Optimizing Adherence in Adult Survivors of Childhood Sexual Abuse
Jeffrey Laurence, M.D.
Cocktails of anti-HIV drugs known as HAART have dramatically raised the life expectancy of people with HIV/AIDS. But they can only help if a person knows his or her HIV status, has affordable access to appropriate medications under the care of a knowledgeable physician, and faithfully takes those medications as prescribed. Many federal and local programs address the first two issues, but the problem of HIV medication adherence is just as complex, if not more so.
Child sexual abuse was a much more important predictor of low adherence to HIV treatment than a frank psychiatric diagnosis.
amfAR fellow Dr. Christina Meade, working initially at Harvard Medical School and now at the Global Health Institute at Duke University, explored whether childhood sexual abuse interferes with treatment utilization.
One-third to one-half of all HIV-positive adults in the U.S. are survivors of child sexual abuse, according to estimates. Writing in the April issue of AIDS Patient Care and STDs, Dr. Meade and colleagues at Yale and Duke investigated HAART utilization, mental health, substance abuse, and other psychosocial factors among a group of HIV-positive men and women with a history of such abuse who were participating in a coping intervention trial in New York City.
Childhood sexual abuse is known to be closely tied to psychological trauma, substance abuse, and poor social support, and is also a predictor of poor treatment utilization. However it is unclear how or why such trauma interferes with adherence to medical treatments. Dr. Meade sought to identify relevant factors that might be modified through social and behavioral interventions.
Dr. Christina Meade
She found that while nearly all study participants—99 percent—had access to medical care, one-quarter were not compliant with their medications. Poor adherence, she discovered, was associated with severity of sexual abuse trauma symptoms, including hopelessness, mistrust, flashbacks, hyperarousal, intrusive images, and having few links to networks of friends or family.
In striking contrast, the presence of either a general psychiatric disorder, depressive symptoms, or perceived stress did not impact HAART use. In other words, the traumatic stresses and interpersonal difficulties classically experienced by survivors of child sexual abuse were much more important predictors of low adherence to HIV treatment, and thus poorer long-term outcomes, than a frank psychiatric diagnosis.
Dr. Meade concluded that better case management utilizing a care team, coupled with mental health treatment for trauma, could be the key to optimizing the medical care of people with HIV/AIDS who have a history of childhood sexual abuse.
Dr. Jeffrey Laurence is amfAR’s senior scientific consultant.