Handbook of Psychology

Secondary Prevention 231

bene“ts from AZT proved to be elusive, in part because of the
ability of HIV to develop resistance to individual antiretrovi-
ral agents (Larder & Kemp, 1989). Further, the use of AZT
was frequently associated with dose-limiting side effects
such as anemia (Richman et al., 1987), and in many patients
its prolonged use was not well-tolerated. In subsequent years,
the ef“cacy of sequencing AZT monotherapy with additional
drug agents was explored. With aggressive early HIV man-
agement, patients who had already received AZT and were
later switched to other antiretrovirals were shown to experi-
ence better clinical outcomes (Hammer et al., 1997). This
monotherapy approach to treatment remained the standard of
care up until the mid-1990s, but typically provided only tran-
sient bene“ts, along with a host of toxic side ef fects.
It was within the context of limited treatment options and
bleak health prospects that two nearly simultaneous medical
breakthroughs occurred. The “rst was the development of a
diagnostic test to quantify levels of HIV RNA or •viral loadŽ
in the blood plasma of infected individuals. Although CD4
counts provided useful information about the impact of HIV
on immune functioning, the ability to measure viral load pro-
vided a more precise tool for tracking progression of viral
replication and assessing the impact of therapeutic medica-
tions, and led to a greater appreciation of the high HIV bur-
den in infected persons from the onset of the illness (Ho et al.,
1995). The second major breakthrough was the discovery of
protease inhibitors,a new class of drugs that, when used in
combination with two or more new or existing antiretrovirals,
could target HIV at multiple points in the replication cycle.
Initial clinical trials showed that many patients treated with
combinations of HAART experienced reduced viral load to
undetectable levels, fewer opportunistic infections, and in-
creased life expectancies (Collier et al., 1996; Gulick et al.,
1997). As a result, HIV combination therapies became the
standard of care.
The availability of HIV treatments affected disease course
where new treatments were available. Data from the United
States indicated a 44% drop in AIDS-related deaths between
1996 and 1997 (CDC, 1997), a decline attributable to the use
of combination HIV therapies (Palella et al., 1998). Many
people have experienced miraculous turnarounds and sus-
tained HIV viral suppression as a result of the newer thera-
pies; unfortunately, however, treatment bene“ts are not
shared equally by all persons living with HIV disease. A sub-
stantial minority of patients treated with combination thera-
pies do not achieve or sustain lasting bene“ts from the newer
HIV therapies. Estimates of treatment failures„stemming
from drug discontinuation due to intolerable side effects,
poor medication adherence, or multidrug resistant strains of
HIV (Hecht et al., 1998)„range from 15% to 25% in RCT s

(Gulick et al., 1997) and are as high as 60% in uncontrolled

community-based samples (Fatkenheuer et al., 1997).

In addition, access to treatment is limited to only the wealth-

iest of nations. It has been estimated that as few as 10% of pa-

tients worldwide have access to therapy. Even within the United

States, there are disparities in treatment access (Shapiro et al.,

1999). Mirroring overall seroprevalence patterns, the urban

poor, ethnic minorities, women, and other the disenfranchised

groups have reduced access to the new treatments (Andersen

et al., 2000). Indeed, there is increasing fear that disparities in

treatment access and variable treatment response may lead to

two classes of persons living with HIV disease, with more

favorable outcomes occurring among those with higher socioe-

conomic status (Rapiti, Porta, Forastiere, Fusco, & Perucci,

2000). Thus, although it was hoped that HIV might soon resem-

ble a serious but chronic health condition, disparities in treat-

ment access and wide variability in treatment response suggest

that it is too premature to describe HIV as a manageable disease.

Talk of a •cureŽ has therefore been replaced by a mood of

guarded optimism within the HIV care community.

Critical Issues in Secondary Prevention

With this background, we now consider the important role of

health psychology research and practice in improving med-

ical outcomes and quality of life among persons living with

HIV. Interventions to improve quality of life and medical

management of HIV disease often must include psychosocial

support and treatment to addresses the long-term adjustment

and coping challenges that confront patients living with HIV.

In addition, favorable treatment outcomes depend not just on

access to new medications, but on patients• ability to consis-

tently adhere to complex medication regimens. Finally,

longer term treatment success also may hinge on the ability

of patients• to maintain protective health behaviors to avoid

re-infection with a drug resistant HIV strain.

Psychological Intervention Needs among People

Living with HIV

For much of the history of the epidemic, mental health re-

search involving HIV-positive men and women focused on

the psychosocial impact of an incurable, progressively wors-

ening health condition. Not surprisingly, studies conducted

prior to the advent of HAART suggest that HIV-positive men

and women were at considerable risk for Axis I mood and

adjustment disorders (Rabkin, Wagener, & Rabkin, 1996).

Although there is some evidence pointing to a recent de-

cline in the prevalence of depressive disorders among some

populations of HIV-positive persons because of improved