June 27, 2014
A clinical review published in the peer-reviewed journal LGBT Health in early June by Jaclyn M. White, M.P.H., Janna R. Gordon, and Matthew J. Mimiaga, Sc.D., M.P.H., from Harvard and the Fenway Institute in Massachusetts, indicates that there may be relief at hand for HIV-positive gay men struggling with added mental health and substance abuse issues that can add difficulty to sticking to an HIV medication regimen. White et al concluded that interventions that combine both adherence counseling with standard cognitive behavioral therapy have made some headway with participants in several recent intervention trials.
Mental health issues, as well as substance use, can lend comorbidity to HIV -- that is, an additional condition that compounds the effect of a primary disease. These factors can make adherence to medication more difficult than normal, though this connection is not yet well established.
White et al pointed out that concentration problems and feelings of worthlessness and hopelessness behave as barriers to self-care behavior patterns that are required for optimal outcomes on antiretroviral therapy (ART). Optimal outcomes are measured by self-efficacy efforts; those who believe in their ability to manage their own condition are more likely to approach the 80%-plus adherence level required to thrive while living with HIV, according to White et al.
They also noted that depression affects gay men who are HIV positive at a rate of nearly double that of their HIV-negative counterparts. Past trauma, particularly experiences involving childhood sexual abuse, are also common among gay men.
Avoidant coping is a behavior pattern for dealing with stress that is a danger to HIV-positive gay men, whereby a substitution of excessive food, sleep, work or solitude is used as a means of displacement. This kind of avoidance can result in a desire to also avoid adhering to HIV meds.
Additionally, post-traumatic stress disorder affects gay men at roughly twice the numbers of that of heterosexual men. General anxiety disorder is also prevalent among gay men, and this level of anxiety can disrupt a prescribed HIV medication regimen.
Body image dysmorphia (BID), while prevalent among perceived culture norms, can take on an additional dimension for HIV-positive gay men who experience fat redistribution, or lipodystrophy, as a side effect of ART. Fully 31% of this group reported BID, and while new medication regimens have less instances of lipodystrophy, people still remain vulnerable to body image concerns. White et al pointed to depression as the possible link in the chain between negative self-image and a loss of interest in staying adherent to medication.
Substance use, defined as heavy alcohol consumption and/or crystal methamphetamine (meth) use, contributes vastly to ART non-adherence, according to White et al. In one urban study, half of all HIV-positive men reported drinking in the past three months, while 20% indicated heavy drinking. The Los Angeles County Department of Health reported in another study that gay men use meth at twenty times the rate among the general population.
The immediate effects of substance use include impaired judgment and disruption of daily routine, both seen as imperative factors in maintaining adherence to HIV medication. A static sleep/wake cycle is viewed as key to self-efficacy and optimal outcomes.
Preliminary success has been seen when staging interventions for ART adherence, coupled with addressing mental health and/or substance abuse issues, White et al stated. More attention is given to the adherence portion of the intervention, with underlying ties to other problems that may exist.
According to White et al, this is done because there may be depression over the actual situation at hand, as well as the notion that cessation of substance use wasn't necessarily the best solution. Especially in cases of meth users, the withdrawal symptoms usually fed a sense of apathy and distress, initiating a cycle back into medication non-adherence. This was also reported among heavy drinkers.
While these are early reports, this combination approach to interventions seems to be yielding positive results, White et al suggested. Additionally, they noted that success is being attributed to pairing multiple therapy sessions with one "Life-Steps" session, an intervention focused entirely on ART-adherence.
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