Trauma, dissociation, and antiretroviral adherence among persons living with HIV/AIDS
Introduction
There are estimated to be over 1,000,000 persons living with HIV/AIDS in the United States and approximately 55,000 new HIV infections every year (Center for Disease Control and Prevention, 2010). With the development of highly active antiretroviral therapy (HAART), the number of persons living with HIV (PLH) continues to increase. Adherence to a HAART regimen, defined as correspondence between the behavior of a patient and the health care recommendations received (Haynes et al., 1980), has the potential to decrease HIV-1 RNA (viral load), increase immune function, and enhance quality of life (Hammer et al., 2006). By contrast, inconsistent adherence to antiretroviral regimens is correlated with elevated viral load and decreased CD4 cell count (Paterson et al., 2000), as well as increased HIV-related morbidity (Roca et al., 2000) and mortality (Jensen-Fangel et al., 2004).
HAART regimens have low tolerance of nonadherence such that optimal viral suppression requires correct use of HAART 90–95% of the time (Paterson et al., 2000). Moreover, nonadherence to antiretroviral medications may increase viral resistance to numerous classes of medications, thereby rendering various medication options ineffective (Bangsberg et al., 2004). This is problematic because increased transmission of resistant HIV strains raises a variety of public health concerns (Wainberg and Friedland, 1998), including increased morbidity and mortality rates. Thus, it is critical to identify individuals living with HIV/AIDS who are likely to be nonadherent so that they can receive targeted interventions designed to increase adherence to HAART.
Adherence to antiretroviral therapy is a problem for many HIV-positive individuals, with an estimated 50%–80% of PLH unable to practice adequate adherence (Belzer et al., 1999, Johnson et al., 2003, Spire et al., 2002). The reasons for nonadherence are varied. Adherence to antiretroviral regimens is logistically challenging, as the therapy often consists of three or four separate medications. If first-line or second-line treatments have been ineffective, the patient may be expected to take over twenty pills each day while following a strict diet (Berg et al., 2007). Additionally, side effects of HAART include nausea, vomiting, anemia, and peripheral neuropathy, which can contribute to nonadherence (Ammassari et al., 2001). Furthermore, a variety of patient-related psychosocial factors have been associated with poor HAART adherence (Vervoort et al., 2007), including low patient self-efficacy, psychological distress, depression, exposure to trauma, forgetfulness, substance use disorders, low social support from family and friends, inadequate confidence in treatment effectiveness, and poor understanding of the relationship between nonadherence and viral resistance (Ammassari et al., 2002, Deschamps et al., 2004, Leserman, 2008). Moreover, depression has been associated with disease progression among PLH (Leserman, 2008). Although the mechanism by which psychosocial factors result in nonadherence is not fully known, there is evidence that the occurrence of psychological symptoms of distress is associated with disease progression through a decrease in adherence among PLH (Gore-Felton and Koopman, 2008).
High rates of trauma exist among both women and men living with HIV (Brief et al., 2004, Gore-Felton et al., 2002). Studies have shown a 33% lifetime prevalence of physical assault and 30%–68% lifetime prevalence of sexual assault among HIV-positive individuals, versus 6.9% and 9.2% in the general population, respectively (Kalichman et al., 2002, Kessler et al., 1995, Kimerling et al., 1999b). A study among 242 primarily African American gay or bisexual HIV-positive men found that 35% of the sample had a history of sexual assault (Kalichman et al., 2002). This is considerably higher than rates reported in the general population, in which 1% of men report a lifetime history of rape and 2.8% report past molestation (Kessler et al., 1995). Similarly, PLH have higher rates of childhood physical and sexual abuse compared to the general population (Brief et al., 2004). The psychological sequelae of trauma experiences have been well documented and often result in acute or chronic anxiety symptoms (Gore-Felton et al., 1999b).
According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (APA, 2000), post-traumatic stress disorder (PTSD) is an anxiety disorder that can occur after an individual witnesses or experiences a traumatic event involving the threat of injury or death. The hallmark symptoms of PTSD include reexperiencing, avoidance/numbing, and hyperarousal (APA, 2000).
PTSD is a debilitating disorder that is prevalent at greater rates among PLH than in the general population; furthermore, it has been shown to negatively impact HIV-related health outcomes (Kimerling et al., 1999a, Kimerling et al., 1999b). A study among HIV-positive women found that more than one-third (35%) reported a history of trauma and currently met criteria for PTSD diagnosis (Kimerling et al., 1999b). In contrast, the lifetime prevalence of PTSD among women in the general population is 9.7% (Kessler et al., 2005). A similar finding among HIV-positive gay and bisexual men showed that 36% met criteria for PTSD (Kelly et al., 1998b), whereas 3.6% of men in the general population have a lifetime history of PTSD diagnosis (Kessler et al., 2005). Additionally, the diagnosis of HIV itself can be a traumatic stressor. In fact, 32% of HIV-positive men meet criteria for PTSD as a result of being diagnosed with HIV (Kelly et al., 1998a). This is higher than the rates of PTSD following diagnosis of other life-threatening illnesses: for example, only 5% of patients meet PTSD criteria after being diagnosed with breast cancer (Andrykowski and Cordova, 1998). Among persons living with hepatitis C, a population whose psychosocial profile is similar to that of PLH, the estimated prevalence of PTSD is 19%–33.5% (Lehman and Cheung, 2002, El-Serag et al., 2002, Yovtcheva et al., 2001). One study showed a PTSD prevalence of 33.5% among veterans diagnosed with hepatitis C versus 24.5% among uninfected veterans (El-Serag et al., 2002). The increased rate of PTSD following a positive HIV diagnosis may combine with the already higher rate of traumatic experiences found in PLH, resulting in a cumulative stress effect. More research is needed to understand the increased psychiatric morbidity found among PLH who also report a trauma history.
In addition to their general negative impact on health outcomes, there is a growing body of evidence suggesting that symptoms of traumatic stress are associated with antiretroviral nonadherence. A positive correlation exists between depression and nonadherence to antiretrovirals (Ammassari et al., 2004), and PLH with past trauma report more depressive symptoms than PLH with no history of trauma (Kalichman et al., 2002). Also, emotional distress has been shown to increase nonadherence to antiretrovirals (Singh et al., 1996), and PLH with a history of trauma report greater distress than PLH with no past trauma (Kimerling et al., 1999a).
More than half of patients living with HIV who report inconsistent adherence to HAART regimens meet diagnostic criteria for PTSD (Safren et al., 2003). Although several studies have reported an association between PTSD and antiretroviral nonadherence (Boarts et al., 2006, Cohen et al., 2001, Safren et al., 2003, Whetten et al., 2008), it has not always been clear whether it is PTSD alone or in fact comorbid depression that drives this relationship (Boarts et al., 2006, Delahanty et al., 2004, Sledjeski et al., 2005, Vranceanu et al., 2008). Additionally, the relationship of specific symptoms of PTSD to HAART nonadherence has yet to be clarified.
Dissociative symptoms are a common but little-understood response to trauma. Dissociation is defined as a disruption or breakdown of memory, awareness, identity and/or perception. It can develop following long-term physical, sexual or psychological abuse (Vermetten et al., 2007), or following an acute life stressor (Morgan et al., 2001). A dissociative coping style in the face of an inescapable traumatic experience may prevent subsequent cognitive and emotional processing of the pain associated with the trauma (Spiegel, 1997, Spiegel and Cardena, 1991); in fact, acute dissociative responses to psychological trauma increase the risk of developing chronic dissociation and chronic PTSD (Bremner et al., 1992, Butler et al., 1996, Marmar et al., 1994).
There is substantial clinical and neurobiological evidence for the existence of a dissociative subtype of PTSD that involves emotional overmodulation and is mediated by prefrontal inhibition of the limbic system (Lanius et al., 2010). In contrast, the more common PTSD subtype is marked by reexperiencing and hyperarousal symptoms, and is thought to involve emotional undermodulation mediated by a failure of the prefrontal cortex to inhibit limbic regions.
Despite the dramatically elevated rates of past trauma in PLH, no studies to date have investigated the relationship between dissociative disorders (or dissociative symptoms) and antiretroviral adherence in HIV-positive individuals. Therefore, this study examined the relationship of PTSD symptoms and dissociation to antiretroviral adherence among adults with HIV/AIDS. Specifically, we hypothesized that PTSD and dissociation would be associated with lower antiretroviral adherence, and that dissociation would moderate the relationship between PTSD and nonadherence.
Section snippets
Procedure
Forty-three individuals with HIV were recruited from community-based clinics in the San Francisco Bay Area to participate in a cross-sectional, audio computer-assisted self interview (ACASI) survey examining the relationships of trauma symptoms, particularly PTSD and dissociation, to antiretroviral medication adherence. While some of these individuals were recruited either through advertising or their HIV health care providers, the majority were recruited from a larger Bay Area study of the
Participant characteristics
Of the 43 participants who were surveyed, 38 subjects provided sufficient information to determine factors related to HIV antiretroviral adherence. A total of 32 of these subjects were males and 6 were females.
A total of 57.9% of the subjects (n = 22) reported that, in the four days preceding assessment, they followed their HIV medication schedule all of the time and did not miss any HIV medication doses. These participants were classified as “adherent”, and the remaining 42.1% (n = 16) of
Discussion
This study represents an initial examination of the relationship between PTSD, dissociative symptoms, and antiretroviral adherence among persons living with HIV/AIDS. The presence of PTSD symptoms was significantly associated with a decreased probability of HIV medication adherence, and this relationship was moderated by dissociative symptoms. Participants with high levels of dissociation showed a significant association between PTSD symptoms and lower odds of HIV medication adherence, whereas
Role of funding sources
This research was supported in part by the Stanford University School of Medicine Medical Scholars Research Program (PI: Alex Keuroghlian, MD; Faculty Research Advisor: Cheryl Gore-Felton, PhD) and the National Institute of Mental Health (NIMH) grant #R01MH072386 (PI: Cheryl Gore-Felton, PhD). Both sources of funding had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Conflict of interest
All authors declare that they do not have any conflicts of interest.
Acknowledgments
We would like to thank the patients who participated in this study. We thank Susan Sharp for recommendations related to the audio computer-assisted self interview. We also thank Evelyn Nelson, Anna Hinohara and Amy Frohnmayer who kindly assisted with the recruitment and assessment of participants.
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