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This prospective multisite Phase III clinical trial (Miami, New York, New Jersey) investigated the long-term (one year) effects of a 10-week group cognitive-behavioral stress management/expressive supportive therapy (CBSM+) intervention on disadvantaged minority women living with AIDS. The CBSM+ intervention consisted of 10-weekly group session of stress management, cognitivebehavioral skill training, relaxation techniques and expressive-supportive therapeutic strategies. The primary study outcome was self-reported depression scores as measured by the BDI. The CBSM+ Group intervention significantly decreased depression scores on the BDI for women following the intervention and maintained the decreased level at one-year follow-up. Keywords AIDS; CBSM+; depression; womenMinority women have sustained the largest increase in rates of newly acquired immune deficiency syndrome (AIDS) cases in the USA (Centers for Disease Control and Prevention, 2002). Although recent guidelines from the National Institutes of Health (NIH) mandate the inclusion of women in clinical trials, minority women remain one of the least studied populations (Weijer, 1999). Minority women with AIDS have many other life stressors including single parenthood (Marcenko & Samost, 1999), unstable income and limited access to health care (Gonzalez-Calvo, Jackson, Hansford, & Woodman, 1998). Of particular relevance to the objectives of this study, depression has been found to be related to disease progression and mortality in women with HIV (Ickovics et al., 2001 Numerous studies have documented the prevalence of distress among HIV/AIDS infected individuals (Chandra, Ravi, Desai, & Subbakrishna, 2001;Fukunishi et al., 1997) and have linked this distress to stressful life events (Crystal & Kersting, 1998), health status (Grassi et al., 1999), illness-related stressors, including social stigmatization (Kadushin, 1996) and cognitive deficits (Claypoole et al., 1998), loss of employment and autonomy (Hoffman, 1991) and faster disease progression (Cruess et al., 2003;Leserman, 2003).Cognitive-behavioral interventions have been found to be successful in reducing distress associated with human immunodeficiency virus (HIV) disease (Church, 1998;Kelly et al., 1993). Investigators from our research team have tested the utility of a targeted cognitivebehavioral stress management (CBSM) intervention in reducing distress in gay men with clinically significant results (Antoni et al., 1991;Lutgendorf et al., 1997), as well as predicting clinical outcomes (Ironson et al., 1994) for those with better attendance. However, this intervention has not been tested with a population of women with case-defined AIDS. The present study was designed to extend previous research by examining the efficacy of the standard CBSM intervention, with an added expressive-supportive therapy component, in decreasing levels of depression among women living with AIDS. Method ParticipantsParticipants were recruited from the three major epicenters for women living with HIV/AIDS: Miami-Da...

The principal objective of these multisite studies (Florida, New York, New Jersey: epicenters for human immunodeficiency virus [HIV] among women) was to develop and implement effective combinations of behavioral interventions to optimize the health status of the most neglected and understudied population affected by the acquired immunodeficiency syndrome (AIDS) epidemic in the United States: poor women of color living with HIV. The two studies enrolled nearly 900 women randomly assigned to “high intensity” (cognitive–behavioral stress management training combined with expressive–supportive therapy [CBSM]+ group) or “low intensity” (individual psychoeducational program) treatment conditions over a period of 9 years. The initial study of the stress management and relaxation training/expressive–supportive therapy (SMART/EST) Women’s Project (SWP I) focused on reducing depression and anxiety, as well as improving self-efficacy and overall quality of life for women with case-defined AIDS. Findings from this study demonstrated the utility of CBSM+ in reducing distress (depression, anxiety) and denial, while improving social support, self-efficacy, coping skills, and quality of life. The second study (SWP II), which included all women living with HIV, extended these findings by demonstrating that exposure to CBSM+ significantly improved the ability of the participants to take advantage of a health behavior change program encouraging the adoption and maintenance of healthier lifestyle behaviors (high levels of medication adherence, appropriate nutritional intake and physical activity, safer sexual practices, and reduced alcohol use/abuse) essential for optimal health in the context of living with HIV. SWP II also determined that the intervention program was equally beneficial to less-acculturated segments of the affected population (ie, non-English speaking HIV+ women) through the creation of culturally and linguistically sensitive Spanish and Creole versions of the program. A third study (SWP III) is currently underway to “translate” this evidence-based treatment program into Community Health Centers in Miami, New York City, and metropolitan New Jersey.

This study examined the effects of a ten-session cognitive-behavioural stress management/expressive supportive therapy (CBSM+) intervention on adherence to antiretroviral medication. Although the intervention was not designed to influence adherence, it was theorized that improved coping and social support could enhance adherence. Women with AIDS (N = 174) in Miami, New York and New Jersey, USA, were randomized to a group CBSM+ intervention or individual control condition. Participants were African American (55%), Latina (18%) and Caribbean (18%) with drug (55%) and/or alcohol (32%) histories. Participants were assessed on self-reported medication adherence over seven days, HIV-related coping strategies and beliefs regarding HIV medication. Baseline overall self-reported adherence rates were moderate and related to coping strategies and HIV medication beliefs. Low adherent (80%) participants in the intervention condition increased their mean self-reported medication adherence (30.4% increase, t44 = 3.1, p < 0.01), whereas low adherent women in the control condition showed a non-significant trend (19.6% increase, t44 = 2.0, p > 0.05). The intervention did not improve adherence in this population; conditions did not differ significantly on self-reported adherence. Low adhering intervention participants significantly decreased levels of denial-based coping (F1,88 = 5.97, p < 0.05). Results suggest that future interventions should utilize group formats and address adherence using coping and medication-knowledge focused strategies.

The purpose of the present study was to determine whether changes in self-efficacy over time would be related to changes in disease progression markers (CD4, viral load) in a sample of women with AIDS. A self-efficacy measure was developed and two sub-scales emerged via factor analysis of 391 HIV-positive women: AIDS Self-efficacy and Cognitive Behavioral Skills Self-efficacy. Subsequently, the sub-scales and an additional adherence self-efficacy item were given to 56 HIV-positive women who were measured at two time points three months apart. Half of these women were randomly assigned to a CB intervention and half to a low intensity comparison condition. Increases in AIDS Self-efficacy over the three-month period were significantly related to increases in CD4 and decreases in viral load. Similarly, increases in Cognitive Behavioral Skills Self-efficacy were significantly related to decreases in distress over time. Findings were maintained within the intervention group alone. Interestingly, increases in cognitive behavioral skills self-efficacy and increases in the self-efficacy adherence item were also significantly related to decreases in viral load. Implications of the findings and suggestions for future research are discussed.