live longer and healthier lives, the challenges of maintaining these behavior changes will be greater and more sustained.
Since very early in the HIV epidemic, there has always been the hope-articulated throughout the years in the health care provider community, the AIDS activist community, and the community of persons living with HIV-that HIV infection might someday become a serious, chronic, but manageable, disease. Advances in medical treatment are bringing this hope closer to reality. It is still too early to declare success in making HIV disease manageable; too many patients still do not derive or maintain benefit from even the newest antiretroviral combinations, and the history of HIV disease is one with many treatment hopes that did not prove durable. Nonetheless, the potential outlook for many persons living with HIV is brighter than it has ever been before. To a large extent, psychological and behavioral medicine interventions will play a key role in determining whether this potentially hopeful outlook will endure. The effective treatment of persons living with HIV will require that difficult problems be addressed. These include promoting adherence to difficult medical regimens that are remarkably unforgiving of lapses; assisting patients in coping with successes, failures, and uncertainty in their health outlook; and encouraging the avoidance of transmission risk behavior among both seropositive and seronegative persons.
When AIDS first appeared, many aspects of the disease were startling because they were new. HIV/AIDS continues to remain, in many respects, a unique disease by virtue of its stigmatized public perception, sexually transmitted infectious characteristics, concentration within certain communities and social networks, and the coping challenges that confront persons with HIV. To a very great extent, American society has not yet come to terms with the types of policies- including improved sexual education for young people, ensuing ready access to condoms, and needle exchange for out-of-treatment Ides-that stopping the epidemic. However, medical aspects of HIV disease and, more specifically, the roles for health psychologists to contribute to HIV prevention and care are coming to resemble the psychological profession's role in other chronic disease areas. What has been learned about promoting treatment adherence in diseases such as hypertension, diabetes, and other illnesses can be applied to the newer problem of HIV treatment adherence. Lessons learned in helping people cope with serious chronic diseases with uncertain long-term outlooks such as cancer can provide a framework for assisting patients with HIV to cope with similar uncertainties. Behavioral medicine paradigms and principles useful in other health behavior areas can guide efforts related to HIV. What is learned in the HIV/AIDS behavioral medicine area can, in turn, contribute to efforts to assist persons with diseases other than AIDS. There is not a need to reinvent the wheel of behavioral medicine knowledge for health behavior problems experienced by persons with HIV. However, there is a need to make the wheel turn faster given the urgencies of this disease.
Finally, the challenges created by AIDS will continue to evolve. There have already been important changes in the demography of the American HIV epidemic. Persons contract ing HIV are younger, poorer, more disenfranchised, and more estranged from traditional health and mental health service systems than ever before. Substance abuse has become even more closely intertwined with HIV risk than in the past, and groups now most vulnerable to HIV disease (including drug-involved and impoverished women, young and ethnic minority men who have sex with men, IDUs, and the homeless) are populations highly underrepresented in the behavioral medicine field. For all of these vulnerable groups, coping, mental health, treatment adherence, and transmission risk avoidance efforts are likely to be exceptionally difficult. They will require that health psychologists develop new culturally tailored approaches, service delivery mechanisms, and-perhaps-sensitivities. Ultimately, meeting these challenges will also expand and benefit this field.
Preparation of this chapter was supported by center grant P30-MH52776 from the National Institute of Mental Health (NIMH) and from Office of AIDS Research (OAR) and NIMH grant ROl-MH54935.
Agras, S. (1989). Understanding adherence to the medical regimen: The scope of the problem and a theoretical perspective. Arthritis Cure and Research, 2, S2-ST.
Aversa, S. L., & Kimberlin, C. (1996). Psychosocial aspects of antiretroviral medication use bong HIV patients. Patient Edna catiun and Counselling, 29, 20'7–219.
Bailey, W. C., Richards, J. M., Brooks, C. M., Soong, S. J., Windsor, R. A., & Manzella, B. A. (1990). A randomized trial to improve self-management practices of adults with asthma. Archives of Internal Medicine, 1 SO, 1664-I 668.
Blackwell, B. (1992). Compliance. Psychotherapy and
Psychostatics, 58, 162–169.
will prove essential for
Carpenter, CCJ., Fischl, M. A., Hammer, S. M., Hirsch, M. S., Jacobsen, D. M., Katzenstein, D. A., Montaner., J.S.G., Richman, D. D., Saag, M. S., Schooley, R. T., Thompson, M. A., Vella, S., Yeni, P. G., & Volberding, therapy for HIV infection in 1998: Updated recommendations of the International AIDS Society-USA panel. Journal of the Americas
P. A. (1998). Antiretroviral
Medical Association, 280, 78–86.
Centers for Disease Control and Prevention. (1992). 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. Morbidity and Mortality Weekly Report, 4l(RR-17), l–19.
Centers for Disease Control and Prevention. (1996). Continued sexual risk behavior among HIV-seropositive, drug using men- Atlanta; Washington, DC; and San Juan, Puerto Rico, 1993. Morbidity and Mortality Weekly Report, 45, 151–152.
Clear-y, P. D., Van, N., Rogers, T., Singer, E., Shipton-Levy, R., Steilen, M., Stuart, A., Avom, J., & Pindyck, J. (1991). Behavior changes after notification of HIV infection. American Journal of Public Health, 81, 1586–1590.
Deeks, S. G., Loftus, R,, Cohen, P., Chin, S., &Grant, R. (1997, September). Incidence and predictors of virological failure of indinavir and/or ritonavir in an urban health clinic (Abstract