11(5): 663-75.
As more people are living long-term with HIV there are growing concerns about specific behaviors that can affect both personal and the public health. This study examined the relationship between antiretroviral therapy (ART) adherence and sexual risk behavior and their association with psychosocial and health factors among a diverse sample of 2,849 HIV-infected adults. Only 8.5% of the sample reported both non-adherence and sexual risk. Individuals were 46% more likely to report one of these risk outcomes when the other one was present and the presence of both outcomes was associated with an increased likelihood of having a detectable viral load. A simultaneous polytomous regression analysis revealed complex relationships among a range of psychosocial variables and the two primary behavioral risk outcomes. There is a need for targeted interventions and integration of mental health and substance use services into primary HIV care settings.

Pequegnat, W., B. R. Rosser, A. M. Bowen, S. S. Bull, R. J. DiClemente, W. O. Bockting, J. Elford, M. Fishbein, L. Gurak, K. Horvath, J. Konstan, S. M. Noar, M. W. Ross, L. Sherr, D. Spiegel and R. Zimmerman (2007). "Conducting Internet-based HIV/STD prevention survey research: considerations in design and evaluation." AIDS Behav 11(4): 505-21.
The aim of this paper is to advance rigorous Internet-based HIV/STD Prevention quantitative research by providing guidance to fellow researchers, faculty supervising graduates, human subjects' committees, and review groups about some of the most common and challenging questions about Internet-based HIV prevention quantitative research. The authors represent several research groups who have gained experience conducting some of the first Internet-based HIV/STD prevention quantitative surveys in the US and elsewhere. Sixteen questions specific to Internet-based HIV prevention survey research are identified. To aid rigorous development and review of applications, these questions are organized around six common criteria used in federal review groups in the US: significance, innovation, approach (broken down further by research design, formative development, procedures, sampling considerations, and data collection); investigator, environment and human subjects' issues. Strategies promoting minority participant recruitment, minimizing attrition, validating participants, and compensating participants are discussed. Throughout, the implications on budget and realistic timetabling are identified.

Israelski, D. M., D. E. Prentiss, S. Lubega, G. Balmas, P. Garcia, M. Muhammad, S. Cummings and C. Koopman (2007). "Psychiatric co-morbidity in vulnerable populations receiving primary care for HIV/AIDS." AIDS Care 19(2): 220-5.
Considerable evidence suggests that people with HIV disease are significantly more distressed than the general population, yet psychiatric disorders are commonly under-detected in HIV care settings. This study examines the prevalence of three stress-related psychiatric diagnoses--depression, posttraumatic stress disorder (PTSD), and acute stress disorder (ASD), among a vulnerable population of HIV-infected patients. Among approximately 350 patients attending two county-based HIV primary care clinics, 210 participants were screened for diagnostic symptom criteria for depression, PTSD, and ASD. Standardized screening measures used to assess for these disorders included the Beck Depression Inventory, the Posttraumatic Stress Checklist, and the Stanford Acute Stress Questionnaire. High percentages of HIV-infected patients met screening criteria for depression (38 per cent), PTSD (34 per cent), and ASD (43 per cent). Thirty eight percent screened positively for two or more disorders. Women were more likely to meet symptom criteria for ASD than men (55 per cent vs. 38 per cent, OR=1.94, CI95 per cent=1.1-3.5). ASD was detected more commonly among African-American and white participants (51 per cent and 50 per cent respectively), compared with other ethnic groups. Latinos were least likely to express symptoms of ASD (OR=0.52, CI95 per cent=0.29-0.96). Of the 118 patients with at least one of these disorders, 51 (43 per cent) reported receiving no concurrent mental health treatment. Patients with HIV/AIDS who receive public healthcare are likely to have high rates of acute and posttraumatic stress disorders and depression. These data suggest that current clinical practices could be improved with the use of appropriate tools and procedures to screen and diagnose mental health disorders in populations with HIV/AIDS.

Remien, R. H., T. Exner, R. M. Kertzner, A. A. Ehrhardt, M. J. Rotheram-Borus, M. O. Johnson, L. S. Weinhardt, L. E. Kittel, R. B. Goldstein, R. M. Pinto, S. F. Morin, M. A. Chesney, M. Lightfoot, C. Gore-Felton, B. Dodge and J. A. Kelly (2006). "Depressive symptomatology among HIV-positive women in the era of HAART: a stress and coping model." Am J Community Psychol 38(3-4): 275-85.
OBJECTIVE: An enhanced stress and coping model was used to explain depression among HIV-positive women in healthcare and community settings where highly active anti-retroviral treatment (HAART) was commonplace. METHOD: HIV-infected women in four cities (N=978) were assessed, cross-sectionally, for mental and physical health, stress, social support, and other background factors. RESULTS: Self-reported level of depressive symptomatology was high. Number of physical symptoms, illness intrusiveness, and perceived stress were positively associated with depressed mood, while coping self-efficacy and social support were negatively associated. Stress mediated the effect of health status on depression and coping self-efficacy mediated the effect of psychosocial resources on depression. Our enhanced stress and coping model accounted for 52% of variance in depressive symtpomatology. CONCLUSIONS: Interventions focused on improving coping self-efficacy, bolstering social supports, and decreasing stress in the lives of HIV-positive women may help to reduce the negative effects of HIV disease on mood.

Pramanik, S., M. Chartier and C. Koopman (2006). "HIV/AIDS stigma and knowledge among predominantly middle-class high school students in New Delhi, India." J Commun Dis 38(1): 57-69.
This study examined stigmatizing attitudes toward HIV/AIDS among predominantly middle-class adolescents in New Delhi high schools. This study was specifically designed to: 1) assess stigmatizing attitudes toward HIV/AIDS and sexuality; HIV/AIDS knowledge, and awareness of HIV-related health resources; and 2) examine whether HIV-related stigma and knowledge are related to one another and to gender, parents' education, and exposure to HIV/AIDS education. In four high schools in New Delhi, 186 students completed a questionnaire assessing stigmatization of HIV/AIDS, stigmatization of sexuality, knowledge of HIV/AIDS, HIV/AIDS education and resources, and demographic characteristics. Adolescents varied in how much they stigmatized persons with HIV/AIDS. They generally lacked accurate knowledge about the disease and of related health resources. However, those with greater exposure to HIV/AIDS education demonstrated significantly greater HIV/AIDS knowledge. Female adolescents demonstrated significantly less knowledge about HIV/AIDS compared with male adolescents, while the males reported significantly greater exposure to HIV/AIDS education compared with the females. These results suggest a need for greater HIV/AIDS education and awareness of health resources, especially among female adolescents. Education must directly address stigmatizing attitudes about HIV/AIDS, gaps in HIV/AIDS knowledge and awareness of HIV-related health resources.

Johnson, M. O., M. A. Chesney, R. B. Goldstein, R. H. Remien, S. Catz, C. Gore-Felton, E. Charlebois and S. F. Morin (2006). "Positive provider interactions, adherence self-efficacy, and adherence to antiretroviral medications among HIV-infected adults: A mediation model." AIDS Patient Care STDS 20(4): 258-68.
Adherence to antiretroviral (ARV) therapy for HIV infection is critical for maximum benefit from treatment and for the prevention of HIV-related complications. There is evidence that many factors determine medication adherence, including adherence self-efficacy (confidence in one's ability to adhere) and relations with health care providers. However, there are no studies that examine how these two factors relate to each other and their subsequent influence on HIV medication adherence. The goal of the current analysis was to explore a model of medication adherence in which the relationship between positive provider interactions and adherence is mediated by adherence self-efficacy. Computerized self-administered and interviewer-administered self reported measures of medication adherence, demographic and treatment variables, provider interactions, and adherence self-efficacy were administered to 2765 HIV-infected adults on ARV. Criteria for mediation were met, supporting a model in which adherence self-efficacy is the mechanism for the relationship between positive provider interactions and adherence. The finding was consistent when the sample was stratified by gender, race, injection drug use history, and whether the participant reported receipt of HIV specialty care. Positive provider interactions may foster greater adherence self-efficacy, which is associated with better adherence to medications. Results suggest implications for improving provider interactions in clinical care, and future directions for clarifying interrelationships among provider interactions, adherence self-efficacy, and medication adherence are supported.

Hong, D. S., R. B. Goldstein, M. J. Rotheram-Borus, F. L. Wong and C. Gore-Felton (2006). "Perceived partner serostatus, attribution of responsibility for prevention of HIV transmission, and sexual risk behavior with "MAIN" partner among adults living with HIV." AIDS Educ Prev 18(2): 150-62.
Persons living with HIV (PLH) often attribute HIV status to sexual partners based on observable partner characteristics. The present study investigated the relationship of sexual behavior with most recent "main" partner to that partner's perceived serostatus among 1,232 PLH interviewed in clinics and community agencies in Los Angeles, California. PLH who believed their most recent main partner to be HIV-negative more often identified partner appearance as a basis for their perceptions than those who believed their most recent main partner to be HIV-positive. PLH who perceived their most recent main partner as HIV-negative were more likely to assume responsibility for partner protection and always to use condoms, and less likely to report recent unprotected vaginal or anal sex with that partner. Unprotected receptive anal intercourse with their most recent main partner was less common among African American, Latino, and White participants who believed that partner to be HIV-negative. Although PLH appear protective toward HIV-negative main partners, interventions to encourage valid methods of identifying partner serostatus are needed.

Gore-Felton, C., C. Koopman, D. Spiegel, M. Vosvick, M. Brondino and A. Winningham (2006). "Effects of quality of life and coping on depression among adults living with HIV/AIDS." J Health Psychol 11(5): 711-29.
This prospective study examined the effect of maladaptive coping strategies and psychological quality of life (QOL) on depression at two time points in a diverse sample of persons living with HIV/AIDS (N = 85). The use of maladaptive coping strategies to deal with the stress of living with HIV/AIDS, particularly engaging in various kinds of avoidant behaviors, was significantly associated with greater depression at baseline and increased depression at three months. QOL was the single most important predictor of depression. In an effort to develop effective clinical methods aimed at decreasing depression among adults living with HIV, future studies need to focus on improving quality of life and increasing adaptive coping strategies associated with the stress of living with HIV/AIDS.

Sikkema, K. J., E. S. Anderson, J. A. Kelly, R. A. Winett, C. Gore-Felton, R. A. Roffman, T. G. Heckman, K. Graves, R. G. Hoffmann and M. J. Brondino (2005). "Outcomes of a randomized, controlled community-level HIV prevention intervention for adolescents in low-income housing developments." Aids 19(14): 1509-16.
OBJECTIVES: Youth are increasingly at risk for contracting HIV infection, and community-level interventions are needed to reduce behavioral risk. DESIGN: A randomized, controlled, multi-site community-level intervention trial was undertaken with adolescents living in 15 low-income housing developments in five US cities. METHODS: Baseline (n = 1172), short-term follow-up (n = 865), and long-term follow-up (n = 763) risk assessments were conducted among adolescents, ages 12-17, in all 15 housing developments. The developments were randomly assigned in equal numbers to each of three conditions: experimental community-level intervention (five developments); "state-of-the-science" skills training workshops (five developments); and, education-only delayed control intervention (five developments). RESULTS: At long-term follow-up, adolescents living in the housing developments receiving the community-level intervention were more likely to delay onset of first intercourse (85%) than those in the control developments (76%), while those in the workshop developments (78%) did not differ from control condition adolescents. Adolescents in both the community-level intervention (77%) and workshop (76%) developments were more likely to use a condom at last intercourse than those in control (62%) developments. CONCLUSIONS: Community-level interventions that include skills training and engage adolescents in neighborhood-based HIV prevention activities can produce and maintain reductions in sexual risk behavior, including delaying sexual debut and increasing condom use.

Lightfoot, M., T. Rogers, R. Goldstein, M. J. Rotheram-Borus, S. May, S. Kirshenbaum, L. Weinhardt, C. Zadoretzky, L. Kittel, M. Johnson, C. Gore-Felton and S. F. Morin (2005). "Predictors of substance use frequency and reductions in seriousness of use among persons living with HIV." Drug Alcohol Depend 77(2): 129-38.
AIMS: To examine predictors of the current level of substance use and reductions in seriousness of substance use among adults living with HIV. DESIGN: Cross-sectional survey. Setting: Four major metropolitan areas of the United States. PARTICIPANTS: Three thousand eight hundred six adults living with HIV. MEASUREMENT: Self-reported substance use, depression, and quality of life from audio computer assisted self-interviewing and computer assisted personal interviewing structured assessments. FINDINGS: Recent substance use of persons living with HIV was classified as frequent (40%), occasional (32%), or abstinent (28%). Participants using drugs at a frequent level identified as heterosexual, had public insurance, and had higher levels of depression. Participants who reduced from a lifetime high seriousness in substance use were female, older, and knew their HIV status for a longer period of time. CONCLUSIONS: Screening and identification of substance use should be included in all treatment settings and community-based organizations serving adults living with HIV.

Ksobiech, K., A. M. Somlai, J. A. Kelly, C. Gore-Felton, E. Benotsch, T. McAuliffe, K. Hackl, D. Ostrovski and A. P. Kozlov (2005). "Demographic characteristics, treatment history, drug risk behaviors, and condom use attitudes for U.S. and Russian injection drug users: the need for targeted sexual risk behavior interventions." AIDS Behav 9(1): 111-20.
Two separate databases, one on Russian (n = 444) injection drug users (IDUs), and the other on U.S. IDUs (n = 241), were merged, and responses were compared. Results indicated that Russian IDUs perceived themselves to be at greater risk for HIV/AIDS based upon behaviors over the past 90 days. U.S. IDUs were more likely to be tested for HIV, report a negative HIV result, and know more people with HIV. U.S. IDUs consumed greater amounts of alcohol and marijuana, and made more alcohol/drug treatment attempts than Russian IDUs. Russian IDUs injected more frequently, although were more likely to recently use clean needles. Russian and U.S. IDUs responded significantly differently to eight AIDS knowledge questions. Eight condom attitude questions were asked of each group, and each revealed significantly different responses. Gender differences for Russian IDUs were also observed. There is a clear need to create culturally targeted sexual risk reduction interventions.

Johnson, M. O., E. Charlebois, S. F. Morin, S. L. Catz, R. B. Goldstein, R. H. Remien, M. J. Rotheram-Borus, J. D. Mickalian, L. Kittel, F. Samimy-Muzaffar, M. A. Lightfoot, C. Gore-Felton and A. Chesney (2005). "Perceived adverse effects of antiretroviral therapy." J Pain Symptom Manage 29(2): 193-205.
Adverse effects from antiretroviral therapy (ARV) for HIV are associated with medication nonadherence. The purposes of this study were to explore group differences in the reporting of adverse effects, identify individual adverse effects that are linked to nonadherence, and to explore the role of coping in the relationship between adverse effects and adherence. Cross-sectional interviews of 2,765 HIV-positive adults on ARV therapies in four U.S. cities were performed using a computerized assessment of self-reported adverse effects, coping self-efficacy, and adherence. There were no gender differences in the rate or severity of adverse effects reported. Latino respondents reported more adverse effects than either White or African Americans. Those taking a protease inhibitor (PI) reported a higher rate and greater severity of adverse effects. Older participants reported fewer adverse effects despite being more likely to be on a regimen containing a PI. Respondents with less than 90% adherence reported greater numbers and severity of adverse effects overall. In multivariate analyses, nausea, skin problems, vomiting, and memory adverse effects were independently related to less than 90% adherence over the prior three days. Coping moderated the relationship between nausea and adherence such that individuals who reported lower coping self-efficacy and experienced nausea were at increased risk for nonadherence, regardless of the length of time on the current ARV regimen. Women and men are similar in their overall reports of adverse effects, and Latinos report more adverse effects to ARVs than White or African American patients. Specific adverse effects (skin problems, memory problems, vomiting, and nausea) are more likely than others to be associated with missing ARV medications. Increasing adaptive coping self-efficacy among patients experiencing nausea may be a particularly effective strategy in increasing medication adherence.

Gore-Felton, C., M. J. Rotheram-Borus, L. S. Weinhardt, J. A. Kelly, M. Lightfoot, S. B. Kirshenbaum, M. O. Johnson, M. A. Chesney, S. L. Catz, A. A. Ehrhardt, R. H. Remien and S. F. Morin (2005). "The Healthy Living Project: an individually tailored, multidimensional intervention for HIV-infected persons." AIDS Educ Prev 17(1 Suppl A): 21-39.
The NIMH Healthy Living Project (HLP), a randomized behavioral intervention trial for people living with HIV, enrolled 943 individuals, including women, heterosexual men, injection drug users, and men who have sex with men from Los Angeles, Milwaukee, New York, and San Francisco. The intervention, which is based on qualitative formative research and Ewart's Social Action Theory, addresses three interrelated aspects of living with HIV: stress and coping, transmission risk behavior, and medication adherence. Fifteen 90-minute structured sessions, divided into 3 modules of five sessions each, are delivered to individuals. Sessions are tailored to individuals within a structure that uses role-plays, problem solving, and goal setting techniques. A 'Life Project'--or overarching goal related to personal striving-provides continuity throughout sessions. Because this is an ongoing project with efficacy yet to be established, we do not report intervention outcomes. However, the intervention was designed to be useful for prevention case management, settings where repeated one-on-one contact is possible, and where a structured but highly individualized intervention approach is desired.

Goldstein, R. B., M. J. Rotheram-Borus, M. O. Johnson, L. S. Weinhardt, R. H. Remien, M. Lightfoot, S. L. Catz, C. Gore-Felton, S. Kirshenbaum and S. F. Morin (2005). "Insurance coverage, usual source of care, and receipt of clinically indicated care for comorbid conditions among adults living with human immunodeficiency virus." Med Care 43(4): 401-10.
BACKGROUND AND OBJECTIVES: Associations of insurance coverage and source of care with use of human immunodeficiency virus (HIV)-related health, mental health, and substance abuse services are examined in a large, diverse, highly active antiretroviral therapy-era cohort. METHODS: Adults who were infected with HIV (n = 3818) were interviewed in clinics and community agencies in Los Angeles, Milwaukee, New York, and San Francisco regarding drug use behaviors, health status, and health care utilization. RESULTS: Most participants were insured by Medicaid. During the previous 3 months, 90% of privately insured, 87% of publicly insured, and 78% of uninsured participants had visited any provider. Publicly and privately insured participants were similar in receipt of antiretrovirals, prophylaxis against Pneumocystis carinii pneumonia, substance abuse services, and antidepressants. Uninsured participants were less likely to receive antiretrovirals but were more likely to use substance abuse services. Participants with no usual source of care were less likely to receive PCP prophylaxis. CONCLUSIONS: A lack of insurance is associated with barriers to care, but the advantage of private over public coverage appears smaller than in previous studies. PCP prophylaxis, substance abuse treatment, and antidepressants remain markedly underutilized. Educational initiatives about these treatments targeting providers and patients are indicated.

Belanoff, J. K., B. Sund, C. Koopman, C. Blasey, J. Flamm, A. F. Schatzberg and D. Spiegel (2005). "A randomized trial of the efficacy of group therapy in changing viral load and CD4 counts in individuals living with HIV infection." Int J Psychiatry Med 35(4): 349-62.
OBJECTIVE: This randomized pilot study evaluates whether seropositive patients who are randomly assigned to receive a supportive-expressive group therapy plus education intervention show greater improvements in increased immune function and decreased viral load compared to those randomly assigned to an education-only intervention. METHOD: Fifty-nine individuals who had been HIV-seropositive for at least 6 months prior to inclusion in the study and had been receiving standard pharmacologic treatment were entered in a prospective randomized trial of the effects of weekly supportive-expressive group therapy on changes in immune status. Participants were matched for AIDS status and sex and randomized to receive weekly sessions of group psychotherapy plus educational materials on HIV/AIDS, or to receive the educational materials alone. Participants were assessed before treatment and then 12 weeks later. RESULTS: Individuals who were randomized to group therapy showed a statistically significant increase in CD4 count and decrease in HIV viral load. Among individuals randomized to the education only condition, no significant change occurred in CD4 count or viral load. CONCLUSIONS: These results provide preliminary data suggesting that HIV-seropositive individuals who receive supportive-expressive group psychotherapy may experience concomitant improvements in CD4 cell count and viral load. Further research with a larger sample should examine the possible underlying mechanisms of such benefits.

Ashton, E., M. Vosvick, M. Chesney, C. Gore-Felton, C. Koopman, K. O'Shea, J. Maldonado, M. H. Bachmann, D. Israelski, J. Flamm and D. Spiegel (2005). "Social support and maladaptive coping as predictors of the change in physical health symptoms among persons living with HIV/AIDS." AIDS Patient Care STDS 19(9): 587-98.
This study examined social support and maladaptive coping as predictors of HIV-related health symptoms. Sixty-five men and women living with HIV/AIDS completed baseline measures assessing coping strategies, social support, and HIV-related health symptoms. The sample was primarily low-income and diverse with respect to gender, ethnicity, and sexual orientation. Three, 6, and 12 months after completing baseline assessments, physical health symptoms associated with HIV disease were assessed. After controlling for demographic characteristics, CD4 T-cell count, and baseline HIV-related health symptoms, individuals reporting lower increase in HIV-related health symptoms used less venting (expressing emotional distress) as a strategy for coping with HIV. However, when satisfaction with social support was added to the model, the use of this coping strategy was no longer significant, and individuals reporting more satisfying social support were more likely to report lower increase in their HIV-related health symptoms, suggesting that social support is a robust predictor of health outcomes over time independent of coping style and baseline medical status. These findings provide further evidence that social support can buffer deleterious health outcomes among individuals with a chronic illness. Future research needs to examine mediating pathways that can explain this relationship.

Winningham, A., S. Corwin, C. Moore, D. Richter, R. Sargent and C. Gore-Felton (2004). "The changing age of HIV: sexual risk among older African American women living in rural communities." Prev Med 39(4): 809-14.
BACKGROUND: African American women aged 50 and older are disproportionately affected by the HIV/AIDS epidemic. Despite African Americans making up 11% of all older women in the United States, in 2001, they accounted for more than 50% of AIDS cases among older women and more than 65% of HIV cases among older women. Using the AIDS Risk Reduction Model as a conceptual framework, this study investigated HIV risk behavior among older rural African American women (mean age = 58 years). METHODS: A cross-sectional survey was conducted (n = 181) in three rural counties in South Carolina. RESULTS: Most (67%) of the women had at least one sex partner in the past five years, and of these, more than half (59.5%) reported at least one sexual risk behavior. High-risk behavior was associated with less education, lower condom use self-efficacy, more peers who discussed HIV-related risk behavior, and less comfort communicating with partners about sex. CONCLUSIONS: A significant proportion of older African American women living in rural counties are at increased risk for HIV infection, suggesting an urgent need for HIV prevention efforts to target this population.

Weinhardt, L. S., J. A. Kelly, M. J. Brondino, M. J. Rotheram-Borus, S. B. Kirshenbaum, M. A. Chesney, R. H. Remien, S. F. Morin, M. Lightfoot, A. A. Ehrhardt, M. O. Johnson, S. L. Catz, S. D. Pinkerton, E. G. Benotsch, D. Hong and C. Gore-Felton (2004). "HIV transmission risk behavior among men and women living with HIV in 4 cities in the United States." J Acquir Immune Defic Syndr 36(5): 1057-66.
Determining rates of HIV transmission risk behavior among HIV-positive individuals is a public health priority, especially as infected persons live longer because of improved medical treatments. Few studies have assessed the potential for transmission to the partners of HIV-positive persons who engage in high-risk activities. A total of 3723 HIV-infected persons (1918 men who have sex with men [MSM], 978 women, and 827 heterosexual men) were interviewed in clinics and community-based agencies in Los Angeles, Milwaukee, New York City, and San Francisco from June 2000 to January 2002 regarding sexual and drug use behaviors that confer risk for transmitting HIV. Less than one quarter of women and heterosexual men had 2 or more sexual partners, whereas 59% of MSM reported having multiple partners. Most unprotected vaginal and anal sexual activity took place in the context of relationships with other HIV-positive individuals. Approximately 19% of women, 15.6% of MSM, and 13.1% of heterosexual men engaged in unprotected vaginal or anal intercourse with partners who were HIV-negative or whose serostatus was unknown. The majority of sexually active participants disclosed their serostatus to all partners with whom they engaged in unprotected intercourse. An estimated 30.4 new infections (79.7% as a result of sexual interactions with MSM) would be expected among the sex partners of study participants during the 3-month reporting period. Eighteen percent of 304 participants who injected drugs in the past 3 months reported lending their used injection equipment to others. In addition to the more traditional approaches of HIV test counseling and of focusing on persons not infected, intensive prevention programs for persons with HIV infection are needed to stem the future spread of the virus.

Vosvick, M., C. Gore-Felton, E. Ashton, C. Koopman, T. Fluery, D. Israelski and D. Spiegel (2004). "Sleep disturbances among HIV-positive adults: the role of pain, stress, and social support." J Psychosom Res 57(5): 459-63.
OBJECTIVE: Investigate the relationships between pain, stress, social support, and sleep disturbance among a diverse sample of HIV-positive adults. METHOD: Participants (N = 146) completed self-report measures on pain, stress, social support, and sleep disturbance. CD4 T-cell count was obtained from medical records. RESULTS: Greater pain and stress were associated with greater sleep disturbance. Greater assistance from friends was associated with greater sleep disturbance, whereas greater understanding from friends regarding participants' HIV-related stress was associated with less sleep disturbance. CONCLUSION: As expected, pain was significantly associated with sleep disturbance. Additionally, psychosocial variables were strongly associated with sleep. The type of support from friends differentiated whether the support was positively or negatively associated with sleep problems. Social support, depending on the type, may not always be helpful for adults living with HIV/AIDS. Future studies need to examine factors that may mediate the relationship between psychosocial constructs and healthy sleep.

Sikkema, K. J., M. J. Brondino, E. S. Anderson, C. Gore-Felton, J. A. Kelly, R. A. Winett, T. G. Heckman and R. A. Roffman (2004). "HIV risk behavior among ethnically diverse adolescents living in low-income housing developments." J Adolesc Health 35(2): 141-50.
PURPOSE: To describe patterns and predictors of HIV risk behaviors among ethnically diverse, low-income adolescents. METHODS: Computer-assisted surveys were administered to 1172 adolescents between the ages of 12 and 17 years living in 15 low-income housing developments in three urban areas in the United States to characterize and identify predictors of HIV risk behavior. Data were analyzed using multinomial logistic regression to identify variables predictive of "no risk," "lower risk," and "higher risk" group classification. RESULTS: Most adolescents were not yet sexually active; nonetheless, a subset of youth reported high rates of HIV risk-related behaviors. HIV risk was highest among adolescents who were older, had weaker intentions to reduce risk, stronger beliefs that their sexual partners did not favor risk-reduction, lower risk-reduction behavioral skills, higher risk-reduction outcome expectation, and higher rates of substance use. CONCLUSIONS: HIV prevention efforts are needed that are tailored to ethnically diverse communities of adolescents, including those in early adolescence and those at highest risk.

Kelly, J. A., A. M. Somlai, E. G. Benotsch, T. L. McAuliffe, Y. A. Amirkhanian, K. D. Brown, L. Y. Stevenson, M. I. Fernandez, C. Sitzler, C. Gore-Felton, S. D. Pinkerton, L. S. Weinhardt and K. M. Opgenorth (2004). "Distance communication transfer of HIV prevention interventions to service providers." Science 305(5692): 1953-5.
Most acquired immunodeficiency syndrome (AIDS) service providers are in countries with little access to scientific developments relevant to their programs. It is critical to transfer advances from the scientific arena to service providers on a global scale. Human immunodeficiency virus (HIV) prevention organizations in 78 countries were randomized to receive either a control condition or a technology transfer condition with an interactive distance learning computer training curriculum and individualized distance consultation. Of 42 nongovernmental organizations in the technology transfer condition, 29 adopted the science-based program in their communities or trained other agencies to also use it. Advanced communication technologies can create a cost-effective infrastructure to disseminate new intervention models to service providers worldwide.

Kalichman, S. C., C. Gore-Felton, E. Benotsch, M. Cage and D. Rompa (2004). "Trauma symptoms, sexual behaviors, and substance abuse: correlates of childhood sexual abuse and HIV risks among men who have sex with men." J Child Sex Abus 13(1): 1-15.
Childhood sexual abuse is associated with high-risk sexual behavior in men who have sex with men. This study examined psychological and behavioral correlates of HIV risk behavior associated with childhood sexual abuse in a sample of men who have sex with men. Men attending a large gay pride event (N = 647) completed anonymous surveys that assessed demographic characteristics, childhood sexual abuse history, symptoms of dissociation and trauma-related anxiety, borderline personality characteristics, substance use, and sexual risk behavior. Results indicated that men who have a history of childhood sexual abuse were more likely to: engage in high-risk sexual behavior (i.e., unprotected receptive anal intercourse), trade sex for money or drugs, report being HIV positive, and experience non-sexual relationship violence. Results of this study extend previous research to show that men who have sex with men and who have a history of child sexual abuse are more likely to be at high risk for HIV infection.

Benotsch, E. G., A. M. Somlai, S. D. Pinkerton, J. A. Kelly, D. Ostrovski, C. Gore-Felton and A. P. Kozlov (2004). "Drug use and sexual risk behaviours among female Russian IDUs who exchange sex for money or drugs." Int J STD AIDS 15(5): 343-7.
Countries of the former Soviet Union are experiencing the steepest increases in annual HIV incidence in the world. Over 80% of registered HIV cases in Russia have occurred among intravenous drug users (IDUs), but current conditions set the stage for a heterosexually-transmitted epidemic. IDUs who also trade sex for money or drugs may serve as a conduit, or 'bridge' group, through which HIV could make inroads into the general Russian population. The present study examined the prevalence of sex trading among female Russian IDUs, and further examined drug use, sexual behaviour, and perceived vulnerability in this group. Female IDUs (n=100) in St Petersburg, Russia participated; 37% reported a history of sex trading. This group reported a mean of 49.5 male sexual partners in the previous month and an average of 15.4 unprotected vaginal intercourse acts in the previous 30 days. A significant minority (44%) also reported sharing injection equipment with others. Mathematical models to calculate risk estimates for HIV seroconversion indicated that participants were at significant risk of contracting HIV and infecting sexual partners. Despite significant rates of risk behaviours, most participants perceived themselves to be at little risk of contracting HIV. Effective HIV prevention programmes targeted at this group are urgently needed and are likely to be a cost-effective step in curtailing the spread of HIV in the region.

Vosvick, M., C. Koopman, C. Gore-Felton, C. Thoresen, J. Krumboltz and D. Spiegel (2003). "Relationship of functional quality of life to strategies for coping with the stress of living with HIV/AIDS." Psychosomatics 44(1): 51-8.
The authors examined factors associated with four dimensions of functional quality of life (physical functioning, energy/fatigue, social functioning, and role functioning) in 142 men and women living with HIV/AIDS. Participants completed the Brief COPE inventory and the Medical Outcomes Study Health Survey, with HIV-relevant items added. Greater use of maladaptive coping strategies was associated with lower levels of energy and social functioning. Pain severe enough to interfere with daily living tasks was associated with a lower level of functional quality of life on all four quality of life dimensions. Interventions aimed at developing adaptive coping strategies and improving pain management may improve functional aspects of quality of life in persons living with HIV/AIDS.

Rotheram-Borus, M. J., J. Song, M. Gwadz, M. Lee, R. Van Rossem and C. Koopman (2003). "Reductions in HIV risk among runaway youth." Prev Sci 4(3): 173-87.
Runaway youth are 6-12 times more likely to become infected with HIV than other youth. Using a quasi-experimental design, the efficacy of an HIV prevention program was evaluated over 2 years among 2 groups of runaways: (1) those at 2 shelters who received Street Smart, an intensive HIV intervention program, and (2) youth at 2 control shelters. Street Smart provided youth with access to health care and condoms and delivered a 10-session skill-focused prevention program based on social learning theory to youth. Prior to analysis of the intervention's outcomes, propensity scores were used to identify comparable subgroups of youth in the intervention (n = 101) and control conditions (n = 86). Compared to females in the control condition, females in the intervention condition significantly reduced their unprotected sexual acts at 2 years and alcohol use, marijuana use, and the number of drugs used over 12 months. Male adolescents in the intervention condition showed significant reductions in marijuana use over 6 months compared to control youth. Adolescent HIV prevention programs must proactively identify mechanisms for maintaining behavior change over the long-term, and innovative research designs are needed to allow examination of agency-level interventions.

Power, R., C. Koopman, J. Volk, D. M. Israelski, L. Stone, M. A. Chesney and D. Spiegel (2003). "Social support, substance use, and denial in relationship to antiretroviral treatment adherence among HIV-infected persons." AIDS Patient Care STDS 17(5): 245-52.
This study examined the relationship of adherence to antiretroviral treatment with three types of social support (partner, friends, and family) and use of two coping strategies (denial and substance use). Participants were 73 men and women with HIV infection drawn from a larger sample of 186 clinical trial patients. Based on inclusion criteria, parent trial participants taking antiretroviral therapies, and those with complete data on self-reported measures of adherence were considered eligible for the present study. Overall, 26% of participants were found to be nonadherent, which was defined as one or more missed doses of treatment in the prior 4-day period. Logistic regression analysis was conducted to determine associations of sociodemographic and psychosocial variables with adherence to antiretroviral regimen. Results indicated that heterosexual participants (p < 0.01) and participants of Latino ethnicity (p < 0.05) were significantly more likely to report missed medications. Perceived satisfaction with support from a partner was associated with taking antiretroviral therapy as prescribed, whereas satisfaction with support from friends and from family was not significantly related to adherence. Examination of coping strategies showed that participants reporting drug and alcohol use (p <.05) to cope with HIV-related stress were more likely to be nonadherent. These findings call for adherence interventions designed to address barriers and strengths, such as community norms or traditional cultural values, specific to certain populations. Furthermore, couple-based approaches enlisting partner support may help persons living with HIV to adhere to antiretroviral regimens.

Johnson, M. O., S. L. Catz, R. H. Remien, M. J. Rotheram-Borus, S. F. Morin, E. Charlebois, C. Gore-Felton, R. B. Goldsten, H. Wolfe, M. Lightfoot and M. A. Chesney (2003). "Theory-guided, empirically supported avenues for intervention on HIV medication nonadherence: findings from the Healthy Living Project." AIDS Patient Care STDS 17(12): 645-56.
OBJECTIVES: Adherence to antiretroviral therapy (ART) remains a challenge in efforts to maximize HIV treatment benefits. Previous studies of antiretroviral adherence are limited by low statistical power, homogeneous samples, and biased assessment methods. Based on Social Action Theory and using a large, diverse sample of men and women living with HIV, the objectives of the current study are to clarify correlates of nonadherence to ART and to provide theory-guided, empirically supported direction for intervening on ART nonadherence. DESIGN: Cross-sectional interview study utilizing a computerized interview. SETTING: Recruited from clinics, agencies, and via media ads in four U.S. cities from June 2000 to January 2002. PARTICIPANTS: Two thousand seven hundred and sixty-five HIV-positive adults taking ART. MAIN OUTCOME MEASURE: Computer-assessed self-reported antiretroviral adherence. RESULTS: Thirty-two percent reported less than 90% adherence to ART in the prior 3 days. A number of factors were related to nonadherence in univariate analysis. Multivariate analyses identified that being African American, being in a primary relationship, and a history of injection drug use or homelessness in the past year were associated with greater likelihood of nonadherence. Furthermore, adherence self-efficacy, and being able to manage side effects and fit medications into daily routines were protective against nonadherence. Being tired of taking medications was associated with poorer adherence whereas a belief that nonadherence can make the virus stronger was associated with better adherence. CONCLUSIONS: Results support the need for multifocused interventions to improve medication adherence that address logistical barriers, substance use, attitudes and expectancies, as well as skills building and self-efficacy enhancement. Further exploration of issues related to adherence for African Americans and men in primary relationships is warranted.

Greig, F. E. and C. Koopman (2003). "Multilevel analysis of women's empowerment and HIV prevention: quantitative survey Results from a preliminary study in Botswana." AIDS Behav 7(2): 195-208.
This preliminary study explored relationships between women's empowerment and HIV prevention on the national and individual level with a focus on Botswana. Among sub-Saharan Africa countries, HIV prevalence was positively correlated with indirect indicators of women's empowerment relating to their education (female enrollment in secondary education and ratio of female to male secondary school enrollment), but not to their economic status (female share of paid employment in industry and services) or political status (women's share of seats in national parliament), while controlling for gross national income, percentage of births attended, and percentage of roads paved. Condom use at last sexual encounter was positively and significantly correlated with both indicators of women's educational empowerment, but was not significantly related to the other two indices. Empowerment at the individual level was explored through a preliminary quantitative survey of 71 sexually active women in Gaborone, Botswana, that was conducted in February 2001. Regression analyses showed that women's negotiating power and economic independence were the factors most strongly related to condom use, and did not show that education was a crucial factor. Economic independence was the factor most strongly related to negotiating power. These results suggest that in Botswana, HIV prevention efforts may need to improve women's negotiating skills and access to income-generating activities.

Gore-Felton, C., M. Vosvick, R. Power, C. Koopman, E. Ashton, M. H. Bachmann, D. Israelski and D. Spiegel (2003). "Alternative therapies: a common practice among men and women living with HIV." J Assoc Nurses AIDS Care 14(3): 17-27.
This study examined the prevalence and factors associated with alternative therapy use in an ethnically diverse, gender-balanced sample of persons living with HIV/AIDS. More than two thirds (67%) of the participants who were taking HIV-related medications were also taking an alternative supplement. Half of the sample (50%) reported that they took one or more multivitamins, 17% reported using mineral supplements, 12% reported using Chinese herbs, and 12% reported using botanicals. Substantial proportions of the sample also reported using acupuncture (31%), massage (23%), and meditation (28%) to specifically treat HIV-related symptoms. Women were four times more likely to use alternative therapies than men. Also, Caucasians were nearly four times more likely to use alternative treatments compared to other ethnic groups. The results of this study indicate a strong need to assess individual patients' use of alternative treatment approaches as well as to further investigate their efficacy among HIV-positive patients.

Gore-Felton, C., M. Vosvick, T. Bendel, C. Koopman, B. Das, D. Israelski, M. Herrera, K. Litzenberg and D. Spiegel (2003). "Correlates of sexually transmitted disease infection among adults living with HIV." Int J STD AIDS 14(8): 539-46.
This study examined the prevalence of sexually transmitted diseases (STDs) as well as the relationships between STDs and coping strategies used to deal with the stress of living with HIV among adults. The sample comprised 179 men and women, 58% were Caucasian, 54% were male, more than half (61%) were diagnosed with AIDS, 43% were heterosexual, and 39% reported an STD post-HIV diagnosis. Logistic regression analysis indicated that individuals reporting longer time elapsed since HIV diagnosis and greater use of emotion-focused coping were more likely to report STDs. There was an interaction effect between time and coping such that the less time that elapsed since HIV diagnosis and the more an individual used emotion-focused coping, the more likely they were to report an STD. Tailoring interventions to address specific stressors associated with length of time living with HIV, may be a particularly effective prevention strategy.

Gore-Felton, C., A. M. Somlai, E. G. Benotsch, J. A. Kelly, D. Ostrovski and A. Kozlov (2003). "The influence of gender on factors associated with HIV transmission risk among young Russian injection drug users." Am J Drug Alcohol Abuse 29(4): 881-94.
HIV infection rates are dramatically increasing in the Russian Federation. Epidemiological studies indicate that the greatest rise of HIV incidence has been among injection drug users (IDU). Young adults (N = 188) who reported injecting drug use completed surveys and interviews that assessed injection drug use behavior, sexual behavior, and HIV-related knowledge. The average age of participants was 21.3 years. Multiple linear regression analysis found male gender and younger age at sexual debut was positively and significantly associated with having multiple sexual partners. Gender moderated the effects of sexual debut and number of times injected drugs were used in the past month. Males who initiate sex at a younger age were more likely to report multiple sex partners and females who reported higher frequency of drug use were more likely to report multiple sex partners. Gender is an important factor, as well as moderator of risk behavior among Russian injection drug users. Delaying sexual debut, particularly for males, may be an effective strategy to reduce subsequent risk behavior. Prevention efforts among IDUs need to address sexual risk behavior in conjunction with injection risk behavior.

Ananth, P. and C. Koopman (2003). "HIV/AIDS knowledge, beliefs, and behavior among women of childbearing age in India." AIDS Educ Prev 15(6): 529-46.
This study investigated the relationships of health beliefs and HIV/AIDS knowledge with frequency of condom use among women of childbearing age in four major Indian cities. Surveys were completed by 210 women attending six primary health care centers. Among the sexually active women (N = 139), 68% noted rare or no use of condoms during intercourse. Perceived benefits (p < .05) and normative efficacy in requesting condom use (p = .01) were related to a greater frequency of condom use. About 54% of women knew that breast milk could transmit HIV, but fewer than a third were aware that an HIV-positive mother does not always infect her infant at delivery. Most participants endorsed HIV testing for women prior to pregnancy. Approximately three fourths of participants advocated abortion for HIV-seropositive pregnant women. Intervention efforts may benefit from dispelling misconceptions about AIDS (particularly regarding vertical transmission), emphasizing perceived benefits and women's efficacy in requesting condom use, increasing the availability of HIV testing, and highlighting choices for seropositive women of reproductive age as alternatives to abortion.

Turner-Cobb, J. M., C. Gore-Felton, F. Marouf, C. Koopman, P. Kim, D. Israelski and D. Spiegel (2002). "Coping, social support, and attachment style as psychosocial correlates of adjustment in men and women with HIV/AIDS." J Behav Med 25(4): 337-53.
The purpose of this study was to examine psychosocial correlates of adjustment to HIV/AIDS in a sample of 137 HIV-positive persons (78 men and 59 women). Multiple regression analysis was used to examine relationships between perceived quality of general social support, three attachment styles, and three coping styles with total score on Positive States of Mind Scale (PSOMS), our measure of adjustment. The influence of demographic and medical status variables was also accounted for. PSOMS total score was significantly associated with greater satisfaction with social support related to HIV/AIDS, more secure attachment style, and less use of behavioral disengagement in coping with HIV/AIDS. These results indicate that for people with HIV or AIDS, those individuals who are more satisfied with their relationships, securely engaged with others, and more directly engaged with their illness are more likely to experience positive adjustment. Implications for physical health outcome and opportunities for intervention are discussed.

Somlai, A. M., J. A. Kelly, E. Benotsch, C. Gore-Felton, D. Ostrovski, T. McAuliffe and A. P. Kozlov (2002). "Characteristics and predictors of HIV risk behaviors among injection-drug-using men and women in St. Petersburg, Russia." AIDS Educ Prev 14(4): 295-305.
The purpose of this study was to establish the prevalence of high-risk sexual behaviors and drug-using behaviors in a large community sample of male and female injection drug users (IDUs) in St. Petersburg, Russia. This investigation used a data collection plan that systematically recruited a drug user sample from venues where IDUs were known to congregate and could be accessed. Surveys were completed by 239 IDUs (males = 139, females = 100), aged 13-25. Participants averaged 44 injections (range = 0-240) in the past 30 days, with heroin (70%) and heroin plus other drugs (20%) the most frequently used. Participants' mean age of first drug injecting was 17.6 years, 41% of participants regularly shared needles, most had multiple sexual partners (mean = 9.3 partners in the past 3 months), and 70% reported engaging in vaginal intercourse without condoms. Stepwise logistic regression showed that high-risk sexual behavior was predicted by being female, young, using heroin several times a month, and less negative attitudes toward using condoms. Effective HIV prevention efforts for IDUs in Russia must be tailored to their age, gender, drug use, and condom attitudes. These programs will also have to address the dual risk factors, unique to IDUs, of risky sexual behaviors and needle sharing. Without a rapid intervention response, Russia's HIV/AIDS crisis will soon turn catastrophic.

Power, R., C. Gore-Felton, M. Vosvick, D. M. Israelski and D. Spiegel (2002). "HIV: effectiveness of complementary and alternative medicine." Prim Care 29(2): 361-78.
Outcome studies examining the efficacy of CAM among people living with HIV-AIDS are often conducted among small sample sizes with very little follow-up data or time points. Generalizability of many of the study findings is further limited by participant attrition. It is difficult to conduct clinical studies on chronically ill patients without participants dropping out, typically because the study demands coupled with their illness become too burdensome. Several studies have been conducted that include control groups, double-blind designs, and randomization. These scientifically sound studies have demonstrated promising results that strongly indicate a need for further research with larger samples in a prospective research design so that safety and efficacy can be determined over time. Many of the studies with small sample sizes reported trends, but did not find statistical significance. Increasing sample sizes in future studies is necessary to evaluate the scientific merit of these trends. Moreover, researchers need to evaluate the clinical and statistical significance in CAM use. The psychologic benefits of taking CAM should not be underestimated. For the purposes of this article, the authors did not include psychologic outcomes; however, there is evidence suggesting that decreasing depression can decrease HIV-related somatic complaints [69]. Studies need also to examine the effectiveness of CAM on psychologic outcomes and physical outcomes. This article and the authors' own research (Gore-Felton C et al, unpublished data) have revealed a high prevalence of alternative supplement use in conjunction with HIV medication, indicating an urgent need to understand the health benefits and the health risks of alternative supplements among patients with HIV and AIDS. Patients and physicians need more empirically based research to examine the toxicities, interactions, and health benefits of CAM. Many patients do not report the use of CAM to their physicians and very few physicians record treatments in the clinical record [70]. This will likely change as CAM becomes more widely recognized as a legitimate medical intervention; however, controlled outcome studies among large, diverse samples of people living with HIV-AIDS are needed. Health care providers need to assess the use of herbal and alternative therapy practices by their patients. Some patients may not be aware that they are taking a supplement or plant-based herb. Furthermore, some patients may believe that they are using something innocuous and even healthy simply because it came from a health food store. Understanding the contraindications of alternative therapies is necessary to prevent deleterious outcomes and to facilitate the safe and efficacious use of CAM in the management of HIV disease and related symptoms. As the epidemic in the United States continues to rise among women and minority populations, clinical research trials must include ethnically diverse patient populations that are gender balanced. Current available studies indicate that many CAM interventions may improve the quality of life of people living with HIV-AIDS; however, further studies using longitudinal, controlled designs are needed to accurately assess the safety of such interventions.

Martinez, A., D. Israelski, C. Walker and C. Koopman (2002). "Posttraumatic stress disorder in women attending human immunodeficiency virus outpatient clinics." AIDS Patient Care STDS 16(6): 283-91.
This study examined posttraumatic stress disorder (PTSD) in human immunodeficiency virus (HIV)-positive women seeking medical care. Specifically, we examined traumatic life events, psychiatric treatment, social support, and demographic characteristics in relation to level of PTSD symptoms. We recruited and obtained informed consent from 47 ethnically diverse HIV-positive women from two HIV outpatient clinics in a county medical system. Forty-one of these women provided complete data on measures assessing demographics, traumatic life events, PTSD symptoms, social support, and psychotherapy/medical history. Analysis of the data demonstrated that a high percentage (42%) of the HIV-positive women were likely to meet criteria for full current PTSD, and an additional 22% for partial PTSD. Of the women likely with full PTSD, 59% were not receiving any psychiatric treatment, and of those likely with partial PTSD, 78% were not receiving any psychiatric treatment. Also, women reported having experienced a mean of 12 traumatic life events. As hypothesized, the level of PTSD was significantly related to the number of life events experienced (rs = 0.52, p < 0.001), and to perceived social support from friends (rs = - 0.34, p < 0.02) and family (rs = - 0.29, p < 0.05). Given the high percentages of women who were found to have experienced traumatic life events and high levels of PTSD symptoms, it seems important to assess and treat PTSD in women with HIV/acquired immune deficiency syndrome (AIDS).

Koopman, C., C. Gore-Felton, N. Azimi, K. O'Shea, E. Ashton, R. Power, S. De Maria, D. Israelski and D. Spiegel (2002). "Acute stress reactions to recent life events among women and men living with HIV/AIDS." Int J Psychiatry Med 32(4): 361-78.
OBJECTIVE: This study examined the prevalence of acute stress reactions to recent life events among persons living with HIV/AIDS. A second aim was to investigate the relationship of acute stress reactions among HIV-infected men and women to posttraumatic stress disorder (PTSD) symptoms to previous traumatic life events. METHOD: Participants included 64 HIV-seropositive persons (33 men and 31 women) drawn from a larger study examining the effects of group therapy on quality of life and health behavior. These individuals were assessed at baseline on demographic and medical status characteristics and (PTSD) symptoms andthen randomly assigned to either receive group therapy plus education or education alone. Three months later they were assessed for acute stress reactions to recent life events. RESULTS: Nearly a third (31.3 percent) of the participants reported levels of acute stress reactions to recent life events that met all symptom criteria for the diagnosis of acute stress disorder. However, only 9.4 percent of the respondents described a recent stressful life event that was threatening to the life or physical integrity of themselves or others. Acute stress reactions to recent life events were significantly and positively related to experiencing PTSD symptoms to prior traumatic life events. Acute stress did not differ significantly by gender, AIDS status, or whether or not participants had received 12 weeks of group therapy. CONCLUSIONS: A subset of individuals with HIV/AIDS experience high levels of acute stress reactivity to life events considered non-traumatic. HIV-infected individuals who react strongly to ongoing life stressors are more likely to have developed PTSD symptoms in response to previous traumatic life events.

Catz, S. L., C. Gore-Felton and J. B. McClure (2002). "Psychological distress among minority and low-income women living with HIV." Behav Med 28(2): 53-60.
The growing incidence of HIV infection among low-income and minority women makes it important to investigate how these women adjust to living with HIV and AIDS. Psychological distress associated with HIV infection may compound the adjustment difficulties and increase the barriers to care associated with living in poverty. The authors surveyed 100 women who were receiving HIV care at a public hospital in the southeastern United States on measures of depression, anxiety, life stress, social support, and coping; they also assessed demographic and medical characteristics of the sample. Participants' annual incomes were low (87% < $10,000), and most participants were minorities (84% African American). Their levels of depression, stress, and anxiety symptoms were elevated relative to community norms. Greater anxiety and depression symptoms were associated with women who reported higher stress, using fewer active coping strategies, and perceiving less social support (ps < .001).

Volk, J. E. and C. Koopman (2001). "Factors associated with condom use in Kenya: a test of the health belief model." AIDS Educ Prev 13(6): 495-508.
This study examined specific cultural beliefs and knowledge about HIV as well as tested components of the Health Belief Model in relation to condom use in Kisumu, Kenya. Interviews were conducted with 223 participants at six governmental and private clinics. Although 75% had engaged in intercourse during the preceding month, fewer than 20% had used a condom. For both men and women, perceived barriers was the only component of the Health Belief Model significantly associated with condom use, with greater perceived barriers being associated with lower frequency of condom use (p < .05). Additionally, individuals with more education and HIV/AIDS knowledge were less likely to endorse stigmatizing beliefs toward HIV/AIDS (p < .001), whereas people who believe that HIV originated in the United States were more likely to endorse these stigmatizing beliefs (p <.002). Nearly everyone (97%) reported that AIDS is the disease that scares them most, suggesting that educational efforts have successfully communicated the severity of this disease. Future intervention efforts must now focus more extensively on addressing stigmatizing beliefs and providing education to overcome barriers to condom use.

Israelski, D., C. Gore-Felton, R. Power, M. J. Wood and C. Koopman (2001). "Sociodemographic characteristics associated with medical appointment adherence among HIV-seropositive patients seeking treatment in a county outpatient facility." Prev Med 33(5): 470-5.
BACKGROUND: Adherence is a major problem facing HIV-seropositive patients. Low adherence has been associated with faster disease progression as well as development of drug-resistant strains of HIV. Thus it is critical to understand factors associated with treatment compliance. This study examined the independent contributions of disease severity, age, gender, household income, homelessness, ethnicity, and sexual orientation on appointment adherence. METHODS: Participants (n = 671) scheduled for appointments in an outpatient county treatment facility for HIV-related medical care completed demographic questionnaires and clinic staff collected appointment attendance data. RESULTS: Multiple regression analyses indicated that patients diagnosed with AIDS, older in age, and receiving a higher income were more likely to keep medical appointments. Additionally, African American ethnicity and identifying as heterosexual were associated with missing scheduled medical appointments. CONCLUSIONS: These data suggest that cultural and sociodemographic characteristics influence patients' adherence to outpatient services. Implications for interventions aimed at increasing medical adherence are discussed.

Gore-Felton, C., C. Koopman, E. McGarvey, N. Hernandez and R. J. Canterbury, Jr. (2001). "Relationships of sexual, physical, and emotional abuse to emotional and behavioral problems among incarcerated adolescents." J Child Sex Abus 10(1): 73-88.
This study examined the relationships of sexual, physical and emotional abuse to emotional (internalizing) and behavioral (externalizing) problems among incarcerated girls and boys. Participants were youth who were remanded to the correctional facilities within a statewide juvenile correctional system in a southern state in the United States of America. Each participant completed a structured interview regarding abuse history, emotional and behavioral difficulties, and demographic characteristics. Multiple regression analyses indicated that girls were more likely than boys to internalize their problems. The only abuse variable that was positively and significantly associated with emotional problems was emotional abuse. Greater behavioral problems were significantly related to youths being younger in age, white ethnicity, history of sexual abuse, and history of physical abuse. There were overall gender differences for internalizing problems, but not for externalizing problems among incarcerated adolescents. Furthermore, physical and sexual abuses were related to externalizing problems but not to internalizing problems. Thus, different types of abuse appear to have different effects on adolescent behavior. Implications for future research and practice are discussed.

Gore-Felton, C., L. D. Butler and C. Koopman (2001). "HIV disease, violence, and post-traumatic stress." Focus 16(6): 5-6.

Koopman, C., C. Gore-Felton, F. Marouf, L. D. Butler, N. Field, M. Gill, X. H. Chen, D. Israelski and D. Spiegel (2000). "Relationships of perceived stress to coping, attachment and social support among HIV-positive persons." AIDS Care 12(5): 663-72.
The purpose of this study was to examine the relationships of coping, attachment style and perceived social support to perceived stress within a sample of HIV-positive persons. Participants were 147 HIV-positive persons (80 men and 67 women). Multiple regression analysis was used to examine the relationships of the demographic variables, AIDS status, three coping styles, three attachment styles and perceived quality of general social support with total score on the Perceived Stress Scale (PSS). PSS score was significantly associated with less income, greater use of behavioural and emotional disengagement in coping with HIV/AIDS, and less secure and more anxious attachment styles. These results indicate that HIV-positive persons who experience the greatest stress in their daily lives are those with lower incomes, those who disengage behaviourally/emotionally in coping with their illness, and those who approach their interpersonal relationships in a less secure or more anxious style.

Rotheram-Borus, M. J., M. Rosario, H. Reid and C. Koopman (1995). "Predicting patterns of sexual acts among homosexual and bisexual youths." Am J Psychiatry 152(4): 588-95.
OBJECTIVE: This longitudinal study examined predictors of patterns of change in HIV sexual risk acts among homosexual and bisexual adolescent males. METHOD: A consecutive series of 136 homosexual and bisexual males aged 14-19 years were recruited into the study. Subjects were predominantly Hispanic (51%) and African American (31%) and seeking services at a homosexual-identified community-based agency in New York City. All subjects participated in an intensive HIV intervention program. Patterns of change in HIV sexual risk acts were based on assessments at four points (intake and 3, 6, and 12 months later) and were used to classify youths as demonstrating one of five patterns of anal and oral sexual acts: protected (anal: 45%, oral: 25%), improved (32% and 28%, respectively), relapse (5% and 8%), variable (8% and 15%), and unprotected (10% and 24%). Components of the health belief, self-efficacy, peer influence, coping, and distress models were assessed as predictors of these patterns. RESULTS: Protected and improved patterns of sexual risk acts were associated with low levels of anxiety, depression, and substance use and high self-esteem. CONCLUSIONS: These data suggest that HIV interventions must address non-HIV-related issues confronting youths in difficult life circumstances, particularly emotional distress and the role of peer networks for homosexual and bisexual youths.

Canterbury, R. J., E. L. McGarvey, A. E. Sheldon-Keller, D. Waite, P. Reams and C. Koopman (1995). "Prevalence of HIV-related risk behaviors and STDs among incarcerated adolescents." J Adolesc Health 17(3): 173-7.
PURPOSE: To determine the HIV-related risk behaviors and STDs in a population of incarcerated adolescents in order to strategically target education and prevention efforts. METHODS: A single point-in-time prevalence study based on an analysis of intake medical records of 1,215 incarcerated youth were analyzed for HIV risk behaviors and STD history. RESULTS: Incarcerated adolescents report high rates of risk behaviors for HIV infection and STDs, with 75% reporting three or more sex partners, 25% never using condoms and 19% having a current diagnosis of at least one STD. Significantly more females than males reported a history of STDs and had higher rates of current diagnoses of chlamydia/non-gonococcal urethritis, trichomonas and gonorrhea. CONCLUSIONS: Ethnic/racial and gender differences were found in risk behaviors for STDs among a sample of incarcerated adolescents.

Koopman, C., M. Rosario and M. J. Rotheram-Borus (1994). "Alcohol and drug use and sexual behaviors placing runaways at risk for HIV infection." Addict Behav 19(1): 95-103.
Lifetime and current alcohol and drug use and sexual risk acts were examined among 154 male and 148 female runaways, aged 11-19, predominantly Black and Hispanic, residing at four residential shelters in the New York City area. Most runaways reported alcohol (71%) and drug use (46%), with about a quarter (27%) using either alcohol or drugs at least once a week during the past 3 months. Physical symptoms of substance abuse were reported by 47%; 17% reported addiction. Current substance use was higher among males and Hispanics, and increased with age. Substance use was significantly related to reporting more sexual partners and less frequent condom use. The results suggest that HIV/AIDS prevention programs must target the reduction of alcohol and drug use as well as sexual risk acts.

Rotheram-Borus, M. J., H. F. Meyer-Bahlburg, M. Rosario, C. Koopman, C. S. Haignere, T. M. Exner, M. Matthieu, R. Henderson and R. S. Gruen (1992). "Lifetime sexual behaviors among predominantly minority male runaways and gay/bisexual adolescents in New York City." AIDS Educ Prev Suppl: 34-42.
Lifetime sexual behaviors were examined among two samples of predominantly minority, male adolescents in New York City aged 12 to 18 (M = 16.3), believed to be at high risk for HIV infection: 59 runaway males in two residential shelters and 60 males attending a community agency (HMI) for gay and bisexual youths. Interviews regarding psychosexual milestones indicated that 93% of these youths had engaged in oral, anal or vaginal intercourse and/or anilingus, with a median of 11.0 female partners among runaway males and a median of 7.0 male partners among HMI males. Both groups initiated sexual activity at a relatively early mean age of 12.6 years. Each group reported a unique developmental sequence of psychosexual milestones. Consistent condom use was reported by 13% of the youths. One quarter of the youths reported involvement in prostitution. These findings detail the need for AIDS prevention programs for these youths.

Koopman, C., M. J. Rotheram-Borus, L. Dobbs, M. Gwadz and J. Brown (1992). "Beliefs and behavioral intentions regarding human immunodeficiency virus testing among New York City runaways." J Adolesc Health 13(7): 576-81.
From 1988 to 1991, 139 runaways aged 11-19 years in the New York City area (n = 70 males, 69 females) were recruited from four shelters. Each runaway participated in a semistructured interview assessing beliefs and behavioral intentions regarding human immunodeficiency virus (HIV) testing. When asked how they would respond to being seropositive for HIV, 29% of runaways reported that they would engage in self-destructive acts and/or harm others (e.g., suicide, unprotected sex), 80% anticipated extreme distress, 47% expected difficulty securing housing and food, and 61% believed that friends were likely to avoid them. When presented with specific alternatives, fewer runaways anticipated self-destructive acts. Drug use, rather than sexual behaviors, would lead runaways to get tested for HIV. These results suggest that health-care providers must anticipate emotional distress and potential self-destructive behavior following receipt of documentation of HIV positive serostatus among runaways. Furthermore, prior to testing, youths' access to food, shelter, medical care, and social support must be secured.

Rotheram-Borus, M. J., C. Koopman, C. Haignere and M. Davies (1991). "Reducing HIV sexual risk behaviors among runaway adolescents." Jama 266(9): 1237-41.
OBJECTIVE. Reductions in runaways' sexual risk behaviors were evaluated in response to an intensive program to prevent human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS). DESIGN. In a nonrandomized control trial, sexual risk behaviors among 78 runaways at one residential shelter who received up to 30 HIV/AIDS intervention sessions were compared with 67 runaways at a nonintervention shelter with sexual behaviors assessed at baseline and 3 and 6 months. SETTING. Runaways were recruited from the only two publicly funded shelters in New York, NY. PARTICIPANTS. The runaways were aged 11 to 18 years, 64% female, and predominantly black or Hispanic. INTERVENTION. The intervention addressed general knowledge about HIV/AIDS, coping skills, access to health care and other resources, and individual barriers to safer sex. MAIN OUTCOME MEASURES. Consistent condom use, a high-risk pattern of sexual behavior, and sexual abstinence over a 3-month time frame were assessed. MAIN RESULTS. As the number of intervention sessions increased, runaways' reports of consistent condom use increased significantly (at 3 months, unique R2 = .06, P less than .05; at 6 months, unique R2 = .09, P less than .05), and their reports of engaging in a high-risk pattern of sexual behavior decreased significantly (at 3 months, unique R2 = .03, P = .06; at 6 months, unique R2 = .04, P less than .05). Abstinence did not change. CONCLUSIONS. The demonstrated effectiveness of the intensive HIV/AIDS program highlights the importance of enlarging the scope of most current HIV/AIDS prevention programs.

Rotheram-Borus, M. J., C. Koopman and A. A. Ehrhardt (1991). "Homeless youths and HIV infection." Am Psychol 46(11): 1188-97.
Risk of human immunodeficiency virus (HIV) infection exacerbates the already difficult lives of 1.5 million homeless adolescents in the United States. Homeless youths engage in sexual and substance-abuse behaviors that place them at increased risk of contracting HIV, and they demonstrate other problem behaviors that reduce their coping responses. Model HIV prevention programs and interventions for HIV-positive youths, implemented for homeless adolescents, need to be disseminated on a national level. Social policies must recognize adolescents' rights to satisfaction of basic survival needs; comprehensively address the needs of dysfunctional, disenfranchised, and single-parent families; and provide continuity of care for adolescents to facilitate independent living. Special provisions must be made when designing programs for gay, sexually abused, and substance-abusing youths.

Rotheram-Borus, M. J. and C. Koopman (1991). "Sexual risk behavior, AIDS knowledge, and beliefs about AIDS among predominantly minority gay and bisexual male adolescents." AIDS Educ Prev 3(4): 305-12.
Current sexual risk behavior, AIDS knowledge, and beliefs about AIDS prevention were examined among 59 black and Hispanic male adolescents attending a community center for gay and lesbian youth. Most (73%) were sexually active in the last 3 months, with a median of 2.0 partners and with only 21% reporting consistent condom use. These youths demonstrated moderately high AIDS knowledge (82%) and positive beliefs endorsing AIDS prevention (71%). When risk pattern was defined on the basis of partners, risk acts, and condom use, positive AIDS prevention beliefs were significantly and inversely associated with the high-risk pattern, but not with abstinence. These results suggest that youths who frequently engage in high-risk acts need intervention targeting changes in beliefs and behavior, as well as knowledge.

Rotheram-Borus, M. J. and C. Koopman (1991). "Sexual risk behaviors, AIDS knowledge, and beliefs about AIDS among runaways." Am J Public Health 81(2): 208-10.
Sexual risk behaviors, knowledge of acquired immunodeficiency syndrome (AIDS), and beliefs about AIDS prevention were examined among 126 runaways. In the previous 3 months, 65 percent of youths had been sexually active. Among the sexually active runaways, males reported a median of 2.7 partners and females reported 1.3 partners, and only 18 percent reported consistent condom use. Runaways demonstrated moderately high AIDS knowledge and beliefs endorsing AIDS prevention. Condom use and abstinence were directly related to beliefs about preventing AIDS.

Rotheram-Borus, M. J., J. V. Becker, C. Koopman and M. Kaplan (1991). "AIDS knowledge and beliefs, and sexual behavior of sexually delinquent and non-delinquent (runaway) adolescents." J Adolesc 14(3): 229-44.
This study assessed general knowledge of AIDS, beliefs about preventing AIDS, and sexual behavior among two groups of male adolescents at high risk of HIV/AIDS: 60 sexually delinquent males and 57 non-delinquent runaway males. Significantly fewer sexually delinquent than non-delinquent (runaway) males had experienced sexual intercourse with a consenting female partner (45 vs. 89 per cent). Sexually delinquent youths scored significantly lower than non-delinquent youths in general knowledge of AIDS (65 vs. 73 per cent) and were not able to discriminate safer behaviors from those which were less safe (42 vs. 71 per cent). Both groups reported moderate support for beliefs about preventing AIDS. These results suggest HIV/AIDS prevention programs that attempt to increase knowledge are needed by these youths, particularly for sexually delinquent youths.

Koopman, C., M. J. Rotherman-Borus, R. Henderson, J. S. Bradley and J. Hunter (1990). "Assessment of knowledge of AIDS and beliefs about AIDS prevention among adolescents." AIDS Educ Prev 2(1): 58-69.
This report describes the development of measures of AIDS knowledge and beliefs about AIDS prevention for adolescents. Review of the literature, focus groups, pilot testing, and reviews by advisory councils assured that the process of developing the measures contributed to their validity. These measures were administered to three samples of adolescents at high risk for contracting AIDS: 43 runaway males, 43 runaway females, and 36 self-identified gay males. Both the knowledge and the beliefs instruments showed moderately high internal consistency and test-retest reliability and successfully avoided ceiling effects. Gay males demonstrated significantly greater knowledge of AIDS; however, there were few differences in beliefs among the groups. Knowledge of AIDS was significantly correlated with beliefs about AIDS prevention. The results suggest that these measures identify gaps in knowledge and beliefs among high-risk youth.

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