Secondary Prevention 233Drawing on research suggesting the bene“ts of positive
psychological adjustment to HIV disease, a number of inves-
tigators have sought to evaluate the impact of stress-reduction
interventions on mental health functioning and, in some in-
stances, HIV disease course. For example, Folkman and
Chesney (1991) developed an intensive coping intervention
for HIV-positive individuals called Coping Effectiveness
Training (CET). The CET intervention consists of 10 group-
based training sessions designed to improve coping skills
through the use of cognitive behavioral strategies and en-
hancement of social support. An RCT involving 128 HIV-
positive gay men with some depressive symptoms (Chesney,
Folkman, & Chambers, 1996) showed promising results for
CET. Subjects were assigned to either CET or to an HIV
education support group. Those receiving the CET interven-
tion showed a signi“cant increase in self-ef“cacy, and
decreased distress compared to participants in the informa-
tion only group. However, no differences were found
between the CET and control group on CD4 cell counts or
HIV-related symptoms.
A multifaceted cognitive behavioral stress management
program (CBSM) developed by Antoni et al. (1991) has
shown even greater promise as an approach to reducing psy-
chological distress and improved health-related outcomes
among persons living with HIV. The CBSM is a 10-week
group-based intervention that includes techniques for build-
ing awareness of stress and negative thoughts, cognitive re-
structuring techniques, relaxation and imagery techniques,
coping skills training, interpersonal skills training, and meth-
ods for enhancing social support. In one of the earliest stud-
ies involving CBSM, asymptomatic gay and bisexual men
newly diagnosed with HIV and who received the CBSM ex-
perienced improvement in immune functioning in the form of
increased CD4 counts relative to participants assigned to a
control condition. Somewhat surprisingly, however, partici-
pants in the CBSM group showed no improvements in mood-
related symptoms (Antoni et al., 1991).
Other studies provide more direct evidence of the potential
utility of cognitive behavior interventions to ameliorate psy-
chological distress and improve health outcomes. Antoni
et al. (2000) tested the effects of CBSM among symptomatic
HIV-positive gay men. Seventy-three men were randomized
to the intervention or a wait-list control (WLC) condition.
Men assigned to CBSM showed lower posttreatment levels of
self-reported anxiety, anger, total mood disturbance, and per-
ceived stress. In addition, men receiving the CBSM demon-
strated less norepinephrine output as compared with men in
the WLC group. Even more noteworthy were “ndings con-
cerning long-term immune functioning. Signi“cantly greater
numbers of T-cell lymphocytes were found 6 to 12 months
later in those assigned to CBSM relative to those in the con-
trol group, suggesting that the intervention resulted in lasting
improvement in immune functioning.
Research is needed to clarify whether psychological inter-
ventions improve health outcomes among diverse popula-
tions of HIV-positive men and women. These studies, along
with “ndings from studies involving the use of support
groups (Kelly et al., 1993), nonetheless provide evidence that
group-based stress management and supportive interventions
can reduce distress and contribute to improved quality of life
for people living with HIV. As the number of people living
with HIV disease continues to rise, it will become increas-
ingly important to incorporate promising research-based cop-
ing interventions into standard care.Medication AdherenceSuccessful treatment with combination therapy results in al-
most total suppression of HIV viral load. Failure to achieve
sustained suppression of HIV viral load can lead to the devel-
opment of multidrug resistant strains of the virus and,
ultimately, poor clinical outcomes (Mayer, 1999). Several bio-
medical factors, including prior experience with antiretroviral
medications, disease stage, and the timing of the initiation of
combination therapies can contribute to poor treatment
response (Fatkenheuer et al., 1997). Also important to the
sustained success of HIV combination therapies is patient ad-
herence. Indeed, the critical importance of adherence has
led to calls for behavioral research on the dynamics of medica-
tion adherence as a means of improving HIV medical care
(Chesney, Ickovics, Hecht, Sikipa, & Rabkin, 1999; Kelly,
Otto-Salaj, et al., 1998; Rabkin & Ferrando, 1997). Because re-
search on adherence to HIV medications is just beginning to ap-
pear in the scienti“c literature, our focus here is to describe the
nature and scope of the adherence challenge, and to identify
promising directions for interventions to improve adherence.Nature and Scope of the Problem. Combination ther-
apy regimens have been described as being perhaps the most
rigorous, demanding, and unforgiving of any outpatient oral
treatments ever introduced (Rabkin & Chesney, 1999). Com-
bination therapy regimens typically require patients to take a
protease inhibitor and two or more antiretroviral therapies
throughout the day and night, often at varying time intervals.
Some treatments must be taken on an empty stomach,
whereas others are to be taken with food. To complicate mat-
ters further, some medications must be kept in refrigeration
whereas others do not. Together with other medications pre-
scribed as a prophylactic (i.e., to prevent opportunistic infec-
tions or illnesses) or for symptomatic illnesses, patients are