Journal Article Annotations
2025, 2nd Quarter

HIV Psychiatry

Annotations by John A R Grimaldi MD, Mary Ann Cohen MD, FAPM, Kelly Cozza MD, DFAPA, FACLP, Luis Pereira MD
July, 2025

Effect of Mental Health Care Visits on HIV Care Outcome.
Pilot Trial of a Transdiagnostic Cognitive Behavioral Therapy (CBT)-Based Group Intervention to Reduce Psychological Distress, Facilitate Positive Behavior Change, and Mitigate Inflammation in Older People with HIV.

PUBLICATION #1 — HIV Psychiatry

Effect of Mental Health Care Visits on HIV Care Outcome.

Morgan E Bussard, Sunbal Ashraf, Nathan A Summers.

Abstract: AIDS Behav. 2025 Feb;29(2):601-606. doi: 10.1007/s10461-024-04542-5. Epub 2024 Nov 8.

To improve the quality of life for people living with HIV (PLWH), it is vital their treatment plans closely follow the HIV care continuum. However, many barriers, such as mental health disorders (MHD), can complicate treatment. Patients being treated for HIV with comorbid MHD are more likely to not be retained in care and maintain an unsuppressed viral load. As PLWH and people vulnerable to acquiring HIV are more commonly diagnosed with MHD in comparison to the general population, it is important that steps to mitigate the possible effects of MHD are addressed during treatment. This study examines how minimal mental health care in a safety-net hospital system in the U.S. South can show benefits in retaining patients throughout their treatment of HIV. The results showed that older individuals retained a higher level of viral suppression when they followed up regularly with a mental health care provider during treatment. In addition, regardless of age, the higher the number of mental health care visits a patient attended during treatment, the higher the likelihood of viral suppression. By incorporating mental health care into the HIV treatment plan, the patients who met at least one of these criteria had better treatment outcomes and progressed further along the HIV care continuum.

Annotation

Findings:
This retrospective, cohort study explored the effect of attending at least one clinic visit with a mental health provider, on HIV care outcomes of patients attending an HIV primary care clinic during the 2-year study period. The primary outcome measures were in accord with CDC-defined retention in care – attending 2 HIV clinic appointments 90 days apart within a 12-month period and viral suppression. The proportion of patients who attended 2 HIV clinic visits in the 12 months following an appointment with a mental health provider did not differ significantly from the proportion meeting this criterion prior seeing a mental health provider. However, there was a significant difference in the percentage of patients with viral suppression, 57% vs 80% (p<0.0001), before and after mental health intervention, respectively. Additionally, older patients and those with greater number of more mental health visits were more likely to be virally suppressed.

Strengths and limitations:
The southeastern region of the US has a greater number of people living with HIV (PLW) than any other part of the country. Additionally, a larger proportion of PWH in the SE are living in rural areas where access to HIV prevention and treatment resources is limited. Study participants were receiving care in a Ryan White Program-funded clinic located in a safety-net hospital system in Memphis, TN, which attracts patients from an underserved population in the surrounding states of Mississippi and Arkansas. The inclusion of a broad range of mental health providers comprising licensed counselors, psychiatric nurse practitioners, and psychiatrists, suggests that findings may be applicable to settings with limited resources. The study aimed to demonstrate that even a modest intervention such as one visit with a mental health provider may have significant benefit. Study participants did not include clinic patients with mental health disorders who did not access mental health services either within or outside the heath-care system, which limits study findings. Other limitations include the lack of a comparison group, and lack of subgroup analysis of patients with comorbid substance use. The study’s retrospective, observational design limits any conclusions about causality.

Relevance:
Psychiatric disorders are a risk factor for HIV acquisition, are overrepresented in people with HIV, and are associated with poorer treatment adherence and increased morbidity and mortality in PWH. Ample research has demonstrated that identification and treatment of mental health disorders lead to better HIV outcomes and overall quality of life. It is promising that even as modest an intervention as one visit with a licensed mental health provider may be beneficial. Additionally, increasing the number of visits may increase the likelihood of viral suppression. The study subjects’ location in an understudied, poorly resourced and relatively rural region adds significance to study findings. The study setting’s dependence on the federally funded Ryan White Program is important as government support for healthcare for underserved and vulnerable populations is currently being questioned.

PUBLICATION #2 — HIV Psychiatry

Pilot Trial of a Transdiagnostic Cognitive Behavioral Therapy (CBT)-Based Group Intervention to Reduce Psychological Distress, Facilitate Positive Behavior Change, and Mitigate Inflammation in Older People with HIVs.

Jacklyn D Foley, Madison Davis, Stephanie Schiavo, Lauren Bernier, Shibani S Mukerji, Abigail W Batchelder.

Abstract: AIDS Behav. 2025 Jun;29(6):1784-1795. doi: 10.1007/s10461-025-04647-5. Epub 2025 Feb 3.

More than half of adults with HIV in the United States are aged 50 or older. Older people with HIV (OPWH) are disproportionately affected by age-related health disparities and non-communicable diseases associated with inflammation. The current pilot randomized controlled trial (RCT) evaluated the feasibility and acceptability, while exploring signals of effects of a transdiagnostic cognitive behavioral therapy (CBT) modular group teaching skills to cope with distress, make positive health behavior changes, and ultimately reduce inflammation. Participants were 31 virally undetectable, and psychiatrically stable OPWH (age [Formula: see text]50 years). Participants were randomized 1:1 to enhanced usual care or CBT for HIV and Symptom Management (CHAMP). CHAMP consists of 12-weekly virtual group sessions led by two interventionists. Self-report questionnaires and intravenous blood draws were collected at baseline and follow-up. Intervention participants completed an exit interview. Of those screened eligible, 96.8% (30/31) were randomized (n = 15 per group), 86.7% (13/15) completed the intervention, and 87% (26/30) completed the follow-up. On acceptability questionnaires scaled 0-3, participants reported high satisfaction and the intervention to be of high quality (M(SD)=3.00(0.0) for both). They also indicated their needs were met (2.67(0.50)) and coping improved (2.60(0.52)). Intervention participants showed a mean decrease in anxiety (-1.07(6.08)) and depressive (-1.71(5.37)) symptoms on clinical screeners, and mean increase in quality of life (2.86(3.59)). CHAMP is both feasible and acceptable for OPWH. Exploratory analyses indicate favorable outcomes for improving psychological distress and health-related quality of life.

Annotation

Findings:
This pilot, randomized controlled trial of a transdiagnostic, modular, group, cognitive-behavioral psychotherapy evaluated the feasibility and acceptability of this virtual 12-week intervention in older PWH. Secondary outcome measures included psychological distress, health risk behaviors, health-related quality of life, and inflammation biomarkers, A recruitment rate of 77.5%, with 86.7% of participants completing follow-up, were consistent with benchmarks of feasibility and acceptability in previous pilot trials of psycho-behavioral intervention studies. Qualitative feedback from participants indicated the value of an accessible, online platform, and the importance of a group format to increase socialization. The quality of facilitation and content of the modules also favorably influenced participation satisfaction and acceptability. Although this was a pilot study and not powered to detect significant differences between the two arms, there was a detectable signal in the data suggesting a possible benefit to the intervention compared to control. Participants in the group intervention experienced meaningful improvements from baseline in depression, anxiety, and quality of life scores. Neither intervention nor control group showed meaningful change from baseline in health behaviors such as HIV-specific stress, nicotine dependence, alcohol use, physical activity or diet. The results for inflammation biomarkers were mixed. Both groups showed a reduction in interleukin-6, but an increase in C-reactive protein. Overall, this one-year study provides data that can be extrapolated to estimate what could be accomplished by a larger study given more time and a larger budget.

Strengths and limitations:
The strengths of this study included its randomized, controlled design, use of standardized measures, and inclusion of biomarkers. Qualitative assessments provided meaningful data that can be used to inform and strengthen the quality of future, larger, higher-powered efficacy trials. The intervention – CBT modules delivered in a group format – was transdiagnostic and evidence-informed, and leveraged multiple CBT evidence-based strategies. Additionally, the potential for bias was mitigated by having a research assistant, as opposed to the intervention facilitators, conduct interviews. Although the use of biomarkers enhanced the study by probing underlying biological mechanisms, they lacked precision and did not control for time of day, medication use, acute illness, body composition, or encourage fasting/non-fasting prior to blood draw. However, the study’s primary goal of evaluating feasibility was met by demonstrating participants’ willingness to provide biospecimens. Budget and timeframe limitations resulted in a small sample size and meant that the study was underpowered to assess significant differences between arms. At baseline, participants were relatively mentally well with low levels of unhealthy risk behaviors, thus introducing a floor effect. However, this problem could be addressed by enrolling older participants with greater needs in future iterations. Also, a longer timeframe would permit post-intervention improvements in psychological distress to influence downstream behavior change.

Relevance:
The remarkable success of antiretroviral therapy has created a critical need to address problems associated with aging in people with HIV. CDC estimates that over half of PWH in the US are aged 50 or older. This population is disproportionately affected by age-related comorbidities, including neurodegenerative disorders as well as psychosocial complications of living with HIV. Additionally, there is growing research interest in investigating chronic HIV immune activation, despite virologic control, as a significant pathway linking underlying inflammation and associated medical and psychiatric comorbidity. However, interventions aimed at disrupting this pathway are lacking and research into effective treatments for these age-related conditions is limited. More specifically, there is a dearth of knowledge on the effects of CBT on inflammatory processes in PWH. By establishing the feasibility and acceptability of the CHAMP intervention, this pilot study paves the way for conducting a more rigorous trial to determine treatment efficacy and mechanisms of action. This study also addressed an increasing public health need among older PWH by identifying key characteristics that would make interventions more acceptable to this population. Future studies using larger sample sizes and better biomarker study designs are needed to explore the impact of CBT on reducing inflammation and immune activation biomarkers in older PWH.