Striving Towards Empowerment and Medication Adherence (STEP-AD): A Tailored Cognitive Behavioral Treatment Approach for Black Women Living With HIV

doi:10.1016/j.cbpra.2017.10.004

Cognitive and Behavioral Practice

Volume 25, Issue 3, August 2018, Pages 361-376

https://doi.org/10.1016/j.cbpra.2017.10.004 Get rights and content

Highlights

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A case series of a tailored CBT approach for Black women living with HIV
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10-session treatment to improve medication adherence and decrease trauma symptoms
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To enhance coping with race- and HIV- related discrimination and gender roles
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Presents the cases of five Black women with HIV who completed the treatment
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Treatment shows promise for improving adherence and decreasing trauma symptoms

Abstract

In the U.S. Black women with HIV face numerous psychosocial challenges, particularly trauma, racism, HIV-related discrimination, and gender role expectations, that are associated with negative HIV health outcomes and low medical treatment adherence. Yet many of these factors are unaddressed in traditional cognitive behavioral approaches. This study presents a case series of a tailored cognitive behavioral treatment approach for Black women living with HIV. Striving Towards EmPowerment and Medication Adherence (STEP-AD) is a 10-session treatment aimed at improving medication adherence for Black women with HIV by combining established cognitive behavioral strategies for trauma symptom reduction, strategies for coping with race- and HIV-related discrimination, gender empowerment, problem-solving techniques for medication adherence, and resilient coping. A case series study of five Black women with HIV was conducted to evaluate the preliminary acceptability and feasibility of the treatment and illustrate the approach. Findings support the potential promise of this treatment in helping to improve HIV medication adherence and decrease trauma symptoms. Areas for refinement in the treatment as well as structural barriers (e.g., housing) in the lives of the women that impacted their ability to fully benefit from the treatment are also noted.

Section snippets

Overview of Approach

Interviews with BWLWH were previously conducted, qualitatively analyzed, and published (Dale et al., 2017), and those findings were used to inform the development of the Striving Toward EmPowerment and Medication Adherence (STEP-AD) intervention. As depicted in Table 1, the STEP-AD treatment consists of 10 sessions delivered on a weekly basis with content on (a) Life-Steps for Medication Adherence, (b) Psychoeducation on the CBT treatment model, (c) PTSD and Cognitive Strategies, (d) Strategies

Participants and Procedures

Participants were recruited in an urban city in the Northeastern United States by distributing flyers in community-based clinics and organizations as well as presenting information about the study at community events and to providers who service BWLWH. After hearing about the study or seeing a posted flyer potential participants contacted the study research coordinator via phone. The research coordinator conducted a phone screen and if the potential participant met the screening criteria, they

Case Examples

For each of the five case examples, we describe background information, adherence level and trauma symptoms at baseline, course of STEP-AD, and outcome data. In order to protect participant confidentiality, we changed some details about each participant.

Discussion

Five Black women with HIV, histories of trauma, and suboptimal adherence (< 80%) and/or detectable HIV viral loads within the past 6 months completed an open pilot trial of the 10-week STEP-AD treatment aimed at improving HIV medication adherence and decreasing trauma symptoms. The aim of the open pilot was to assess the preliminary acceptability and feasibility of the STEP-AD treatment, which was based on empirically validated CBT approaches for trauma and tailored for BWLWH, as well as

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Despite high rates of Post-Traumatic Stress Disorder (PTSD) in persons living with HIV (PLWH) and poor HIV-related health outcomes associated with PTSD, an effective evidence-based treatment for PTSD symptoms in PLWH does not exist. Negative reinforcement conceptual models posit that avoidant behavior (hallmark symptom of PTSD) demonstrated by PLWH with co-occurring PTSD can contribute to poor antiretroviral therapy (ART) adherence. However, research evaluating the impact of evidence-based treatment for PTSD among HIV infected populations on HIV outcomes is scarce. The Cognitive Processing Therapy (CPT) protocol is an evidence-based PTSD treatment that may address internalized stigma with targeted modifications and improve ART adherence and subsequent viral suppression through reduction of avoidant coping. This study will be the first pilot open-label randomized control trial (RCT) to test feasibility of an integrated evidence-based PTSD treatment (CPT) with an adherence intervention (Lifesteps) delivered in a Ryan White clinic to improve PTSD symptoms, adherence to ART, and retention in HIV care. Primary aims are to (1) conduct theater testing of the CPT and Lifesteps research protocol and evaluate acceptability (n = 12) and (2) deliver a modified CPT protocol (CPT-Lifesteps, or CPT-L) in 60 PLWH/PTSD exploring impact of CPT-L on PTSD symptoms and HIV outcomes compared to a Lifesteps + Standard of Care condition. This innovative research extends PTSD treatment approaches as a paradigm to reduce barriers to ART adherence. Findings of this innovative study are significant because they support the Undetectable = Untransmittable (UU) campaign and can help prevent the transmission of HIV infection through increased viral suppression.
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^☆: The authors declare that there are no conflicts of interest.

^☆☆: We would like to thank the participants, research staff, and community stakeholders who gave their time and effort and made this research possible. The research reported in this publication and the principal investigator (Dr. Sannisha Dale) were funded by 1K23MH108439 from the National Institute of Mental Health. Preliminary work that informed the development of the treatment manual described was supported by a scholar award (PI Dr. Sannisha Dale) from the Harvard University Center for AIDS Research (HU CFAR National Institute of Health /National Institute of Allergy and Infectious Disease fund 2P30AI060354-11). Dr. Steven Safren was funded by grant K24 DA040489. The content of this publication is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Striving Towards Empowerment and Medication Adherence (STEP-AD): A Tailored Cognitive Behavioral Treatment Approach for Black Women Living With HIV☆,☆☆

Highlights

Abstract

Section snippets

Overview of Approach

Participants and Procedures

Case Examples

Discussion

Cognitive and Behavioral Practice

Infectious Disease Clinics of North America

Behavioural Research Therapy

Cognitive and Behavioral Practice

Diagnostic and statistical manual of mental disorders

Efficacy of antiretroviral therapy adherence interventions: A research synthesis of trials, 1996 to 2004

Journal of Acquired Immune Deficiency Syndrome

Adherence to protease inhibitors, HIV-1 viral load, and development of drug resistance in an indigent population

AIDS

Coping with discrimination among HIV-positive Black men who have sex with men

Culture, Health and Sexuality

Longitudinal relationships between antiretroviral treatment adherence and discrimination due to HIV-serostatus, race, and sexual orientation among African–American Men with HIV

Annals of Behavioral Medicine

Gender roles, power strategies, and precautionary sexual self-efficacy: Implications for Black and Latina women’s HIV/AIDS protective behaviors

Sex Roles

Gender role behaviors of high affiliation and low self-silencing predict better adherence to antiretroviral therapy in women with HIV

AIDS Patient Care and STDS

Gender roles and mental health in women with and at risk for HIV

Psychology of Women Quarterly

Women, Gender, HIV by Group, HIV/AIDS, CDC

Domestic violence and childhood sexual abuse in HIV-infected women and women at risk for HIV

American Journal of Public Health

Medically eligible women who do not use HAART: The importance of abuse, drug use, and race

American Journal of Public Health

Development of a new resilience scale: The Connor-Davidson Resilience Scale (CD-RISC)

Depression and Anxiety

Resilience among women with HIV: Impact of silencing the self and socioeconomic factors

Sex Roles

Abuse and resilience in relation to HAART medication adherence and HIV viral load among women with HIV in the United States

AIDS Patient Care and STDs

Resilience moderates the association between childhood sexual abuse and depressive symptoms among women with and at-risk for HIV

AIDS and Behavior

Still I Rise: The need for self-validation and self-care in the midst of adversities faced by Black women with HIV

Cultural Diversity and Ethnic Minority Psychology

Assessment of a new self-rating scale for post-traumatic stress disorder

Psychological Medicine

Davidson Trauma Scale (DTS): Normative scores in the general population and effect sizes in placebo-controlled SSRI trials

Depression and Anxiety

Efficacy of the trial-based thought record, a new cognitive therapy strategy designed to change core beliefs, in social phobia

Journal of Clinical Pharmacy and Therapeutics