AIDS and Behavior, Vol. 4, No. 3, 2000
Lifestyle Choices of Parents Living with AIDS: Differences in Health Behavior and Mental Health Marguerita Lightfoot,1,3 Leah Robin,1 Mary Jane Rotheram-Borus,1 Debra A. Murphy,1 Marie M. Diaz,1 Julie Lehane,2 and Laura R. Rosen1 Received Oct. 15, 1998; revised July 1, 1999; accepted July 6, 1999
Health behaviors and mental health symptoms of parents living with AIDS (PLAs) were examined as a function of their sexual and substance-use lifestyles. The lifestyles of PLAs were classified as (1) Safe and Clean: having only protected sex and abstaining from substance use, (2) Safe Users: having protected sex, but engaging in substance use, (3) Unsafe and Clean: having unprotected sex, but abstaining from substance use, and (4) Unsafe Users: having unprotected sex and engaging in substance use. About half of the PLAs were Safe and Clean. Unsafe Users were more likely to miss doctor appointments and to have been diagnosed longer. Safe and Clean PLAs experienced fewer major life events. Changes in specific daily routines were associated with subgroup status; however, there were no consistent patterns across health behaviors linked with lifestyle. These data suggest there are different types of lifestyle changes made by PLAs when they know their serostatus. A disturbing number of PLAs continue to engage in HIV-transmission risk behaviors, demonstrating the need for preventive interventions. KEY WORDS: AIDS; parents; substance use; HIV.
INTRODUCTION
1995, 1998b). African American and Latina women account for 21% of the U.S. population, but constitute 76% of cumulative AIDS cases in women (CDC, 1998a). Most women with AIDS were infected through high-risk situations: heterosexual sex with an injection drug user or through their own injection drug use (CDC, 1998b). Each year in the United States, approximately 6,000–7,000 women with HIV become pregnant and give birth (Riley and Green, 1999). Consequently, by the year 2000, it is projected that there will be as many as 70,000 children orphaned by AIDS in the United States (United Nations Joint Commission on AIDS, 1998). Therefore, there is an increasing focus on parents, particularly mothers, as the epidemiology of HIV shifts. Substance use and patterns of multiple sexual relationships are likely to significantly influence the ability of parents living with AIDS (PLAs) to meet the challenge of maintaining health. Substance abusers are less likely to care for their health, and substance abuse has been hypothesized to be a method of self-medicating for depression (Khantzian, 1997;
More Americans are living with AIDS (currently about 665,000; Centers for Disease Control and Prevention [CDC], 1998b), but it is anticipated that they will have longer life spans and better health due to combination antiretroviral therapies (Kaplan et al., 1995; Sharp, 1996). The greatest number of people living with AIDS are men who have sex with men and injecting drug users; however, the greatest proportional increases in AIDS cases and new HIV infections are occurring among women. For example, the proportion of women among AIDS cases has increased from 18% in 1995 to 22% in 1998 (CDC, 1
Division of Social and Community Psychiatry, Department of Psychiatry, University of California, Los Angeles, Los Angeles, California. 2 American Liver Foundation, New York, New York. 3 Requests for reprints should be directed to Marguerita Lightfoot, Ph.D., Department of Psychiatry, Division of Social and Community Psychiatry, UCLA, 10920 Wilshire Blvd., Suite 350, Los Angeles, California 90024 (e-mail:
[email protected]).
253 1090-7165/00/0900-0253$18.00/0 2000 Plenum Publishing Corporation
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Weiss et al., 1992). Similarly, multiple sexual partners and non-injection drug use are linked with a cluster of problem behaviors (e.g., criminal justice contact, unemployment; Hser et al., 1998) that are associated with poor health adherence and high levels of mental health symptoms (Batki and Ferrando, 1996; Ferrando et al., 1996). To benefit others and to prevent reinfection, reductions in transmission behaviors are desirable (Brown and Beschner, 1993; Bux et al., 1995; Pickens et al., 1993). Unfortunately, many adults continue to engage in unprotected sex and substance-use risk activities following notification of their serostatus (Lemp et al., 1994; Rhodes et al., 1993; Robins et al., 1994). Thus, the first goal of this paper is to examine parents’ substance use and sexual risk behaviors after learning that they are seropositive for HIV. PLAs have the responsibility for their children’s mental health and social and behavioral adjustment (Gonzalez et al., 1989; Rolland, 1988; RotheramBorus et al., 1998). Not accessing medical care is likely to increase the PLAs’ medical symptoms, consequently increasing the effect of the PLAs’ illness on their children (Rabkin et al., 1993; Rotheram-Borus and Stein, 1999). Additionally, the impact of serious parental illness has typically been evaluated in middle-class families who have access to health care (Sandler et al., 1992; Siegel et al., 1992). PLAs are overwhelmingly poor (Levine, 1994) and are more likely to have difficulty accessing health care and to experience more barriers in adhering to medical regimens (Rotheram-Borus et al., 1996). Early research suggests that transmission behaviors are associated with poor medical adherence (Ferrando et al., 1996). Therefore, the second goal of this study is to examine health-related behaviors among PLAs who exhibit transmission behaviors and those who do not. PLAs are likely to be increasingly distressed as their illness progresses (Cates et al., 1990). Living with a chronic illness is associated with higher rates of mental health symptoms and negative outcomes (Coyne and Downey, 1991; Dohrenwend and Dohrenwend, 1981). Adults living with AIDS have exhibited rates of depression and anxiety in the clinical range (Rotheram-Borus et al., 1999), which is likely to affect both their health status and health adherence behaviors (Robins et al., 1994). The presence of psychiatric diagnoses among injecting drug users and depression among gay men also has been associated with nonadherence (Chesney and Folkman, 1994; Susser et al., 1996). One factor that predicts HIV risktaking behavior is mental health problems (Meyer
and Dean, 1995). Given the importance of mental health, the association of PLAs’ emotional distress with transmission behaviors is also examined. In summary, the lifestyles chosen by PLAs can affect quality of life and longevity. Individuals living with AIDS who make efforts to improve their physical health, for example, through increasing exercise are likely to experience healthy outcomes such as higher CD4⫹ cell counts (LaPerriere et al., 1997). Therefore, the PLAs’ physical health, adherence to medical regimens, and health-related lifestyle changes are likely to differ among those who engage in transmission behaviors and those who do not. This paper will examine the differences in health behavior and mental health symptoms among PLAs with differing lifestyles.
METHODS Participants From August 1993 through March 1995, a consecutive series of 456 families who met the criteria for inclusion into the current study were referred for services to the New York City Human Resources Administration’s Division of AIDS Services (DAS). Inclusion in the study required (1) at least one parent who met CDC-defined criteria for advanced HIV disease or AIDS, and (2) at least one uninfected adolescent child 11–18 years of age. Among the 456 families, 396 were traceable and were approached about the study. Of the traceable 396 families, 307 (77%) were recruited into the current study (68% if untraceable included). For those not recruited, the parent could not be interviewed in English or Spanish in 3.1% of the cases. The parent was too ill to complete the assessment in 1.7% of the cases, and the parent refused to be interviewed in 16% of the cases.
Procedures The PLAs were interviewed in their homes by interviewers who were predominantly African American or Latino (62%); nine were bilingual in Spanish, and all received at least 3–6 weeks of training that covered interviewing, ethics, confidentiality, child abuse, emergency crisis protocols, HIV and AIDS, and conducting in-home assessments with computerized interviews. In addition, interviewers conducted mock interviews, observed interviews, and had to
Parents Living with AIDS meet established criteria for successful interviewers prior to conducting any field interviews. On an ongoing basis, interviews were audiotaped, and 10% were randomly selected to be monitored for completeness, quality of the relationships, and accuracy of the reporting. The interviews were computer-assisted, with an interviewer inputting the participant’s responses directly into a laptop computer. Each interview lasted from 1.5 to 3 hr. The nature of the domains and scale questions covered in the interview are as follows.
Classification of Lifestyle Risk Based on Sexual and Substance-Use Acts In order to determine lifestyle risk behaviors, sexual risk and substance use acts were classified into a dichotomous variable. PLAs who reported that they were abstinent or used condoms all of the time were categorized as always engaging in protected sex (0); all others were classified as engaging in risky sex (1). PLAs also reported recent substance use. Specifically, PLAs indicated whether or not they had used alcohol or any drugs within the previous 3 months. Substance use included specific probes using street names for alcohol, marijuana, crack, cocaine, injecting drug use, heroin, barbiturates, inhalants, hallucinogens, and methamphetamines. Given the low base rate of substance use (60% of PLAs were abstinent), the substance use data were organized based on abstinence. PLAs were classified as either engaging in substance use or not. The reports of substance use and sexual risk resulted in four distinctive lifestyle classifications: PLAs who were (1) Safe and Clean, or who have protected sex and abstain from substance use, (2) Safe Users, who have protected sex, but engage in substance use, (3) Unsafe and Clean, who have unprotected sex but abstain from substance use, and (4) Unsafe Users, who engage in both unprotected sex and substance use.
Health Behaviors The following information was gathered on health status and health behaviors: (1) the PLAs’ current T-cell count and how often they monitored their T-cell count (1 ⫽ never to 7 ⫽ every week); (2) PLAs’ ratings of the availability of food in the previous 3 months (1 ⫽ available every day to 4 ⫽ very difficult to get most days); (3) current residence; (4) number of major illnesses over their lifetime (re-
255 vised from Hein et al., 1995, and based on piloting and medical consultation with seropositive adolescents); (5) the number and type of 23 current physical symptoms over the previous 3 months and the level of distress (1 ⫽ none to 5 ⫽ extreme) associated with each symptom for four symptom clusters: pain symptoms (움 ⫽ .86; e.g., physical or bodily pain), respiratory symptoms (움 ⫽ .75; e.g., coughing or wheezing), minor or self-limiting symptoms (움 ⫽ .70; e.g., sore throat), and somatic loss (움 ⫽ .56; e.g., hair or weight loss) (symptom clusters were developed through principal component analysis); (6) the number of medical appointments missed in the previous 3 months and barriers to keeping appointments (e.g., ‘‘Forgot about appointment’’); and (7) the PLAs’ ratings of the effects of 32 life events (1 ⫽ very bad effect to 4 ⫽ very good effect; e.g., ‘‘Financial status changed’’). The Brief Symptom Inventory (BSI; Derogatis, 1992) was administered to assess overall emotional distress. Participants reported the degree of distress for each symptom during the previous week on a scale from 0 ⫽ not at all to 4 ⫽ extreme (e.g., ‘‘Tell me how much this problem has bothered you: feeling easily annoyed or irritated’’). The scale yielded a score of overall emotional distress (Cronbach’s alpha [움] ⫽ .98), depression (움 ⫽ .88), and anxiety (움 ⫽ .87).
RESULTS Description of the Sample The 307 PLAs ranged in age from 25 to 70 years (M ⫽ 38.03 years, SD ⫽ 5.6). Of the 307 PLAs, 19 had missing sex or drug behavior reports; therefore, analyses were conducted for 288 PLAs. The sample was predominantly Latino (44.5%), mostly of Puerto Rican and Dominican descent, or African American (34.2%); 11.3% were Anglo, and 10% reported other ethnic heritages. Mothers represented 81% of the sample (see Table I). Almost all PLAs had children living with them (94%). PLAs had a mean of 2.98 children who ranged in age from a few months to over 18 years old (M ⫽ 13.2 years). The households also included an adult partner for 23% of the PLAs, a parent of the PLA for 9%, and relatives for 3%, and 2% of the PLAs lived alone without a partner or family. A family member had died within the previous 3 months in 15% of the households. As a result of services received from the recruitment agency, the New York City Division of AIDS Services, almost
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Lightfoot, Robin, Rotheram-Borus, Murphy, Diaz, Lehane, and Rosen Table I. Background Variables of Parents Living with AIDS Across Transmission Categories
Female (%) Ethnicity (%) Latino White African Ameican Other Age (years; M ) Number of children Currently have current partner (%)
Safe and clean (n ⫽ 136)
Unsafe and clean (n ⫽ 47)
Safe users (n ⫽ 64)
Unsafe users (n ⫽ 41)
79
89
83
76
81
45 8 38 10 38.5 2.9 46
40 13 30 17 37.3 2.9 60
47 13 33 8 38.1 2.9 50
46 17 32 5 36.3 3.0 76
45 11 34 10 37.9 2.9 53
all PLAs (91%) had stable housing and were on public assistance, although unemployed. Financial status was perceived by 47% of PLAs as having gotten worse within the previous 3 months.
Lifestyles In their lifetime, most PLAs practiced unsafe sexual behaviors and engaged in substance use (85%). Only 13% practiced unprotected sex and did not use substances, and 2% used substances and when having sex, always used condoms. In order to assess continued risk, PLAs were classified by the reports of their HIV risk behaviors since learning their HIV serostatus, as (1) Safe and Clean: 47% who always had protected sex and abstained from substance use, (2) Unsafe and Clean: 16% who had unprotected sex, but abstained from substance use, (3) Safe Users: 22% who always had protected sex, but also used substances, and (4) Unsafe Users: 14% who had unprotected sex and used substances. Health behaviors and mental health symptoms were then examined based on the different lifestyles (Table II).
Lifestyles and Health In general, the health history, current health symptoms, and health adherence were similar for PLAs with different lifestyles. The average time since diagnosis with AIDS or advanced HIV disease was 14.76 months (SD ⫽ 18.96 months; median ⫽ 7.59). Unsafe Users had known their HIV status longer (M ⫽ 57.9 months, SD ⫽ 29.76 months) than the PLAs in the other categories (Safe and Clean, M ⫽ 34.8 months, SD ⫽ 31.1 months; Unsafe and Clean, M ⫽ 39.6 months, SD ⫽ 34.4 months; Safe Users,
Overall (n ⫽ 288)
M ⫽ 33.2 months, SD ⫽ 28.2 months; F ⫽ 6.517, df ⫽ 3, p ⬍ .0001). PLAs were tested multiple times for HIV over their lifetime (M ⫽ 3.1, SD ⫽ 5.1, range ⫽ 1–50). The most common reasons for testing were provider recommendation (43%) and trigger events, such as physical health symptoms (38%) or injecting drugs (23%). Romantic relationships also seemed to be a strong influence on getting tested: 19% had a seropositive partner, 34% had an intravenous drug-using partner, and 21% had multiple partners. Among those with different lifestyles, having a seropositive partner was significantly more common as a reason for testing among those who continued to use drugs (29%) compared to groups who did not use drugs ( 2 ⫽ 10.87, df ⫽ 3, p ⬍ .05). Most PLAs routinely monitored their T cells, with only 7% not getting routine T-cell counts. There were no differences in the health monitoring based on the PLAs’ lifestyles. Daily health patterns were similar across those with different lifestyles. The majority of PLAs indicated that they had adequate food daily (62%), and about half reported eating healthy meals (47%). Sleep patterns were routinely disturbed for 67.5% of the sample. In the previous 3 months, physical symptoms were reported by 39% of the PLAs (M ⫽ 14.6, SD ⫽ 5.6, range ⫽ 0–23). The average level of distress associated with physical symptoms was mild (M ⫽ 1.9, SD ⫽ 1.0, range 0–5), and did not differ between lifestyle groups. In the previous 3 months, half of the PLAs (50%) missed a medical appointment. The most frequently mentioned reasons for missing appointments were ease of rescheduling (48%), forgetting the appointment (39%), too sick to attend (35%), and difficulty getting to the office (24%). PLAs who were Unsafe Users missed significantly more medical appointments than PLAs in the other lifestyle categories
Parents Living with AIDS
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Table II. Health Status and Mental Health of Parents Living with AIDS Across Transmission Categories
Health status Months since HIV diagnosis** T-cell count (M ) Missed doctors appointments (M)** Number of physical symptoms Number of life events** Mental health status—overall Emotional distress Depression Anxiety
Safe and clean (n ⫽ 136)
Unsafe and clean (n ⫽ 47)
Safe users (n ⫽ 64)
Unsafe users (n ⫽ 41)
Overall (n ⫽ 288)
34.8 171.6 0.79 14.5 4.6
39.6 200.5 1.0 13.9 5.6
33.2 178.9 0.91 14.6 6.2
57.9 209.6 1.9 13.5 6.9
38.4 183.6 1.0 14.3 5.5
M SD M SD M SD
2.03 0.78 2.18 0.98 1.99 0.96
1.84 0.64 1.79 0.76 1.83 0.89
1.99 0.73 2.22 0.95 1.99 0.95
2.05 0.73 2.21 0.95 1.91 0.77
1.99 0.74 2.13 0.94 1.95 0.92
*p ⬍ 0.05; **p ⬍ 0.01.
(F ⫽ 6.265, df ⫽ 3, p ⬍ .0001). Many PLAs were very satisfied with their doctors (48%), felt the doctors were very positive with them (65%), and were very comfortable asking questions of their doctor (59%). Most of the PLAs (87%) experienced one or more serious illnesses in their lifetime, with a mean of 2.9 illnesses (SD ⫽ 2.0, range ⫽ 0–9). Many of the PLAs suffered from allergies (35%), asthma (34%), eye problems (24%), and blood disorders (15%) in their lifetime. A little less than one fourth of the sample (21%) had some type of hepatitis at some point over their lifetime, 25% had pneumonia, 6% had cancer, and 7% had tuberculosis. PLAs who were Unsafe Users were significantly more likely to have sustained a head injury than Unsafe and Clean PLAs (2 ⫽ 7.83, df ⫽ 3, p ⬍ .05). Over the previous year, 45% of the PLAs had a major illness (M ⫽ 0.7, SD ⫽ .86, range ⫽ 0–5) and only 2% of the sample experienced hepatitis, 8% pneumonia, 1% cancer, and 2% tuberculosis. Since their HIV diagnosis, many of the PLAs had changed their health habits (M ⫽ 4.53, SD ⫽ 2.74; see Table III). The most common changes in health behaviors were taking more vitamins (78%), educating others (57%), changing their diet (49%), and receiving psychological counseling (45%). Although both used drugs, Safe Users were more likely than Unsafe Users to make changes to their diet ( 2 ⫽ 13.06, df ⫽ 3, p ⬍ .01) and attempt to quit abusing drugs (2 ⫽ 11.55, df ⫽ 3, p ⬍ .01). Unsafe Users were the least likely to take vitamins (2 ⫽ 9.09, df ⫽ 3, p ⬍ .05). Unsafe Users’ most common change in health behaviors was to educate
others about HIV, and they were significantly more likely to make that change than PLAs in the other groups ( 2 ⫽ 8.5, df ⫽ 3, p ⬍ .05).
Lifestyles and Mental Health PLAs reported a mean of 2.1 symptoms of depression (SD ⫽ 0.9; see Table II) and a mean of 2.0 symptoms of anxiety (SD ⫽ 0.9), levels which were similar across lifestyle categories. The PLAs also reported experiencing a number of major life events (e.g., divorce, child went to jail, relocation) in the previous 3 months (M ⫽ 5.5, SD ⫽ 3.9). Those PLAs who were Safe and Clean had significantly fewer major life events than PLAs who were Safe Users or Unsafe Users (F ⫽ 4.75, df ⫽ 3, p ⬍ .01).
DISCUSSION A major strength of this study is that the sample was recruited from a central registry of cases of AIDS/advanced HIV disease in New York City. Substantial precautions were instituted to ensure that a complete listing of all family cases referred to the New York City Division of AIDS Services was secured on a weekly basis. PLAs in New York City reflect 30% of the parents with AIDS in the United States. From among this list, the recruitment rate was 77% of traceable families. While it would have been desirable to have had a higher recruitment rate, this sample is unique in that the sampling frame of all parents with adolescent children over a specified pe-
258
Lightfoot, Robin, Rotheram-Borus, Murphy, Diaz, Lehane, and Rosen Table III. Lifestyle Changes of Parents Living with AIDS Across Transmission Categories Safe and clean (n ⫽ 136) Lifestyle changes since HIV diagnosis (%) Quit smoking** Quit drug abuse** Quit alcohol** Increase exercise Changed diet** Yoga Psychological counseling Vitamins* Support group Stress management group Involved in HIV prevention Educate others* Total number of lifestyle changes since HIV⫹
23 38 32 25 52 3 48 82 36 8 24 58 4.8
Unsafe and clean (n ⫽ 47) 9 36 33 19 43 6 30 75 43 11 26 40 4.1
Safe users (n ⫽ 64) 11 44 24 19 61 9 52 83 48 14 38 58 5.0
Unsafe users (n ⫽ 41) 10 29 15 17 27 0 42 61 29 10 34 71 4.0
Overall (n ⫽ 288) 16 38 28 22 49 5 45 78 39 10 29 57 4.6
*p ⬍ 0.05; **p ⬍ 0.01.
riod was identified. We know that the sample recruited is similar to those not recruited in terms of gender, ethnicity, and socioeconomic status (all were poor). Our findings indicate that many PLAs in this sample had made a change in their lifestyle since being diagnosed with HIV. Prior to an HIV diagnosis, 85% of the PLAs had engaged in unsafe sex and substance use. Since an HIV diagnosis, about half of PLAs (47%) were abstaining from any drug use and were abstaining from sex or always using condoms. However, a disturbing number of parents, the Safe (22%) and Unsafe Users (14%), continued to engage in unprotected sex and/or substance use. The risk of continued unprotected sex is clear: reinfection, sexually transmitted diseases, and transmission to others (Carre et al., 1996; Kalichman et al., 1997). This continued risk has multiple implications for the potential impact of parental AIDS on children, especially when one considers that those parents who used drugs (Safe and Unsafe Users) were experiencing significantly more major negative life events. Given the previous research on how lifestyle, particularly substance use, influences risk behaviors, there were surprisingly few differences associated with lifestyle. Although Unsafe Users knew their HIV status for a longer period of time, they were the least likely to make any major adjustments in their lifestyle. This group of PLAs miss more medical appointments than the others, and they were the least likely to take vitamins (often part of the medical regimen for HIV patients). Disturbingly, it was this
subgroup that was most likely to be involved in HIV prevention activities as educator, a pattern also found among seropositive youth (Luna and RotheramBorus, 1999). Safe Users were more likely to have attempted making a lifestyle change by attempting to quit drugs. Those PLAs who use drugs and are making other healthy choices, such as having safe sex, are struggling to also become safe in other areas of their lives, such as in their drug use. A limitation of this study is the classification of substance use risk into dichotomous variables. An individual who consumes a drink 12 times in the previous 3 months is classified as a user, the same as an individual who uses cocaine 12 times in the previous 3 months. However, surprisingly, the base rates of any substance use were low; over 60% of the PLAs were abstaining. Therefore, the most feasible way to capture subgroup differences was to organize the data based on abstinence. Given that fewer PLAs engage in risk behavior after an HIV-seropositive diagnosis, future research would need to address differentiating risk in a population with fewer or decreasing risk behaviors. In addition, given the multiple comparisons that were done across multiple symptoms and health behaviors, post-hoc analysis, such as the Bonferroni correction, may have been useful. Using the Bonferroni would have informed us of the stability of significant findings at the 95% confidence level (i.e., lifestyle changes of vitamin use and educating others). Physical health status was similar across adults with different lifestyles. However, many of the PLAs
Parents Living with AIDS had suffered from recent illnesses; most were very ill and most experienced daily pain (almost half had been hospitalized in the previous 3 months). Perhaps the PLAs’ sickness and symptoms are so acute that PLAs respond to them similarly regardless of lifestyle. Future research would need to examine the reasons PLAs change their behavior or why they do not. Although receiving medical care consistently is one way to cope effectively with these symptoms, many of the PLAs had missed an appointment with the doctor. Those parents who continued to use drugs and practice unprotected sex missed more appointments than PLAs in any other category. These data show the necessity for interventions to encourage medical adherence among those continuing risky lifestyles. Given the level of physical distress, it is surprising that PLAs were not experiencing heightened emotional distress. Their symptoms were in the normal range (Derogatis, 1992), and emotional distress was unrelated to lifestyle. PLAs face a substantial number of problems while attempting to maintain positive daily routines for themselves and their children. Yet many of the PLAs made positive changes in health behaviors: exercise, sleep, eating, support groups, etc. These positive changes were unrelated to the PLAs’ lifestyle, again suggesting that PLAs’ style of coping with their sexual and substance use is not influencing their daily health routines. These data suggest that physical health and daily routines are maintained while PLAs use substances and engage in sexual risk; however, continued transmission acts by seropositive PLAs place others at risk and demonstrate the need for preventive interventions. Further, given that PLAs made substantial changes following their HIV diagnosis, early detection is crucial so that prophylactic treatment and initiation of programs to reduce transmission behaviors can be enacted.
ACKNOWLEDGMENTS This paper was completed with the support of National Institute of Mental Health grant #1ROI MH49958-04 to Dr. Mary Jane Rotheram-Borus. We thank the parents who participated in this study, as well as those who assisted in it, including Coleen Cantwell, Timothy Cline, Barbara Gardner-Williams, Jan Hudis, Vandana Joshi, Kris Langabeer, Patrice Lewis, Sutherland Miller, Lucia Orellana, Marion Riedel, Omayra Rolon, Stephanie Singer, Nancy Tricamo, and Karen Wyche.
259 REFERENCES Batki, S. L., and Ferrando, S. J. (1996). Diagnoses and treatment of substance use disorders in patients with HIV infection. International Review of Psychiatry, 8, 245–252. Brown, B. S., and Beschner, G. M. (Eds.). (1993). Handbook on risk of AIDS: Injection drug users and sexual partners. Westport, CT: Greenwood. Bux, D. A., Lamb, R. J., and Iguchi, M. Y. (1995). Cocaine use and HIV risk behavior in methadone maintenance patients. Drug and Alcohol Dependence, 37, 29–35. Carre, N., Meyer, L., Boufassa, F., Deveau, C., Persoz, A., Rouzioux, C., and Vilde, J. L. (1996). High risk of HIV disease progression after infection through a sexual partner with AIDS. AIDS, 10, 77–80. Cates, J. A., Graham, L. L., Boeglin, D., and Tielker, S. (1990). The effect of AIDS on the family system. Families in Society, 71, 195–201. Centers for Disease Control and Prevention. (1995). U.S. HIV and AIDS cases reported through June 1995. HIV/AIDS surveillance report, No. 7. Atlanta, GA: Author. Centers of Disease Control and Prevention. (1998a, June). HIV fact sheet: Critical need to pay attention to HIV prevention for women: Minority and young women bear greatest burden [Available at http://www.cdc.gov/nchstp/hiv—aids/pubs/facts/ women.htm]. Centers for Disease Control and Prevention. (1998b). U.S. HIV and AIDS cases reported through June 1998. HIV/AIDS surveillance report No. 10. Atlanta, GA: Author. Chesney, M. A, and Folkman, S. (1994). Psychological impact of HIV disease and implications for intervention. Psychiatric Clinics of North America, 17, 163–182. Coyne, J. C., and Downey, G. (1991). Social factors and psychopathology: Stress, social support, and coping processes. Annual Review of Psychology, 42, 401–425. Derogatis, L. R. (1992). Brief Symptom Inventory: Administration, scoring and procedures manual-II. Baltimore, MD: Clinical Psychometric Research. Dohrenwend, B. P., and Dohrenwend, B. S. (1981). Socioenvironmental factors, stress, and psychopathology. American Journal of Community Psychology, 9, 128–164. Ferrando, S. J., Wall, T. L., Batki, S. L., and Sorensen, J. L. (1996). Psychiatric morbidity, illicit drug use and adherence to zidovudine (AZT) among injection drug users with HIV. American Journal of Drug and Alcohol Use, 22, 475–487. Gonzalez, S., Steinglass, P., and Reiss, D. (1989). Putting the illness in its place: Discussion groups for families with chronic medical illnesses. Family Progress, 28, 69–87. Hein, K., Dell, R., Futterman, D., Rotheram-Borus, M. J., and Shaffer, N. (1995). Comparison of HIV⫹ and HIV⫺ adolescents: Risk factors and psychosocial determinants. Pediatrics, 95, 96–104. Hser, Y.-I., Boyle, K., and Anglin, M. D. (1998). Drug use and correlates among sexually transmitted disease patients, emergency room patients, and arrestees. Journal of Drug Issues, 28, 437–453. Kalichman, S. C., Kelly, J. A., and Rompa, D. (1997). Continued high-risk sex among HIV seropositive gay and bisexual men seeking HIV prevention services. Health Psychology, 16, 369–373. Kaplan, J. E., Masur, H., Jaffe, H. W., and Holmes, K. K. (1995). Reducing the impact of opportunistic infections in patients with HIV infection. New guidelines. Journal of the American Medical Association, 274, 347–348. Khantzian, E. J. (1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4, 231–244. LaPerriere, A., Klimas, N., Fletcher, M. A., Perry, A., Ironson,
260
Lightfoot, Robin, Rotheram-Borus, Murphy, Diaz, Lehane, and Rosen
G., Perna, F., and Schneiderman, N. (1997). Change in CD4⫹ cell enumeration following aerobic exercise training in HIV1 disease: Possible mechanisms and practical applications. International Journal of Sports Medicine, 18 (Supplement 1), S56–S61. Lemp, G. F., Hirozawa, A. M., Givertz, D., Nieri, G. N., Anderson, L., Lindegren, M. L., Janssen, R. S., and Katz, M. (1994). Seroprevalence of HIV and risk behaviors among young homosexual and bisexual men. The San Francisco/Berkeley Young Men’s survey. Journal of the American Medical Association, 272, 449–454. Levine, C. (1994). The new orphans and grieving in the time of AIDS. In B. O. Dane and C. Levine (Eds.), AIDS and the new orphans: Coping with death (pp. 1–11). Westport, CT: Auburn House/Greenwood. Luna, G. C., and Rotheram-Borus, M. J. (1999). Youth living with HIV as peer leaders. American Journal of Community Psychology, 27, 1–23. Meyer, H. I., and Dean, L. (1995). Patterns of sexual behavior and risk taking among young New York City gay men. AIDS Education and Prevention, 7, 13–23. Pickens, R. W., Battjes, R., Svikis, D. S., and Gupman, A. E. (1993). Substance use risk factors for HIV infection. Psychiatric Clinics of North America, 16, 119–125. Rabkin, J. G., Remien, R., Katoff, L., and Williams, J. G. (1993). Resilience in adversity among long-term survivors of AIDS. Hospital and Community Psychiatry, 44, 162–167. Rhodes, T. J., Donoghoe, M. C., Hunter, G. M., and Stimson, G. V. (1993). Continued risk behavior among HIV positive drug injectors in London: Implications for intervention. Addiction, 88, 1553–1560. Riley, L. E., and Greene, M. F. (1999). Elective cesarean delivery to reduce the transmission of HIV. New England Journal of Medicine, 340, 1034. Robins, A. G., Dew, M. A., Davidson, S., Penkower, L., Becker, J. T., and Kingsley, L. (1994). Psychosocial factors associated with risky sexual behavior among HIV-seropositive gay men. AIDS Education and Prevention, 6, 483–492.
Rolland, J. S. (1988). A conceptual model of chronic and lifethreatening illness and its impact on families. In C. S. Chilman, E. W. Nunnally, and F. M. Cox (Eds.), Chronic illness and disability. Families in trouble series (Vol. 2, pp. 17–68). Newbury Park, CA: Sage. Rotheram-Borus, M. J., Murphy, D., and Miller, S. (1996). Intervening with adolescent girls living with HIV. In A. O’Leary and L. S. Jemmott (Eds.), Women and AIDS: Coping and care (pp. 87–108). New York: Plenum. Rotheram-Borus, M. J., Robin, L., Reid, H. M., and Draimin, B. H. (1998). Parent–adolescent conflict and stress when parents are living with AIDS. Family Process, 37, 83–94. Rotheram-Borus, M. J., Lightfoot, M., and Shen, H. (1999). Levels of emotional distress among parents living with AIDS and their adolescent children. AIDS and Behavior, 3, 367–372. Rotheram-Borus, M. J., and Stein, J. A. (1999). Problem behavior of adolescents whose parents are living with AIDS. American Journal of Orthopsychiatry, 69, 228–239. Sandler, I. N., West, S. G., Baca, L., Pillow, D. R., Gersten, J. C., Rogosch, F., Virdin, L., Beals, J., Reynolds, K. D., Kallgren, C., Tein, J-Y., Kriege, G., Cole, E., and Ramirez, R. (1992). Linking empirically based theory and evaluation: The Family Bereavement Program. American Journal of Community Psychology, 20, 491–521. Sharp, D. (1996). Vancouver AIDS meeting highlights combination attack on HIV. Lancet, 348, 115. Siegel, K., Mesagno, F. P., Karus, D., Christ, G., Banks, K., and Moynihan, R. (1992). Psychosocial adjustment of children with a terminally ill parent. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 327–333. Susser, E., Miller, M., Valencia, E., Colson, P., Roche, B., and Conover, S. (1996). Injection drug use and risk of HIV transmission among homeless men with mental illness. American Journal of Psychiatry, 153, 794–798. United Nations Joint Commission on AIDS. (1998, June). Report on the global HIV/AIDS epidemic, 66. Weiss, R. D., Griffin, M. L., and Mirin, S. M. (1992). Drug abuse as self-medication for depression: An empirical study. American Journal of Drug and Alcohol Abuse, 18, 121–129.
