Mental Health Treatment to Reduce HIV Transmission Risk Behavior: A Positive Prevention Model Authors
First Online: 15 December 2009 DOI:
Cite this article as: Sikkema, K.J., Watt, M.H., Drabkin, A.S. et al. AIDS Behav (2010) 14: 252. doi:10.1007/s10461-009-9650-y
Secondary HIV prevention, or “positive prevention,” is concerned with reducing HIV transmission risk behavior and optimizing the health and quality of life of people living with HIV/AIDS (PLWHA). The association between mental health and HIV transmission risk (i.e., sexual risk and poor medication adherence) is well established, although most of this evidence is observational. Further, a number of efficacious mental health treatments are available for PLWHA yet few positive prevention interventions integrate mental health treatment. We propose that mental health treatment, including behavioral and pharmacologic interventions, can lead to reductions in HIV transmission risk behavior and should be a core component of secondary HIV prevention. We present a conceptual model and recommendations to guide future research on the effect of mental health treatment on HIV transmission risk behavior among PLWHA.
Secondary HIV prevention
UNAIDS. Report on the global AIDS epidemic. Geneva: UNAIDS; 2008.
Hall HI, Song R, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA. 2008;300(5):520–9.
Lima VD, Harrigan R, Bangsberg DR, et al. The combined effect of modern highly active antiretroviral therapy regimens and adherence on mortality over time. J Acquir Immune Defic Syndr. 2009;50(5):529–36.
Baker JV, Peng G, Rapkin J, et al. CD4 + count and risk of non-AIDS diseases following initial treatment for HIV infection. AIDS. 2008;22(7):841–8.
Crepaz N, Marks G, Liau A, et al. Prevalence of unprotected anal intercourse among HIV-diagnosed MSM in the United States: a meta-analysis. AIDS. 2009;23(13):1617–29.
Weinhardt L, Kelly JA, Brondino M, et al. HIV transmission risk behavior among men and women living with HIV in 4 cities in the United States. J Acquir Immune Defic Syndr. 2004;36(5):1057–66.
Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001;58(8):721–8.
Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr. 2005;39(4):446–53.
Mills EJ, Nachega JB, Buchan I, et al. Adherence to antiretroviral therapy in sub-Saharan Africa and North America: a meta-analysis. JAMA. 2006;296(6):679–90.
Boily MC, Baggaley RF, Wang L, et al. Heterosexual risk of HIV-1 infection per sexual act: systematic review and meta-analysis of observational studies. Lancet Infect Dis. 2009;9(2):118–29.
Xiridou M, Geskus R, de Wit J, Coutinho R, Kretzschmar M. Primary HIV infection as source of HIV transmission within steady and casual partnerships among homosexual men. AIDS. 2004;18(9):1311–20.
Flaks RC, Burman WJ, Gourley PJ, Rietmeijer CA, Cohn DL. HIV transmission risk behavior and its relation to antiretroviral treatment adherence. Sex Transm Dis. 2003;30(5):399–404.
Chakraborty H, Sen PK, Helms RW, et al. Viral burden in genital secretions determines male-to-female sexual transmission of HIV-1: a probabilistic empiric model. AIDS. 2001;15(5):621–7.
Porco TC, Martin JN, Page-Shafer KA, et al. Decline in HIV infectivity following the introduction of highly active antiretroviral therapy. AIDS. 2004;18(1):81–8.
Mugavero MJ, Lin HY, Allison JJ, et al. Racial disparities in HIV virologic failure: do missed visits matter? J Acquir Immune Defic Syndr. 2009;50(1):100–8.
Lima VD, Harrigan R, Murray M, et al. Differential impact of adherence on long-term treatment response among naive HIV-infected individuals. AIDS. 2008;22(17):2371–80.
Baum MK, Rafie C, Lai S, Sales S, Page B, Campa A. Crack-cocaine use accelerates HIV disease progression in a cohort of HIV-positive drug users. J Acquir Immune Defic Syndr. 2009;50(1):93–9.
Mugavero MJ, Lin HY, Willig JH, et al. Missed visits and mortality among patients establishing initial outpatient HIV treatment. Clin Infect Dis. 2009;48(2):248–56.
Mullins CD, Whitelaw G, Cooke JL, Beck EJ. Indirect cost of HIV infection in England. Clin Ther. 2000;22(11):1333–45.
Gardner EM, Maravi ME, Rietmeijer C, Davidson AJ, Burman WJ. The association of adherence to antiretroviral therapy with healthcare utilization and costs for medical care. Appl Health Econ Health Policy. 2008;6(2–3):145–55.
Chesney MA, Ickovics JR, Chambers DB, et al. Self-reported adherence to antiretroviral medications among participants in HIV clinical trials: the AACTG adherence instruments. AIDS Care. 2000;12(3):255–66.
Kleeberger CA, Phair JP, Strathdee SA, Detels R, Kingsley L, Jacobson LP. Determinants of heterogenous adherence to HIV-antiretroviral therapies in the Multicenter AIDS Cohort Study. J Acquir Immune Defic Syndr. 2001;26(1):82–92.
Crepaz N, Lyles CM, Wolitski RJ, et al. Do prevention interventions reduce HIV risk behaviours among people living with HIV? A meta-analytic review of controlled trials. AIDS. 2006;20(2):143–57.
Johnson BT, Carey MP, Chaudoir SR, Reid AE. Sexual risk reduction for persons living with HIV: research synthesis of randomized controlled trials, 1993 to 2004. J Acquir Immune Defic Syndr. 2006;41(5):642–50.
Fisher JD, Smith L. Secondary prevention of HIV infection: the current state of prevention for positives. Curr Opin HIV AIDS. 2009;4(4):279–87.
Grossman CI, Gordon CM. Mental health considerations in secondary HIV prevention. AIDS Behav. [Published online 5 Dec 2008].
Ciesla JA, Roberts JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry. 2001;158(5):725–30.
Lyketsos CG, Hutton H, Fishman M, Schwartz J, Treisman GJ. Psychiatric morbidity on entry to an HIV primary care clinic. AIDS. 1996;10(9):1033–9.
Olley BO, Seedat S, Stein DJ. Persistence of psychiatric disorders in a cohort of HIV/AIDS patients in South Africa: a 6-month follow-up study. J Psychosom Res. 2006;61(4):479–84.
Pence BW, Miller WC, Gaynes BN, Eron JJ Jr. Psychiatric illness and virologic response in patients initiating highly active antiretroviral therapy. J Acquir Immune Defic Syndr. 2007;44(2):159–66.
Atkinson JH Jr, Grant I, Kennedy CJ, Richman DD, Spector SA, McCutchan JA. Prevalence of psychiatric disorders among men infected with human immunodeficiency virus. A controlled study. Arch Gen Psychiatry. 1988;45(9):859–64.
Israelski DM, Prentiss DE, Lubega S, et al. Psychiatric co-morbidity in vulnerable populations receiving primary care for HIV/AIDS. AIDS Care. 2007;19(2):220–5.
Safren SA, Gershuny BS, Hendriksen E. Symptoms of posttraumatic stress and death anxiety in persons with HIV and medication adherence difficulties. AIDS Patient Care STDS. 2003;17(12):657–64.
Atkinson JH, Higgins JA, Vigil O, et al. Psychiatric context of acute/early HIV infection. The NIMH Multisite Acute HIV Infection Study: IV. AIDS Behav. 2009;13:1061–67.
Humfleet GL, Delucchi K, Kelley K, Hall SM, Dilley J, Harrison G. Characteristics of HIV-positive cigarette smokers: a sample of smokers facing multiple challenges. AIDS Educ Prev. 2009;21(3 Suppl):54–64.
Martinez A, Israelski D, Walker C, Koopman C. Posttraumatic stress disorder in women attending human immunodeficiency virus outpatient clinics. AIDS Patient Care STDS. 2002;16(6):283–91.
Cohen MA, Batista SM, Gorman JM. Anxiety disorders. In: Cohen MA, Gorman JM, editors. Comprehensive textbook of AIDS psychiatry. New York: Oxford University Press; 2008. p. 121–30.
Kelly B, Raphael B, Judd F, et al. Posttraumatic stress disorder in response to HIV infection. Gen Hosp Psychiatry. 1998;20(6):345–52.
Kalichman SC. Co-occurrence of treatment nonadherence and continued HIV transmission risk behaviors: implications for positive prevention interventions. Psychosom Med. 2008;70(5):593–7.
Bradley MV, Remien RH, Dolezal C. Depression symptoms and sexual HIV risk behavior among serodiscordant couples. Psychosom Med. 2008;70(2):186–91.
Ryan K, Forehand R, Solomon S, Miller C. Depressive symptoms as a link between barriers to care and sexual risk behavior of HIV-infected individuals living in non-urban areas. AIDS Care. 2008;20(3):331–6.
Bousman CA, Cherner M, Ake C, et al. Negative mood and sexual behavior among non-monogamous men who have sex with men in the context of methamphetamine and HIV. J Affect Disord. 2009;119(1–3):84–91.
Valverde EE, Cassetti I, Metsch LR, et al. Sex risk practices among HIV-positive individuals in Buenos Aires, Argentina. AIDS Patient Care STDS. 2009;23(7):551–6.
Mugavero M, Ostermann J, Whetten K, et al. Barriers to antiretroviral adherence: the importance of depression, abuse, and other traumatic events. AIDS Patient Care STDS. 2006;20(6):418–28.
Gordillo V, del Amo J, Soriano V, Gonzalez-Lahoz J. Sociodemographic and psychological variables influencing adherence to antiretroviral therapy. AIDS. 1999;13(13):1763–9.
Mellins CA, Kang E, Leu CS, Havens JF, Chesney MA. Longitudinal study of mental health and psychosocial predictors of medical treatment adherence in mothers living with HIV disease. AIDS Patient Care STDS. 2003;17(8):407–16.
Rajabiun S, Mallinson RK, McCoy K, et al. “Getting me back on track”: the role of outreach interventions in engaging and retaining people living with HIV/AIDS in medical care. AIDS Patient Care STDS. 2007;21(Suppl 1):S20–9.
Hutton HE, Lyketsos CG, Zenilman JM, Thompson RE, Erbelding EJ. Depression and HIV risk behaviors among patients in a sexually transmitted disease clinic. Am J Psychiatry. 2004;161(5):912–4.
Reisner SL, Mimiaga MJ, Skeer M, Mayer KH. Beyond anal sex: sexual practices associated with HIV risk reduction among men who have sex with men in Boston, Massachusetts. AIDS Patient Care STDS. 2009;23(7):545–50.
Klein H, Elifson KW, Sterk CE. Depression and HIV risk behavior practices among at risk women. Womens Health. 2008;48(2):167–88.
Hart TA, James CA, Purcell DW, Farber E. Social anxiety and HIV transmission risk among HIV-seropositive male patients. AIDS Patient Care STDS. 2008;22(11):879–86.
Reyes JC, Robles RR, Colon HM, et al. Severe anxiety symptomatology and HIV risk behavior among Hispanic injection drug users in Puerto Rico. AIDS Behav. 2007;11(1):145–50.
Hutton HE, Treisman GJ, Hunt WR, et al. HIV risk behaviors and their relationship to posttraumatic stress disorder among women prisoners. Psychiatr Serv. 2001;52(4):508–13.
Reisner SL, Mimiaga MJ, Safren S, Mayer K. Stressful or traumatic life events, post-traumatic stress disorder (PTSD) symptoms, and HIV sexual risk taking among men who have sex with men. AIDS Care. 2009;21(12):1481–9.
Crepaz N, Marks G. Are negative affective states associated with HIV sexual risk behaviors? A meta-analytic review. Health Psychol. 2001;20(4):291–9.
Crepaz N, Marks G. Towards an understanding of sexual risk behavior in people living with HIV: a review of social, psychological, and medical findings. AIDS. 2002;16(2):135–49.
Kalichman SC, Weinhardt L. Negative affect and sexual risk behavior: comment on Crepaz and Marks (2001). Health Psychol. 2001;20(4):300–1.
Chesney MA, Koblin BA, Barresi PJ, et al. An individually tailored intervention for HIV prevention: baseline data from the EXPLORE study. Am J Public Health. 2003;93(6):933–8.
Rogers G, Curry M, Oddy J, Pratt N, Beilby J, Wilkinson D. Depressive disorders and unprotected casual anal sex among Australian homosexually active men in primary care. HIV Med. 2003;4(3):271–5.
Reisner SL, Mimiaga MJ, Skeer M, et al. Clinically significant depressive symptoms as a risk factor for HIV infection among black MSM in Massachusetts. AIDS Behav. 2009;13(4):798–810.
Meade CS, Hansen NB, Kochman A, Sikkema KJ. Utilization of medical treatments and adherence to antiretroviral therapy among hiv-positive adults with histories of childhood sexual abuse. AIDS Patient Care STDS. 2009;23(4):259–66.
Vranceanu AM, Safren SA, Lu M, et al. The relationship of post-traumatic stress disorder and depression to antiretroviral medication adherence in persons with HIV. AIDS Patient Care STDS. 2008;22(4):313–21.
DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160(14):2101–7.
World Health Organization. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization; 2003.
Ammassari A, Trotta MP, Murri R, et al. Correlates and predictors of adherence to highly active antiretroviral therapy: overview of published literature. J Acquir Immune Defic Syndr. 2002;31(Suppl 3):S123–7.
Vervoort SC, Borleffs JC, Hoepelman AI, Grypdonck MH. Adherence in antiretroviral therapy: a review of qualitative studies. AIDS. 2007;21(3):271–81.
Mocroft A, Madge S, Johnson AM, et al. A comparison of exposure groups in the EuroSIDA study: starting highly active antiretroviral therapy (HAART), response to HAART, and survival. J Acquir Immune Defic Syndr. 1999;22(4):369–78.
Fairfield KM, Libman H, Davis RB, Eisenberg DM. Delays in protease inhibitor use in clinical practice. J Gen Intern Med. 1999;14(7):395–401.
Gebo KA, Fleishman JA, Conviser R, et al. Racial and gender disparities in receipt of highly active antiretroviral therapy persist in a multistate sample of HIV patients in 2001. J Acquir Immune Defic Syndr. 2005;38(1):96–103.
Turner BJ, Fleishman JA, Wenger N, et al. Effects of drug abuse and mental disorders on use and type of antiretroviral therapy in HIV-infected persons. J Gen Intern Med. 2001;16(9):625–33.
Scott-Sheldon LA, Kalichman SC, Carey MP, Fielder RL. Stress management interventions for HIV+ adults: a meta-analysis of randomized controlled trials, 1989 to 2006. Health Psychol. 2008;27(2):129–39.
Himelhoch S, Medoff DR, Oyeniyi G. Efficacy of group psychotherapy to reduce depressive symptoms among HIV-infected individuals: a systematic review and meta-analysis. AIDS Patient Care STDS. 2007;21(10):732–9.
Crepaz N, Passin WF, Herbst JH, et al. Meta-analysis of cognitive-behavioral interventions on HIV-positive persons’ mental health and immune functioning. Health Psychol. 2008;27(1):4–14.
Himelhoch S, Medoff DR. Efficacy of antidepressant medication among HIV-positive individuals with depression: a systematic review and meta-analysis. AIDS Patient Care STDS. 2005;19(12):813–22.
Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale: Erlbaum; 1988.
Cuijpers P, Van Straten A, Warmerdam L, Smits N. Characteristics of effective psychological treatments of depression: a metaregression analysis. Psychother Res. 2008;18(2):225–36.
Robinson LA, Berman JS, Neimeyer RA. Psychotherapy for the treatment of depression: a comprehensive review of controlled outcome research. Psychol Bull. 1990;108(1):30–49.
Katzman MA, Tricco AC, McIntosh D, et al. Paroxetine versus placebo and other agents for depressive disorders: a systematic review and meta-analysis. J Clin Psychiatry. 2007;68(12):1845–59.
Moncrieff J, Wessely S, Hardy R. Active placebos versus antidepressants for depression. Cochrane Database Syst Rev. 2004;1:CD003012.
Cuijpers P, van Straten A, Andersson G, van Oppen P. Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. J Consult Clin Psychol. 2008;76(6):909–22.
Hunot V, Churchill R, Silva de Lima M, Teixeira V. Psychological therapies for generalised anxiety disorder. Cochrane Database Syst Rev. 2007;1:CD001848.
Sikkema KJ, Wilson PA, Hansen NB, et al. Effects of a coping intervention on transmission risk behavior among people living with HIV/AIDS and a history of childhood sexual abuse. J Acquir Immune Defic Syndr. 2008;47(4):506–13.
Coates TJ, McKusick L, Kuno R, Stites DP. Stress reduction training changed number of sexual partners but not immune function in men with HIV. Am J Public Health. 1989;79(7):885–7.
Williams JK, Wyatt GE, Rivkin I, Ramamurthi HC, Li X, Liu H. Risk reduction for HIV-positive African American and Latino men with histories of childhood sexual abuse. Arch Sex Behav. 2008;37(5):763–72.
Kelly JA, Murphy DA, Bahr GR, et al. Outcome of cognitive-behavioral and support group brief therapies for depressed, HIV-infected persons. Am J Psychiatry. 1993;150(11):1679–86.
Healthy Living Project Team. Effects of a behavioral intervention to reduce risk of transmission among people living with HIV: the healthy living project randomized controlled study. J Acquir Immune Defic Syndr. 2007;44(2):213–21.
Wyatt GE, Longshore D, Chin D, et al. The efficacy of an integrated risk reduction intervention for HIV-positive women with child sexual abuse histories. AIDS Behav. 2004;8(4):453–62.
Safren SA, O’Cleirigh C, Tan JY, et al. A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected individuals. Health Psychol. 2009;28(1):1–10.
Johnson MO, Charlebois E, Morin SF, Remien RH, Chesney MA. Effects of a behavioral intervention on antiretroviral medication adherence among people living with HIV: the healthy living project randomized controlled study. J Acquir Immune Defic Syndr. 2007;46(5):574–80.
Antoni MH, Baggett L, Ironson G, et al. Cognitive-behavioral stress management intervention buffers distress responses and immunologic changes following notification of HIV-1 seropositivity. J Consult Clin Psychol. 1991;59(6):906–15.
Goodkin K, Fuchs I, Feaster DJ, Leeka J, Rishel DD. Life stressors and coping style are associated with immune measures in HIV-1 infection—a preliminary report. Int J Psychiatry Med. 1992;22:155–72.
McCain NL, Zeller JM, Cella DF, Urbanski PA, Novak RM. The influence of stress management training in HIV disease. Nurs Res. 1996;45:246–53.
Sikkema KJ, Hansen NB, Tarakeshwar N, Kochman A, Tate DC, Lee RS. The clinical significance of change in trauma-related symptoms following a pilot group intervention for coping with HIV-AIDS and childhood sexual trauma. AIDS Behav. 2004;8(3):277–91.
Greenberg J. Childhood sexual abuse and sexually transmitted diseases in adults: a review of and implications for STD/HIV programmes. Int J STD AIDS. 2001;12(12):777–83.
Senn TE, Carey MP, Vanable PA. Childhood and adolescent sexual abuse and subsequent sexual risk behavior: evidence from controlled studies, methodological critique, and suggestions for research. Clin Psychol Rev. 2008;28(5):711–35.
Kalichman SC, Sikkema KJ, DiFonzo K, Luke W, Austin J. Emotional adjustment in survivors of sexual assault living with HIV/AIDS. J Trauma Stress. 2002;15(4):189–296.
O’Leary A, Purcell D, Remien RH, Gomez C. Childhood sexual abuse and sexual transmission risk behaviour among HIV-positive men who have sex with men. AIDS Care. 2003;15(1):17–26.
Mimiaga MJ, Noonan E, Donnell D, et al. Childhood sexual abuse is highly associated with HIV risk-taking behavior and infection among MSM in the EXPLORE study. J Acquir Immune Defic Syndr. 2009;51(3):340–8.
Lazarus R, Folkman S. Stress, appraisal and coping. New York: Springer; 1984.
Folkman S, Chesney M, McKusick L, Ironson G, Johnson D, Coates T. Translating coping theory into an intervention. In: Eckenrode J, editor. The social context of coping. New York: Plenum Press; 1991. p. 239–60.
Sikkema KJ, Hansen NB, Kochman A, et al. Outcomes from a group intervention for coping with HIV/AIDS and childhood sexual abuse: reductions in traumatic stress. AIDS Behav. 2007;11:49–60.
Meade C, Drabkin AS, Wilson PA, Hansen NB, Kochman A, Sikkema K. Reductions in alcohol and cocaine use following a group coping intervention for HIV positive adults with childhood sexual abuse histories. Boston: CFAR Social and Behavioral Sciences Research Network Meeting; 2009.
Carrico AW, Chesney MA, Johnson MO, et al. Randomized controlled trial of a cognitive-behavioral intervention for HIV-positive persons: an investigation of treatment effects on psychosocial adjustment. AIDS Behav. 2009;13(3):555–63.
Wong FL, Rotheram-Borus MJ, Lightfoot M, et al. Effects of behavioral intervention on substance use among people living with HIV: the healthy living project randomized controlled study. Addiction. 2008;103(7):1206–14.
Kumar V, Encinosa W. Effects of antidepressant treatment on antiretroviral regimen adherence among depressed HIV-infected patients. Psychiatr Q. 2009;80:131–41.
Tsai A, Weiser S, Petersen M, Raglans K, Bangsberg D. Effect of antidepressant medication treatment on antiretroviral adherence and HIV-1 RNA viral load in HIV+ homeless and marginally housed individuals. In: 16th Conference on retroviruses and opportunistic infections. Montreal; 2009.
Yun LW, Maravi M, Kobayashi JS, Barton PL, Davidson AJ. Antidepressant treatment improves adherence to antiretroviral therapy among depressed HIV-infected patients. J Acquir Immune Defic Syndr. 2005;38(4):432–8.
Walkup J, Wei W, Sambamoorthi U, Crystal S. Antidepressant treatment and adherence to combination antiretroviral therapy among patients with AIDS and diagnosed depression. Psychiatr Q. 2008;79(1):43–53.
Horberg MA, Silverberg MJ, Hurley LB, et al. Effects of depression and selective serotonin reuptake inhibitor use on adherence to highly active antiretroviral therapy and on clinical outcomes in HIV-infected patients. J Acquir Immune Defic Syndr. 2008;47(3):384–90.
Gaynes BN, Pence BW, Eron JJ Jr, Miller WC. Prevalence and comorbidity of psychiatric diagnoses based on reference standard in an HIV+ patient population. Psychosom Med. 2008;70(4):505–11.
World Health Organization. The World Health Report 2001: mental health—new understanding, new hope. Geneva: World Health Organization; 2001.
© Springer Science+Business Media, LLC 2009