Adherence to antiretroviral therapy (ART) among HIV-infected individuals is necessary to both individual and public health, and psychosocial problems have independently been associated with poor adherence. To date, studies have not systematically examined the effect of multiple, co-occurring psychosocial problems (i.e., “syndemics”) on ART adherence. Participants included 333 HIV-infected individuals who completed a comprehensive baseline evaluation, as part of a clinical trial to evaluate an intervention to treat depression and optimize medication adherence. Participants completed self-report questionnaires, and trained clinicians completed semi-structured diagnostic interviews. ART non-adherence was objectively measured via an electronic pill cap (i.e., MEMS). As individuals reported a greater number of syndemic indicators, their odds of non-adherence increased. Co-occurring psychosocial problems have an additive effect on the risk for poor ART adherence. Future behavioral medicine interventions are needed that address these problems comprehensively, and/or the core mechanisms that they share.

Increased access to testing and treatment means HIV can be managed as a chronic illness, though successful management requires continued engagement with the healthcare system. Most of the global HIV burden is in sub-Saharan Africa where rates of new infections are consistently higher in women versus men. Pregnancy is often the point at which an HIV diagnosis is made. While PMTCT interventions significantly reduce the rate of vertical transmission of HIV, women must administer ARVs to their infants, adhere to breastfeeding recommendations, and test their infants for HIV after childbirth. Some women will be expected to remain on the ARVs initiated during the pregnancy period, while others are expected to engage in routine testing so treatment can be reinitiated when appropriate. The postpartum period presents many barriers to sustained treatment adherence and engagement in care. While some studies have examined adherence to postpartum PMTCT guidelines, few have focused on continued engagement in care by the mother, and very few examine adherence beyond the six week postpartum visit. Here, we attempt to identify gaps in the research literature and make recommendations on how to address barriers to ongoing postpartum HIV care.

Objective To test cognitive behavioral therapy (CBT) for persistent ADHD symptoms in a sample of medication treated adolescents. Methods 46 adolescents (ages 14-18), with clinically significant ADHD symptoms despite stable medication treatment were randomly assigned to receive CBT for ADHD or wait list control in a cross-over design. 24 were randomized to CBT, 22 to wait list, and 15 crossed-over from wait list to CBT. A blind independent evaluator (IE) rated symptom severity on the ADHD Current Symptom Scale, by adolescent and parent report, and rated each subject using the Clinical Global Impression Severity Scale (CGI), a global measure of distress and impairment. These assessments were performed at baseline, 4-months (post-CBT or post-wait list), and 8-months (post-treatment for those originally assigned to the wait list condition and 4-month follow-up for those originally assigned to CBT). Trial Registration: http://clinicaltrials.gov/show/NCT01019252. Results Using all available data, mixed effects modeling, and pooling for the wait list crossover, participants who received CBT received a mean score 10.93 lower on the IE-rated parent assessment of symptom severity (95% CI: -12.93, -8.93; p<.0001), 5.24 lower on the IE-rated adolescent assessment of symptom severity (95% CI: -7.21, -3.28; p<.0001), and 1.17 lower IE-rated CGI (95% CI:-1.39, -.94; p<.0001). Results were consistent across 100 multiple imputations (all p-values < 0.0001). There was a greater proportion of responders after CBT by parent (50% vs 18%, p=.00) and adolescent (58% vs. 18% p=.02) report. Conclusions This study demonstrates initial efficacy of CBT for adolescents with ADHD who continued to exhibit persistent symptoms despite medications.