Culturally Adapted CBT Reaches Depressed HIV-Positive Hispanics

Fran Lowry

June 08, 2012

June 8, 2012 (Miami Beach, Florida) — A cognitive behavioral therapy program designed to treat depression and nonadherence in people with HIV infection has been adapted to the Latino culture, and shows promise in the treatment of Hispanic people living on the American–Mexican border.

"Although antiretroviral therapy is increasingly available and accessible on the US–Mexico border, preliminary studies indicate that poor adherence and depressive symptomatology detract from its potential success," lead study author Jane Simoni, PhD, from the University of Washington in Seattle, reported here at the 7th International Conference on HIV Treatment and Prevention Adherence.

"People living with HIV have this great medication to help them, but adherence can be a problem," Dr. Simoni told Medscape Medical News.

Some of the issues preventing people living on the border from adhering to their medication are mental health issues related to the stigma of illness, particularly depression. "People could have their meds, know how to take them, and just not be able to commit to a routine of taking them consistently. It isn't just a matter of forgetting, it is all the factors that surround depression that impede adherence, like cognitive slowing, lack of motivation, helplessness about the situation, and lack of drive," she explained.

Treat Depression First, Then Address Adherence

This realization prompted Dr. Simoni and her colleagues to try to address depression in this population before addressing the issue of adherence.

The first step was to adapt the cognitive behavioral therapy program for the treatment of poor adherence and depression (CBT-AD) — developed by Steven Safren, PhD, from the Massachusetts General Hospital in Boston — to the Hispanic population living on both sides of the border.

"This is a program for people living with chronic illness that addresses both depression and adherence; we thought it might work for this population," Dr. Simoni noted.

Forty clients of Mexican descent were recruited from a community-based HIV primary care clinic in El Paso, Texas. All of the participants reported depressive symptomatology and less than optimal adherence.

They received at least 12 sessions of CBT-AD in English or Spanish over 6 months. They also received electronic reminders from the MedSignals medication management system.

Participants in the control group received usual care.

The sessions were done individually; they were not group sessions, Dr. Simoni noted.

"There is a lot of stigma, so they weren't interested as much in group work; they wanted some kind of one-on-one approach," she explained. "We also tried to make the sessions frequent enough for patients to develop a relationship and commit to therapy, but not so frequent that it was disruptive to their routine."

Adaptation From the "East Coast" Approach

The Hispanics living on the US–Mexico border required an approach that was different than Dr. Safren's "East Coast" approach, explained Dr. Simoni.

Dr. Safren "is very direct in his communication, and he's very time oriented. Some of the folks on the border were appalled by his technique. We discovered the Latino values of personal relationships, empathy, connection to another person, family, religion — all of these are very important," she said.

In the first session, participants were asked about other issues that were affecting their HIV, such as stigma and disclosure.

Dr. Safren "has worked with a lot of gay men, and most have a large community of people. But some of these folks, even the gay men, are still living at home, with their family, who they haven't told, so they're very isolated. They appreciated time just to be able to tell us a little about themselves and their families, and for us to make a connection with them," Dr. Simoni said.

Instead of focusing on individual needs and wants, the adapted CBT-AD focused more on spirituality and family.

"Western messages tend to stress the individual. You deserve it, you're worth it, do it for yourself; these don't resonate as well in a more collectivist culture. For Latinos, the message was more about being strong for your family...; we changed the original focus of the therapy," Dr. Simoni said.

Study Design and Results

At baseline, after the 6-month intervention (postintervention), and 9 months later, study participants — including men, women, gay men, and seniors — were assessed for adherence using a 7-day visual analog scale and 2-week electronic data monitoring.

The researchers found that from baseline to postintervention, the culturally adapted intervention improved both self-reported adherence and adherence measured by electronic drug monitoring.

For self-reported adherence, the postintervention odds ratio [OR] was 3.43 (P = .001); for adherence measured by electronic drug monitoring, the OR was 3.92 (P = .03).

This improvement was maintained at 9-month follow-up for self-reported adherence (OR, 2.11; P = .08) and for adherence measured by electronic drug monitoring (OR, 3.23; P = .22).

Depressive symptoms also improved with the culturally adapted intervention on the self-reported Beck Depression Inventory (BDI) and on the clinician-administered Montgomery–Åsberg Depression Rating Scale (MADRS).

On the BDI, the average decrease from baseline to postintervention was 3.64 (P = .05); at 9 months it was 4.80 (P = .01). On the MADRS, the average decrease from baseline to postintervention was 5.14 (P = .14); at 9 months it was 1.41 (P = .68).

There was improvement in CD4 cell count from baseline to postintervention (69.45 cells/mm3; P = .07); however, this improvement did not remain significant at the 9-month follow-up (25.71 cells/mm3; P = .89).

There were negligible effects on viral load, possibly because of ceiling effects, Dr. Simoni reported.

"We think this small pilot study of culturally adapted CBT-AD warrants further evaluation in this population," she said.

Culturally Appropriate Interventions Critical

"Cultural adequacy is a critical element of interventions intended to improve adherence," Rafael Maizín, MD, MPH, senior advisor on HIV, TB, and hepatitis at the Pan American Health Organization, in Washington, DC, told Medscape Medical News.

"The development of culturally appropriate interventions entails more than the translation of a successful one from one language to another. Knowing the beliefs, aspirations, and perceptions of health and wellbeing of a given population or group should be a requisite when adapting interventions," said Dr. Maizín, who was not part of the study.

Dr. Simoni and Dr. Maizín have disclosed no relevant financial relationships.

7th International Conference on HIV Treatment and Prevention Adherence: Abstract 80064. Presented June 5, 2012.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.