Lactancia

Infect Dis Clin N Am 21 (2007) 181–200

Behavioral Aspects of HIV Care: Adherence, Depression, Substance Use, and HIV-Transmission Behaviors
Carla J. Berg, MAa, Susan E. Michelsona, Steven A. Safren, PhDa,b,*
Massachusetts General Hospital/Harvard Medical School, 15 Parkman Street, ACC 812, Boston, MA 02114, USA b Fenway Community Health, 7 Haviland Street, Boston, MA 02115, USA
a

Morethan 900,000 Americans are infected with HIV [1,2], and the rate of new infections continues each year at 40,000 [3]. With the advent and access of highly active antiretroviral therapy (HAART) and with continued incidence of HIV, more and more individuals are living with this illness. Hence, a growing and substantial number of people are faced with the quality of life impairments associated with HIVinfection, including managing the complex aspects of behavioral self-care. Specific self-care concerns among HIV patients that impact quality of life and HIV outcomes for the patients themselves include medication adherence, depression, sexual risk-taking, and substance abuse. These concerns can sometimes be additive if and when they co-occur. Depression and substance abuse, for example, decreasequality of life and can impact adherence to medical regimens [4]. Adherence has a direct influence on treatment outcomes and functioning [5–7]. Sexual risk-taking can cause new infections that can hinder quality of life and advance disease progression [8–10]. In addition to the burden on the quality of life of patients, these behavioral aspects of self-care also have an influence on the continuedtransmission of HIV [11–14]. Despite educational prevention messages, new HIV infections have not declined significantly in the United States [3] or many other nations [15] in recent years. Although many HIV-infected individuals
Funding for investigator time for this paper came from an R01 award from NIH/NIDA to Dr. Steven A. Safren (1 R01 DA018603-01). * Corresponding author. Department ofPsychiatry, Massachusetts General Hospital, 1 Bowdoin Square BS-07B, Boston, MA 02114. E-mail address: ssafren@partners.org (S.A. Safren). 0891-5520/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.idc.2007.01.005

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avoid risky behaviors that can transmit the virus to others, approximately 33% of HIV-infected individualscontinue to engage in high-risk behaviors [3,12,13,16–18] regardless of demographic or HIV-risk group. Health care providers may be able to play a central role in integrating HIV prevention into HIV care to improve patient outcomes and transmission behaviors [19]. Many HIV-infected individuals are aware of their disease and regularly come into contact with the health care system [2,20]. Although it isestimated that approximately one quarter of HIV-infected patients are unaware of their diagnosis [21], substantially more individuals are expected to be screened and triaged into care with the new Centers for Disease Control and Prevention guidelines for opt-out HIV testing in health care settings [22]. Once diagnosed and in treatment, most HIV-infected persons have at least one annual primarymedical care visit [20,23], although current HIV treatment guidelines recommend assessment of plasma HIV-1 RNA viral load and CD4 count every 4 to 8 weeks until it reaches levels below the limits of detection of the assay and regularly thereafter (eg, three to four times per year) [24]. Given the importance of self-care behaviors in HIV care, this article reviews clinical and research findings regardingfour important psychosocial concerns relevant to HIV: (1) medication adherence, (2) depression, (3) sexual risk-taking, and (4) substance use. Each section summarizes research findings on the occurrence of these issues, their correlates, and interventions. The article concludes with an overview of selected general behavioral change models that HIV providers can use when they discuss behavioral...