Impact of a secondary prevention intervention among HIV-positive older women.

Despite the fact that older women represent a growing risk group for HIV, they have been rarely targeted by public health campaigns designed to prevent HIV/AIDS and are often excluded from many prevention studies. This unique cohort may be often overlooked due to beliefs that older women are not sexually active and do not engage in high risk sexual activity. Data suggest a need for increased attention to this unique cohort. Risk reduction interventions tailored to the special needs of people living with HIV/AIDS have begun to demonstrate promising results. In this manuscript, we report the 6 month outcomes for female participants in Project ROADMAP, a secondary prevention intervention designed to reduce high risk sexual behavior in older adults living with HIV/AIDS. Our results indicate that female participants in the intervention group were more likely to report a reduction in high risk sexual behavior than women in the control condition. Our findings also suggest that the intervention succeeded in increasing the HIV-related knowledge of the participants and decreasing their stigma vis-à-vis the HIV condition. The study findings suggest that Project ROADMAP is an effective secondary prevention intervention for sexually active older HIV positive women.

Project ROADMAP: Reeducating Older Adults in Maintaining AIDS Prevention: a secondary intervention for older HIV-positive adults.

The number of older adults living with HIV/AIDS is larger than ever. Little is known about their sexual behaviors, although contrary to stereotypes, older adults desire and engage in sexual activity. Despite increased recognition of the need for prevention interventions targeting HIV-positive individuals, no secondary HIV prevention interventions have specifically targeted the older HIV-positive adult. Efforts to target high-risk sexual behaviors may be even more critical in the older population because of sociocultural, biological, and behavioral vulnerabilities. In response, Project ROADMAP (Reeducating Older Adult in Maintaining AIDS Prevention) intervention was developed to reduce high-risk sexual behaviors among older HIV-positive patients in primary care clinics. The purpose of this article is to report the 6-month outcomes of a behavioral intervention designed to reduce sexual risk behaviors in older HIV-positive adults.

Sexual risk behaviors in late middle age and older HIV seropositive adults.

Little is known about the sexual behaviors of older adults, although the prevalence of HIV/AIDS is rapidly increasing in this population. As part of a larger multi-site study examining secondary HIV prevention, we recruited from an HIV primary care clinic 210 sexually active HIV positive individuals aged 45 and over (125 men, 85 women) who had engaged in vaginal or anal sex within the past six months. Twenty percent of the participants reported inconsistent use of condoms and 33% had multiple sexual partners during the previous six months. Negative mood and perceived HIV stigma were associated with inconsistent condom use. In addition, multiple sex partners and higher level of education were related to inconsistent condom use during sex with partners of negative or unknown serostatus. These findings indicate that contrary to current beliefs, sexually active older adults, similar to younger ones, may be engaging in high risk transmission behaviors.

The role of family functioning in the stress process of dementia caregivers: a structural family framework.

PURPOSE: The purpose of the study was to evaluate the role of family functioning in the stress process in a sample of caregivers of dementia patients by using a structural family framework. The stress-process model of caregiver distress included family functioning as an intervening variable in the relationship between objective burden and distress. We theorized family functioning to partially mediate the relationship between objective burden and distress and to significantly account for the prediction of distress beyond well-recognized predictors. DESIGN AND METHODS: One hundred eighty-one family caregivers from the Miami site of the Resources for Enhancing Alzheimer's Caregiver Health project participated in this study. We assessed sociodemographics, burden, depression, anxiety, and perceived health for each caregiver. We measured family functioning by using a multidimensional and observational instrument. We used structural equation modeling to assess the fit of the model for the overall sample and for different caregiver subgroups and to examine whether demographic variables affected the relationships in the model. RESULTS: The results of the study indicated that family functioning significantly contributed to distress in the overall sample and partially mediated the relationship between objective burden and distress. We also found that the stress-process model was adequately fit by the hypothesized relationships between objective burden, family functioning, and distress for the overall sample and all of the subsamples, except for wives. IMPLICATIONS: This study provides support for the structural family approach as an explanatory model for the influence of family functioning on dementia caregivers. Family structural functioning is one contributor to the caregiver stress process. This suggests that interventions targeting structural family problems may reduce caregiver distress.

The value of telephone support groups among ethnically diverse caregivers of persons with dementia.

PURPOSE: Dementia caregiving is a rapidly growing public health problem. Logistical problems prevent many caregivers from utilizing available interventions. This article provides a demonstration of the usefulness of technology for conducting telephone-based support groups in ethnically diverse dementia caregivers. DESIGN AND METHODS: Participants were 41 White American and Cuban American dementia caregivers participating at the Miami site of the Resources for Enhancing Alzheimer's Caregiver Health (known as REACH) program. Support groups were conducted over the telephone in English and Spanish as appropriate. RESULTS: Eighty-one percent of the participants found the group "valuable," largely because of the social and emotional support and useful information obtained from other group members. The majority of caregivers also reported that their participation had increased their knowledge and skills as caregivers. IMPLICATIONS: The findings demonstrate that telecommunications technology can overcome the often formidable logistical problems faced by both English- and Spanish-speaking caregivers, and it can provide benefits similar to those obtained in face-to-face support groups.

Split treatment: a measurement of coordination between psychiatrists.

The objective of this study was to examine the adherence rates of psychiatrists with APA standards for coordination of care in split treatment. Coordination of care in split treatment is monitored from claims paid data in an academic MBHO as an ongoing quality improvement activity. For an 18-month period, 93 psychiatrists were identified with 559 patients in split treatment and were mailed a survey. Surveys were controlled for change of providers. Self-report survey results were obtained from 69 psychiatrists for 295 patients in split treatment. The average rate of coordination was 66 percent; however, the distribution was bimodal with 36 percent of psychiatrists always coordinating and 26 percent never coordinating. Not obtaining a release accounted for 87 percent of non-coordination. In conclusion, while coordination of care in split treatment is an APA standard of practice, only 36 percent of psychiatrists fully complied. That one third of patients in split treatment did not receive coordinated care suggests a need for improvement to meet the APA standards of practice and avoid legal exposure.

HIV-1 infection and its impact on the HPA axis, cytokines, and cognition.

Immediately after infection, Human immunodeficiency virus, type 1 (HIV-1) enters the central nervous system (CNS) and is localized in highest concentration in the hippocampus and basal ganglia. Since these areas are associated with HPA axis and autonomic activities as well as cognition, it has been hypothesized that these functions will be impacted adversely in HIV-1 infection. In the treatment of HIV infection, although the highly potent antiretroviral (HAART) drugs have been effective in reducing peripheral viral load and prolonging life expectancy, these drugs do not cross the blood-brain barrier in therapeutic concentrations. Therefore, it has been proposed that the beneficial effects of HAART on the CNS will be limited. Our investigations on seropositive individuals, showing hypo-reactivity of the autonomic system and HPA axis activity suggest that HIV-1 infection is a model of chronic stress. Furthermore, an elevated baseline TNF-alpha level as well as its increased reactivity to an alpha-adrenergic challenge among HIV-1+ individuals, may lead to additional neurodegeneration. It is proposed that the effects of HIV-1 infection on the brain will have implications for neurocognitive and mental health functioning in seropositive individuals even in patients undergoing HAART therapy. These outcomes may result in the need to develop facilities for long term "care-giving".

The effect of a family therapy and technology-based intervention on caregiver depression.

PURPOSE: The majority of persons with Alzheimer's disease (AD) are cared for at home by a family member such as a spouse or daughter. Caregiving places enormous demands on these caregivers, and the negative consequences associated with caregiving are well documented. This paper reports results from the Miami site of the REACH (Resources for Enhancing Alzheimer's Caregiver Health) program that examined the efficacy of a family therapy and technology-based intervention in reducing depressive symptoms (according to the Center for Epidemiological Studies Depression scale) among family caregivers of AD patients at 6 months and 18 months follow-up. DESIGN AND METHODS: There were 225 White American and Cuban American caregivers that were randomized into a structural ecosystems therapy, structural ecosystems therapy + computer-telephone integrated system, or minimal support control condition. RESULTS: Caregivers in the combined family therapy and technology intervention experienced a significant reduction in depressive symptoms at 6 months. The 18-month follow-up data indicated that the intervention was particularly beneficial for Cuban American husband and daughter caregivers. IMPLICATIONS: The results indicate that information technology has a promising role in alleviating distress and depression among groups of AD caregivers. The data also demonstrate that interventions have differential impacts according to ethnic group and the caregiver-patient relationship.

Cognitive functioning in younger and older HIV-1-infected adults.

In young adults, a major neurologic complication of HIV-1 infection is cognitive motor impairment. Epidemiologic findings suggest that increasing age is a significant risk factor for HIV-1-associated dementia as the AIDS-defining illness. Findings from the few studies that have directly measured cognition in younger and older HIV-1-infected adults, however, have been mixed, in part, because of small sample sizes and other methodologic differences between studies. The authors present preliminary findings on cognitive functioning in symptomatic HIV-1-infected younger (aged 20-39 years) and older (aged 50 years or older) adults. Independent of age, HIV-1 infection was accompanied by learning and memory retrieval deficits, which were significantly associated with high plasma viral loads in the young adults. Relative to the younger and older HIV-1-negative (HIV-1-) groups, only the younger HIV-1-positive (HIV-1+) group had significantly longer reaction times (RTs). Within the older HIV-1+ group, however, longer simple and choice RTs were significantly correlated with higher viral loads and lower CD4 cell counts. Although HIV-1 infection affects cognition independent of age, longitudinal studies involving large numbers of older individuals are needed to determine whether there are age differences in the prevalence, nature, and severity of HIV-1-associated cognitive dysfunction.

"Putting a face" on HIV infection/AIDS in older adults: a psychosocial context.

Older HIV-1-seropositive individuals largely have not been investigated with respect to their psychosocial characteristics. In this article, the authors review research reported to date regarding the psychosocial context of this growing subgroup of HIV-1-infected individuals. Specifically, the authors consider the characteristics of mood state, life stressor burden, social support network, and coping strategies that individuals older than 50 years are more likely to adopt in adjusting to HIV-1 infection. The authors also separately consider issues of caregiving burden. Data supporting a theoretically based stressor-support-coping model are presented and related to targeting psychotherapeutic interventions for this age group.

The HPA axis in HIV-1 infection.

Several lines of evidence suggest that neuroendocrine abnormalities in general and HPA axis activity in particular occur in both HIV-1 infection and individuals engaging in chronic drug use. For instance, our studies showing attenuated norepinephrine as well as ACTH and cortisol responses to a cold pressor challenge in asymptomatic HIV-1 persons support such a concept. Furthermore, our data on investigations on mirror-star tracing and speech challenges also support the finding that neuroendocrine responses are compromised in HIV-1 infection. Although the mechanisms leading to adverse effects on HPA axis activity in HIV infection are not fully understood, several lines of evidence suggest that a number of mechanisms may be involved, including homologies in molecular structures of various mediators of neuroendocrine activity and HIV-related structures, HIV as a chronic stress model, and virus-induced toxic factors. This article reviews our recent findings in this area and also presents research hypotheses needed for testing and understanding the mechanisms involved in the development of neuroendocrine abnormalities in HIV-1-infected injection drug users.

The role of macrophage/microglia and astrocytes in the pathogenesis of three neurologic disorders: HIV-associated dementia, Alzheimer disease, and multiple sclerosis.

Macrophage/microglia (M phi) are the principal immune cells in the central nervous system (CNS) concomitant with inflammatory brain disease and play a significant role in the host defense against invading microorganisms. Astrocytes, as a significant component of the blood-brain barrier, behave as one of the immune effector cells in the CNS as well. However, both cell types may play a dual role, amplifying the effects of inflammation and mediating cellular damage as well as protecting the CNS. Interactions of the immune system, M phi, and astrocytes result in altered production of neurotoxins and neurotrophins by these cells. These effects alter the neuronal structure and function during pathogenesis of HIV-1-associated dementia (HAD), Alzheimer disease (AD), and multiple sclerosis (MS). HAD primarily involves subcortical gray matter, and both HAD and MS affect sub-cortical white matter. AD is a cortical disease. The process of M phi and astrocytes activation leading to neurotoxicity share similarities among the three diseases. Human Immunodeficiency Virus (HIV)-1-infected M phi are involved in the pathogenesis of HAD and produce toxic molecules including cytokines, chemokines, and nitric oxide (NO). In AD, M phis produce these molecules and are activated by beta-amyloid proteins and related oligopeptides. Demyelination in MS involves M phi that become lipid laden, spurred by several possible antigens. In these three diseases, cytokine/chemokine communications between M phi and astrocytes occur and are involved in the balance of protective and destructive actions by these cells. This review describes the role of M phi and astrocytes in the pathogenesis of these three progressive neurological diseases, examining both beneficent and deleterious effects in each disease.