Although antiretrovirals can prolong life, medication adherence also poses a constant challenge for HIV-infected individuals because the success of antiretroviral regimens demands nearly perfect adherence to medications. This paper describes the psychiatric and social barriers to adherence in a convenience sample of HIV-positive clients in methadone treatment in the Bronx, New York. The study sample was part of a national study of HIV treatment adherence and health care utilization among triply diagnosed populations, the HIV/AIDS Treatment Adherence Health Outcomes and Cost Study. The triply diagnosed study sample is defined here as HIV-infected individuals who screened into the study with at least one psychiatric diagnosis in addition to opioid dependence on agonist therapy (methadone treatment) and at least one substance use diagnosis. Interviewers utilized modified versions of the Structured Clinical Interview for DSM-IV Disorders (SCID-I), the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), and the Addiction Severity Index (ASI-Lite), among a battery of Cost Study instruments. Results showed that within this sample, borderline personality disorder was significantly associated with nonadherence to HIV medications. A related finding showed a significant relationship between serious social/family problems and nonadherence. These findings build on previous research on the impact of psychiatric illness on HIV medication adherence and suggest that psychiatric assessment and treatment options be linked to adherence interventions.

Seattle Children's Hospital is a tertiary referral hospital that has provided telepsychiatry to seven partner sites in the north-west since 2001. Service utilization data, patient demographics and diagnoses were collected for the period from the service inception in October 2001 until November 2007. During the study period, 701 patients were treated with a mean of 2.8 appointments per patient (SD 1.9). Five psychiatrists and four psychologists provided care. Utilization varied across referring sites and was largely dependent upon the availability of telepsychiatrists, although the degree of support from administration and stakeholders also contributed to the success of the service. A total of 190 primary care practitioners referred patients to telepsychiatry, including 106 family physicians and 71 paediatricians. Paediatricians referred to the service more frequently than family physicians (t = 2.8, P < 0.05). Overall, telepsychiatry with young people is feasible, acceptable and increases access to mental health care. There appear to be four core components necessary to a successful telepsychiatry programme: psychiatrists who are interested in exploring new ways to reach underserved young people; clearly identified stakeholders who can collaborate with one another to make good use of the telepsychiatry service; a children's mental health 'champion' who represents these stakeholders and wants services for their community; and a stable administration that perceives telepsychiatry as valuable for their patients and their doctors.

Adherence to antiretroviral medications is central to reducing morbidity and mortality among people living with HIV/AIDS. Relatively few studies published to date address HIV adherence among special populations. The purpose of this article is to review the existing literature on HIV antiretroviral adherence, with an emphasis on studies among the triply diagnosed population of people living with HIV/AIDS, mental illness, and chemical dependency. In order to reflect the most current information available, data from conference proceedings, federally funded studies in progress, and the academic literature are presented for consideration.

New web-based applications can be used by investigators with limited programming experience to implement user-friendly, efficient, and cost-effective tools for multi-site clinical trials with small distant communities. Such systems allow the inclusion in research of populations that are not usually involved in clinical trials.