Copyright © 1998 Elsevier Science Ltd. All rights reserved.

8.10
HIV and AIDS
MICHAEL H. ANTONI and NEIL SCHNEIDERMAN
University of Miami, Coral Gables, FL, USA

8.10.1 INTRODUCTION 238

8.10.1.1 Pathogenesis of HIV Infection 238
8.10.1.2 Health Psychology and HIV Infection 239
8.10.1.2.1 Psychoneuroimmunology research and HIV infection 240
8.10.2 PREDICTING ADJUSTMENT TO HIV INFECTION 242
8.10.2.1 Psychological Challenges in HIV Infection 242
8.10.2.2 HIV-associated Psychosocial and Behavioral Sequelae 244
8.10.2.2.1 Distress and depression 244
8.10.2.2.2 Risk behavior and substance use 246
8.10.2.3 Psychosocial Factors Predictive of Depression and Risk Behaviors in HIV Infection 247
8.10.2.3.1 Uncontrollable stressors 247
8.10.2.3.2 Stressor appraisals 248
8.10.2.3.3 Coping with HIV-related symptoms 248
8.10.2.3.4 Social support 248
8.10.3 PREDICTING THE HEALTH COURSE OF HIV INFECTION 250
8.10.3.1 Biological Factors and Disease Progression 250
8.10.3.1.1 Constitutional factors 250
8.10.3.1.2 Other viral infections 251
8.10.3.2 Behavioral and Psychosocial Factors and Disease Progression 252
8.10.3.2.1 Behavioral factors 252
8.10.3.2.2 Depressive symptoms 253
8.10.3.2.3 Stressful life events 254
8.10.3.2.4 Stressor appraisals 255
8.10.3.2.5 Coping strategies 256
8.10.3.2.6 Social support 257
8.10.3.3 Psychosocial Factors in Long-term Survivors of AIDS 258
8.10.4 INTERVENTIONS, ADJUSTMENT, AND HEALTH COURSE IN HIV INFECTION 259
8.10.4.1 Health Psychosocial Interventions with HIV-infected People 259
8.10.4.2 Stress Management Intervention Effects at Different Critical Points in HIV Infection 259
8.10.4.2.1 The initial HIV seropositive diagnosis 261
8.10.4.2.2 The asymptomatic stage of HIV infection 262
8.10.4.2.3 The pre-AIDS symptomatic stage of HIV infection 263
8.10.4.2.4 Full-blown AIDS 263
8.10.4.3 Common Features of Psychosocial Interventions in HIV Infection 264
8.10.4.3.1 Relaxation aspects 264
8.10.4.3.2 Delivery format 264
8.10.4.3.3 Treatment orientation 264
8.10.4.4 Summary of Completed Studies of Psychosocial Interventions with HIV-infected Persons 265
8.10.5 CONCLUSION 266
8.10.6 REFERENCES 267

237
238 HIV and AIDS
8.10.1 INTRODUCTION
8.10.1.1 Pathogenesis of HIV Infection
The human immunodeficiency virus (HIV) is
a retrovirus of the human T-cell leukemia/
lymphoma line and is the causative agent of the
acquired immunodeficiency syndrome (AIDS).
(Although AIDS is believed to be caused by the
human immunodeficiency virus-type 1 (HIV-1),
we have for simplicity used the term HIV
throughout this chapter.) A unique feature of
HIV infection is that it can have a long
asymptomatic phase lasting up to 10±15 years
(Munoz et al., 1988) followed by the appearance
of constitutional signs and symptoms of disease
progression. In most people full-blown AIDS
develops next (Kaplan, Wofsy, & Volberding,
1987), and even with aggressive and timely
treatment, death often occurs a few years later
(Lemp, Payne, Neal, Temelson, & Rutherford,
1990). A diagnosis of AIDS is made when a
person shows laboratory-based signs of severe
decline in the number of T-helper±inducer
(CD4) cells (5 200 cell mm73), or clinical signs
consistent with the emergence of opportunistic
infections and neoplasias. Some of these
include: candidiasis of the esophagus, trachea,
bronchi, or lungs; cryptoccosis; cryptosporidio-
sis with diarrhea persisting longer than one
month; cytomegalovirus disease of an organ
other than the liver, spleen, or lymph nodes;
herpes simplex virus infection causing a muco-
cutaneous ulcer for longer than one month;
Kaposi's sarcoma; primary lymphoma of the
brain; pneumocystis carinii pneumonia; pro-
gressive multifocal leukoencephelopathy; tox-
oplasmosis of the brain; and a variety of other
opportunistic infections and neoplasias. Since
some infected people can remain free of clinical
symptoms for a prolonged period of time and
given that appropriate patient management can
delay the onset of AIDS, it may be useful to view
HIV as a chronic disease.
Many staging systems for HIV infection have
been developed over the past decade (Walter
Reed system, World Health Organization, and
Centers for Disease Control), though the most
widely accepted system used today is that
developed by the Centers for Disease Control
(CDC) in 1993. People with primary HIV
infection often develop an acute mononucleosis-
like syndrome about a month after initial
infection (Tindall & Cooper, 1991). This period
is associated with a high level of viral load or free
virus released throughout the circulation (i.e.,
viremia) (Daar, Moudgil, Meyer, & Ho, 1991)
which usually occurs 4±12 weeks after the onset
of acute infection (Clerici, Berzofsky, Shearel, &
Tacket, 1991). The virus becomes widely
disseminated during this early stage of infection,
suggesting that the course of infection may be
influenced by the ªseedingº of the virus
throughout the lymph nodes and other immune
system components (Tindall & Cooper, 1991).
Even after this acute stage of the infection it
appears that viral replication is not completely
curtailed since it remains detectable in lymph
nodes during the quiescent stages of the infection
(Pantaleo, Poli, & Fauci, 1993).
A period of clinical, but not microbiological,
latency lasting for a number of years follows the
initial sequence of primary infection, viral
dissemination, development of HIV specific
immunity, and curtailment of extensive viral
replication. Importantly, during the clinically
latent period the disease is still progressing. This
is observable in an increasing viral load, the
depletion of CD4 cells in peripheral blood, and
in the increasing proportion of HIV infected
lymphoid cells (Pantaleo et al., 1993). It is
generally accepted that the decline in CD4 cells
leaves the infected person susceptible to a
number of opportunistic infections and cancers
characteristic of AIDS, though there is evidence
that malfunctions in other aspects of immune
functioning may also be associated with disease
progression. Some of the more commonly
observed infections include pneumocystic carinii
pneumonia (PCP) cryptococcal meningitis,
toxoplasmosis, and candida esophagitis (Ka-
plan et al., 1987). Many other diseases manifest
in HIV-infected persons are caused by ubiqui-
tous herpes viruses (e.g., cytomegalovirus
(CMV) associated retinitis is a major cause of
blindness in HIV-infected persons). HIV in-
fected persons are also vulnerable to relatively
rare cancers including Kaposi's sarcoma and
Burkitt's lymphoma and, in women, cervical
carcinoma. Interestingly these cancers are
believed to be promoted by fairly common
viruses as well (e.g., human papillomavirus
types are associated with cervical neoplasia and
squamous cell cervical carcinoma (Maiman &
Fruchter, 1996). In contrast, it is rare that these
viruses are successful in eluding the immune
system for long enough to establish a clinical
neoplastic process in healthy people, unless
these people are undergoing pharmacologic
treatments that suppress the immune system
(Antoni, Esterling, Lutgendorf, Fletcher, &
Schneiderman, 1995). HIV-infected persons
are then extremely vulnerable to a wide range
of pathogens normally controlled by the
immune system and, with time, these individuals
may contract a number of life-threatening
diseases over the course of the infection.
Because a person's awareness of their diagnosis
and, more importantly, their symptom status
may play an important role in determining their
 Introduction
perceived psychosocial and physical burdens as
well as their chosen coping strategies, this
chapter shall later refer to different phenomen-
ological stages of HIV infection tied to critical
events as follows: the initial HIV seropositive
diagnosis; the (post diagnosis) asymptomatic
stage; the pre-AIDS symptomatic stage (for-
merly referred to as AIDS related Complex
(ARC); and AIDS (often referred to as full-
blown or frank AIDS).
Because there is no cure for AIDS, prevention
is the major tool for limiting the spread of the
disease. Primary prevention efforts use many
behavioral change techniques, aimed at increas-
ing availability and promoting use of condoms,
and substance abuse management and treat-
ment (Schneiderman, Antoni, Ironson, LaPier-
riere, & Fletcher, 1992). Many of these
techniques are those that are commonly
employed by health psychologists working in
the area of risk management. Secondary
prevention programs have also been undertaken
to slow HIV spectrum disease progression.
Because only a relatively small proportion of the
one million people in the United States infected
with HIV have AIDS (CDC, 1995) and because
of the relatively prolonged period of time
between the onset of infection and the devel-
opment of AIDS (Munoz et al., 1989), there is a
clear need to develop treatments to manage HIV
spectrum disease and slow down disease
progression. Much of this chapter will focus
on such secondary prevention activities.
Many pharmacologic agents have been
developed to manage symptoms and to slow
HIV progression. These include such agents as
pentamidine (to combat acute PCP and as a
prophylaxic) and a large number of antiretro-
virals, the most well-known being azidothymi-
dine (AZT), to block the replication of HIV. To
at least some extent advances in patient
management have been successful in ameliorat-
ing symptoms and dealing with intercurrent
illnesses (Longini, Clark, & Karon, 1993). In
contrast, the benefits of antiviral therapies such
as AZT, dideoxyinosine (ddI), and dideoxycy-
tidine (ddC) appear to be only marginally
effective and more controversial. In fact, in a
letter to the Lancet, the Concorde Coordinating
Committee (Aboulker & Swart, 1993) reported
that although AZT modestly boosted the
number of CD4 cells in the blood of asympto-
matic patients, it did not delay progression to
AIDS. Previous research had already shown
that AZT only prolonged the life of HIV infected
people for a few months (Fischl et al., 1987). The
antiviral drugs also have undesirable physiolo-
gical (e.g., bone marrow suppression, anemia,
neutropenia; Richman, et al., 1987) and psy-
chological (e.g., depression) side effects. We now
239
know that using a single antiretroviral agent
may lead to the development of AZT-resistant
strains of HIV which are ultimately harder to
treat; thus contemporary treatment approaches
often focus on combination therapies (e.g., AZT
and ddC). Newly emerging treatments such as
triple combination therapy and protease in-
hibitors offer some hope that viral replication
can be slowed more efficiently and with a lower
likelihood of resistance or undue side effects
(Lewin, 1996). However, we are now learning
that the effectiveness of these newer regimens is
critically dependent on the ability of patients to
adhere to a rigid and demanding medication
schedule. Failure to do so can substantially
increase the risk of developing drug-resistant
strains of the virus (Lewin, 1996; Schneiderman,
Antoni, & Ironson, 1997).
8.10.1.2 Health Psychology and HIV Infection
Behavioral scientists focusing on HIV infec-
tion are usually involved in either primary
prevention efforts (e.g., examining factors
underlying risk behaviors that lead to infection
in order to inform community-wide interven-
tions and health policies) or secondary preven-
tion efforts (e.g., examining factors contributing
to the mental and physical health course of
HIV-infected persons in order to develop
clinical interventions). This chapter will focus
on the role of health psychology in such
secondary prevention efforts, though findings
relevant to primary prevention efforts (e.g.,
predictors of sexual behavior and substance use)
will also be addressed.
Managing HIV disease involves addressing
psychosocial as well as biomedical issues
(Antoni, Schneiderman et al., 1990; Schneider-
man et al., 1994). The anticipation and the
impact of HIV antibody test notification, for
instance, is highly stressful (Ironson et al.,
1990). Here, feelings of life-threat, doom, and
anger are usually encountered as is the need to
contemplate making major lifestyle changes
(Christ & Wiener, 1985; Kaisch & Anton-
Culver, 1989; Viney, Henry, Walker, & Crooks,
1989). Because of the large and accelerating
number of people who are infected with HIV,
there is a clear need to develop behavioral
interventions to help them cope with the
psychosocial aspects of their situation. There
is also some evidence that improving psycho-
logical adaptation to HIV may have implica-
tions for physical health among infected
individuals. Two areas that have been the focus
of much health psychology research in HIV
infection and AIDS examine how psychosocial
factors such as distress states and depressive
240 HIV and AIDS
symptoms as well as certain risk behaviors
might contribute to (i) the ways in which people
adjust to the having HIV infection; and (ii) the
actual health course of the infection.
Health psychological studies focusing on
HIV and AIDS began in about 1987, coincident
with the identification of HIV as the putative
cause of many AIDS-related conditions that
were emerging in clinics and hospitals around
the world. At that time, behavioral scientists
began studying the effects of psychosocial
factors such as stressors and stress management
interventions in people infected with HIV. The
first major reason for this health psychological
research concerned the issue of psychological
adjustment. HIV infection presents multiple
burdens at the psychological and physical levels,
thereby creating a state of chronic stress that
may overwhelm an individual's coping re-
sources, thus greatly impairing their ability to
emotionally adjust to what will likely be a long
journey. Accordingly, it was reasoned that HIV
infected individuals are among the groups who
might benefit substantially from interventions
that teach them to cope with the chronic
demands that many people will never have to
face. By learning how stress-reducing psycho-
social interventions help such people adapt,
adjust, and adhere to various lifestyle changes
health psychologists gain insight into ways to
facilitate the coping process in people facing this
life-threatening condition as well as other
chronic diseases (for reviews see Antoni, 1991;
Ironson, Antoni, & Lutgendorf, 1995; Lutgen-
dorf, Antoni, Schneiderman, Ironson et al.
1994; Schneiderman et al., 1994).
A second major reason for examining the
effects of psychosocial factors in this population
follows from a conceptualization of HIV
infection as a chronic disease whose clinical
course may be affected by multiple behavioral
and biological factors (Antoni, Schneiderman
et al., 1990). As in the case of other chronic
diseases, HIV infection is characterized by a
disorder in one or more bodily systems wherein
signs and symptoms of the disorder are
clinically manifest across long periods of time
as a function of the degree of disorder in the
bodily system(s) affected (e.g., immune system
impairment). People with HIV infection become
ill or die from the complications of their chronic
disease not the disease itself. Just as diabetics
who are unable to maintain their blood glucose
levels within a certain range may develop kidney
disease or suffer heart attacks, HIV-infected
people who are unable to retain adequate
immune system functioning necessary for
surveillance of pathogens go on to develop
the life-threatening infections or cancers that
characterize full-blown AIDS.
8.10.1.2.1 Psychoneuroimmunology research
and HIV infection
To the extent that HIV infection increases
distress levels (Antoni, Schneiderman et al.,
1990; Kaisch & Anton-Culver, 1989; Viney
et al., 1989), which in turn have been shown to
influence the immune system (Calabrese, Kling,
& Gold, 1987; Ironson et al., 1990; Irwin,
Daniels, Bloom et al., 1987; Kiecolt-Glaser
et al., 1987), it is plausible that behavioral
interventions that decrease distress may bene-
ficially impact immune status and possibly
health status in HIV-infected people. Because
the degree to which the immune system becomes
disordered seems to be the strongest predictor of
the progression to HIV-related symptoms and
death, much biomedical research has been
focused upon ways to either slow the growth
of the virus or slow the decline of the immune
system by modulating the function of its cells.
Psychoneuroimmunologic (PNI) research ex-
amines ways in which psychosocial influences
such as stressful life events, distress states, and
stress reducing techniques±±all of which may
contribute to successful adjustment to HIV
infection±±modulate immune system function-
ing and, ultimately, disease course. Applying
these ideas from the point of view of a chronic
disease model, to the extent that health
psychology interventions modify psychosocial
factors such as risk behaviors (unprotected sex,
alcohol and drug abuse), emotional distress,
maladaptive coping strategies, and social isola-
tion, it might also modulate biological factors
such as certain endocrine and immune system
components. By diminishing the impact of
psychosocial and behavioral factors on the
immune system, the individual might retard the
onset of disease complications by maintaining
immunologic status (e.g., by preserving an
adequate number of T-helper cells and/or
maintaining the functioning of surviving im-
mune cells) within a range necessary to defend
against certain infections and cancers.
There are many studies relating psychosocial
and behavioral factors to the immune system in
a wide collection of species using an even wider
number of different experimental paradigms.
This area is marked by significant agreement
and disagreement about the ways in which a
wide range of factors impact the immune system
in healthy animal and human populations.
Clinical researchers have attempted to translate
many of these findings into the clinical arena
in order to classify how psychological phenom-
ena such as self-efficacy and sense of control,
coping strategies, social support, and emotional
states such as depressionÐall reasonable targets
of psychological interventions±±contribute to
 Introduction
impairments in the immune systems of HIV
infected individuals (e.g., Antoni, 1990; Solo-
mon, Kemeny, & Temoshok, 1991). Given
existing evidence that experimentally induced
and naturally occurring stressors, perceived loss
of control, social isolation, and depression are
related to decrements in the numbers and
functions of immune cells known to be altered
by HIV infection, it can be reasoned that these
psychosocial and behavioral factors might
influence immunologic status and, possibly,
disease course in HIV-infected individuals.
Similarly, stress management interventions that
target these factors might provide both psy-
chological and physical benefits for infected
people, especially for those in the early stages of
this chronic disease before the virus has
established a stranglehold on the immune
system and other physiological regulatory
processes.
This line of reasoning can be operationalized
in the context of HIV infection as follows:
because CD4 cells are depleted in the advancing
stages of HIV infection (Klimas et al., 1991),
increases in qualitative aspects of HIV itself
(e.g., mutation and replication rate) (Panteleo
et al., 1993) and of lymphocytes (e.g., prolifera-
tion [growth and reproductive abilities], and
cytotoxicity [recognition and killing abilities])
might be important in predicting those HIV
seropositive individuals who do and do not
develop opportunistic infections quickly. The
ability of lymphocytes to multiply when
challenged by antigens, often evaluated using
tests of lymphocyte proliferative responses to
plant mitogens such as phytohemaglutinin
(PHA), concanavalin-A (conA), or pokeweed
mitogen (PWM), may compensate to some
degree for the smaller number of CD4 lympho-
cytes available as the disease progresses. Innate
immune functions such as natural killer cell
cytotoxicity (NKCC), a largely CD4-cell in-
dependent function, may also compensate in
conferring protection against extant viral
infections. For instance, herpes viruses such
as Epstein Barr virus (EBV) or herpes simplex
virus (HSV) are often poorly controlled in the
context of HIV-induced defects in CD4 cell-
directed cytotoxic function (Biron, Byron &
Sullivan, 1989; Habu, Akamatsu, Tamaoki &
Okumura, 1984, Bancroft, Shellam, & Chalmer,
1981; Bukowski, Warner, Denner & Welsh,
1985). It is plausible that NKCC, which may be
partially preserved in HIV infection, may help
to survey and control these and other infections
in the HIV-infected host. Conversely, stress-
induced impairments in NKCC may permit
herpes virus reactivation to go unchecked in
HIV-infected individuals (Glaser & Kiecolt-
Glaser, 1987) with subsequent effects of HIV
241
replication and progression to AIDS (Carbo-
nari, Fiorilli, Mezzoroma, Cherchi, & Aiuti,
1989; Rosenberg & Fauci, 1991). Because
several herpes viruses are known to have
immunosuppressive effects, in and of them-
selves, reactivation of these viruses could have
implications for compounding HIV-induced
immune system decrements and, possibly,
disease progression (Griffiths & Grundy, 1987).
Implicit in much PNI research is the notion
that psychosocial factors relate to immune
system changes by way of stress- or distress-
induced changes in hormonal regulatory sys-
tems resulting in neuroendocrine elevations and
imbalances (Maier, Watkins, & Fleshner, 1994).
There are several neuroendocrine substances
known to be altered as an function of an
individual's appraisal (i.e., controllable vs.
uncontrollable) of and coping response (i.e.,
active vs. passive) to stressful stimuli that have
also been shown to impair certain components
of the immune system. Some of these hormones,
including those produced by the adrenal gland,
are also known to be dysregulated in depressed
individuals (Calabrese et al., 1987) and those
reporting significant degrees of loneliness
(Kiecolt-Glaser et al., 1984). Given that un-
controllable stressors, perceived loss of control
(similar to low self-efficacy), and social losses
such as divorce and bereavement have been
related to alterations in some of these immu-
nomodulatory hormones, it has been reasoned
that some PNI relationships might be mediated,
in part, by neurohormonal changes that are
linked to an individual's appraisals of and
coping responses to environmental burdens (for
reviews see Antoni, Schneiderman et al., 1990
and Schneiderman et al., 1994). Although many
different neurotransmitters, neurohormones,
and other peptides have been studied as
potentially important mediators of stressor-
induced immunomodulation, two well-deli-
neated ªstress response pathways,º the
hypothalamic±pituitary±adrenal (HPA) axis
and the sympathetic adrenomedullary (SAM)
system, have received the most focus.
The HPA axis is a complex system that is
regulated by several integrated central nervous
system and peripheral mechanisms, a regulation
that may be disrupted at several levels in
depressive illness and other affective distress
states (Amsterdam, Maislin, Gold, & Winokur,
1989). Several of these HPA axis abnormalities
gradually normalize with clinical improvement
in depression (Greden et al., 1983; Amsterdam,
Lucki, & Winokur, 1985). Because immunolo-
gic function is impaired by cortisol (Plaut, 1987)
in humans, immunologic correlates (especially
blastogenesis and NKCC) of depressed states
have been studied extensively. Despite the
242 HIV and AIDS
conclusive evidence for immunologic effects and
neuroendocrine changes in depression, the exact
mechanisms involved are lacking (Stein, Miller,
& Trestman, 1991). However, it has been shown
that glucocorticoids enhance HIV replication
(Markham, Salahuddin, Veren, Orndorf, &
Gallo, 1986), are immunosuppressive (Cupps
& Fauci, 1982), and accompany affective
disorder (Gold et al., 1986) and stressful
experiences (Borysenko & Borysenko, 1982;
Jacobs et al., 1986). On the other hand, one
study found that 24 hour urinary-free cortisol
levels were not related to CD4 (or CD8) cell
counts in HIV positive individuals (Gorman
et al., 1991). However, this does not preclude the
possibility that distress or depression-associated
cortisol elevations impact immune function
(e.g., NKCC) in HIV-infected individuals and
that such functional changes might relate
directly to HIV disease progression by way of
impaired surveillance of latent viruses and other
pathogens.
A separate, but related neuroendocrine
response system, the SAM system, is also
activated during stressful circumstances (e.g.,
bereavement) and releases norepinephrine (NE)
and epinephrine (E). Lymphocytes have beta-
adrenergic receptors (Plaut, 1987), and beha-
vioral stressors (Manuck, 1991; Antoni, Ro-
driguez, Starr et al., 1991; Naliboff et al., 1991)
increase CD8 counts and may induce cyclic
AMP-mediated suppression of lymphocyte and
natural killer (NK) function (Plaut, 1987).
Activation of both the HPA axis and the
SAM system, which may interact (Axelrod &
Reisine, 1984), during exposure to chronic
uncontrollable stressors, could adversely affect
immunologic status (Cupps & Fauci, 1982;
Maier et al., 1994; Roszman et al., 1985). These
neuroendocrine patterns may also be displayed
when an individual is exposed to uncontrollable
chronic stressors, has inadequate social sup-
port, and uses denial/avoidance coping strate-
gies (Antoni et al., 1990; Schneiderman et al.,
1992). If depression and uncontrollable stres-
sors are associated with impaired immunologic
function mediated by neuroendocrine changes
in HIV-infected individuals, and if intervention-
associated decreases in depressed mood help to
normalize neuroendocrine functioning in this
population, then such interventions may con-
currently act to attenuate neuroendocrine-
associated immunosuppression.
Putting all of this information together it can
be hypothesized that stressful events or burdens
that are interpreted by HIV-infected individuals
as beyond their control might lead to social
isolation, loneliness, anxiety, and depressed
affect which might accompany alterations in
some neurohormones (e.g., peripheral catecho-
lamine and cortisol elevations) due to sympa-
thetic nervous system (SNS) activation and
dysregulation of the HPA axis. These neuroen-
docrine changes may also be accompanied by
changes in the immune system (redistribution of
lymphocytes and decrements in functions con-
cerning lymphocyte proliferation and NKCC)
via interactions among neural and neuroendo-
crine signals at the immune cell membrane,
intracellular cyclic nucleotide activation, and
the production of cytokines such as interleukin
(IL)-I and II, and g-interferon (g-IFN). Since
these structural (cell counts) and functional
(proliferation and cytotoxicity) aspects of the
immune system are known to decline progres-
sively across the course of HIV infection
(Panteleo et al., 1993), it can be further
hypothesized that superimposed stressor-in-
duced changes in the functioning of the immune
system may increase the rate at which infected
people develop clinical symptoms such as
opportunistic infections and neoplasias. This
model prescribes at least two sets of related
targets for intervention: psychosocial experi-
ences and pathophysiological processes (see
Figure 1) (for details see Schneiderman et al.,
1994).
8.10.2 PREDICTING ADJUSTMENT TO
HIV INFECTION
8.10.2.1 Psychological Challenges in HIV
Infection
A diagnosis of HIV seropositivity is the
beginning of a long road of challenging life
events and extraordinary personal changes that
can overwhelm even the most psychologically
well-adjusted individuals. One unique aspect of
HIV infection is that it is a chronic physical
disease embedded in an atmosphere of multiple
chronic psychosocial and physical demands and
burdens. From a health psychology perspective,
it is plausible to hypothesize that disease-related
and external ªlife stressorsº operate interac-
tively and that success at managing one can
influence the course of the other. To test these
types of hypotheses behavioral researchers have
for years been examining associations between
the occurrence of stressful life events and
alterations in people's resiliency or suscept-
ibility to a wide variety of pathogenic processes
underlying chronic diseases such as coronary
heart disease, diabetes mellitus, rheumatoid
arthritis, and several types of cancer. In addition
to studying the impact of stressful events, health
psychology researchers, since the mid-1970s,
have also focused on the role of stress
ªmoderatingº psychosocial variables (e.g., per-
sonality characteristics and social support) and
 Predicting Adjustment to HIV Infection 243

STRESS MANAGEMENT

• Relaxation training • Problem Solving

• Cognitive restructuring • Assertion training
• Coping skills training • Anger management
• Social support

(+) sense of control

(+) self-efficacy
(+) self-esteem
(+) adaptive-coping

(–) anxiety, depression,social isolation

(+) quality of life

(+) parasympathetic activation

(–) sympathetic activation

(–) peripheral catecholamines and/or cortisol

IMMUNE OPTIMIZATION

(+) CD4 cell function (+) Herpes virus (+) NK cytotoxicity

surveillance

DECREASED RATE OF HIV DISEASE PROGRESSION

Figure 1 Theoretical model for effects of stress management on disease progression in human immunodefiency
virus (HIV) infection (CD4, T-helper-inducer cells; NK, natural killer cells).

psychosocial interventions (e.g., stress manage-
ment) that might reduce the negative health
influences of stressors in medically vulnerable
populations such as those recovering from
myocardial infarction or taxing treatments for
some types of cancer.
Because more effective medical treatment for
HIV infection is becoming available, there is
now a fast-growing population of infected
individuals who are coping with the complex
and multiple psychosocial demands of a chronic
life-threatening illness (Antoni, 1991). Homo-
sexual men comprise a large majority of HIV-
infected individuals in the United States. Today,
however, an increasingly large percentage of
HIV-infected people are heterosexual male drug
users and women (Centers for Disease Control,
1995). Many of the people who are infected face
244 HIV and AIDS
lifestyle-associated social stigmas in addition to
the direct burdens of the HIV infection. They
endure many of the psychosocial phenomena
previously associated with impairments in the
immune system. Some of these changes include
overt signs of progressive physical deterioration
(Redfield & Burke, 1988), chronic legal pro-
blems (Blendon & Donelan, 1988; Ginzburg &
Gostin, 1986; Walkey, Taylor, & Green, 1990),
astronomical health-care costs (Bloom & Car-
liner, 1988), and multiple losses due to AIDS
deaths (Martin, 1988)Ðall of which can be
characterized as severe, chronic, uncontrollable,
and unpredictable stressors. At the initial onset
of HIV-related signs and symptoms these
individuals may be overwhelmed and socially
isolated, and may employ maladaptive coping
strategies such as denial/avoidance possibly
resulting in an increased likelihood of depres-
sion and distress, and perhaps sexual risk
behaviors and substance useÐall of these are
potentially associated with changes in immu-
nologic status (Antoni, 1991).
Since HIV infection is a chronic, progressive
disease with an uncertain clinical course lasting
up to 10±15 years, affected individuals must
develop lifestyle changes, effective coping
strategies, and, often, new social networks to
meet their daily needs for hope, strength, and
growth. Adjusting to a long-term progressive
lethal illness entails addressing issues such as
changes in self-expectations and preparation for
death. These are, indeed, some of the central
tasks in this stage of HIV infection (Hoffman,
1991; Lutgendorf, Antoni, Schneiderman, &
Fletcher, 1994). A very tangible issue is that
employment status often changes dramatically
at this point in the disease (Chuang, Devins,
Hunsley, & Gill, 1989; Dilley, Ochitil, Pert, &
Volberding, 1985). One study reported that the
average monthly income of patients with AIDS
or ARC had fallen by an average of $1000 per
month since their diagnosis (Ellerman, 1989).
Intermittent episodes of PCP are highly asso-
ciated with diminished abilities to maintain
employment (Wachtel et al., 1992). Change in
employment status can pervade many areas of
lifeÐloss of sources of social support, identity,
income, and medical insuranceÐthat, in turn,
can deplete one's resources for dealing with the
demands of the illness (Lutgendorf, Antoni,
Schneiderman, Ironson et al., 1994).
Even for those who are successful at muster-
ing the energy and resources for taking this
journey, there still remain critical stressor
eventsÐemergence of new symptoms, develop-
ment of resistance to a successful drug regime,
loss of health insurance benefits, deaths of
friends, rejection from family members, etc.Ð
which can trigger lapses into depression,
anxiety, and other distress reactions on the
one hand and negative health behaviors on the
other. Such lapses, if severe and unremitting,
may contribute to a negative health course by
way of increased mental health problems
(Cleary et al., 1988; Jacobsen, Perry, & Hirsch,
1990) and acceleration of disease progression
through PNI processes. If so, then psychosocial
interventions may be capable of reducing the
frequency and severity of these lapses with the
accompanying effect of improving quality of
life, reducing immunologic perturbations, and
slowing the progression of the infection.
Some of the mechanisms that could mediate
the effects of stress management intervention on
the course of HIV infection have been proposed
(Antoni, Schneiderman et al., 1990). According
to this model, cognitive behavioral stress
management (CBSM) interventions such as
relaxation training and cognitive restructuring
may reduce anxiety, depression, and social
isolation by way of their ability to increase a
sense of control, self-efficacy, and self-esteem.
These psychological changes may also be
accompanied by decreases in peripheral cate-
cholamines and cortisol via decreases in sympa-
thetic activation and improved regulation of the
HPA axis, respectively. These neuroendocrine
changes may, in turn, be associated with a
partial normalization of immune system func-
tions such as lymphocyte proliferation and
NKCC that facilitate efficient surveillance of
pathogens. To the degree that such a normal-
ization of stress-associated immune system
decrements can be achieved by stress manage-
ment techniques, then any contribution of
stressor and stress responses processes to
acceleration of disease and expression of clinical
symptoms might be forestalled or minimized.
It is arguable that such interventions can be
targeted first to some of the more prevalent
psychosocial and behavioral sequelae that HIV-
infected people may face at various points in the
disease process and some of the potentially
changeable cognitive, affective, behavioral, and
social factors that may aggravate or forestall
these phenomena. Some of the most well-
established sequelae include distress states,
depressive symptoms, and negative health
behaviors.
8.10.2.2 HIV-associated Psychosocial and
Behavioral Sequelae
8.10.2.2.1 Distress and depression
HIV-infected persons appear to be at some-
what increased risk from DSM-IV-Axis I
affective and adjustment disorders, and many
suffer significant subclinical distress reactions
 Predicting Adjustment to HIV Infection
following the initial news of an HIV seropositive
diagnosis (Cleary et al., 1988; Jacobsen et al.,
1990; Rabkin, Wagner, & Rabkin, 1996).
Among diagnosable reactions, adjustment dis-
order with depressed mood may be the most
common presenting complaint with major
depressive disorder being far lower in preva-
lence (Perkins, Stern, Golden et al., 1994;
Rabkin et al., 1996; Williams, Rabkin, Remien
et al., 1991). One study found that the suicide
rate among HIV-infected men may be up to 36
times that of age-matched uninfected men
(Marzuk et al., 1988; Rundell, Paolucci, &
Beatty, 1988), supporting the view that depres-
sive symptoms are a common sequel to an HIV
diagnosis and especially in those with a prior
history of depression (Rabkin, Rabkin, Harri-
son, & Wagner, 1994). Pharmacologic treat-
ments for depression such as imipramine and
serotonin reuptake inhibitors have been shown
to be safe and effective with HIV-infected
samples (Rabkin et al., 1996). Newer work
suggests that other biological approaches such
as testosterone replacement therapy may also
offer antidepressant effects (Rabkin et al.,
1996). The coexistence of feelings of life-threat,
doom, anger, and responsibility for making
immediate lifestyle changes following a sero-
positive diagnosis (Christ & Wiener, 1985;
Kaisch & Anton-Culver, 1989; Viney et al.,
1989) suggests that psychosocial interventions
that provide support, teach coping strategies,
and offer the opportunity for mastery experi-
ences may also be beneficial. Such interventions
may also help these individuals to ventilate
feelings such as anger (Miller, 1988) and manage
anticipatory grief over the expectation of loss
and death (Cohen, 1990; Pickrel, 1989). To the
extent that HIV infection constitutes a chronic
long-term disease, it is arguable that psychoso-
cial intervention plays a key role in the
treatment of HIV-infected persons. We have
reasoned that all of these putative intervention
effects are likely to be facilitated within a
supportive group environment (Antoni, Schnei-
derman, & Ironson, in press).
Some of the evidence supporting the possible
psychological benefits of a cognitive-behavioral
treatment orientation for HIV-infected indivi-
duals comes from the patterns of results
emerging from natural history studies con-
ducted since the mid-1980s. For instance, there
is growing evidence that the ways in which
individuals cognitively and behaviorally cope
with HIV-related stressors can influence their
ability to establish psychological equilibrium at
least within a given stage of the infection. In a
community sample of 208 HIV-positive and
HIV-negative, successful, and well-educated
gay men, the coexistence of high levels of faith
245
in the future and low levels of syndromal
disorder or depressive symptoms (Rabkin,
Williams, Neugebauer, & Goetz, 1990) sug-
gested that interventions capable of instilling
hope and self-efficacy may facilitate psycholo-
gical adjustment. There is evidence that these
ªmoderatorº variables are not unique to gay
men. Psychosocial characteristics of HIV-posi-
tive hemophiliacs related to elevated depression
and distress included (i) a previous history of
premorbid psychiatric disturbance/distress, (ii)
experiencing recent life events involving loss,
(iii) low social support from spouse, family, and
friends, and (iv) a poor sense of mastery over life
(Dew, Ragni, & Nimorwicz, 1990). Although
based on a small heterosexual sample and a
cross-sectional design, this work suggests the
importance of uncontrollable loss-oriented life
stressors, social isolation, and a lack of self-
efficacy as deterrents of psychological adjust-
ment to HIV infection.
While the psychosocial sequelae of HIV
infection are reasonably well-documented for
male samples, far less is known about what
women experience during the course of this
disease. Such information is imperative given
the fact that the incidence of AIDS has
increased at a faster rate for women than for
any other subgroup in the population of the
United States (Carpenter, Mayer, Fisher, Desai,
& Durand, 1989; CDC, 1995a). AIDS incidence
data through June 1996 indicates nearly 20% of
all new AIDS cases are women (CDC, 1995b).
AIDS cases and infected and at-risk women are
disproportionately represented among minority
populations, especially Blacks (Antoni, Schnei-
derman et al., 1992; CDC, 1995b). Young,
Black American, low socioeconomic status
(SES) women have been characterized as a
group experiencing the triple stigmas of race,
class, and gender, prior to the addition of the
burden of HIV seropositivity (Quinn, 1993) as
well as multiple chronic daily stressors (Freu-
denberg, Lee, & Silver, 1989; Mays & Cochran,
1988). These stressors include drug and alcohol
dependency, poor social networks, medical
problems, financial problems, overburdened
public clinics, lack of transportation, and
inaccessibility of child care, all potentially
fueling a general feeling of helplessness and
powerlessness (Quinn, 1993).
These stressors may be compounded even
more by pregnancy (Antoni, Schneiderman
et al., 1992). Relevant stressors here include
the decision to abort or continue pregnancy to
term, fears of becoming too ill to provide for
offspring, and preparing older children for life
as orphans. Seropositive mothers with unpro-
tected partners are also likely to face rejection
by the father of their children, resulting in
246 HIV and AIDS
emotional and financial isolation at a time when
these women are most in need of support.
Conversely, HIV seropositive women may react
to an infected partner with self-isolation, both
of which are likely to leave her and her offspring
alone. If both mother and child are seropositive,
the lack of emotional and financial support
could make the situation even worse. Thus, the
risk for significant emotional problems in HIV-
infected mothers is obvious. It is critical that
future work focus on factors contributing to
depressive symptoms and mental adjustment in
these growing populations of HIV-infected
persons so that effective interventions can be
developed.
8.10.2.2.2 Risk behavior and substance use
In addition to the influence of mood
disturbances, psychosocial adjustment to HIV
may be intimately related to negative health
behaviors. In fact, certain negative health
behaviors may show a bidirectional relationship
with depression and distress levels. Two such
negative health behaviors that are salient in the
context of HIV infection are sexual risk
behaviors and substance use. It is known for
instance, that depressed people are often more
likely to engage in risky (unprotected) sexual
behaviors (Gold & Skinner, 1992; Kelly et al.,
1993) and substance abuse (Rabkin et al., 1996).
Beyond the fact that these two sets of behaviors
are associated with transmission of the virus, it
is also well known that they occur at very high
rates in persons who are having difficulty
dealing with being HIV-infected.
Despite reductions in sexual risk behaviors
among urban gay men since 1987, a significant
number continue to engage in unprotected anal
intercourse (Martin, 1989), the sexual activity
that carries the highest risk for HIV infection in
gay men (Kingsley et al., 1987). Importantly, as
many as 15% of those gay men who modified
their sexual behaviors in the early years of the
AIDS crisis have relapsed to unsafe sexual
activities (Coates, 1991). One important factor
that may influence such risk-taking behavior is
the use of alcohol and drugs during sex (Martin,
1990b). The prevalence of alcohol abuse in the
gay community is significantly higher (30%)
than for the general population (5±10%)
(Fifield, 1975; Lohrenz, Connelly, Coyne, &
Spare, 1978; Martin, 1990b). Importantly,
alcohol and drug use is strongly asociated with
sexual behaviors and may determine adherence
to safer sex guidelines in gay men (Martin,
1990b) as well as other populations who are at
risk from HIV infection (Lollis, Antoni,
Johnson, Chitwood, & Griffin, 1995; Lollis,
Johnson, Antoni, & Hinkle, 1996). Finally,
depressive symptoms may be more likely to
occur in HIV-infected men and women who are
substance abusers, especially those who are
injection drug users (IDUs) (Rabkin et al.,
1996). Thus, chronic depressive symptoms,
substance abuse, and unprotected sexual beha-
viors may be highly interrelated and self-
perpetuating.
Psychological factors related to the adoption
and maintenance of reduced sexual risk beha-
viors include self-efficacy for safe sex, having
alternative coping strategies for dealing with
high-risk sexual impulses, and possessing skills
for negotiating with interpersonal contacts
(Kelly & St. Lawrence, 1988; McCusick, Horts-
man, & Coates, 1985), while similar constructs
such as condom efficacy and perceived vulner-
ability have been shown to predict sexual risk
behaviors in injection drug users (Lollis et al.,
1995). Denial of virulence and denial of
personal responsibility, and frequent drug and
alcohol use preceding sex (which are likely to
facilitate one another) are also associated with
continued high-risk behavior (Martin, 1990b).
Specifically, Martin (1990b) found consistent
associations between drug use (marijuana,
inhaled nitrates, cocaine, hallucinogens, barbi-
tuates, and amphetamine) and unprotected
insertive and receptive anal intercourse among
604 urban, middle-class gay men in the year
prior to their development of AIDS. Cessation
of drug use with sex predicted subsequent lower
rates of unprotected anal intercourse (Martin,
1990). Thus, one way to intervene to reduce
high-risk sexual behaviors may be to modulate
drug and alcohol use perhaps by improving the
ways individuals manage HIV-related stressors.
Among 624 gay men, two categories of life
stressorsÐdeaths of loved ones due to AIDS
and fear of illness and one's own death due to
HIV infectionÐwere associated with high-risk
sexual behaviors and drug and alcohol use as
well as psychological distress (Martin, 1989).
Perceived self-efficacy and social support have
also been shown to be critical for maintaining
adherence to safer sex guidelines (Stall, Coates,
& Hoff, 1988). Thus, among HIV-infected
individuals, in addition to being associated
with depressive symptoms, low self-efficacy,
social support losses, and denial coping strate-
gies may relate to the onset and maintenance of
substance use and sexual risk behaviors and
these may all be interrelated.
The role of ethnic, racial, cultural, and
religious factors in influencing sexual behavior
patterns is also an important consideration
(Mays & Cochran, 1988); hence sociocultural
influences on risk behavior reduction need to be
understood. For poor ethnic minority women
who are at risk of HIV infection or are already
 Predicting Adjustment to HIV Infection
infected, the risk of AIDS is only one risk in a
long list of multiple risks that are prevalent in
daily existence. The key to behavior change is
where in this list the women place the relatively
longer-term consequences of AIDS-related risk
behavior in relation to the short-term conse-
quences of the risks of daily life (e.g., safety,
food, shelter, human contact). From this
vantage point, behavior change specialists need
to be aware of more immediate survival needs
which, if met, can provide the opportunity for
professionals to educate and intervene effec-
tively. Within this deeper understanding of the
sociocultural milieu is the knowledge that the
pervasive powerlessness experienced by disad-
vantaged women at risk may lead them to
disengage from attempts at coping when
informed about risk behaviors.
8.10.2.3 Psychosocial Factors Predictive of
Depression and Risk Behaviors in HIV
Infection
There is good evidence suggesting that the
risk of depressive symptoms in HIV-infected
persons is strongly tied to a prior history of
depression (Rabkin et al., 1994). Other risk
factors include a family history of depression,
alcohol abuse, other substance abuse, and social
isolation (Rabkin et al., 1996). There are also
several psychosocial events that may follow the
onset of initial HIV diagnosis and related
symptoms (Antoni, Baggett et al., 1991;
Schneiderman et al., 1992) and these may
predict an increased likelihood of depression
and distress, sexual risk behaviors, and sub-
stance use. These include: chronic, uncontrol-
lable, and unpredictable stressors such as
treatment nonresponsiveness and side effects,
disease recurrence, stigmatizing behaviors, and
medical costs (Blendon & Donelan, 1988;
Bloom & Carliner, 1988; Ginzburg & Gostin,
1986; Redfield & Burke, 1988; Walkey, Taylor,
& Green, 1990). Inability to cope with these
mounting stressors may bring about a loss of
self-esteem and self-efficacy, feelings of help-
lessness and hopelessness, depression, and an
increase in maladaptive, potentially self-de-
structive negative health behaviors. The com-
bination of uncontrollable life stressors and
feelings of helplessness may increase cognitive
and emotional burdens (Noh, Chandarana,
Field, & Posthuma, 1990) that may overwhelm
premorbid coping strategies such as active
problem-solving and positive reframing result-
ing in the use of denial/avoidance coping
strategies or giving up entirely. Loss of familiar
sources of social support due to deaths of close
friends (Martin, 1988), the infected person's
247
own desire for social insularity and the
avoidance by acquaintances and significant
others following disclosure of homosexual
orientation (Beckett & Rutan, 1990; Gambe
& Getzel, 1989) may create a chronic lack of
resources available to deal with stressors, thus
compounding these adjustment problems. We
now review some of these phenomena in greater
detail to demonstrate how they interact.
8.10.2.3.1 Uncontrollable stressors
There are numerous psychosocial challenges
following a diagnosis of HIV seropositivity.
Among 240 gay and bisexual men, specific
stressorsÐreceiving an HIV-positive diagnosis,
an AIDS diagnosis, an AIDS-related complex
(ARC) diagnosis (the prior designation for
having overt HIV-related symptoms but not yet
developing AIDS), and learning of the death or
AIDS diagnosis of a loverÐwere rated as the
most emotionally distressing events that these
people deal with (Rosser, Simon, & Michael,
1988). It is well-established that stressful life
events shown to relate to depression and
physical health consequences are those which
are perceived as being beyond the individual's
control (Justice, 1985). These events may also
relate to increases in negative health behaviors.
A variety of stressful events have been asso-
ciated with alcohol consumption (Foy, Sip-
prelle, Rueger et al., 1984; Newcomb & Harlow,
1986) and low personal control is believed to be a
mediator of this relationship (Beckman, 1980;
Pearlin & Radabaugh, 1976). Similar findings
are evident in gay men and may be more
prevalent than in other populations given the
reinforcement of heavy drinking in gay bars, a
primary social gathering place (Nardi, 1982).
Prevalence may similarly be enhanced in
homosexual men as well as in ethnic minority
group members due to the likelihood that
alcohol (and drugs) are used to cope with
burdens associated with being gay or otherwise
disenfranchised in the society (e.g., guilt,
anxiety, alienation, powerlessness) (Lohrenz
et al., 1978). According to the identity disrup-
tion model (Lohrenz et al., 1978), negative life
events that disturb one's self-concept or identity
have the greatest deleterious effects. Self-con-
ceptions determine the way personal informa-
tion is appraised and processed, and the nature
of social interactions. Identity disruptions,
according to this model, may impair functioning
by causing individuals to devote excess time and
energy to the stressor, and undermine their sense
of control and ability to predict other aspects of
their lives. For those diagnosed with HIV
infection, each HIV-associated stressor experi-
enced may erode their previous self-concept
248 HIV and AIDS
giving way, possibly, to self-blame for their
seropositivity (Hoffman, 1991).
8.10.2.3.2 Stressor appraisals
In addition to providing an overt sign of
disease progression, physical changes such as
skin lesions, muscle wasting, and fungal infec-
tions may compromise self-image in HIV-
infected persons (Hoffman, 1991; Ostrow,
Monjan et al., 1989). Infected individuals who
see the onset of these changes as uncontrollable
may attempt to cope by way of denial and
increased substance use (Kaisen & Anton-
Culver, 1989). These maladaptive strategies
may affect psychological adjustment, future risk
behaviors, and physical health (Burns et al.,
1991; Ironson et al., 1992; Penkower et al.,
1991). It is well known that a person's appraisal
of stressful events may determine the indivi-
dual's coping responses and emotional state
(e.g., depression) (Lazarus & Folkman, 1984).
Appraisals that are particularly relevant to the
demands of an HIV diagnosis include those
concerning harm/loss (e.g., loss of relationships,
physical abilities, independence [Beckett &
Rutan, 1990; Ferrara, 1984], threat (e.g.,
threat/anticipation of future symptoms [Hoff-
man, 1991]), and challenge (e.g., opportunities
for personal growth)Ðthree domains that have
been studied extensively by Lazarus and Folk-
man. Thus, one important goal of psychosocial
intervention is to help individuals enhance their
sense of self-efficacy for dealing with the losses,
threats, and challenges characterizing the
physical and psychosocial sequelae of their
HIV infection. Efforts to build self-efficacy may
be most effective early in the course of the
psychosocial intervention and can be enhanced
by constructing a supportive group environ-
ment and teaching participants tangible strate-
gies for managing daily hassles as well as major
environmental stressors and their cognitive,
behavioral, emotional, and interpersonal re-
sponses to these events.
8.10.2.3.3 Coping with HIV-related symptoms
Individuals previously diagnosed with HIV
infection, who have not yet developed AIDS-
defining symptoms, report an overwhelming
sense of uncertainty (Dew et al., 1990). This
uncertainty may actually contribute to the
higher incidence of adjustment disorders re-
ported for those with symptomatic pre-AIDS
conditions vs. those with full-blown AIDS
(Dilley et al., 1985). Uncertainty about one's
immediate future creates critical demands for
coping, the success of which may depend upon
an individual's appraisals, attributions of
blame, opportunities for social comparison,
repertoire of adaptive coping strategies, and the
sense of self-efficacy necessary for using these
strategies.
Coping strategies classified as active-beha-
vioral (planning, seeking social support) or
active-cognitive (finding meaning in an illness,
reframing) have been related to more positive
affect and higher self-esteem in various chronic
disease populations (Billings & Moos, 1981;
Bloom, 1982; Fawzy et al., 1990; Felton,
Revenson, & Hinrichsen, 1984). Conversely,
denial and avoidance strategies are associated
with greater depression and distress (Billings &
Moos, 1981; Namir, Wolcott, Fawzy, &
Alumbaugh, 1987). Individual differences in
available coping strategies for dealing with
stressors may be among the most significant
predictors of depression and future adjustment
to HIV seropositivity (Namir et al., 1987;
Weimer, Nilsson-Schonnesson, & Clement,
1989) and may, possibly, play a role in future
clinical disease progression (Ironson et al.,
1992). One group prospectively related coping
strategies and immunologic measures in HIV
seropositive gay men over the one year period
following notification of their antibody test
results (Antoni et al., 1995a). Asymptomatic
seropositive men's coping responses to antibody
status notification were measured concurrently
with phenotypic and functional immunologic
markers, and these immunologic measures were
taken again one year later. Seropositive men
scoring above the median on postnotification
disengagement coping strategies (denial, beha-
vioral disengagement, mental disengagement)
had significantly lower concurrently measured
T-helper/suppressor (CD4/CD8) cell ratios, T-
helper±inducer subset (CD4+CD45RA+) %
values, and proliferative responses to PHA than
men scoring below the median on these scales.
Disengagement coping responses also predicted
one-year follow-up immune status; greater
disengagement predicted poorer lymphocyte
responsivity to PHA. Together these prelimin-
ary findings suggested that strategies that
distract seropositive individuals from the stress
of infectivity are related to greater levels of
depressed affect and distress, as well as more
impairment on some immunologic measures,
and these relationships appeared to persist over
as long as a 12-month period.
8.10.2.3.4 Social support
Social resources have been found to buffer
the negative physical and psychological effects
of major stressful events ranging from con-
centration camps to hurricanes (Lutgendorf
et al., 1995; Sarason, Potter, Sarason, & Antoni,
 Predicting Adjustment to HIV Infection
1985; Schneiderman et al., 1992). Buffering
effects of social support have been attributed to
increased opportunities for intimacy, integra-
tion through shared concerns, reassurance of
worth, nurturance, reliable alliance, and
guidanceÐall potentially facilitating task-or-
iented thinking and active coping while decreas-
ing helplessness and depression (Sarason, 1979).
On the other hand, socially isolated individuals
may be more likely to maintain maladaptive
stressor appraisals such as catastrophizing, self-
blame, and helplessness, and may employ denial
as a chief coping strategy. The many losses in
interpersonal and institutional support re-
sources (Hoffman, 1991) may be responsible
for the sense of isolation reported by some HIV-
infected individuals (Dilley et al., 1985).
Issues regarding social support may be
especially salient for HIV-infected women,
many of whom are indigent minority group
members who have been marginalized by their
social groups leaving them with limited re-
sources available to care for themselves or their
children (Guinan, 1987; Nyamathi & Lewis,
1991). This threatens their roles as caregivers
and mothers significantly (Buckingham &
Rehm, 1987; Chung & Magraw, 1992). Trying
to cope with being ill and the challenges of
motherhood concurrently can be overwhelm-
ing. Having to disclose to children one's
serostatus and medical condition are further
challenges that these women face. Women with
AIDS feel and experience stigma and shame by
being presumed to be dangerous (Chung &
Magraw, 1992). Community support efforts
may appear to them to be primarily directed to
gay men and they may respond to this with
resentment and despair (Mackie, 1993).
It is important to remember, however, that
gay men may also be at increased risk of social
isolation. Given the number of HIV-infected
gay men experiencing multiple bereavements
(Martin, 1988), coupled with their reported low
average support network size (comprised
mainly of friends) (Namir, Alumbaugh, Fawzy,
& Wolcott, 1989), any loss in such social
support may be especially devastating. Other,
less stable, social resources such as employment
circles (Chung et al., 1989; Dilley, et al., 1985)
may also be lost as the HIV infection progresses,
with job loss having negative effects on both
financial status, self-esteem, and emotional
functioning.
In a recently published review, Zuckerman
and Antoni (1995) suggest that certain social
support criteria are related to optimal psycho-
logical adjustment in HIV-positive individuals.
These include:
(i) a general sense of feeling supported (Na-
mir et al., 1989);
249
(ii) satisfaction with received support (Hays,
Turner, & Coates, 1992);
(iii) perceived helpfulness of peers (Hays,
Chauncey, & Tobey, 1990);
(iv) total perceived availability of support as
well as individual dimensions of support
(O'Brien, Wortman, Kessler, & Joseph, 1990;
Turner, Hays, & Coates, 1993; Zich & Te-
moshok, 1987);
(v) absence of social conflict (Lesserman et
al. 1995; O'Brien et al., 1993);
(vi) greater involvement in AIDS-related
community activities (Lesserman, Perkins, &
Evans, 1992); and
(vii) a greater number of close friends (Hays
et al., 1990).
Each of these aspects of support has been
associated with lower levels of depression and,
in some studies, with lower levels of hope-
lessness, anxiety, mood disturbance, risk beha-
viors, and greater overall sense of psychological
well-being in a variety of populations (Christ &
Wiener, 1985; Cutrona & Russell, 1987; Don-
lou, Wolcott, Gottlieb, & Landsverk, 1985;
Friedman et al., 1991; Namir et al., 1989;
Ostrow, Joseph et al., 1989; Zich & Temoshok,
1987). One study found that greater support
satisfaction and greater involvement in AIDS-
related community activities were associated
with a greater use of coping strategies such as
cognitive reframing and fighting spirit which
were in turn associated with less dysphoria and
greater self-esteem (Lesserman et al., 1992).
Prior studies of HIV-positive men suggest that
social support may determine the choice be-
tween active behavioral coping and less adap-
tive strategies. For instance, greater social
support availability and satisfaction associated
with active coping and lower support avail-
ability is associated with a greater use of denial/
avoidance strategies (Martin, 1989). Also, lack
of family support and other important support
sources have been proposed as contribitors to
alcohol abuse (Nardi, 1982), though little is
known about the ways in which ethnicity and
socioeconomic status may moderate this rela-
tionship. In a large cohort of gay men in San
Francisco, men who reported always using
condoms had higher levels of social support
from informal sources of help (friends, sex
partners) (Catania et al., 1991). Thus social
support may be viewed as a coping resource to
the extent that it channels, facilitates, or perpe-
tuates the use of coping strategies with stress-
buffering properties.
Unfortunately, social support may actually
decrease as the number of symptoms increases
in HIV-infected individuals (Hays et. al., 1990).
This may be due to caregivers and other support
network members pulling back from persons
250 HIV and AIDS
with AIDS (PWA) to prevent burnout and
emotional exhaustion (Turner et. al., 1993).
Since family members may attempt to distance
themselves emotionally from this traumatic
situation, the importance of peers and fellow
PWA's in the social support networks of HIV-
infected individuals may increase. These people
can be important sources of informational
support and often provide the greatest oppor-
tunity for support (Hays et al., 1990). As such,
peers often fill in the ªsupport gapsº left behind
by family and professional caregivers (Zucker-
man & Antoni, 1995).
It is important to realize that some forms of
social interaction may actually be associated
with increased levels of psychological distress in
HIV-infected persons. Among asymptomatic
HIV-infected gay men, increases in social
conflict, and dissatisfaction with social support
in general predicted greater increases in distress
and depression over a one-year period (Lesser-
man et al., 1995). These social conflicts can
include rejection messages from family mem-
bers, breaking up or declining quality of
romantic relationships, and trouble with em-
ployers, among others. Another study revealed
that the type of support deemed most useful
depended largely on the situation confronting
the individual and the context of the support
provision: emotional support was generally
seen as being helpful from all providers in
almost any situation, while informational or
problem-solving support was viewed as helpful
only from medical experts and other PWA's
(Zich & Temoshok, 1987). The relative effec-
tiveness of problem-focused vs. emotional-
focused support may also depend on factors
such as disease stage (asymptomatic vs. AIDS)
and stressor qualities such as controllability.
Folkman and colleagues have suggested that
problem-focused coping strategies may be most
useful when directed toward controllable
aspects of stressors, while emotion-focused
strategies may be most effective when targeted
toward uncontrollable aspects of stressors
(Folkman et al., 1991). Extending the coping
theory of Folkman and her colleagues to the
context of matching social support resources
(e.g., emotional vs. informational) to situa-
tional demands (e.g., uncontrollable vs. con-
trollable) has been proposed as a reasonable
strategy for providing the most useful support
to individuals who are dealing with the different
burdens of HIV infection (Zuckerman &
Antoni, 1995).
In sum, inadequate social support or a sense
of social isolation may exaggerate the deleter-
ious effects of stressful events on depression and
negative health behaviors in HIV-infected
persons (Cutrona & Russell, 1987). A seropo-
sitive diagnosis may reduce both the availability
and utilization of social support (Christ &
Wiener, 1975; Donlou et al., 1985) which may
increase the risk of depression, hopelessness,
and less adaptive strategies such as substance
use (Friedman et al., 1991; Nardi, 1982; Ostrow,
Joseph et al., 1989). Similar phenomena may
occur in those diagnosed with HIV symptoms or
full-blown AIDS for the first time (Namir et al.,
1989; Zich & Temoshok, 1987). Thus social
support may be related to depression, substance
use, and sexual risk behaviors at many stages
HIV infection. Its influence may also vary as a
function of ethnicity, among other factors such
as SES and educational level. While available
and adequate social supports might enhance
HIV-infected people's ability to manage their
infection and related stressors by functioning as
a key coping resource, negative conflictual
social interactions may actually act as a
deterrent to successful adjustment.
8.10.3 PREDICTING THE HEALTH
COURSE OF HIV INFECTION
With the emergence of data in the 1990s from
long-term cohort studies, it is now well-
established that some patients who are HIV
positive develop symptoms rapidly while others
remain free of AIDS symptoms over a decade.
From a secondary prevention standpoint this
means that it is important to isolate factors that
account for the wide variability in the transit
time for the clinical manifestations of HIV
infection. Since 1990, new terms have been
developed to reflect those who somehow outlive
or outpace their prognosis following HIV
infection. One grouping consists of nonpro-
gressors with HIVÐpersons who are HIV-
positive yet maintain near normal levels of CD4
numbers. Another grouping consists of those
who are asymptomatic low CD4Ðpeople with
very low CD4 counts (5 50 cells mm73) who
remain asymptomatic for extended periods of
time. Finally, there are those termed long-term
survivors of symptomatic AIDS. While the
sources of individual variability in HIV pro-
gression remain largely unknown, a growing
body of literature suggests that the key may lie
in some combination of biological and psycho-
logical factors (Ironson et al., 1995).
8.10.3.1 Biological Factors and Disease
Progression
8.10.3.1.1 Constitutional factors
Some biological factors influencing length of
survival (Friedland et al., 1991; Hardy et al.,
1991) include age (e.g., younger persons live
 Predicting the Health Course of HIV Infection
more years once infected [Jacobson et al., 1991;
Lemp et al., 1990]), gender (e.g., men live longer
following diagnosis with AIDS [Brown, 1989]),
ethnicity, and initial AIDS-related disease
manifestation (having Kaposi's sarcoma vs.
PCP as the presenting symptomatic criterion for
AIDS (Friedland et al., 1991). Risk group
membership (Detels et al., 1988; Shine et al.,
1987) and presence of, or prior history of, other
concomitant sexually transmitted diseases
(STDs) also appear important. Disease pro-
gression markers, such as CD4 cell counts, may
also be predictive of disease progression. For
instance, prior rate of CD4 decline and body
mass index predict the amount of time until the
infected people's level of CD4 cells drops below
200 cells mm73, the point at which symptomatic
AIDS often occurs (Hoover et al., 1995).
8.10.3.1.2 Other viral infections
Another set of biological factors influencing
the course of HIV infection may be the degree to
which other latent viruses (e.g., several types of
herpes viruses) become reactivated (Rosenberg
& Fauci, 1991). This point, taken in view of the
psychosocial phenomena reviewed previously,
is a critically important consideration for PNI
research with HIV-infected populations given
that (i) several psychosocial stressors have been
related to immune system decrements and to
signs of reactivation of one or more latent
herpes viruses, and (ii) increases in sexual risk
behaviors, which may ensue following some of
these psychosocial phenomena, may place
infected individuals at greater risk of contract-
ing a new herpes virus infection. It has been
reasoned that if stressors (Glaser & Kiecolt-
Glaser, 1987) and behavioral interventions
(Antoni, Esterling, Lutgendorf et al., 1995)
affect the immune system's ability to control
latent herpes viruses in a wide variety of
populations, then stressors and interventions
might also influence herpes virus-mediated
progression of clinical disease in HIV-infected
individuals.
Importantly, herpes viruses persist in the host
indefinitely once they are infected (Rinaldo,
1990). Varicella and HSV establish latent
infections in neurons, whereas CMV, Human
Herpes Virus Type-6 (HHV-6), and EBV persist
in lymphocytes. When an individual is infected
with one of the herpes viruses, seroconversion
and latency results, with or without the presence
of clinical disease. In healthy individuals, herpes
viruses can reactivate spontaneously and often
in the absence of clinical symptoms. Under
sustained states of cellular immunodeficiency,
such as in persons infected with HIV or in those
undergoing immunosuppressive therapy for
251
renal transplant, reactivation of one or more
of the latent herpes viruses results in severe
morbidity (Ernberg, 1986; McVoy & Adler,
1989; Rinaldo, 1990; Yao, Rickinson, Gaston,
& Epstein, 1985). Moreover, herpes viruses are
known to suppress a wide number of immuno-
logic functions including cytokine production
and lymphocyte blastogenesis to mitogens
(Rinaldo, 1990). These phenomena suggest that
HIV and herpes viruses may interact to
perpetuate disruptions in the biological control
of each respective infection, possibly contribut-
ing to the severity and chronicity of related
clinical signs and symptoms.
Because several herpes viruses prevalent in
HIV-infected individuals are known to have
independent immunosuppressive effects, reacti-
vation of these viruses could have implications
for progression to AIDS (Griffiths & Grundy,
1987). Subclinically these surveillance effects
may be observed as rising antibody (IgG) titers
to EBV, HHV-6, CMV, and HSV-2. One could
speculate that clinically, the inability to survey
these latent viruses may be manifest in EBV-
associated Burkitt's lymphoma (Doll & List,
1982) and oral hairy leukoplakia (Eversole,
Stone, & Beckman 1988; Greenspan et al.,
1985); CMV-associated retinitis, encephalitis
hepatitis, adrenalitis, and gastrointestinal
pathologies (Blumberg, 1984; Henderly et al.,
1987; Schooley, 1990; Tapper et al., 1984); and
HSV-associated proctitis (Goodell et al., 1983),
esophagitis (Levine, Woldenberg, Herlinger, &
Laufer, 1987), and aseptic meningitis (Dahan,
Haettich, LeParc, & Paolaggi, 1987).
There is also evidence that reactivation of
several of these herpes viruses may act to further
stimulate HIV replication and progression to
AIDS (Carbonari et al., 1989; Hammarskjold &
Heimer, 1988; Lusso et al., 1989; Rosenberg &
Fauci, 1991; Sumaya, Boswell, & Ench, 1986).
CMV, one of the herpes viruses, is an important
opportunistic pathogen in HIV infection (Ri-
naldo, 1990) and has been shown to enhance
susceptibility to secondary opportunistic patho-
gens in immunosuppressed populations (Pers-
san et al., 1987). It is among the most
immunosuppressive of the herpes viruses im-
pairing blastogenic responses and g-interferon
production by T-lymphocytes (Rinaldo, 1990)
and it has also been shown to alter the growth
and expression of HIV in culture, possibly
accelerating progression to AIDS among in-
fected persons (Biegalke & Geballe, 1991; Paya,
Virelizier, & Michelson, 1991). Webster (1991)
found that among HIV-infected individuals, the
age-adjusted relative risk of developing AIDS
was 2.5 times higher in those who were
coinfected with CMV compared to those who
were CMV seronegative.
252 HIV and AIDS
In sum, although some mechanisms are still
being explored, the fact that herpes viruses may
be related to HIV associated sequelae is
intriguing. For example, because HHV-6 may
reactivate during EBV infections, and because
both EBV and HHV-6 may reactivate following
immunosuppression by HIV, these three viruses
may potentiate one another in the progression
of clinical disease. Through direct immunosup-
pression or transactivation of HIV (by CMV or
HSV), latent herpes viruses may be considered
as potential cofactors in the development of
AIDS. It is quite plausible that HIV-associated
effects on the cells of the immune system may
perpetuate a downward spiral in the functional
ability of the immune system to survey and
control latent viruses which, when left un-
checked, may act to increase replication of the
primary virus.
The implication of these findings is that the
host's ability to control such viruses may be a
ªdownstreamº immune system marker that has
more meaning as a predictor of HIV clinical
disease and possibly the acceleration of viral
load than does the CD4 cell count alone. We
know that changes in HIV viral load, viral
character (appearance of syncytium-inducing
variants), and CD8-directed cytotoxity against
HIV are the key predictors of individual
differences in clinical disease progression (Pan-
taleo et al., 1993). These ªpredictorsº all speak to
the importance of the host maintaining vigorous
surveillance and control over HIV (through
well-coordinated cytotoxic responses), and sta-
bilized HIV replication (reflected in stable viral
load and predominantly nonsyncytium-produ-
cing types). Given this understanding of the
importance of qualitative aspects of the immune
system (surveillance functions and signs of
poorly surveyed viruses) in HIV disease pro-
gression, it is surprising that so little research has
been published on the effects of biomedical and
psychosocial interventions on qualitative im-
mune measures including those reflecting sur-
veillance of specific pathogens such as latent
herpes viruses.
8.10.3.2 Behavioral and Psychosocial Factors
and Disease Progression
8.10.3.2.1 Behavioral factors
Behavioral factors such as the use of alcohol,
tobacco, caffeine, recreational drugs (cocaine,
nitrites) during sex, unprotected anal inter-
course, and poor nutrition have also been
suggested as possible cofactors of accelerated
HIV disease progression (Chiappelli, Ben-
Eliyahu, Hanson & Wylie 1992; Griensven
et al., 1990; Haverkos, Pinsky, Drotman, &
Bregman, 1985). It is noteworthy that several of
these behaviors have been associated with
immunomodulation in other populations. Ci-
garette smoking has been associated with
significant decreases in helper cells and increases
in suppressor/cytotoxic cells (Miller, Goldstein,
& Murphy, 1982). Alcohol use has been related
to depressed cell-mediated immunity (Watson,
Eskelson, & Hartman, 1984), decreased lym-
phocyte number and diminished lymphocyte
blastogenesis (Glassman, Bennet, & Randal,
1985), bone marrow myelosuppression (Tisman
et al., 1971), and abnormal granulocyte chemo-
taxis (Atkinson et al., 1977). Other work suggests
that alcohol abuse may amplify the suppressive
effects of mental depression on immunologic
impairments (Irwin, Caldwell et al., 1990).
Recreational drug usage (e.g., heroine) has been
associated with depressed cellular immune
functioning in one study (Lazzarin, Mella, &
Trombini, 1984), and with suppressed NK cell
killing in another (Katz, Zaytoun, & Faici,
1982). Some of this work has focused specifically
on HIV-infected samples. For instance, there is
growing evidence that injection drug use (Seage
et al., 1993; Weber, Ledergerber, Opravil,
Siegenthaler & Luthy, 1990) and even cigarette
smoking (Burns et al., 1991; Nieman, Fleming,
Coker, Harris, & Mitchell, 1993; Royce &
Winkelstein, 1990) may be associated with faster
disease progression in HIV-infected people. The
specific mechanisms by which these substances
affect immune functioning are still in the process
of being elucidated. It is noteworthy that some of
these substances are associated with alterations
in those physiological stress response systems
noted previously. For instance, nicotine in
cigarette smoke is associated with catecholamine
discharge (Blaney, 1985) and ethanol consump-
tion is also linked with catecholamine elevations
due to blockage of re-uptake (Davidson, 1985).
Nutritional factors and vitamin deficiencies
may contribute to immunologic decrements in
HIV infection. Protein-caloric malnutrition is
associated with a wide range of immune
impairments and is believed to explain the
increased susceptibility to disease in under-
nourished populations of many Third World
countries (Stites, Stobo, Fudenberg, & Wells,
1982). Some work also suggests that alterations
in certain vitamin levels, for instance, vitamin B6
deficiencies, may be associated with immune
system decrements in HIV-infected persons
(Baum et al., 1991).
A series of studies has presented evidence for
immunomodulatory effects of sleep deprivation
including decreases in lymphoproliferative re-
sponses and diminished granulocyte function-
ing (Palmblad et al., 1976; Palmblad, Petrini,
Wasserman, & Akerstedt, 1979). One study,
 Predicting the Health Course of HIV Infection
done in the mid-1990s, noted that the decre-
ments in immune function (NKCC) evident in
victims of a hurricane over the months follow-
ing the storm were mediated, in part, by sleep
disruptions (Ironson et al., 1997). Other work
has indicated that human IL-1 levels peak at the
onset of slow wave sleep (Krueger & Karnovs-
ky, 1987), suggesting that cellular immunity
may be affected by qualitative, as well as
quantitative, aspects of sleep and accompanying
cytokine changes. Important for HIV-infected
populations is the fact that sleep disruptions are
one of the hallmarks of clinical depression.
Numerous other biological factors may alter
stress hormone levels and immune functioning
such as aging, steroid use, sex hormone
fluctuations, radiation treatment, as well as a
multitude of medication regimens (Stites et al.,
1982). Generally these variables are not likely to
be responsive to health psychology interven-
tions and thus will not be reviewed here.
However, it is essential that these phenomena
and others be measured and carefully controlled
in any investigations of the influence of
biological, behavioral, and psychosocial factors
in HIV disease progression.
Another variable that may deserve further
attention is heightened sympathetic nervous
system responsiveness to stressful situations.
The stress hormonal elevations known to
accompany this hyper-responsiveness (Rose,
1980) may have immunomodulatory effects.
Interestingly, a growing literature suggests that
pharmacologic agents that attenuate cardiovas-
cular hyper-responsiveness (Bonelli, 1982;
Dimsdale, Hartley, Ruskin, Greenblatt, &
Labrie, 1984) may also alter immune function-
ing (Benschop et al., 1994; Hatfield, Petersen, &
DiMicco, 1986; Weisdorf & Jacob, 1987). There
is also some evidence that HIV-infected persons
may display altered cardiovascular, endocrine,
and immunologic reactivity to laboratory
stressors (Kumar, Morgan, Szapocznik, &
Eisdorfer 1991; Starr et al., 1996), indicating
that these individuals may not respond to and
recover from stressful challenges in the same
way that healthy, uninfected people do.
Although there is little known about the
direct immunomodulatory effects of different
forms of sexual behaviors, it is plausible that
repeated exposure to novel strains of HIV and
other sexually transmitted pathogens by way of
unprotected intercourse (e.g., HSV and human
papilloma viruses [HPVs], may contribute
directly to the development of opportunistic
infections (e.g., systemic HSV-2 infections) and
neoplasias (e.g., HPV-associated cervical and
anal intraepithelial neoplasias [Antoni & Good-
kin, 1996]). In addition, exposure to these
pathogens may indirectly contribute to an
253
accelerated disease course by promoting HIV
replication (for review see Antoni, Esterling,
Lutgendorf et al., 1995). Therefore, efforts to
modify risky sexual behaviors in already
infected individuals can be seen as a secondary
prevention strategy. Finally, PCP treatment
prophylaxis, antiretroviral combination ther-
apy, and the new breed of protease inhibitors
may influence survival after AIDS onset (Saah
et al., 1994). From a behavioral standpoint, an
HIV-infected individual's decision and actions
taken to pursue these treatments, at the earliest
point following the emergence of symptoms or
after dropping below landmark values for CD4
cell counts (e.g., 5 200 cell mm73), may play a
large role in health maintenance.
We have reasoned that if psychological
factors affect the immune systems of HIV-
infected individuals, then even small immune
changes might have clinical relevance since this
population's immunologic functioning is al-
ready significantly impaired by the virus
(Antoni, Schneiderman et al., 1990; Schneider-
man et al., 1994). Healthy uninfected people in
the normal population possess many checks,
balances, and compensatory mechanisms built
into their immune systems. Since HIV-infected
individuals are just at, or above, the number of
T-lymphocyte subsets necessary for responding
to encountered pathogens (e.g., 200±500
CD4 cells mm73), then small changes, of un-
known magnitude, could quite possibly have
an impact on the incidence of a wide range
of infections due to normally harmless bacter-
ias, viruses, fungi, and other opportunistic
pathogens.
In addition to behavioral factors, there is
some evidence that several psychosocial
variables may also contribute to individual
differences in disease progression among
asymptomatic HIV-infected individuals as well
as contributing to differences in survival time in
those who have already developed AIDS.
Specifically, longitudinal studies have identified
psychological factors such as depressive symp-
toms, stressful life events, maladaptive coping
strategies, and social isolation that predict
either survival time or CD4 changes over a
period of years.
8.10.3.2.2 Depressive symptoms
There is considerable evidence that depressive
symptoms are correlated with immunosuppres-
sion in otherwise healthy individuals (Herbert &
Cohen, 1993; Irwin, Caldwell et al., 1990; Irwin,
Patterson et al., 1990), though available
evidence suggests that depression and affective
disturbances may be associated with physical
254 HIV and AIDS
disorders in a bidirectional fashion (Cohen &
Rodriquez, 1995). Much of the work relating
clinical depression and depressed affect to
immunologic changes is plagued with incon-
sistencies which may be attributable, in part, to
the use of small samples, variability in control/
comparison groups utilized, and variance in the
depression diagnostic criteria employed (Stein
et al., 1991). However, alterations in NKCC
appear to be the most commonly observed
immunologic correlate of depressed affect and
depressive disorder employed (Stein et al.,
1991). Among the more recent and well-
controlled studies, Irwin, Caldwell et al.
(1990) found significant NKCC decrements
associated with depressive disorders.
Longitudinal studies relating depressive
symptoms to rates of immunologic decline
and disease progression in HIV-infected per-
sons have produced mixed results (Burack et al.,
1993; Lyketsos et al., 1993; Patterson et al.,
1996). Burack and colleagues found that greater
depressive symptoms predicted a faster decline
in CD4 counts but were not associated with
time to AIDS or survival time in early-stage
HIV-infected gay men followed over a six-year
period (Burack et al., 1993). Lyketsos used
similar criteria for documenting the presence of
depressive symptoms and found no prospective
relationship with either CD4 count slopes of
decline or clinical disease progression over a
similar period (Lyketsos et al., 1993). However,
there was a tendency for the men in the
Lyketsos study to be at a more advanced stage
of CD4 cell loss at start of the study than those
men in the Burack study. Another study
following HIV-infected men over a five year
period observed that depressive symptoms
predicted shorter survival time after controlling
for initial symptoms and CD4 cell number
(Patterson et al., 1996). Other psychosocial
factors may interact with depressive symptoms
or distress levels in predicting changes in
immune status and health. Because depressed
affect, substance use, and risky sexual behaviors
may all contribute to health outcomes in HIV-
infected individuals, it seems reasonable that
factors which moderate the occurrence of these
sequelae may also have an influence on
immunity and health. Some of these include
the occurrence of overwhelming stressful life
events, stressor appraisals, individual differ-
ences in coping skills, and differences in social
support.
8.10.3.2.3 Stressful life events
There is now ample literature (Herbert &
Cohen, 1993) showing that stressors are
associated with decrements in immune function.
Some of these stressors may be particularly
prevalent among HIV-infected people attempt-
ing to cope with their illness and include:
bereavement (Bartrop, Lazarus, Luckhurst,
Kiloh, & Penny, 1977; Irwin, Daniels, Bloom
et al., 1987; Kemeny et al., 1995; Linn, Linn, &
Jensen, 1981); unemployment (Arnetz et al.,
1984); the stress of being a caregiver for a loved
one with a terminal disease (Kiecolt-Glaser,
Glaser et al., 1987; Kiecolt-Glaser et al., 1991);
divorce (break-up) (Kiecolt-Glaser, Fisher
et al., 1987); and marital distress (Kiecolt-
Glaser, Fisher et al., 1987; Kiecolt-Glaser et al.,
1988). Chronic uncontrollable stress has been
operationalized in one form as people dealing
with catastrophic environmental changes.
These stressors are also associated with immune
alterationÐfor instance, both at the Three Mile
Island nuclear plant disaster (McKinnon,
Weisse, Reynolds, Bowles, & Baum, 1989)
and in Miami after Hurricane Andrew (Ironson
et al., 1997; Lutgendorf et al., 1995).
Recently conducted investigations indicate
that the most consistent immune decrements
found in studies of stressors are functional
measures associated with cellular immunity
(Bartrop et al., 1977; Glaser, Rice, Speicher,
Stout, & Kiecolt-Glaser, 1986; Glaser, Kiecolt-
Glaser, Speicher, & Holliday, 1985; Glaser et
al., 1987, 1990, 1991; Ironson et al., 1995; Irwin
et al., 1990; Kemeny et al., 1995; Kiecolt-Glaser
et al., 1985, 1987, 1988; Kiecolt-Glaser, Dura,
Speicher, Trask, & Glaser, 1991; Levy, Herber-
man, Lippman, d'Angelo, 1987; Linn et al.,
1981). These include, but are not limited to:
(i) decrements in blastogenic responses to
phytohemaglutinin (PHA) and pokeweed mito-
gen (PWM);
(ii) decreased natural killer cell cytotoxicity
(NKCC);
(iii) increased antibody titers to Epstein-Barr
Virus (EBV) and Herpes Simplex Viruses
(HSV);
(iv) poorer DNA repair; and
(v) disturbance in cytokine regulation in-
cluding less g-interferon and interleukin-2
(IL-2) production and IL-2 receptor gene ex-
pression.
There are some PNI studies that have related
stress responses to people's ability to respond to
viral pathogens. Cohen and colleagues (Cohen,
Tyrrell, & Smith, 1991) innoculated volunteers
with one of five rhinoviruses (cold viruses) in a
restricted environment and then followed them
over a period of weeks. Subjects with the highest
levels of perceived stress were significantly more
likely to display increases in antibody titers to
the specific rhinovirus and clinical colds than
those with the lowest levels of psychological
 Predicting the Health Course of HIV Infection
stress. Stressors have also been related to
alterations in primary immune responses to
other viruses. Glaser et al. (1992) demonstrated
that those medical students undergoing a stres-
sor (exams) who were least stressed and anxious
were also the most likely to seroconvert (pro-
duce a primary antibody response to) the
Hepatitis B virus (HBV) after the first vaccine
innoculation. In addition, participants with the
highest levels of social support had a stronger
immune response to the vaccine at the third
innoculation. Thus, participants with low stress
and anxiety, and high social support, appear to
have been relatively well protected from infec-
tion by HBV. Together these studies suggest
that stressors may influence mechanisms con-
trolling both primary and secondary immune
responses to viruses. This work is important for
understanding the role of stressor±immune
associations as they possibly relate to health
outcomes in the context of HIV infection since
an HIV-infected person's inability to control
viral co-infections may act to aggravate the
course of primary HIV infection (Antoni et al.,
1995).
Despite some of the evidence associating
stressful life events with changes in specific
indices of immune system functioning in healthy
populations that has accrued since the mid-
1980s, there is less conclusive evidence linking
stressors with immune and health changes in
HIV-infected individuals. Briefly, two studies
found that stressful life events were unrelated to
CD4 counts or HIV-related symptoms (Kessler
et al., 1991; Rabkin et al., 1991), while another
found that elevated life events were predictive of
decreases in CD4 counts (Goodkin, Fuchs,
Feaster, Leeka, & Rishel, 1992). It should be
noted that Goodkin and colleagues analyzed
their data in line with a stressor±moderator
model which simultaneously takes into account
the direct effects of life events, plus their
interaction with theoretically derived modera-
tor variables such as coping and social support.
Such more sophisticated statistical modeling
may be necessary to delineate the often
interactive nature of life event effects on the
immune system and health.
One stressful event associated with disease
progression in HIV-infected persons is bereave-
ment (Coates, Stall et al., 1989; Kemeny et al.,
1994). Coates, Stall et al. (1989) found that both
the number of losses and accompanying distress
levels were significantly related to faster HIV
progression during a two-year follow-up. Simi-
larly, Kemeny et al. (1994) found that a bereaved
group of HIV-infected men who had lost a
partner had significantly higher serum neopterin
levels and lower proliferative responses to PHA
than a matched group of nonbereaved HIV-
255
positive men. This suggests that life events that
are commonly experienced by HIV-infected
individuals may have significant effects on the
functioning of their immune system, but that
gross changes in CD4 counts and clinical
symptoms may take longer to develop. While
the Rabkin et al. (1991) and Kessler et al. (1991)
studies found no association between stressful
life events and outcome measures, they did not
assess individual differences in subjectsº per-
ceived control over stressful life events nor their
coping responses for dealing with these stres-
sors. While other life events have been asso-
ciated with some immune measures in HIV-
infected people (Evans, Pettito, & Leserman,
1992; Goodkin et al., 1992), stressful life events
per se have not been shown to be predictive of a
faster rate of disease progression (Kessler et al.,
1991). Patterson and colleagues note that the
interaction between mounting life events and
distress levels may be a more reliable predictor
of immunologic and health changes in HIV-
infected persons (Patterson et al., 1996). Speci-
fically, individuals who display the greatest
distress levels during particularly stressful
periods may show the poorest health outcomes.
It is plausible that those individuals who are at
greater risk of displaying such distress levels are
those who utilize maladaptive stressor apprai-
sals and coping strategies and who also have
inadequate social resources.
8.10.3.2.4 Stressor appraisals
Some aspects underlying the cognitive pro-
cessing of stressors have been associated with
measures of physiological activation and im-
mune functioning in healthy people. Davidson
and Baum (1986) found that both intrusive
imagery and avoidant cognitions, as measured
by the Impact of Event Scale (IES) (Horowitz,
Wilner, & Alvarez, 1979), were positively
associated with increased cortisol levels in
residents living near Three Mile Island (TMI)
following the nuclear reactor accident. Many of
these individuals displayed elevated antibody
titers to certain viruses, suggesting impairments
in immunologic surveillance years after the
reactor accident (McKinnon et al., 1989).
Workman and LaVia (1987) found that in-
trusive cognitions (measured by the IES) related
to an impending medical school examination
were associated with poorer blastogenic re-
sponses to PHA among young healthy medical
students. Ironson and colleagues found that the
intrusive thoughts and post-traumatic stress
symptoms experienced by many victims of
Hurricane Andrew were associated with decre-
ments in NKCC (Ironson et al., 1997).
256 HIV and AIDS
One study examined how the manner in which
HIV-infected individuals processed the stress of
seropositivity notification predicted their im-
munologic status during the early period of
adjustment to this stressor. They found that
changes in style of cognitive processing of this
stressor were significantly correlated with
changes in affective and immunological func-
tioning over this 10 week period (Lutgendorf,
Antoni, Ironson, Schneiderman et al., 1997).
The IES and the Profile of Mood States (POMS)
(McNair, Lorr, & Droppleman, 1981) were
administered five weeks before (baseline) and
five weeks after notification (week 10). A panel
of immune assays were also conducted on blood
samples collected at these time points. The IES
instructions required subjects to report on
intrusive thoughts that they had been experien-
cing in the past week regarding one of the most
salient issues that infected people deal with on a
daily basis: the threat of AIDS in their life. The
IES also tapped the degree to which they had
attempted to distract themselves or avoid
thinking about this threat over this period.
Participants were classified as those who had
IES-Intrusion score increases vs. decreases and
those who had IES-Avoidance score increases
vs. decreases over the 10-week period. Results
indicated that men with avoidance increases
demonstrated greater anxiety, depression, and
confusion at week 10 than those individuals who
had avoidance decreases. Subjects with avoid-
ance increases also displayed lower proliferative
responses to PWM and lower NKCC at the end
of the 10 weeks compared to those who
decreased in avoidance scores over the study.
These findings suggested that postnotification
processing, colored by avoidance, was asso-
ciated with poorer immune system functioning
in the weeks after antibody testing among
asymptomatic HIV-positive men.
Another stressor appraisal variable that has
received some attention in HIV research
concerns a construct called fatalism. In a series
of studies, Kemeny (reviewed in Kemeny, 1994)
found fatalistic appraisals to be related to
poorer health outcomes in HIV-infected gay
men. In the first study, fatalistic gay men with a
diagnosis of AIDS had a significantly shorter
survival time than men scoring low on fatalism
(Reed, Kemeny, Taylor, Visscher et al., 1994).
Interestingly, men who were both fatalistic and
bereaved within the past year had the shortest
survival time (Reed, Kemeny, Taylor, Visscher
et al., 1994), the steepest declines in CD4
number and proliferative response to PHA, and
a more rapid increase in disease progression
markers, including neopterin and beta-2 micro-
globulin (Kemeny et al., 1995). Less is known
about the ways in which other cognitive
appraisal variables, such as optimism, different
cognitive distortions, such as catastrophizing,
and self-efficacy might relate to the course of
HIV infection.
8.10.3.2.5 Coping strategies
There is some evidence that the use of certain
coping strategies for dealing with HIV infection
may be associated with the rate of disease
progression. Ironson et al. (1994) found that the
use of denial and behavioral disengagement to
cope with an HIV-positive diagnosis, was
predictive of lower CD4 counts at 1 year
follow-up (controlling for CD4 counts at entry
to the study) and greater likelihood of progres-
sion to HIV-related symptoms and AIDS at 2-
year follow-up. A more fine-grained analysis
exploring the immunologic changes that oc-
curred in this sample prospectively related
coping strategies and immunologic measures
in the HIV seropositive gay men (and a
seronegative comparison group of gay men)
over the 3 week and 1-year period following
notification of their antibody test results
(Antoni et al., 1995). Seropositive men scoring
above the median on postnotification disen-
gagement coping strategies (denial, behavioral
disengagement, mental disengagement) had
significantly lower concurrently measured T-
helper/suppressor (CD4/CD8) cell ratios, T-
inducer subset (CD4+CD45RA+) percent
values, and proliferative responses to PHA
than subjects scoring below the median on these
coping scales. Greater disengagement coping
responses also predicted poorer lymphocyte
responsivity to PHA at 1-year follow-up.
Consistent with these findings, Goodkin et al.
(1993) found that use of passive coping strategies
(including denial and disengagement) was
inversely related to long-term CD4 cell count
in HIV-positive gay men. Solano et al. (1993)
also found that denial/repression was associated
prospectively with the emergence of symptoms
in an HIV-positive sample. Mulder, Antoni,
Duivenvoorden et al. (1995) found that active
confrontational coping with HIV infection was
predictive of decreased clinical progression over
a 1-year period after taking into account
baseline biomedical and behavioral variables.
Finally, Blomkvist et al. (1994) followed HIV-
infected hemophiliacs longitudinally and found
that self-oriented active-optimistic coping be-
havior was related to prolonged survival after
controlling for age and CD4 counts at study
entry. Thus, there is some evidence that coping
strategies may be reliably associated with certain
immunologic and health measures in HIV-
infected persons from a variety of risk groups.
 Predicting the Health Course of HIV Infection
It should be noted that while Reed, Kemeny,
Taylor, Wang, & Visscher (1994) found that
realistic acceptance was a significant predictor
of decreased survival time in gay men diagnosed
with AIDS, Ironson et al. (1994) observed that
greater use of denial among asymptomatic HIV-
infected gay men predicted a greater likelihood
of developing symptoms or AIDS two years
later. Thus it appears that being at the extreme
end of either denial or realistic acceptance might
be dysfunctional. Kemeny refers to the realistic
acceptance factor as fatalism±acceptance, and
notes, specifically, that ªfatalistic men survived
a significantly shorter period of time when
compared to their less fatalistic counterparts.º
What is not clear is whether this variable
represents acceptance as a healthy coping style
or a predominantly negative view (pessimism)
about the future. One study may shed some light
on the notion of a balance between the extremes
of denial and acceptance. Mulder et al. (in press)
found that greater use of distraction (e.g.,
focusing on other things to take the mind off
things) predicted a slower rate of decline in CD4
cells, less appearance of syncytium-inducing
HIV variants, and less progression to immu-
nologically defined AIDS (5 200 CD4 cells
mm-3) over a 7-year period. Ironson et al. (1995)
notes that together these findings suggest that
strategies which are predictive of longevity may
involve using some distraction coupled with
staying away from the extremes of either denial
or acceptance to the point where fatalism and
rumination occurs.
8.10.3.2.6 Social support
The health promoting effects of social
support that have been most widely researched
are usually in terms of its ability to buffer the
effects of stressors (Cohen & Wills, 1985). A
person's social support network may also
influence their ability to manage, cope with,
and recover from serious illness (Dimatteo &
Hays, 1981; Taylor, Falke, Shoptaw, & Licht-
man, 1986; Wortman & Conway, 1985). Since
the 1970s there has been an enormous amount
of research undertaken studying the ability of
social networks to provide positive physical
health benefits to people (Berkman & Syme,
1979; House, Landis & Umberson, 1988; Smith,
Fernegel, Holcroft, Gerald, & Marien, 1994;
Wortman & Dunkel-Schetter, 1987). Some
findings have converged across investigations.
For instance, it appears that being involved in a
committed relationship (i.e., marriage) is asso-
ciated with greater survival time among patients
who have experienced a myocardial infarction
(Wiklund et al., 1988; Williams et al., 1992) or a
diagnosis of breast cancer (Neale, Tilley, &
257
Vernon, 1986). However, these associations
have not been replicated in other studies.
Although a growing body of evidence supports
the potential benefits of social ties in healthy
people and several chronic disease populations
(e.g., cancer patients), scientists are just begin-
ning to examine the health correlates of social
support in HIV-infected individuals.
A variety of models have been developed to
explain the ways in which social support might
provide direct influences on psychological and
physical well-being (Cohen & Wills, 1985).
Some of these direct psychological benefits may
stem from the possibilities that social support
helps people define certain stressors as being less
overwhelming, provides opportunities for peo-
ple to openly express fears, frustrations, and
other emotions, thereby decreasing ruminations
and obsessive thinking about stressors. Social
support also provides key information and
informational support provided by knowledge-
able others, which may help individuals to
assume a more realistic attitude toward life
goals. In addition, social support may help
people feel connected, which may increase their
sense of self-worth, belongingness, meaning,
purpose, and well-being. Finally, social ties may
reduce initial feelings of burden caused by the
onset of a stressor (e.g., a medical diagnosis),
allowing the person to employ active coping
strategies to deal with the stressor. Obviously,
all of these benefits of social support may be
highly salient for HIV-infected persons (Zuck-
erman & Antoni, 1995).
Some research suggests that the same me-
chanisms which provide these psychological
benefits from social support also seem to buffer
endocrine and immunologic changes associated
with stress responses (e.g., Baron, Cutrona,
Hicklin, Russell, & Lubaroff 1990; Cobb, 1974;
Esterling, Kiecolt-Glaser, & Glaser, 1996; Levy
et al., 1987). It has been hypothesized that HIV-
infected people who maintain strong support
networks may have less extreme and protracted
biological responses to stressors because SAM
and HPA-related stress hormone levels (e.g.,
peripheral catecholamines and cortisol) are
better regulated (Antoni et al., 1990). Some
work provides preliminary evidence that social
support may relate to the rate of HIV disease
progression as well. One study found that larger
social network size and greater perceived
informational social support predicted greater
survival time in HIV-infected men, but only
among those with AIDS symptoms (Patterson
et al., 1996). Other prospective studies have
found that greater social support availability
(Theorell et al., 1995) and more frequent use of
problem-focused support (Solomon, Temoshok,
O'Leary, & Zich, 1987) were predictive of a
258 HIV and AIDS
slower decline in CD4 counts and longer
survival, respectively. Another study may illu-
minate a factor underlying an HIV-infected
person's decision to enlist social support. Cole,
Kemeny, Taylor, Visscher, and Fahey (1996)
followed 80 HIV seropositive (non-AIDS,
normal levels of CD4 lymphocytes at entry)
gay men for 9 years and found that those who
concealed their sexual identity (being at least
ªhalf in the closetº) had a faster decline in CD4
counts, shorter time to AIDS diagnosis, and
shorter time to AIDS mortality than those who
did not conceal their identity. Therefore, social
support availability, decisions to utilize available
support, and identity factors that influence
decisions to make these connections may all
contribute to the course of HIV disease.
In sum, it could be hypothesized that a
mounting number of losses and grieving
experiences, which constitute prevalent life
stressors for HIV-infected individuals, might
contribute to a faster rate of disease progres-
sion. Further work suggests that maintaining
fatalistic stressor appraisals could predict short-
er survival time among men with AIDS.
Moreover, attempting to avoid dealing with
intrusive thoughts concerning future AIDS risk
was associated with greater immune system
decrements in asymptomatic HIV-positive men.
The use of coping strategies such as extreme
denial or acceptance were both associated with
an accelerated disease course, while a certain
degree of distraction (and perhaps low rumina-
tion about the disease) was associated with a
slower rate of progression. Finally, people who
remain socially isolated (and who may be the
least comfortable in approaching their support
network) appear to show the fastest progression
of disease.
8.10.3.3 Psychosocial Factors in Long-term
Survivors of AIDS
Another research strategy for establishing
salubrious psychosocial factors in HIV-infected
individuals has been to document the char-
acteristics of those who substantially ªoutliveº
their prognosis after a diagnosis of AIDS. This
research has been reviewed by Ironson and
colleagues (Ironson et al., 1995). The CDC
currently estimates median survival time after
an AIDS diagnosis (by the 1987 symptomatic
criteria) to be 18±20 months (CDC, personal
communication 1994; Eickhoff, 1994), a num-
ber that increases slowly each year as better
diagnostic and treatment options become
available. The CDC defines ªlong-term survi-
vorsº of AIDS as persons who survive twice the
median expected time. Only a few studies of the
psychosocial characteristics of long-term survi-
vors of AIDS (defined by clinical symptoms)
have been done, and as Ironson and colleagues
note, almost all of these have been cross-
sectional (Ironson et al., 1995). Ironson and her
colleagues did, however, find a good deal of
consensus on the existence of several different
psychosocial characteristics of these indivi-
duals, noting four psychosocial adjustment
strategies (Ironson et al., 1995): (i) healthy
self-care behaviors; (ii) a sense of connected-
ness; (iii) a sense of meaning and purpose; and
(iv) maintaining perspective. The first factor
included three components±±medical care, a
healthy lifestyle, and an awareness and ability to
take action to meet personal needs. The second
factor, maintaining connectedness, is closely
related to the maintenance of social support.
Having at least one confidant is part of this
factor, as is being able to communicate openly
about concerns and, for homosexuals, disclos-
ing a gay lifestyle. This is interesting in light of
the findings of Cole and colleagues (Cole et al.,
1996). The third factor, maintaining a sense of
meaning and purpose, ties into the notion of
having something to live for and, thus,
represents a cognitive appraisal factor. Ironson
and colleagues note that having an optimistic
attitude, (or conversely being low on negative
expectancies) are all a part of this. Some long-
term survivors actually report finding new
meaning as a result of being HIV-positive
(Schwartzberg, 1994). Still others find meaning
in their relationship with a higher power, or
spirituality/religion as they define it (Woods,
Antoni, Ironson, & Kling, 1996). The final
factor is maintaining perspective. A failure to
maintain perspective is represented by depres-
sion, negative affect, and hopelessness. Ironson
et al. (1995) note that accepting the reality of an
AIDS diagnosis without seeing it as an
imminent death sentence is part of this
perspective, as is believing one can live with
AIDS, realizing AIDS is episodic in nature, and
remembering that AIDS usually includes per-
iods of good health. Using selective distraction
as a coping strategy and not allowing AIDS to
become the sole focus of one's life captures the
essence of this factor. Ironson et al. (1995)
conclude that maintaining perspective is quite
close to the idea that balance is very important.
They cogently use the optimism/negative ex-
pectancies construct and the denial/acceptance
construct to point out that the extreme at either
end is probably the least functional. It remains
to be determined which psychological and
biological mechanisms might explain the ways
in which these four long-term survivor strategies
relate to health outcomes in HIV-infected
people.
 Interventions, Adjustment, and Health Course in HIV Infection
8.10.4 INTERVENTIONS, ADJUSTMENT,
AND HEALTH COURSE IN HIV
INFECTION
8.10.4.1 Health Psychosocial Interventions with
HIV-infected People
Since 1990 a small collection of studies have
examined the effects of psychosocial interven-
tions in HIV-infected populations. These stu-
dies used both psychological and immune
measures as dependent variables, although none
of them have completed long enough follow-up
periods to clearly establish a health/disease
progression effect. Most of these interventions
employ cognitive behavioral techniques and
operate in a group-based format. Comprehen-
sive reviews of the psychological effects (Ches-
ney & Folkman, 1994), and immune and health
effects (Ironson et al., 1995) of psychosocial
interventions in HIV populations are now
available.
The psychological, immune, and health
effects of psychosocial interventions in HIV-
infected individuals are summarized in Table 1.
Studies included in this table are restricted to
those that monitored intervention-related
changes in both psychological and immunologic
status. The first study to examine the effects of
stress management intervention on psychologi-
cal and immune status in HIV-infected indivi-
duals was conducted by Coates and colleagues
at the University of California at San Francisco
(Coates, McKusick, Stites, & Kuno, 1989).
They randomized 64 HIV-positive gay men to
either an 8-week stress management training
program or a control group. The intervention
consisted of systematic relaxation (with take-
home tapes), health habit education (diet, rest,
exercise, drug and alcohol use, smoking), and
skills for managing stress. While the interven-
tion appeared to change sexual behavior
(significantly fewer sexual partners), there were
no effects on enumerative or functional immune
measures. The panel of immune assays in-
cluded: CD4 cells CD4/CD8 ratio, NKCC,
lymphocyte response to con A, candida antigen
and CMV. Psychological changes in the inter-
vention or control groups were not reported
though the authors acknowledge that the
protocol they used may have been ineffective
in reducing stress.
Another study which had some positive
effects on psychosocial variables, but no effect
on CD4 cell number, was done by Auerbach and
colleagues (Auerbach, Oleson, & Soloman,
1992). Twenty-six symptomatic seropositive
gay men were randomized to an 8 week
behavioral medicine intervention, thermal bio-
feedback, guided imagery, and hypnosis, or a
259
wait-list control group. The intervention re-
duced self-reported symptoms of HIV (fever,
fatigue, pain, headache, nausea, and insomnia)
and increased vigor and hardiness relative to
controls, but did not change anxiety or
depression. The authors speculate that if they
had selected a more distressed HIV-infected
sample they may have obtained changes in
immune status variables and anxiety and
depression measures. It is also possible that
stress management interventions may work best
if the groups start out with high stress or
encounter a stressor during the course of the
intervention. The most appropriate way to
evaluate the effects of these types of interven-
tions might be to test them in the context of
either high distress states or measurable recent
or ongoing stressful events (e.g., bereavement,
diagnosis notification) and to include a com-
parison group of HIV-negative controls.
8.10.4.2 Stress Management Intervention
Effects at Different Critical Points in
HIV Infection
Some of the most well-documented behavior-
al interventions applied to HIV-infected in-
dividuals have attempted to use procedures that
reduce distress, promote self-efficacy, and
encourage the use of active coping strategies.
Operating from a chronic disease-PNI rationale
we have hypothesized that if behavioral inter-
ventions can retard or normalize declines in
immune status by bringing about these psycho-
social and behavioral changes, then they may be
able to forestall the onset of disease complica-
tions, such as opportunistic infections and
neoplasias (see Figure 1). Our group developed
a 10-week CBSM intervention for HIV infection
that was based specifically upon the psychoso-
cial sequelae that have been reviewed previously
(Antoni, Baggett et al., 1991). For some HIV-
infected people these sequelae include being
faced with a wide variety of chronic, uncontrol-
lable, and unpredictable stressors (e.g., such as
changes in health, job status, health insurance,
and medical costs) and a loss of social support
resources which is triggered by their own
withdrawal, the death of close friends, or the
responses of friends and family. These are likely
to persist across and grow in magnitude over the
course of the infection (see Hoffman, 1991).
This model reasoned that the combination of
multiple uncontrollable burdens and declining
coping resources may overwhelm HIV-infected
personsº previously adequate direct coping
strategies such as active coping, positive
appraisals of burdens, problem-solving, and
seeking social support, resulting in the adoption
of more indirect strategies such as avoidance
 Table 1 Psychosocial intervention effects in HIV infection.

Team Intervention Sample Psychosocial effect Immune effect Health

Coates, McKusick et al. 8 week stress 64 HIV-positive gay men ; number sex partners, distress ND no D CD4 ND
(1989) management vs. no no D PHA
tx. ctrl.

Auerbach et al. (1992) 8 week biofeedback 26 HIV-positive gay men : POMS vigor no D CD4 ; HIV sx.
imagery, hypnosis : hardiness no D POMS anx. dep.
vs. WLC

(i) Antoni, Baggett et al.
(1991)
(ii) Antoni, Ironson et
al. (April, 1992)
(iii) Esterling et al.
(1992)
(iv) Ironson et al. (1994)
(v) Lutgendorf et al.
(1997)
(i)±(iv) 10 week (i), (iii), & (iv) 47 HIV- (i) buffered notification POMS (i) buffered CD4 D, CD56 D, (i), (ii), (iii), &
CBSM vs. no tx. positive asymptomatic distress D & PHA D (v) ND
ctrl. men learning ab. status (i) maintained social support (ii) pre±post notification (iv) 2 year disease
(v) 10 week CBSM vs. (ii) asymptomatic HIV- (ii) ; behavioral and mental : NKCC, : PHA progression
WLC positive men disengagement (iii) ; EBV ab. ; HHV-6 ab. correlates
(v) status known 4 6 mo ; denial (v) ; HSV-2 ab. ; adherence
40 symptomatic HIV- (v) ; BDI depression (ii), (iii), & (v) no D CD4 : denial
positive non-AIDS ; POMS distress : distress
: social support, : acceptance

Mulder et al. (1994, 12 week CBSM, 12 39 HIV-positive ; POMS distress distress D, CD4 D over 2 year ND
1995) week EE vs. WLC asymptomatic gay men, ; BDI depression no D coping,
ab. status known social support emo. exp.

Ironson, Field et al., 4 week daily massage 29 (20 HIV-positive, 9 ; POMS anxiety : CD56, NKCC ND
1995 therapy vs. WLC HIV-negative) gay men : relaxation : cytotoxic cells
no D CD4

tx. = treatment; ab. = antibody; ctrl. = control; WLC = wait-list control; dep. = depression; anx. = anxiety; ND = not done; EE = existential experiential; sx. = symptoms; CD4 = T-helper cells; PHA = lymphocyte
proliferation to PHA; CD56 = natural killer cells; EBV Ab. = Epstein-Barr Virus antibodies; HHV-6 Ab. = human herpes virus type 6 antibodies; HSV-2 Ab. = herpes simplex virus type 2 antibodies; BDI = Beck Depression
Inventory; D = change in.
 Interventions, Adjustment, and Health Course in HIV Infection
and denial, on the one hand, and substance use
and possibly risky sexual behaviors on the
other. One self-defeating ªloopº that this model
highlights follows: the infected person's aware-
ness of the ineffectiveness of their coping modes
and strategies may increase their sense of low
self-efficacy, helplessness, and hopelessness,
which in turn perpetuates social isolation,
depressive symptoms, continued substance
use, and other negative health behaviors.
The intervention that was developed ad-
dresses each of these domains by enhancing self-
efficacy and perceived control, teaching adap-
tive coping strategies, and improving social
support availability, satisfaction, and utiliza-
tion (Antoni, Schneiderman & Ironson, in
press). This program teaches participants a
variety of active coping strategies (e.g., cogni-
tive restructuring, relaxation exercises, assertive
responses) and may enhance their psychological
functioning by increasing perceptions of self-
efficacy, personal control, and mastery (Fish-
man & Loscalzo, 1987); changing maladaptive
cognitive distortions (Simons, Garfield, &
Murphy, 1984); modifying stressor appraisals
and providing the person with an available
coping response (Turk, Holzman & Kerns,
1986); decreasing a sense of hopelessness (Rush,
Beck, Kovacs, Weisenberger, & Hollon, 1982);
and increasing the availability and utilization of
social support networks (Vachon, Lyall, Ro-
gers, Freedman, & Freedman, 1980).
This CBSM intervention program uses 10
weekly modules to address these aims as
follows: (i) to increase personal awareness by
providing information on sources of stress, the
nature of human stress responses, and different
coping strategies used to deal with stressors; (ii)
to teach anxiety reduction skills such as
progressive muscle relaxation and relaxing
imagery; (iii) to modify maladaptive cognitive
appraisals using cognitive restructuring; (iv) to
enhance cognitive, behavioral, and interperso-
nal coping skills through coping skills training,
assertion training, and anger management
techniques; and (v) to provide a supportive
group environment and increase utilization of
social support networks. The effectiveness of
this intervention was systematically evaluated in
different cohorts of HIV-infected persons who
were dealing with different landmark challenges
known to occur during the infection and
focused on specific ªcritical pointsº that these
HIV-infected people were passing through. The
rationale underlying this approach is that HIV
infection comprises not only a ªspectrumº of
diseases, but also a spectrum of psychosocial
challenges that change over time. At least four,
somewhat artificial, critical points can be used
to characterize these challenges: (i) responding
261
to the initial diagnosis of seropositivity; (ii)
adjustment to being infected during the early
asymptomatic period when individuals are still
healthy; (iii) adjustment to the experience of
HIV-related symptoms that are not life-threa-
tening but do impact the quality of life; and (iv)
adjustment to a diagnosis of AIDS (Lutgendorf,
Antoni, Schneiderman, & Fletcher 1994).
8.10.4.2.1 The initial HIV seropositive diagnosis
In the first set of studies, 65 gay men who did
not know their HIV serostatus were randomly
assigned to either a CBSM intervention, an
aerobic exercise intervention, or a control
group. After 5 weeks of participating in one
of these conditions, blood was drawn for
antibody testing and the men received news of
their serostatus 72 hours later. The intervention
continued for another 5 weeks (10 weeks total)
and the men were followed through the initial
ªadjustmentº period. Across the notification
period the HIV-positive controls showed sig-
nificant increases in anxiety and depression,
whereas the HIV-positive CBSM subjects
showed no significant changes in anxiety, or
depression scores (Antoni, Baggett et al., 1991).
The same buffering effect was present for the
HIV-positive men assigned to the aerobic
exercise group (LaPerriere et al., 1990). With
respect to immune findings, the HIV-positive
controls showed slight decrements in respon-
sivity to PHA, NKCC, and NK cell counts pre-
to postnotification (with no change in CD4
counts). In contrast, the HIV-positive CBSM
subjects had significant increases in CD4 and
NK cells and slight increases in PHA respon-
sivity and NKCC, thus showing a ªbufferingº
effect (Antoni, Baggett et al., 1991). Exercise
had a similar buffering effect on several immune
measures, though these are not reviewed in
detail here (see LaPerriere et al. [1990] or
LaPerriere et al. [1994]).
A 2-year follow-up of 23 HIV-positive men
recruited from these studies was conducted by
Ironson and colleagues (Ironson et al., 1994) to
determine psychological predictors of disease
progression to symptoms and death from
AIDS. They found that distress at diagnosis,
HIV-specific denial coping (5 weeks postdiag-
nosis minus prediagnosis), and low treatment
adherence (poorer attendance at either CBSM
or exercise groups, a lower frequency of
relaxation practice during the 10 weeks for
those in the CBSM, and not doing homework
for those in CBSM group) all predicted faster
disease progression. Increases in denial and
better treatment adherence remained significant
even after controlling for initial disease severity
at study entry (CD4 number). Furthermore,
262 HIV and AIDS
decreases in denial and a greater frequency of
relaxation home practice during the 10-week
intervention period were predictive of higher
CD4 cell counts and greater blastogenic
responses to PHA at 1 year follow-up (Ironson
et al., 1994). These findings suggest that those
men who attended intervention sessions reg-
ularly, and dealt with their denial during the
intervention period, were most likely to show
longer term immune and health benefits.
There were also several consistent immune
changes noted over the total 10 week period of
intervention. The CBSM (and exercise) inter-
ventions were associated with a significant
decrease in antibody titers to EBV-VCA and
to HHV-6 as compared to assessment-only
controls, whose antibody titers remained con-
stant over the 10-week intervention period and
elevated relative to healthy male laboratory
controls (Esterling et al., 1992). An analysis of
other psychosocial changes revealed that men in
the control group showed significant decre-
ments in social support during the postnotifica-
tion period, whereas those in the CBSM group
maintained their social support levels (Fried-
man et al., 1991). We also found that pre±
postintervention decrements in social support
were associated with greater declines in NKCC
over a similar period (Antoni, Ironson et al.,
1992) and that the reductions in EBV antibody
titers during this period appeared to be
mediated by increases in social support (Antoni
et al., 1996).
8.10.4.2.2 The asymptomatic stage of HIV
infection
Even asymptomatic HIV disease is accom-
panied by wide-ranging psychosocial challenges
including the many uncertainties with regard to
future health course and available resources.
The former arises due to the unpredictable
physical course of the HIV infection and the
latter as a function of uncontrollable stressors
such as impaired occupational and social
functioning, decreased earning power, high
costs of medical care, complex medical treat-
ments, difficulties with self-care, multiple
bereavements, and declining social supports
(Blendon & Donelan, 1988; Ginzburg & Gostin,
1986; Redfield & Burke, 1988; Walkey et al.,
1990).
The effects of CBSM intervention have been
examined with gay men who knew of their HIV-
positive status for at least 6 months, but were
still asymptomatic. Although their physical
functioning had not yet been affected by the
virus, knowledge of their positive serostatus,
and its eventual implications, had affected their
lifestyle, behaviors, and sense of well-being.
Elsewhere the types of issues that these men
were reporting have been described in greater
detail (Lutgendorf, Antoni, Schneiderman,
Ironson et al., 1994). Some issues included
reluctance to terminate relationships, hesitating
to have sex with someone who was uninfected
for fear of infecting them, deciding to disclose
HIV status to family members, and making job
and career transitions. The predominant emo-
tional experiences reported by these men
included anger, fear, loss, and uncertainty.
The 10-week CBSM intervention developed
for these asymptomatic men was specifically
adapted to address these issues (Antoni,
Ironson et al., 1992). The early part of the
intervention maintained its psychoeducational
focus, with sessions on HIV and the stress
response, cognitive appraisals, refuting, and
replacing cognitive distortions. For this cohort,
the group sessions discussing impending noti-
fication and postnotification concerns were
replaced with a session dealing with unfinished
issues related to seropositivity notification and
notification of others regarding one's seropo-
sitivity. Behavior change, assertiveness, and
social support were addressed extensively in
these group sessions, especially strategies for
eliciting social support. From a sample of 23
men, 11 were randomized to CBSM and 12 to an
aerobic exercise program, each lasting 10 weeks.
Because this was a pilot study there was no
control condition. Participants in CBSM sig-
nificantly reduced their anxiety, depression,
anger, fatigue, and confusion levels, as well as
increasing feelings of vigor (Antoni, Ironson
et al., 1992). They also reported increased use of
adaptive coping strategies, active coping, plan-
ning, and acceptance, and decreases in several
maladaptive coping strategies such as mental
disengagement and denial. These individuals
also revealed significant increases in blastogenic
responses to PHA and NKCC.
Other groups have also reported significant
reductions in distress (Chesney et al., 1996a,
1996b; Kelly et al., 1993; Mulder et al., 1994)
and improvements in self-efficacy (Chesney
et al., 1996a, 1996b) with cognitive behavioral
interventions in asymptomatic HIV-infected
men. Kelly and colleagues randomized partici-
pants to either cognitive-behavioral group
intervention, social support group intervention,
or no-treatment, and found significant reduc-
tions in depression, hostility, and somatization
in the cognitive-behavioral groups, as well as the
social support group, compared to controls.
The cognitive-behavioral group was somewhat
more effective at reducing drug use (Kelly et al.,
1993). Mulder and colleagues compared
cognitive-behavioral group intervention and
existential experiential group intervention in
 Interventions, Adjustment, and Health Course in HIV Infection
HIV-infected gay men and found that both
groups reduced distress and depressive symp-
toms compared with a wait-list control condi-
tion (Mulder et al., 1994). Finally, Chesney et al,
compared the effects of a CBSM group
intervention (Coping Effectiveness Training
(CET)) (Chesney et al., 1994; Folkman et al.,
1991) with an information group and a wait-list
control group, and found that CET significantly
increased self-efficacy and decreased perceived
stress and burnout compared to the other two
conditions (Chesney et al., 1996a, 1996b).
8.10.4.2.3 The pre-AIDS symptomatic stage of
HIV infection
The effects of a group-based CBSM inter-
vention have also been evaluated in HIV-
positive gay men who are dealing with the
symptoms of the infection. Forty HIV-infected
gay men who had mild symptoms (category B of
the 1993 CDC definition) were randomly
assigned to either the CBSM intervention or a
modified wait-list control group in which they
complete a 10 week waiting period before being
reassessed and provided a one day CBSM
seminar. Across the 10 weeks the CBSM group
showed a significant decrease in depression,
anxiety, and antibody titers to HSV-2 (Lutgen-
dorf, Antoni, Ironson, Klimas et al., 1997).
Moreover, the 10 week decreases in HSV-2
antibody titers were strongly associated with the
degree to which participants lowered their
depression scores on the Beck Depression
Inventory (BDI; Beck, Ward, Mendelson,
Mock, & Erbaugh, 1961) over this period.
The control group showed no such changes in
depressive symptoms or antibodies to HSV-2.
Subsequently, conducted path analyses revealed
that the effects of CBSM on HSV-2 antibody
reductions appeared to be mediated by the
intervention-associated depression changes
(Antoni et al., 1996). Since this structured
intervention was designed to increase cognitive
and behavioral coping skills and support among
group members, we next examined the relative
contribution of intervention-related changes in
coping skills and social support to reductions in
dysphoria, anxiety, and distress-related symp-
toms over the study period. Those randomized
to CBSM showed significant improvement in
cognitive coping strategies, such as positive
reframing and acceptance, as well as in total
perceived social support provisions compared
to a wait-list control condition (Lutgendorf
et al., 1996). Cognitive coping changes, speci-
fically acceptance of the HIV infection, were
strongly related to lower dysphoria, anxiety,
and total mood disturbance in this sample. Path
analyses suggested that changes in social
263
support, and in cognitive coping strategies,
appear to mediate the effects of the CBSM
intervention on the changes in distress noted
during the intervention. These results suggest
that cognitive coping strategies and social
support factors can be modified by psychosocial
interventions. These changes may in turn be
important determinants of psychological well-
being and quality of life during symptomatic
HIV infection.
8.10.4.2.4 Full-blown AIDS
To date, the bulk of the published empirical
studies evaluating the efficacy of psychosocial
interventions with HIV-infected people have
focused on gay men at the earlier stages of the
infection. While there is a growing literature
documenting those psychosocial factors that are
predictive of both psychological adjustment and
physical health course in AIDS patients (e.g.,
long-term survivor literature reviewed in Ir-
onson et al. [1995]), little or no work exists
testing the effects of various interventions with
patients who have progressed to AIDS. What
we do know is that the onset of AIDS may be
accompanied by a lessening of psychological
distress from the levels experienced by sympto-
matic (pre-AIDS) HIV-infected men (Dilley
et al., 1985; Tross & Hirsch, 1988). This may
reflect a relief from the unpredictability of not
knowing if and when the first signs of AIDS
may occur.
With the steady progression of HIV infection
to more and more serious symptoms, and
eventually AIDS, individuals go through a
continual process of emotional crises, recycling
through the stages that Kubler-Ross (1969)
originally noted as comprising the dying process
(Lutgendorf, Antoni, Schneiderman, & Fletch-
er, 1994). Moreover, HIV-infected patients may
have emotional reactions that are more intense
and labile than those described by Kubler-Ross
(Hoffman, 1991). The high percentage of HIV-
infected individuals diagnosed with adjustment
disorders is a testimony to the difficulties
encountered as these people try to come to
terms with their illness and its impact on their
lives (Hoffman, 1991). While it is clear that these
individuals are in need of psychosocial services,
one must be cautious in applying what has been
learned from asymptomatic and early-stage
populations to those with AIDS. There is a lack
of empirical studies evaluating the effectiveness
of psychosocial interventions such as CBSM or
other approaches such as Expressive Supportive
therapy conducted in a group or individual-
based format with individuals at this stage of the
infection. It may be that those with AIDS may
find structured CBSM techniques useful, but
264 HIV and AIDS
may also require additional emotional support.
For these individuals a therapeutic plan that
combines a group-based stress reduction inter-
vention with individual-based therapy directed
toward these existential issues may be very
useful. An optimal therapy plan may also
involve pharmacologic treatment blended with
the psychosocial intervention.
8.10.4.3 Common Features of Psychosocial
Interventions in HIV Infection
8.10.4.3.1 Relaxation aspects
It is noteworthy that many of the psychoso-
cial intervention studies with HIV-infected
persons have utilized some form of relaxation-
based technique as part of the intervention
protocol. This is relevant given the great deal of
distress and anxiety that these people experi-
ence. Relaxation strategies are also salient given
the reasonably large literature base relating
relaxation to improvement in immune system
functioning (e.g., Ironson et al., 1995; Kiecolt-
Glaser et al., 1985, 1986). With regard to HIV
infection, one of these studies found that
frequency of home relaxation practice was
related to better immunological functioning
and slower disease progression in HIV-infected
men (Ironson et al., 1994).
Another study examined alternate ways of
inducing relaxation in HIV-infected individuals
(Ironson et al., 1996)Ðmassage therapyÐ
because of its expected relaxing effects, and
because it is easy to monitor objectively how
much massage someone is getting. HIV-infected
gay men showed a significant increase in NK
cell number, NKCC, the soluble CD8 receptor,
and the cytotoxic subset of CD8 cells during the
weeks of daily massage intervention compared
to the same men's values during a no-massage
period. These men also showed significant
decreases in 24 hour urinary cortisol output
during the intervention period, suggesting that
distress decreases and/or relaxation increases
may have mediated these immunologic changes.
Indeed, significant decreases in anxiety and
increases in a sense of relaxation were also
observed, which were both correlated with
increases in NK cell number. This study
suggests that the relaxation components of
CBSM interventions noted previously may
contribute directly to both the psychological
and immunologic changes experienced by the
participants. Psychosocial interventions used
with HIV-infected persons use many other
techniques in addition to relaxation and also
vary considerably in terms of format and
theoretical orientation. It is possible to examine
some of the parameters on which these
approaches converge and diverge.
8.10.4.3.2 Delivery format
Regarding delivery format, it is important to
note that most of the psychosocial interventions
evaluated with HIV-infected persons (including
those involving aerobic exercise training [La-
Perriere et al., 1990]) have been conducted in a
group format (Ironson et al., 1995). These
CBSM interventions typically employed groups
of approximately 6±8 participants facilitated by
two group leaders. The sessions were conducted
in comfortable rooms, ran about 2±2.5 hours in
duration, and ran on a weekly basis over a 10-
week period. While there was some variability in
terms of the duration of programs evaluated
across different research groups (range = 8±12
weeks), the number of participants, group
leaders, and session length and frequency were
quite similar. Because of the fact that these
sessions were conducted in a group format, little
is known about the effects of these sorts of
techniques with HIV-infected persons when
delivered as individual-based psychotherapy
sessions or self-help approaches.
8.10.4.3.3 Treatment orientation
Different treatment orientations to psycho-
social interventions have been compared in
HIV-infected persons by one group in the
Netherlands (in collaboration with the Uni-
versity of Miami). They examined the influence
of treatment orientation by comparing the
psychological (Mulder et al., 1994) and im-
munologic (Mulder, Antoni, Emmelkamp et al.,
1995) effects of one group-based intervention
using a cognitive-behavioral orientation vs. one
using an existential/experiential orientation in
HIV-infected gay men. These men were re-
cruited from a large cohort study conducted
through the Amsterdam Municipal Health
Center. The cognitive-behavioral therapy
(CBT) intervention included training in cogni-
tive restructuring, relaxation exercises, behavior
change, assertiveness skills, coping fit for
controllable vs. uncontrollable stressors, and
information on stress responses. As such, it was
quite similar to the CBSM interventions
described previously. The experiential therapy
(ET) condition was less structured and focused
on increasing awareness of the here and now, of
their inner experiential process, and restoring
congruence between emotional, cognitive, and
behavioral schemata. The intervention also
attempted to help participants deal with a
shortened life perspective and anxiety about
future illness and death. Despite the differences
in theoretical orientation the authors note that
both interventions were designed to reduce
stress, improve coping, build social support,
 Interventions, Adjustment, and Health Course in HIV Infection
and encourage emotional expression. They
found that both (CBT and ET) conditions were
associated with significant decreases in POMS
total mood disturbance, and BDI scores
compared to the controls, though there were
no changes in coping style, social support, or
emotional expression over the intervention
period.
Mulder and colleagues compared the 26 men
randomized ultimately to either CBT or ET with
men from the Amsterdam cohort study who did
not participate in the intervention study for
differences in slope of immune changes that had
occurred over the period after the intervention
(Mulder, Antoni, Emmelkamp et al., 1995).
Those intervention group participants with the
largest decreases in distress, between the begin-
ning of either intervention and 9 months later,
showed the least decline in CD4 cell counts over
a 2-year follow-up period from the beginning of
the intervention. These findings suggest that
while theoretical orientation may not determine
the psychological improvements gained by
HIV-infected men participating in group-based
psychosocial interventions, the size of
treatment-related reductions in distress may
be predictive of longer-term health benefits.
This interpretation seems to be in line with the
findings reviewed previously (Antoni, Baggett
et al. [1991] for short-term effects and Ironson
et al. [1994] for longer-term effects).
8.10.4.4 Summary of Completed Studies of
Psychosocial Interventions with HIV-
infected Persons
Here we summarized the qualities character-
izing the psychosocial intervention studies with
HIV-infected individuals that were completed
between 1989 and 1997. These studies recruited
moderate sized samples that were approxi-
mately equally distributed across experimental
conditions usually resulting in 10±30 people
actually receiving the intervention in any single
trial. While individuals participating in these
studies were all gay or bisexual men, congruent
with the predominant AIDS incidence patterns
occurring in the 1980s, it should be noted that
women now make up nearly 15% of all AIDS
cases and current incidence patterns for HIV
infection suggest that this proportion will
increase. Therefore, these studies need to be
replicated with other HIV-infected populations
such as indigent women.
Of the interventions tested to date, most were
conducted in groups, used trained facilitators or
therapists, and met at least once weekly over
periods of 8±12 weeks. Since the studies
evaluating these interventions were designed
to test their immediate efficacy, cohorts were
265
typically assessed at single time points at the
beginning and end of the intervention period. At
least two studies followed subjects over a 2-year
postintervention period (Ironson et al., 1994;
Mulder et al., 1995).
While the results of this set of studies are not
entirely consistent, they suggest the potential
efficacy of psychosocial interventions for in-
creasing psychological adjustment, immune
functioning, and health status in HIV-infected
people at early and middle stages of the disease
who are dealing with mounting stressors. Less is
known about the effects of these interventions
with people at the more advanced stages of the
disease. One study focused specifically on how a
time-limited CBSM intervention could moder-
ate the acute impact of learning one's HIV
serostatus for the first time (Antoni, Baggett
et al., 1991), while the remainder have examined
how psychosocial interventions can improve
psychological functioning in people dealing
with the more chronic stress of having had
HIV for a number of years (Auerbach et al.,
1992; Coates, McKusick et al., 1989; Ironson
et al., 1995; Mulder et al., 1994). The most
consistent trends among the psychological
effects of these interventions are: a decrease in
distress and depressed affect; a decrease in the
use of avoidance and denial as coping strategies;
an increase in the use of acceptance and positive
reframing strategies; and an increase or main-
tenance of social support provisions.
While CBSM intervention has been shown to
reduce antibodies to herpes viruses and to
modulate NKCC, no direct effects have been
observed on HIV disease progression markers.
Three group-based stress management inter-
ventions reported no significant impact on CD4
cell counts (Auerbach et al., 1992; Coates,
McKusick et al., 1989; Mulder, Antoni, Em-
melkamp et al., 1995), but none of these
measured herpes virus antibodies or NKCC,
which were the measures found to be most
responsive to change in some of the other
studies (Esterling et al., 1992; Ironson et al.,
1996; Lutgendorf, Antoni, Schneiderman, &
Fletcher, 1994). Ironson et al. (1995) note that
no studies have tested the long-term effects of
these interventions on 5- or 10-year survival,
although one study with a small sample showed
that intervention-related variables (denial cop-
ing reductions and greater treatment adherence)
were predictive of 2-year survival (Ironson et al.,
1994). Another study (Mulder, Antoni, Em-
melkamp et al., 1995) showed distress changes
(which can often be modified by psychosocial
interventions) were related to changes in CD4
counts over a similar 2-year period. However, it
should be noted that ªassignment to a psycho-
social interventionº has not been causally
266 HIV and AIDS
related to a slower rate of disease progression or
greater survival time in HIV-infected persons.
This lack of a causal effect may be due to the
limited statistical power offered by the small
samples that have been studied to date. Clinical
trials that utilize hundreds of participants may
be necessary to capture the effects of psycho-
social interventions on the health course of this
disease. It is also possible that measures of
immune function might be more sensitive to the
effects of stress-reducing psychosocial interven-
tions than lymphocyte counts because stress
hormone interactions with receptors that med-
iate cell activity and certain immune functional
indices may be especially relevant to the
pathophysiology of HIV infection in particular.
Finally, it has been suggested that health
psychology interventions possessing cognitive
and behavioral elements, similar to those just
noted, may be quite useful in addressing other
aspects of HIV infection, such as nutritional
disorders, pain, sleep problems, and medication
adherence, all having a potentially huge impact
on the quality of life of infected individuals
(Sikkema & Kelly, 1996). It will be important to
incorporate these additional variables into
intervention protocols conducted in the future
as more and more people live longer and longer
with this disease.
8.10.5 CONCLUSION
This chapter has summarized the rationale
and empirical support for the role of health
psychology in the context of HIV infection and
AIDS. Based on this work it is plausible to
suggest that psychosocial targets of interven-
tions should include reductions in distress and
depression, as well as avoidance, denial, and
rumination as methods of dealing with the
chronic stress of the infection. Equally impor-
tant intervention targets would involve increas-
ing active coping and a sense of social
attachment as important stress buffers. Several
studies are underway which further examine the
effects of psychosocial interventions on psy-
chological adjustment, immune status, and
disease course in HIV-infected individuals.
There are several reasons to be encouraged by
the trends that are apparent across ongoing
investigations of psychosocial interventions in
HIV-infected populations.
First, all of the studies use standardized time-
limited interventions (10±17 weeks) that have
been ªmanualizedº with specific treatment
modules and criteria for therapist training
and implementation (e.g., Antoni, Schneider-
man, & Ironson, in press). In some cases these
interventions follow a CBSM orientation and in
others a more experiential-existential approach
is utilized while, in others, CBSM and experi-
ential techniques have been integrated into the
same intervention condition. The efficacy of
these different treatment orientations may
ultimately be shown to vary systematically as
a function of the disease stage and demographic
characteristics of the targeted population.
Second, these investigations are each recruit-
ing people who meet specific inclusion and
exclusion criteria that are similar across studies.
Specifically, the samples are largely gay men at
the early to middle stages of the infection (pre-
AIDS symptoms and a restricted range of CD4
counts) who are dealing with similar psychoso-
cial issues. Shifting demographic patterns of the
HIV/AIDS epidemic make it imperative to
develop techniques to help other HIV-infected
populations, such as women of color, manage
their disease. One study, led by Antoni, Green-
wood, and Schneiderman in Miami, is examin-
ing the effects of a 10-week CBSM intervention
in HIV-infected African-American women who
are developing the first symptoms of the
infection. Another trial is evaluating the effects
of a similar intervention in women who have
already developed AIDS. Clearly, a next step is
to develop psychosocial interventions to address
secondary prevention issues in the growing
number of HIV-infected injection drug users.
Third, each study is assessing the psychoso-
cial effects of these interventions with a
collection of well-validated instruments de-
signed to track changes in distress and depres-
sion as well as intermediary psychosocial
variables such as coping, social support, and
stressor appraisals. In most cases, the most
reliable instruments have been employed in
these batteries supplemented with more specific
measures designed to tap the most salient areas
of participantsº lives.
Fourth, most of these studies currently being
done reflect an excellent breadth of immuno-
logic measures (including qualitative and quan-
titative indices). For instance, several studies are
now assessing the effects of psychosocial
interventions on NKCC and blastogenic re-
sponses to PHA. Several studies are also
examining changes in IgG antibody titers to a
panel of relevant herpes viruses (e.g., EBV,
HHV-6, CMV, HSV) and assessing serum
neopterin as a subclinical disease progression
marker. In the future it is likely that assessments
of HIV viral load will join this list of assays as a
way to monitor treatment-related changes in
disease status. It is also imperative that more
disease- and antigen-specific immunologic mea-
sures be incorporated into assessment protocols
to better understand specific pathophysiologic
links between psychological changes and health
course.
 References
Fifth, all of the studies are tracking the effects
of their interventions on clinical health changes
using standardized staging procedures and
criteria (Centers for Disease Control, 1993).
Due to the relatively large sample sizes, these
studies should be able to assess long-term effects
on survival. All of these studies are also
monitoring changes in several other behavioral
measures such as sexual behaviors, substance
use, physical activities, sleep, and medications.
Information about changes in these additional
measures, over the course of the interventions,
may be useful for clarifying the mechanisms
underlying treatment changes in affective,
immunologic, and health endpoints, as well as
representing important quality of life changes
that may be likely to occur following participa-
tion in psychosocial interventions. Once com-
pleted these studies may provide efficacy data
supporting the initiation of larger clinical trials
as well as informing behavioral scientists about
the psychosocial mechanisms underlying psy-
chological adjustment, physiological function-
ing, and health preservation in this chronic
disease.
Sixth, the arrival of protease inhibitors and
triple combination therapies to the treatment
arena has brought about important improve-
ments in the health care of AIDS patients
(Lewin, 1996; Schneiderman et al., 1997). The
resulting treatment philosophy for HIV and
AIDS increasingly views HIV infection as a
chronic disease in which patient management is
critical. It is quite reasonable to propose that
psychosocial interventions can be an essential
part of this management (Schneiderman et al.,
1997). The key here is consistent adherence to a
demanding medication schedule in the context
of an already stressful daily existence. We now
know, for example, that once patients are given
protease inhibitors, medication protocols must
be rigidly followed with respect to drug
schedules and food intake or the virus may
mutate and become drug resistant (Lewin,
1996). Failure to adhere to specific guidelines
cannot only compromise the effects of the
particular protease inhibitor being used, but can
also reduce the efficacy of other related
compounds to which cross-resistance has devel-
oped (Lewin, 1996). Psychosocial interventions
that provide information, skills, and support to
patients can facilitate adherence to difficult
medication protocols. Since interventions such
as CBSM can decrease denial and depressed
affect, they may, in turn, decrease negative
health behaviors and facilitate adherence to
medical treatment regimens. It has been shown
that better adherence to a stress management
protocol is predictive of a slower rate of disease
progression (Ironson et al., 1994). The improve-
267
ments in immune function that have been
associated with these psychosocial interventions
raise the interesting question of whether CBSM
can help reconstitute the compromised immune
system once pharmacologic agents such as
protease inhibitors have contained the virus.
These latter questions constitute the focus of the
ongoing work using health psychology strate-
gies to address contemporary secondary pre-
vention issues in the growing populations of
HIV-infected persons who are attempting to
manage their disease.
8.10.6 REFERENCES
Aboulker, J. P., & Swart, A. M. (1993). Preliminary
analysis of the Concorde trial. Lancet, 341, 889±890.
Amsterdam, J. D., Lucki, I., & Winokur, A. (1985). The
ACTH stimulation test in depression. Psychiatric Med-
icine, 3, 91±100.
Amsterdam, J. D., Maislin, G., Gold, P., & Winokur, A.
(1989). The assessment of abnormalities in hormonal
responsiveness at multiple levels of the hypothalamic±
pituitary±adrenocortical axis in depressive illness. Psy-
choneuroendocrinology, 14, 43±62.
Antoni, M. H. (1991). Psychosocial stressors and stress
management with HIV-1 seropositive and seronegative
gay men, International Reviews in Psychiatry, 3, 385±402.
Antoni, M. H., August, S., LaPerriere, A., Baggett, H. L.,
Klimas, N., Ironson, G., Schneiderman, N., & Fletcher,
M. A. (1990). Psychological and neuroendocrine mea-
sures related to functional immune changes in anticipa-
tion of HIV-1 serostatus notification. Psychosomatic
Medicine, 52, 496±510.
Antoni, M. H., Baggett, L., Ironson, G., August, S.,
LaPerriere, A., Klimas, N., Schneiderman, N., &
Fletcher, M. A. (1991). Cognitive behavioral stress
management intervention buffers, distress responses,
and immunologic changes following notification of
HIV-1 seropositivity. Journal of Consulting and Clinical
Psychology, 59, 906±915.
Antoni, M. H., Esterling, B., Lutgendorf, S., Fletcher, M.
A., & Schneiderman, N. (1995). Psychosocial stressors,
herpes virus reactivation and HIV-1 infection. In M.
Stein & A. Baum (Eds.), Chronic disease: Perspectives in
behavioral medicine. Hillsdale, NJ: Erlbaum.
Antoni, M. H., Goldstein, D., Ironson, G., LaPerriere, A.,
Fletcher, M. A., & Schneiderman, N. (1995a). Coping
responses to HIV-1 serostatus notification predict
concurrent and prospective immunologic status. Clinical
Psychology and Psychotherapy, 2(4), 234±248.
Antoni, M. H., & Goodkin, K. (1996). Cervical neoplasia,
human papilloma virus, and psychoneuroimmunology.
In H. Friedman et al. (Eds.), Psychoneuroimmunology
and infectious disease (pp. 243±262). Boca Raton, FL:
CRC Press.
Antoni, M. H., Goodkin, K., Goldstein, V., LaPerriere, A.,
Ironson, G., Fletcher, M. & Schneiderman, N. (1991).
Coping responses to HIV-1 serostatus notification
predict short-term affective distress and one-year im-
munologic status in HIV-1 seronegative and seropositive
gay men. Psychosomatic Medicine, 53, 227.
Antoni, M. H., Ironson, G., Helder, L., Lutgendorf, S.,
Friedman, A., LaPerriere, A., Fletcher, M. A. &
Schneiderman, N. (1992, April). Stress management
intervention reduces social isolation and maladaptive coping
behaviors in gay men adjusting to an HIV-1 seropositive
diagnosis. Paper presented at the scientific meeting of the
Society of Behavioral Medicine, New York.
268 HIV and AIDS
Antoni, M. H., Lutgendorf, S., Ironson, G., Fletcher, M.
A., & Schneiderman, N. (1996). CBSM intervention
effects on social support, coping, depression, and
immune function in symptomatic HIV-infected men.
Psychosomatic Medicine, 58, 86.
Antoni, M. H., Rodriguez, M., Starr, K., et al. (1991,
August). Neuroendocrine and immunologic reactivity to
behavioral challenge in HIV-infected gay men. Paper
presented at the American Psychological Association,
San Francisco, CA.
Antoni, M. H., Schneiderman, N., Fletcher, M. A.,
Goldstein, D., Ironson, G., & LaPerriere, A. (1990)
Psychoneuroimmunology and HIV-1. Journal of Con-
sulting and Clinical Psychology, 58, 38±49.
Antoni, M. H., Schneiderman, N., & Ironson, G. (in press).
Stress management for HIV-infection. Society of Beha-
vioral Medicine Clinical Research Guidebook Series.
Antoni, M. H., Schneiderman, N., LaPerriere, A., O'Sulli-
van, M. J., Marks, J., Efantis, J, Skyler, J., & Fletcher,
M. A. (1992). Mothers with AIDS. In P. Ahmed (Ed.),
Living and dying with AIDS. NJ: Plenum.
Arnetz, B. B., Wasserman, J., Petrini, B., Brenner, S. O.,
Levi, L., Eneroth, P., Salovaara, H. K., Hjelm, R.,
Salovaara, L., Theorell, T., et al. (1987). Immune
function in unemployed women. Psychosomatic Medi-
cine, 49, 3±12.
Atkinson, J., Sullivan, T., Kelly, J., et al. (1977).
Stimulation by alcohols and cyclic AMP metabolism in
human leukocytes. Journal of Clinical Investigation, 6,
284.
Auerbach, J. E., Oleson, T. D., & Solomon, G. F. (1992). A
behavioral medicine intervention as an adjunctive treat-
ment for HIV-related illness. Psychology and Health, 6,
325±334.
Axelrod, J., & Reisine, T. (1984). Stress hormones: their
interaction and regulation. Science, 224, 452±459.
Bancroft, G., Shellam, G., & Chalmer, J. (1981). Genetic
influences on the augmentation of natural killer cells
(NK) during murine cytomegalovirus infection: correla-
tion with patterns of resistance. Journal of Immunology,
126, 988±994.
Baron, R. S., Cutrona, C. E., Hicklin, D., Russell, D. W.,
& Lubaroff, D. M. (1990). Social support and immune
function among spouses of cancer patients. Journal of
Personality and Social Psychology, 59, 344±352.
Bartrop, R., Lazarus, L., Luckhurst, E., Kiloh, L., &
Penny, R. (1977). Depressed lymphocyte function after
bereavement. Lancet, i, 834±836.
Baum, M. K., Mantero-Atienza, E., Shor-Posner, G.,
Fletcher, M. A., Morgan, R., Eisdorfer, C., Sauberlich,
H. E., Cornwell, P. E., & Beach, R. S. (1991).
Association of vitamin B6 status with parameters of
immune function in early HIV-1 infection. Journal of
Acquired Immune Deficiency Syndrome, 4, 1122±1132.
Beck, A. I., Ward, C. H., Mendelson, M., Mock, J., &
Erbaugh (1961). An inventory for measuring depression.
Archives of General Psychiatry, 4, 561±571.
Beckett, A., & Rutan, J. S. (1990). Treating persons with
ARC and AIDS in group psychotherapy. International
Journal of Group Psychotherapy, 40, 19±29.
Beckman, L. (1980). Perceived antecedents and effects of
alcohol consumption in women. Journal of Studies of
Alcohol, 41, 518.
Benschop, R. J., Nieuwenhuis, E. E., Tromp, E. A.,
Godaert, G. L., Ballieux, R. E., & van Doornen, L. J.
(1994). Effects of b-adrenergic blockade on immunologic
and cardiovascular changes induced by mental stress.
Circulation, 89, 762±769.
Berkman, L., & Syme, S. (1979). Social networks, host
resistance, and mortality: A nine-year follow-up study of
Alameda County residents. American Journal of Epide-
miology, 109, 186±204.
Biegalke, B. J., & Geballe, A. P. (1991). Sequence
requirements of reactivation of the HIV-1 LTR by
human cytomegalovirus. Virology, 183, 381±385.
Billings, A., & Moos, R. (1981). The role of coping
responses and social resources in attenuating the stress of
life events. Journal of Behavioral Medicine, 4, 139±157.
Biron, C. A., Byron, K., & Sullivan, J. (1989). Severe
herpes virus infections in an adolescent without natural
killer cells. New England Journal of Medicine, 320,
1731±1735.
Blaney, N. (1985). Smoking: Psychophysiological causes
and treatment. In N. Schneiderman & J. Tapp (Eds.),
Behavioral medicine: The biopsychosocial approach
(pp. 347±377). Hillsdale, NJ: Erlbaum.
Blendon, R. J., & Donelan, K. (1988). Discrimination
against people with AIDS: The public's perspective. New
England Journal of Medicine, 319, 1022±1026.
Blomkvist, V., Theorell, T., Jonsson, H., et al. (1994).
Psychosocial self-prognosis in relation to mortality and
morbidity in hemophiliacs with HIV infection. Psy-
chother Psychosom, 62, 185±192.
Bloom, D. E. (1982). Social support, accommodation to
stress and adjustment to breast cancer. Social Science
and Medicine, 16, 1329±1338.
Bloom, D. E. & Carliner, G. (1988). The economic impact
of AIDS in the United States. Science, 239, 604±610.
Blumberg, R., Kelsey, P., Perrone, T., et al. (1984).
Cytomegalovirus-associated and cryptosporidium-asso-
ciated acalculous gangrenous cholecystis. American
Journal of Medicine, 76, 1118±1123.
Bonelli, J. (1982). Stress, catecholamines, and beta-block-
ade. Acta Medical Scandinavia, 660, 214±218.
Borysenko, M., & Borysenko, J. (1982). Stress, behavior,
and immunity: Animal models and mediating mechan-
isms. General Hospital Psychiatry, 4, 59±67.
Buckingham, S., & Rehm, S. (1987, Winter). AIDS and
women at risk. Health and Social Work, 12, 5±11.
Bukowski, J., Warner, J., Dennert, G. & Welsh, R. (1985).
Adoptive transfer studies demonstrating the antiviral
effect of natural killer cells in vivo. Journal of Experi-
mental Medicine, 161, 40±52.
Burack, J. H., Barrett, D. C., Stall, R. D., Chesney, M. A.,
Ekstrand, M. L., & Coates, T. J. (1993). Depressive
symptoms and CD4 lymphocyte decline among HIV-
infected men. Journal of the American Medical Associa-
tion, 270, 2568±2573.
Burns, D. N., Kramer, A., Yellin, F., Fuchs, D., Wachter,
H., DiGioia, R. A., Sanchez, W. C., Grossman, R. J.,
Gordin, F. M., Biggar, R. J., & Goedert, J. J. (1991).
Cigarette smoking: A modifier of Human Immunodefi-
ciency Virus Type 1 infection? Journal of Acquired
Immune Deficiency Syndromes, 4, 76±83.
Calabrese, J., Kling, M., & Gold, P. (1987). Alterations in
immunocompetence during stress, bereavement, and
depression: Focus on neuroendocrine regulation. Amer-
ican Journal of Psychiatry, 14, 1123±1134.
Carbonari, M., Fiorilli, M., Mezzaroma, I., Cherchi, M., &
Aiuti, F. (1989). CD4 as the receptor for retroviruses of
the HTLV family: Immunopathogenetic implications.
Advances in Experimental Medicine and Biology, 257, 3±7.
Carpenter, C., Mayer, K., Fisher, A., Desai, M., &
Durand, L. (1989). Natural history of acquired immu-
nodeficiency syndrome in women in Rhode Island.
American Journal of Medicine, 86, 771±775.
Catania, J., Coates, T., Stall, R., Bye, L., Kegeles, S.,
Capell, F., Henne, J., McKusick, L., Morin, S., Turner,
H., & Pollack, L. (1991). Changes in condom use among
homosexual men in San Francisco. Health Psychology,
10, 190±199.
Centers for Disease Control (1993). Revised classification
system for HIV infection and expanded surveillance case
definition for AIDS among adolescents and adults.
Morbidity and Mortality Weekly Report, RR17, 1±19.
Centers for Disease Control (1995a). CDC: Update: AIDS
 References
among womenÐUnited States 1994. Journal of the
American Medical Association, 273(10), 767.
Centers for Disease Control (1995b). HIV/AIDS Surveil-
lance Report, 7(2).
Chesney, M. A., & Folkman, S. (1994). Psychological
impact of HIV disease and implications for intervention.
Psychiatric Clinics of North America, 17, 163±182.
Chesney, M. A., Folkman, S., & Chambers, D. (1996a).
Coping effectiveness training for men living with HIV:
Preliminary findings. International Journal of STDs and
AIDS, 7(Suppl. 2), 75±82.
Chesney, M. A., Folkman, S., & Chambers, D. (1996b).
The impact of a cognitive-behavioral intervention on
coping with HIV disease. Psychosomatic Medicine, 58,
86.
Chiapelli, F., Ben-Eliyahu, S., Hanson, L., & Wylie, T.
(1992). Modulation of immune surveillance of HIV-
related cancers by alcohol and cocaine metabolites.
Alcologia, 4, 219±227.
Christ, G., & Weiner, L. (1985). Psychosocial issues for
AIDS. In V. Devita, Jr., S. Hellman, & S. Rosenberg
(Eds.), AIDS (pp. 275±297). Philadelphia: Lippincott.
Chuang, H. T., Devins, G. M., Hunsley, J., & Gill, M. J.
(1989). Psychosocial distress and well-being among gay
and bisexual men with human immunodeficiency virus
infection. American Journal of Psychiatry, 146, 876±880.
Chung, J., & Magraw, M. (1992). A group approach to
psychosocial issues faced by HIV-positive women.
Hospital and Community Psychology, 43, 891±894.
Cleary, P., Singer, E., Rogers, T., Avorn, J., VanDevanter,
N., Soumerai, S., Perry, S., & Pindyck, J. (1988).
Sociodemographic and behavioral characteristics of
HIV antibody-positive blood donors. American Journal
of Public Health, 78, 953±857.
Clerici, M., Berzofsky, J. A., Shearer, G. M., & Tacket, C.
O. (1991). Exposure to human immunodeficiency virus
(HIV) type 1 indicated by HIV-specific T-helper cell
responses before detection of infection by polymerase
chain reaction and serum antibodies. Journal of In-
fectious Diseases, 164, 178±184.
Coates, T. (August, 1991). Who has been tested for HIV
antibodies in the United States? The National AIDS
Behavioral Survey (NABS). Paper presented at the
American Psychological Association, San Francisco,
CA.
Coates, T., McKusick, L., Stites, D., & Kuno, R. (1989).
Stress reduction training changed number of sexual
partners but not immune function in men infected with
HIV. American Journal of Public Health, 79, 885±887.
Coates, T., Stall, R., Ekstrand, M., & Solomon, G. (June,
1989). Psychological predictors as cofactors for disease
progression in men infected with HIV: The San Francisco
men's health study. Presented at the Vth International
AIDS Conference, Montreal, Quebec, Canada.
Cobb, S. (1974). Physiological changes in men whose jobs
are abolished. Journal of Psychosomatic Research, 18,
245±258.
Cohen, E. D. (1990). Confidentiality, counseling, and
clients who have AIDS: Ethical foundations of a model
rule. Journal of Counseling and Development, 68,
282±286.
Cohen, S., & Rodriquez, M. (1995). Pathways linking
affective disturbances and physical disorders. Health
Psychology, 14, 374±380.
Cohen, S., Tyrrell, D. A, & Smith, A. P. (1991).
Psychological stress in humans and susceptibility to the
common cold. New England Journal of Medicine, 325,
606±612.
Cohen, S., & Wills, T. A. (1985). Stress, social support, and
the buffering hypothesis. Psychological Bulletin, 98(2),
310±357.
Cole, S., Kemeny, M., Taylor, S., Visscher, B., & Fahey, J.
(1996). Accelerated course of HIV infection in gay men
269
who conceal their homosexuality. Psychosomatic Medi-
cine, 58, 219±231.
Cupps, T., & Fauci, A. (1982). Corticosteroid-mediated
immunoregulation in man. Immunology Review, 65,
133±155.
Cutrona, C., & Russell, D. (1987). The provisions of social
relationships and adaptation to stress. In Jones &
Perlman (Eds.), Advances in personal relationships.
Greenwich, CT: JAI Press.
Daar, E. S., Moudgil, T., Meyer, R. D., & Ho, D. D.
(1991). Transient high levels of viremia in patients with
primary human immunodeficiency virus type 1 infection.
New England Journal of Medicine, 324, 961±964.
Dahan, P., Haettich, B., Le Parc, J., & Paolaggi, J. (1988).
Meningoradiculitis due to herpes simplex virus disclosing
HIV infection [letter]. Annals of Rheumatic Disease, 47,
440.
Davidson, L. M., & Baum, A. (1986). Chronic stress and
posttraumatic stress disorders. Journal of Consulting and
Clinical Psychology, 54, 303±308.
Davidson, R. (1985). Behavioral medicine and alcoholism.
In N. Schneiderman & J. Tapp (Eds.), Behavioral
medicine: The biopsychosocial approach. Hillsdale, NJ:
Erlbaum.
Detels, R., English, P. A., Giorgi, J. V., Visscher, B. R.,
Fahey, J. L., Taylor, J. M. G., Dudley, J. P., Nishanian,
P., Munoz, A., Phair, J. P., Polk, B. F., & Rinaldo, C. R.
(1988). Patterns of CD4+ cell changes after HIV-1
infection indicate the existance of a co-determinant of
AIDS. Journal of the Acquired Immune Deficiency
Syndrome, 1, 390±395.
Dew, M., Ragni, M., & Nimorwicz, P. (1990). Infection
with human immunodeficiency virus and vulnerability to
psychiatric distress: A study of men with hemophilia.
Archives of General Psychiatry, 47, 737±744.
Dilley, J. W., Ochitil, H. N., Perl, M., & Volberding, P. A.
(1985). Findings in psychiatric consultations with
patients with acquired immune deficiency syndrome.
American Journal of Psychiatry, 142, 82±86.
DiMatteo, M. R., & Hays, R. (1981). Social support and
serious illness. In B. H. Gottlieb (Ed.), Social networks
and social support (pp. 117±148). Beverly Hills, CA: Sage.
Dimsdale, J., Hartley, L., Ruskin, J., Greenblatt, D., &
Labrie, R. (1984). Effect of beta blockade on plasma
catecholamine levels during psychological and exercise
stress. American Journal of Cardiology, 54, 182±185.
Doll, D. C., & List, A. F. (1982). Burkitt's lymphoma in a
homosexual. Lancet, 1, 1026±1027.
Donlou, J. N., Wolcott, D. L., Gottlieb, M. S., &
Landsverk, J. (1985). Psychosocial aspects of AIDS
and AIDS-related complex: A pilot study. Journal of
Psychosocial Oncology, 3, 39±55.
Eickhoff, T. (1994). Doctors urged to offer more HIV tests.
American Medical News, 37(9), 15.
Ellerman, D. (1989). Quality of life of persons with AIDS/
ARC. Proceedings of the Vth International Conference
on AIDS, Montreal, Quebec, Canada.
Ernberg, I. (1986). The role of Epstein-Barr virus in
lymphomas of homosexual males. In E. Klein (Ed.),
Acquired immunodeficiency syndrome (pp. 301±318).
Basel, Switzerland: Karger.
Esterling, B., Antoni, M., Schneiderman, N., Ironson, G.,
LaPerriere, A., Klimas, N., Fletcher, M. A., & Carver,
C. S. (1992). Psychosocial modulation of antibody to
Epstein-Barr viral capsid antigen and herpes virus type-6
in HIV-1 infected and at-risk gay men. Psychosomatic
Medicine, 54, 354±371.
Esterling, B., Kiecolt-Glaser, J., & Glaser, R. (1996).
Psychosocial modulation of cytokine-induced natural
killer cell activity in older adults. Psychosomatic Medi-
cine, 58, 264±272.
Evans, D., Pettito, J., & Lesserman, J. (1992). Stress,
depression and natural killer cells: Potential clinical
270 HIV and AIDS
relevance. Clinical Neuropharmacology, 15(Suppl. 1A),
656A±657A.
Eversole, L., Stone, C., & Beckman, A. (1988). Detection
of EBV and HPV DNA sequences in oral ªhairyº
leukoplakia by in situ hybridization. Journal of Medical
Virology, 26, 271.
Fawzy, F., Cousins, N., Fawzy, N., Kemeny, M., Elashoff,
R., & Morton, D. (1990). A structured psychiatric
intervention for cancer patients I. Changes over time in
methods of coping and affective disturbance. Archives of
General Psychiatry, 47, 720±725.
Felton, B., Revenson, T., & Hinrichsen, G. (1984). Stress
and coping in the explanation of psychological adjust-
ment among chronically ill adults. Social Science and
Medicine, 18, 889±898.
Ferrara, A. J. (1984). My personal experience with AIDS.
American Psychologist, 39, 1285±1287.
Fifield, L. (1975). On my way to nowhere: An analysis of gay
alcohol abuse and an evaluation of alcoholism rehabilita-
tion services. Los Angeles Gay Community Services
Center and Department of Health Services.
Fischl, M. A., Richman, D., Grieco, M., Gottlieb, M.,
Volberding, P., Laskin, O., Leedom, J., Groopman, J.,
Moldvan, D., Schooley, R., Jackson, G., Durack, D., &
King, D. (1987). The efficacy of azidothymidine (AZT) in
the treatment of patients with AIDS and AIDS-related
complex. New England Journal of Medicine, 317, 185±191.
Fishman, B., & Loscalzo, M. (1987). Cognitive-behavioral
interventions in management of cancer pain: Principles
and application. Medical Clinics of North America, 71(2),
271±287.
Folkman, S., Chesney, M., McKusick, L., Ironson, G.,
Johnson, D., & Coates, T. J. (1991). Translating coping
theory into intervention. In J. Eckenrode (Ed.), The
social context of coping (pp. 239±260). New York:
Plenum.
Foy, D., Sipprelle, P., Rueger, D., Carroll, E. M. et al.
(1984). Etiology of post-traumatic stress disorder in
Vietnam veterans: Analysis of premilitary, military, and
combat exposure influences. Journal of Consulting and
Clinical Psychology, 52, 79±87.
Freudenberg, N., Lee, J., & Silver, D. (1989). How Black
and Latino community organizations respond to the
AIDS epidemic: A case study in one New York city
neighborhood. AIDS Education and Prevention, 1 (1),
12±21.
Friedland, G. H., Saltzman, B., Vileno, J., Freeman, K.,
Schrager, L. K., & Klein, R. S. (1991). Survival
differences in patients with AIDS. Journal of Acquired
Immune Deficiency Syndromes, 144±153.
Friedman, A., Antoni, M. H., Ironson, G., LaPerriere, A.,
Schneiderman, N., & Fletcher, M. A. (1991). Behavioral
interventions, changes in perceived social support and
depression following notification of HIV-1 seropositiv-
ity. Presented at Society of Behavioral Medicine Annual
Meeting, Washington, DC.
Gambe, R., & Getzel, G. S. (1989). Group work with gay
men with AIDS. Social Casework, 70, 172±179.
Ginzburg, H. M., & Gostin, L. (1986). Legal and ethical
issues associated with HTLV-III diseases. Psychiatric
Annals, 16, 180±185.
Glaser, R., & Kiecolt-Glaser, J. (1987). Stress-associated
depression in cellular immunity: implications for ac-
quired immune deficiency syndrome (AIDS). Brain,
Behavior and Immunity 1, 107±112.
Glaser, R., Kiecolt-Glaser, J. K., Bonneau, R., et al.
(1992). Stress-induced modulation of the immune
response to recombinant hepatitis B vaccine. Psychoso-
matic Medicine, 54, 22±29.
Glaser, R., Kiecolt-Glaser, J. K., Speicher, C. E., &
Holliday, J. E. (1985). Stress, loneliness, and changes in
herpesvirus latency. Journal of Behavioral Medicine, 8,
249±260.
Glaser, R., Kennedy, S., Lafuse, W. P., Bonneau, R. H.,
Speicher, C. E., Kiecolt-Glaser, J. K., & Hillhouse, J.
(1990). Psychological stress-induced modulation of IL-2
receptor gene expression and IL-2 production in
peripheral blood leukocytes. Archives of General Psy-
chiatry, 47, 707±712.
Glaser, R., Pearson, G. P., Jones, J. F., Hillhouse, J.,
Kennedy, S., Mao, H., & Kiecolt-Glaser, J. K. (1991).
Stress-related activation of Epstein-Barr virus. Brain,
Behavior and Immunity, 5, 219±232.
Glaser, R., Rice, J., Sheridan, J., Fertal, R., Stout, J.,
Speicher, C., Pinshy, D., Kotur, M., Post, A., Beck, M.,
& Kiecolt-Glaser, J. (1987). Stress-related immune
suppression: Health implications. Brain, Behavior and
Immunity, 1, 7±20.
Glaser, R., Rice, J., Speicher, C. E., Stout, J. C., Kiecolt-
Glaser, J. K. (1986). Stress depresses interferon produc-
tion by leukocytes concomitant with a decrease in
natural killer cell activity. Behavioral Neuroscience, 100,
675±678.
Glassman, A., Bennet, C., & Randal, C. (1985). Effects of
ethyl alcohol on human peripheral lymphocytes. Ar-
chives of Pathology and Laboratory Medicine, 109, 540.
Gold, R., & Skinner, M. (1992). Situational factors and
thought processes associated with unprotected inter-
course in young gay men. AIDS, 6, 1021±1030.
Goodell, S., Quinn, T., Mkritichian, E., et al. (1983).
Herpes simplex virus proctitis in homosexual men:
Clinical, sigmoidoscopic, and histopathological features.
New England Journal of Medicine, 308, 868±871.
Goodkin, K., Fuchs, I., Feaster, D., Leeka, J., & Rishel, D.
D. (1993). Life stressors and coping style are associated
with immune measures in HIV-1 infectionÐa prelimin-
ary report. International Journal of Psychiatry in
Medicine, 22, 155±172.
Gorman, J., Kertzner, R., Cooper, T., Goetz, R.,
Lagomasino, I., Novacenko, H., Williams, J., Stern,
Y., Mayeux, R., & Ehrhardt, A. (1991). Glucocorticoid
level and neuropsychiatric symptoms in homosexual men
with HIV infection. American Journal of Psychiatry, 148,
41±45.
Greden, J., Gardner, R., King, D., Grunhaus, L., Carroll,
B., & Kronfol, A. (1983). Dexamethasone suppression
tests in antidepressant treatment of melancholia: The
process of normalization and test±retest reproducibility.
Archives of General Psychiatry, 40, 493±500.
Greenspan, J., Greenspan, D., Lennette, E., et al. (1985).
Replication of Epstein-Barr virus within the epithelial
cells of oral ªhairyº leukoplakia, an AIDS-associated
lesion. New England Journal of Medicine, 313,
1564±1571.
Griensven, G., Vroome, E., Wolf, F., Goudsmit, J., Roos,
M., & Coutinho, R. (1990). Risk factors for progression
of human immunodeficiency virus (HIV) infection
among seroconverted and seropositive homosexual
men. American Journal of Epidemiology, 132, 203±210.
Griffiths, P. D., & Grundy, J. E. (1987). Molecular biology
and immunology of cytomegalovirus. Journal of Bio-
chemistry, 241, 313±324.
Guinan, M. (1987). Women, children and AIDS. Journal of
the American Medical Womens Association, 42, 186.
Habu, S., Akamatsu, K., Tamaoki, N., Okumura, K.
(1984). In vivo significance of the NK cell in resistance
against (HSV-1) infections in mice. Journal of Immunol-
ogy, 133, 2743±2747.
Hammarskjold, M. L., & Heimer, J. (1988). Activation of
the HIV LTR by EBNA2 and LMP. Journal of
Experimental Cancer Research, 7, 148.
Hardy, A. M., & the Long-term Survivor Collaborative
Study Group (1991). Characterization of long-term
survivors of acquired immunodeficiency syndrome. Jour-
nal of Acquired Immune Deficiency Syndromes, 4, 386±391.
Hatfield, S., Petersen, B., & DiMicco, J. (1986). Beta
 References
adrenoreceptor modulation of the generation of murine
cytotoxic T lymphocytes in vitro. Journal of Pharmacol-
ogy and Experimental Therapeutics, 239(2), 460±466.
Haverkos, H. W., Pinsky, P. F., Drotman, D. P., &
Bregman, D. J. (1985). Disease manifestation among
homosexual men with acquired immunodeficiency syn-
drome: A possible role of nitrates in Kaposi's Sarcoma.
Sexuality Transmitted Diseases, 12, 203±208.
Hays, R. B., Chauncey, S., & Tobey, L. A. (1990). The
social support networks of gay men with AIDS. Journal
of Community Psychology, 18, 374±385.
Hays, R. B., Turner, H., & Coates, T. J. (1992). Social
support, AIDS-related symptoms, and depression
among gay men. Journal of Consulting and Clinical
Psychology, 60(3), 463±469.
Henderly, D., Freeman, W., Smith, R. et al. (1987).
Cytomegalovirus retinitis as the initial manifestation of
acquired immune deficiency syndrome. American Journal
of Opthalmology, 103, 316±320.
Herbert, T. B., & Cohen, S. (1993). Stress and immunity in
humans: a meta-analytic review. Psychosomatic Medi-
cine, 55, 364±379.
Hoffman, M. A. (1991). Counseling the HIV infected
client: A psychosocial model for assessment and inter-
vention. The Counseling Psychologist, 19, 467±542.
Hoover, D. R., Rinaldo, C., He, Y., Phair, J., Fahey, J., &
Graham, N. M. H. (1995). Long-term survival without
clinical AIDS after CD4+ cell counts fall below 200 6
106/1. AIDS, 9, 145±152.
Horowitz, M., Wilner, N., & Alvarez, (1979). Impact of
event scale. Psychosomatic Medicine, 41, 209±218.
House, J. S., Landis, K. R., & Umberson, D. (1988). Social
relationship and health. Science, 241, 540±545.
Ironson, G., Antoni, M., & Lutgendorf, S. (1995). Can
psychological interventions affect immunity and survi-
val? Present findings and suggested targets with a focus
on cancer and human immunodeficiency virus. Mind/
Body Medicine, 1(2), 85±110.
Ironson, G., Antoni, M., Simoneau, J., Starr, K.,
LaPerriere, A., Klimas, N., Schneiderman, N., &
Fletcher, M. A. (1992). Denial, distress, and treatment
adherence predict disease progression in HIV-1 infected
asymptomatic gay men. Presented at American Psycho-
somatic Society, New York.
Ironson, G., Field, T., Scafidi, F., Hashimoto, M., Kumar,
M., Kumar, A., Price, A., Goncalves, A., Burman, I.,
Tetenman, C., Patarca, R., & Fletcher, M. A. (1996).
Massage therapy is associated with enhancement of the
immune systems cytotoxic capacity. International Journal
of Neuroscience, 84, 205±217.
Ironson, G., Friedman, A., Klimas, N., Antoni, M.,
Fletcher, M. A., LaPerriere, A., Simoneau, J., &
Schneiderman, N. (1994). Distress, denial and low
adherence to behavioral interventions predict faster
disease progression in gay men infected with Human
Immunodeficiency Virus. International Journal of Beha-
vioral Medicine, 1 (1), 90±105.
Ironson, G., LaPerriere, A., Antoni, M., O'Hearn, P.,
Klimas, N., Fletcher, M. A., & Schneiderman, N. (1990).
Changes in immunologic and psychological measures as
a function of anticipation and reaction to news of HIV-1
antibody status. Psychosomatic Medicine, 52, 247±270.
Ironson, G., Wynings, C., Schneiderman, N., Baum, A.,
Rodriguez, M., Greenwood, D., Benight, C. C., Antoni,
M., LaPerriere, A., Huang, H. S., Klimas, N., &
Fletcher, M. A. (1997). Post traumatic stress symptoms,
intrusive thoughts, loss and immune function after
Hurricane Andrew. Psychosomatic Medicine, 59,
128±141.
Irwin, M., Caldwell, C., Smith, T., Brown, S., Schuckit,
M., & Gillin, C. (1990). Major depressive disorder,
alcoholism, and reduced natural killer cell cytotoxicity.
Archives of General Psychiatry, 47, 713±719.
271
Irwin, M., Daniels, M., Bloom, E., Smith, T., & Weiner, H.
(1987). Life events, depressive symptoms, and immune
function. American Journal of Psychiatry, 144, 437±441.
Irwin, M., Daniels, M., Smith, T., Bloom, E., & Weiner, H.
(1987). Impaired natural killer cell activity during
bereavement. Brain, Behavior, and Immunity, 1(1),
98±104.
Irwin, M., Daniels, M., & Weiner, H. (1987). Immune and
neuroendocrine changes during bereavement. Psychiatric
Clinic of North America, 10(3) 449±465.
Irwin, M., Patterson, T., Smith, T., Caldwell, C., Brown,
S., Grant, I., & Gillin, J. C. (1990). Reduction of immune
function by life stress and depression. Biological Psy-
chiatry, 27, 22±30.
Jacobs, S., Mason, J., Kosten, T., Wahby, V., Kasl, S., &
Ostfeld, A. (1986). Bereavement and catecholamines.
Journal of Psychosomatic Research, 30, 489±496.
Jacobsen, P., Perry, S., & Hirsch, D. (1990). Behavioral and
psychological responses to HIV antibody testing. Journal
of Consulting and Clinical Psychology, 58(1), 31±37.
Jacobson, M. A., Bacchetti, P., Kolokathis, A., Chaisson,
R. E., Szabo, S., Polsky, B., Valainis, G. T., Mildvan,
D., Abrams, D., Wilber J., Winger, E., Sacks, H. S.,
Hendricksen, C., & Moss, A. (1991). Surrogate markers
for survival in patients with AIDS and AIDS-related
complex treated with zidovudine. British Medical Jour-
nal, 302, 73±78.
Justice, A. (1985). Review of the effects of stress on cancer
in laboratory animals: Importance of time of stress
application and type of tumor. Psychological Bulletin,
98, 108±138.
Kaisch, K., & Anton-Culver, H. (1989). Psychological and
social consequences of HIV exposure: Homosexuals in
Southern California. Psychology and Health, 3, 63±75.
Kaplan, L. D., Wofsy, C. B., & Volberding, P. A. (1987).
Treatment of patients with acquired immunodeficiency
syndrome and associated manifestations. Journal of the
American Medical Association, 257, 1367±1374.
Katz, P., Zaytoun, A., & Fauci, A. (1982). Mechanisms of
human cell-mediated cytotoxicity. Modulation of natur-
al killer cell activity by cyclic nucleotides. Journal of
Immunology, 129, 287±296.
Kelly, J. A. Murphy, D., Bahr, G., Koob, J., Morgan, M.,
Kalichman, S., Stevenson, L., Brashfield, T., Bernstein,
B., & St. Lawrence, J. S. (1993). Factors associated with
severity of depression and high-risk sexual behavior
among persons diagnosed with human immunodefic-
ciency virus (HIV) infection. Health Psychology, 12,
215±219.
Kelly, J. A., & St. Lawrence, J. S. (1988). AIDS prevention
and treatment: Psychology's role in the health crisis.
Clinical Psychology Review, 8, 255±284.
Kemeny M. E. (1994). Stressful events, psychological
responses and progression of HIV infection. In R.
Glaser & J. K. Kiecolt-Glaser (Eds.), Handbook on
human stress and immunity (pp. 245±266). San Diego,
CA: Academic Press.
Kemeny, M. E., Weiner, H., Duran, R., Taylor, S. E.,
Visscher, B., & Fahey, J. L. (1995). Immune system
changes after the death of a partner in HIV-positive gay
men. Psychosomatic Medicine, 57, 547±554.
Kemeny, M. E., Weiner, H., Taylor, S. E., Schneider, S.,
Visscher, B., & Fahey, J. L. (1994). Repeated bereave-
ment, depressed mood, and immune parameters in HIV
seropositive and seronegative gay men. Health Psychol-
ogy, 13, 14±24.
Kessler, R. C., Foster, C., Joseph, J., Ostrow, D., Wort-
man, C., Phair, J., & Chmiel, J. (1991). Stressful life
events and symptom onset in HIV infection. American
Journal of Psychiatry, 148, 733±738.
Kiecolt-Glaser, J. K., Dura, J. R., Speicher, C. E., Trask,
O. J., & Glaser, R. (1991). Spousal caregivers of
dementia victims: Longitudinal changes in immunity
272 HIV and AIDS
and health. Psychosomatic Medicine, 53, 345±362.
Kiecolt-Glaser, J. K., Fisher, L. D., Ogrocki, P., Stout, J.
C., Speicher, C. E., & Glaser, R. (1987). Marital quality,
marital disruption, and immune function. Psychosomatic
Medicine, 49, 13±34.
Kiecolt-Glaser, J. K., Garner, W., Speicher, C., Penn, G.
M., Holiday, J., & Glaser, R. (1984). Psychosocial
modifiers of immunocompetence in medical students.
Psychosomatic Medicine, 46, 7±14.
Kiecolt-Glaser, J. K., Glaser, R., Shuttleworth, E. C.,
Dyer, C. S., Ogrocki, P., & Speicher, C. E. (1987).
Chronic stress and immunity in family caregivers of
Alzheimer's disease victims. Psychosomatic Medicine, 49,
523±535.
Kiecolt-Glaser, J. K., Glaser, R., Strain, E., Stout, J., Tarr,
K., Holiday, J., & Speicher, C. E. (1986). Modulation of
cellular immunity in medical students. Journal of
Behavioral Medicine, 9, 5±21.
Kiecolt-Glaser, J. K., Glaser, R., Williger, G., Stout, J.,
Messick, G., Sheppard, S., Ricker, D., Romisher, S. C.,
Briner, W., Bonnell, G., Donnerberg, R. (1985).
Psychosocial enhancement of immunocompetence in a
geriatric population. Health Psychology, 4(1), 25±41.
Kiecolt-Glaser, J. K., Kennedy, S., Malkoff, S., Fisher, L.,
Speicher, C. E., & Glaser, R. (1988). Marital discord and
immunity in males. Psychosomatic Medicine, 50,
213±229.
Kingsley, L., Kaslow, R., Rinaldo, C., Detre, K., Odaka,
N., VanRaden, M., Detels, R., Polk, B., Chmiel, J.,
Kelsey, S., Ostrow, D., & Visscher, B. (1987). Risk
factors for sero-conversion to human immunodeficiency
virus among male homosexuals. Lancet, 1, 345±349.
Klimas, N., Caralis, P., LaPerriere, A., Antoni, M. H.,
Schneiderman, N., & Fletcher, M. A., (1991). Evaluation
of immunological status in a cohort of HIV-1 positive
and negative healthy gay men. Journal of Clinical
Microbiology, 29, 1413±1421.
Krueger, J., & Karnovsky, M. (1987). Sleep and the
immune response. Annals of the New York Academy of
Sciences, 496, 510±516.
Kubler-Ross, E. (1969). On death and dying. New York:
MacMillan.
Kumar, M., Morgan, R., Szapocznik, J., & Eisdorfer, C.
(1991). Norepinephrine response in HIV+ subjects.
Journal of Acquired Immune Deficiency Syndrome, 4,
782±785.
LaPerriere, A., Antoni, M. H., Schneiderman, N., Ironson,
G., Klimas, N., Klimas, N., Caralis, P., & Fletcher, M.
A. (1990). Exercise intervention attenuates emotional
distress and natural killer cell decrements following
notification of positive serologic status for HIV-1.
Biofeedback and Self-Regulation, 15, 125±142.
LaPerriere, A., Ironson, G., Antoni, M. H., Schneiderman,
N., Klimas, N., & Fletcher, M. A. (1994). Exercise and
psychoneuroimmunology. Medicine and Science in
Sports and Exercise, 26, 182±190.
Lazarus, R. S., & Folkman, S. (1984). Stress appraisal and
coping. New York: Springer.
Lazzarin, A., Mella, L., & Trombini, M. (1984). Immuno-
logic status in heroine addicts: Effects of methadone
maintenance treatment. Drug and Alcohol Dependency,
13, 117±123.
Lemp, G. F., Payne, S. F., Neal, D., Temelso, T., &
Rutherford, G. W. (1990). Survival trends for patients
with AIDS. JAMA, 263, 402±406.
Lesserman, J., DiSantostefano, R., Perkins, D., Murphy,
C., Golden, R., & Evans, D. (1995). Longitudinal study
of social support and social conflict as predictors of
depression and dysphoria among HIV-positive and HIV-
negative gay men. Depression, 2, 189±199.
Lesserman, J., Perkins, D., & Evans, D. (1992). Coping
with the threat of AIDS: The role of social support.
American Journal of Psychiatry, 149, 1514±1520.
Levine, M., Woldenberg, R., Herlinger, H., & Laufer, I.
(1987). Opportunistic esophagitis in AIDS: Radio-
graphic diagnosis. Radiology, 165, 815±820.
Levy, S., Herberman, R., Lippman, M., & d'Angelo, T.
(1987). Correlation of stress factors with sustained
depression of natural killer cell activity and predicted
prognosis in patients with breast cancer. Journal of
Clinical Oncology, 5, 348±353.
Lewin, D. (1996). Protease inhibitors: HIV-1 summons a
Darwinian defense. Journal of NIH Research, 8, 33±35;
Linn, B. S., Linn, M. W., & Jensen, J. (1981). Anxiety and
immune responsiveness. Psychological Reports, 49,
969±970.
Lohrenz, L., Connelly, L., Coyne, L., & Spare, K. (1978).
Alcohol problems in several midwestern homosexual
communities. Journal of Studies of Alcohol, 39,
1959±1963.
Lollis, C., Antoni, M. H., Johnson, E., Chitwood, D., &
Griffin, D. (1995). Does the health belief model predict
risky sexual practices in injection drug users? Clinical
Psychology and Psychotherapy, 2(4), 227±233.
Lollis, C., Johnson, E., Antoni, M. H., & Hinkle, Y.
(1996). Characteristics of African Americans with multi-
ple risk factors associated with HIV/AIDS. Journal of
Behavioral Medicine, 19, 55±70.
Longini, I. M., Clark, W. S., & Karon, J. M. (1993). The
effect of routine use of therapy in slowing the clinical
course of HIV infection in a population-based cohort.
American Journal of Epidemiology, 137, 1229±1240.
Lusso, P., Ensoli, B., Markham, P. D., Ablashi, D. V.,
Salahuddin, S. Z., Tschachler, E., Wong-Staal, F., &
Gallo, R. C. (1989). Productive dual infection of human
CD4+ T lymphocytes by HIV-1 and HHV-6. Nature,
337, 370±373.
Lutgendorf, S., Antoni, M. H., Ironson, G., Fletcher, M.
A., Renedo, F., VanRiel, F., Baum, A., Schneiderman,
N., & Klinas, N. (1995). Physical symptoms of chronic
fatigue syndrome are exacerbated by the stress of
Hurricane Andrew. Psychosomatic Medicine, 57,
310±323.
Lutgendorf, S., Antoni, M. H., Ironson, G., Klimas, N.,
Starr, K., Schneiderman, N., & Fletcher, M. A. (1996,
March). Coping and social support predict distress
changes in symptomatic HIV-seropositive gay men follow-
ing a cognitive behavioral stress management intervention.
Paper presented at the Society of Behavioral Medicine,
Washington, DC.
Lutgendorf, S., Antoni, M. H., Ironson, G., Klimas, N.,
Starr, K., Schneiderman, N., McCabe, P., Cleven, K., &
Fletcher, M. A. (1997). Cognitive behavioral stress
management decreases dysphoric mood and Herpes
Simplex Virus-Type 2 antibody titers in symptomatic
HIV-seropositive gay men. Journal of Consulting and
Clinical Psychology, 65, 31±43.
Lutgendorf, S. K., Antoni, M. H., Ironson, G., Schneider-
man, N., & Fletcher, M. A. (1997). Cognitive processing
style, affective status, and immune function following
HIV seropositivity notification. Cognitive Therapy and
Research, 57, 60±61.
Lutgendorf, S. K., Antoni, M. H., Kumar, M., &
Schneiderman, N. (1994). Changes in cognitive coping
strategies predict EBV antibody titre following a stressor
disclosure induction. Journal of Psychosomatic Research,
38, 63±78.
Lutgendorf, S., Antoni, M. H, Schneiderman, N., &
Fletcher, M. A. (1994). Psychosocial counseling to
improve quality of life in HIV-infected infection. Patient
Education and Counseling, 24, 217±235.
Lutgendorf, S., Antoni, M. H., Schneiderman, N., Ironson,
G., & Fletcher, M. A. (1994). Psychosocial interventions
and quality of life changes across the HIV spectrum. In
A. Baum & J. Dimsdale (Eds.), Perspectives in behavioral
medicine (pp. 205±239). Hillsdale, NJ: Erlbaum.
 References
Lyketsos, C. G., Hoover, D. R., Guccione, M., Senterfitt,
W., Dew, M. A., Wesch, J., VanRaden, M., Treisman,
G. J., & Morganstem, H. (1993). Depressive symptoms
as predictors of medical outcomes in HIV infection.
Journal of the American Medical Association, 270,
2563±2567.
Mackie, I. (1993). AIDS, the female patient and the family
physician. Canadian Family Physician, 39, 1600±1607.
Maier, S. F., Watkins, L. R., & Fleshner, M. (1994).
Psychoneuroimmunology: The interface between beha-
vior, brain, and immunity. American Psychologist, 49,
1004±1017.
Maiman, M., & Fruchter, R. (1996). Cervical neoplasia
and the human immunodeficiency virus. In S. Rubino &
W. Hoskins (Eds), Cervical cancer and preinvasive
neoplasia (pp. 405±416). Philadelphia: Lippincott-Raven.
Manuck, S. (1991), Individual differences in cellular
immune response to stress. Psychological Science, 2,
111±115.
Markham, P., Salahuddin, S., Veren, K., Orndorff, S., &
Gallo, R. (1986). Hydrocortisone and some other
hormones enhance the expression of HTLV-III. Inter-
national Journal of Cancer, 37, 67±72.
Martin, D. (1989). Human immunodeficiency virus infec-
tion and the gay community: Counseling and clinical
issues. Special Issue: Gay, lesbian, and bisexual issues in
counseling. Journal of Counseling and Development, 68,
67±72.
Martin, J. (1988). Psychological consequences of AIDS-
related bereavement among gay men. Journal of Con-
sulting and Clinical Psychology, 56, 856±862.
Martin, J. (1990). Drug use and unprotected anal inter-
course among gay men. Health Psychology, 9, 450±465.
Marzuk, P. M., Tierney, H., Tardiff, K., Gross, E. M.,
Morgan, E. B., Hsu, M. A., & Mann, J. (1988).
Increased risk of suicide in persons with AIDS. Journal
of the American Medical Association, 259, 1333±1337.
Mays, V., & Cochran, S. (1988). Issues in the perception of
AIDS risk and risk reduction activities by Black and
Hispanic/Latina women. American Psychologist, 43(11),
949±957.
McKinnon, W., Weisse, C. S., Reynolds, C. P., Bowles, C.
A., & Baum, A. (1989). Chronic stress, leukocyte
subpopulations, and humoral response to latent viruses.
Health Psychology, 8, 399±402.
McKusick, L., Horstman, W., & Coates, T. (1985). AIDS
and sexual behavior reported by gay men in San
Francisco. American Journal of Public Health, 75,
493±496.
McNair, D. Lorr, M., & Droppleman, L. (1981). EITS
manual for the profile of mood states. San Diego, CA:
Educational and Industrial Testing Service.
McVoy, M. A., & Adler, S. P. (1989). Immunologic
evidence for frequent age-related cytomegalovirus reac-
tivation in seropositive immunocompetent individuals.
Journal of Infectious Disease, 160, 1±10.
Miller, D. (1988). HIV and social psychiatry. British
Medical Bulletin, 44, 130±148.
Miller, L., Goldstein, G., Murphy, M., & Ginns, L. C.
(1982). Reversible alterations in immunoregulatory T
cells in smoking. Chest, 82, 526±529.
Mulder, C. L., Antoni, M. H., Duivenvoorden, H.,
Kauffmann, R., & Goodkin, K. (1995). Active con-
frontational coping predicts decreased clinical progres-
sion over a one-year period in HIV-infected homosexual
men. Journal of Pyschosomatic Research, 39(8), 957±965.
Mulder, C. L., Antoni, M. H., Emmelkamp, P., Veugelers,
P., Sandfort, T., Vijver, F. vander, & Vries, M. de (1995).
Psychosocial group intervention and the rate of decline
of immunologic parameters in asymptomatic HIV-
infected homosexual men. Journal of Psychotherapy
and Psychosomatics, 63, 185±192.
Mulder, C. L., Emmelkamp, P., Antoni, M. H., Mulder, J.,
273
Sandfort, T., & de Vries, M. (1994). Cognitive-behavior-
al and experiential group psychotherapy for HIV-
infected homosexual men: A comparative study. Psy-
chosomatic Medicine, 56, 423±431.
Mulder, C. L., Vroome, E. de, Griensven, G. van, Antoni,
M. H., & Sandfort. T. (in press). Avoidance as a
predictor of the virological course of HIV-1 infection
over a 7-year period in gay men. Health Psychology.
Munoz, A., Wang, M. C., Good, R., Detels, H., Ginsberg,
L., Kingsley, J., Phair, J., & Polk, B. F. (1988, June).
Estimation of the AIDS-free times after HIV-1 serocon-
version. Paper presented at the IVth Annual Meeting of
the International Conference on AIDS, Stockholm,
Sweden.
Naliboff, B., Benton, D., Solomon, G., Morley, J., Fahey,
J., Bloom, E., Makinodan, T., & Gilmore, S. (1991).
Immunological changes in young and old adults during
brief laboratory stress. Psychosomatic Medicine, 53,
121±132.
Namir, S., Alumbaugh, M. J., Fawzy, F. I., & Wolcott, D.
L. (1989). The relationship of social support to physical
and psychological aspects of AIDS. Psychology and
Health, 3, 77±86.
Namir, S., Wolcott, D. L., Fawzy, F. I., & Alumbaugh, M.
J. (1987). Coping with AIDS: Psychological and health
implications. Journal of Applied Social Psychology, 17,
309±328.
Nardi, P. (1982). Alcoholism and homosexuality: A
theoretical perspective. Journal of Homosexuality, 7, 9±25.
Neale, A., Tilley, B., & Vernon, S. (1986). Marital status,
delay in seeking treatment and survival from breast
cancer. Social Science and Medicine, 23, 305±312.
Newcomb, M., & Harlow, L. (1986). Life events and
substance use in adolescents: Mediating effects of
perceived loss of control and meaninglessness in life.
Journal of Personality and Social Psychology, 51, 564±577.
Nieman, R., Fleming, J., Coker, R., Harris, J., & Mitchell,
D. (1993). The effect of cigarette smoking on the
development of AIDS in HIV-1-seropositive individuals.
AIDS, 7, 705±710.
Noh, S., Chandarana, P., Field, V., & Posthuma, B. (1990).
AIDS epidemic, emotional strain, coping and psycholo-
gical distress in homosexual men. AIDS Education and
Prevention, 2, 272±283.
Nyamathi, A., & Lewis, C. (1991). Coping of African
American women at risk for AIDS. Women's Health
Issues, 1, 53±61.
O'Brien, K. O., Wortman, C. B., Kessler, R. C., & Joseph,
J. G. (1993). Social relationships of men at risk for
AIDS. Social Science and Medicine, 36(9), 1161±1167.
Ostrow, D., Joseph, J., Kessler, R., Soucy, J., Tal, M.,
Eller, M., Chmiel, J., & Phair, J. (1989). Disclosure of
HIV antibody status: Behavioral and mental health
correlates. AIDS Education and Prevention, 1, 1±11.
Ostrow, D. G., Monjan, A., Joseph, J., VanRaden, M.,
Fox, R., Kingsley, L., Lawrence, K., Dudley, J., & Phair,
J. (1989). HIV-related symptoms and psychological
functioning in a cohort of homosexual men. American
Journal of Psychiatry, 146, 737±742.
Palmblad, J., Cantrell, K., Strander, H., Froberg, J.,
Karlesson, C., Levi, L., Granstan, M., & Unger, P.
(1976). Stressor exposure and immunological response in
man: Interferon-producing capacity and phagocytosis.
Journal of Psychosomatic Research, 20, 193±199.
Palmblad, J., Petrini, B., Wasserman, J., & Akerstedt, T.
(1979). Lymphocyte and granulocyte reactions during
sleep deprivation. Psychosomatic Medicine, 41, 273±278.
Pantaleo, G., Poli, G., & Fauci, A. S. (1993). The
immunopathogenesis of human immunodeficiency virus
infection. Clinical and Infectious Diseases, 17(Suppl. 1),
S224±S229.
Patterson, T., Shaw, W., Semple, S., Cherner, M., McCutch-
an, J., Atkinson, J., Grant, I., & Nannis, E. (1996).
274 HIV and AIDS
Relationship of psychosocial factors to HIV disease
progression. Annals of Behavioral Medicine, 18, 30±39.
Paya, C. V., Virelizier, J. L., & Michelson, S. (1991).
Modulation of T-cell activation through protein kinase
C- or A-dependent signalling pathways synergistically
increases human immunodeficiency virus long terminal
repeat induction by cytomegalovirus immediate-early
proteins. Journal of Virology, 65, 5477±5484.
Pearlin, L., & Radabaugh, C. (1976). Economic strains and
coping functions of alcohol. American Journal of
Sociology, 82, 652.
Penkower, L., Dew, M. A., Kingsley, L., Becker, J. T.,
Satz, P., Schaerf, F. W., & Sheridan, K. (1991).
Behavioral, health and psychosocial factors and risk
for HIV infection among sexually active homosexual
men: The multicenter AIDS cohort study. American
Journal of Public Health, 81, 194±196.
Perssan, U., Myrenfors, P., Ringden, O., Sundberg, B.,
Larsson, P., Gunnar, S., & Johansson, O. (1987). T-
lymphocytes subpopulations in bone marrow-trans-
planted patients in relation to graft-versus-host disease
and cytomegalovirus-induced infection. Transplantation,
43, 663±668.
Pickrel, J. (1989). ªTell me your storyº: Using life review in
counseling the terminally ill. Death Studies, 13, 127±135.
Plaut, M. (1987). Lymphocyte hormone receptors. Annual
Review of Immunology, 5, 621±669.
Quinn, S. (1993). AIDS and the African American woman.
The triple burden of race, class and gender. Health
Education Quarterly, 20, 305±320.
Rabkin, J., Rabkin, R., Harrison, W., & Wagner, G. (1994).
Effect of imipramine on mood and enumerative measures
of immune status in depressed patients with HIV illness.
American Journal of Psychiatry, 151, 516±523.
Rabkin, J., Wagner, G. & Rabkin, R. (1996). Treatment of
depression in HIV+ men: Literature review and report
of an ongoing study of testosterone replacement therapy.
Annals of Behavioral Medicine, 18, 24±29.
Rabkin, J., Williams, J., Neugebauer, R., & Goetz, R. (1990).
Maintenance of hope in HIV-spectrum homosexual
men. American Journal of Psychiatry, 147, 1322±1326.
Rabkin, J. G., Williams, J. B. W., Remien, R. H., Goetz, R.
R., Kertzner, R., & Gorman, J. M. (1991). Depression,
lymphocyte subsets, and human immunodeficiency virus
symptoms on two occasions in HIV-positive homosexual
men. Archives of General Psychiatry, 48, 111±119.
Redfield, R., & Burke, D. (1988). HIV infection: The
clinical picture. Scientific American, 259, 90±98.
Reed, G. M., Kemeny, M. E., Taylor, S. E., Visscher, B.
R., & Fahey, J. L. (1994, April). Negative HIV-specific
expectancies and health outcomes in HIV-related disease.
Invited symposium presented at the 52nd Annual
Scientific Meeting of the American Psychosomatic
Society, Boston, MA.
Reed, G. M., Kemeny, M. E., Taylor, S. E., Wang, H. J., &
Visscher, B. (1994). Realistic acceptance as a predictor of
decreased survival time in gay men with AIDS. Health
Psychology, 13, 299±307.
Richman, D. D., Fischl, M., Grieco, M., Gottlieb, M.,
Volberding, P., Laskin, O., Leedom, J., Groopman, J.,
Mildvan, D., Hirsch, M., Jackson, G., Durack, D., &
Nusinoff-Lehrman, S. (1987). The toxicity of azidothy-
midine (AZT) in the treatment of patients with AIDS
and AIDS-related complex. New England Journal of
Medicine, 317, 192±197.
Rinaldo, C. R. (1990). Immune suppression by herpes
viruses. Annual Reviews of Medicine, 41, 331±338.
Rose, R. (1980). Endocrine responses to stressful psycho-
logical events. Psychiatric Clinics of North America, 3,
251±276.
Rosenberg, Z. F., & Fauci, A. S. (1991). Activation of
latent HIV infection. Journal of the National Institutes of
Health Research, 2, 41±45.
Rosser, B., Simon, R., & Michael, W. (1988). Perceived
emotional and life change impact of AIDS on homo-
sexual men in two countries. Psychology and Health, 2,
301±317.
Roszman, T., Jackson, J., Cross, R., Titus, M., Markesb-
ery, W., & Brooks, N. H. (1985). Neuroanatomic and
neurotransmitter influences on immune function. Jour-
nal of Immunology, 135, 769s±772s.
Royce, R., & Winkelstein, W. (1990). HIV infection,
cigarette smoking and CD4+ T-L lymphocyte counts:
Preliminary results from the San Francisco Men's Health
Study. AIDS, 4, 327±333.
Rundell, J., Paolucci, S., Beatty, D., & Boswell, R. (1988).
Psychiatric illness at all stages of human immunodefi-
ciency virus infection [letter]. American Journal of
Psychiatry, 145, 652±653.
Rush, A., Beck. A., Kovacs, M., Weisenberger, J., &
Hollon, S. (1982). Comparison of the effects of cognitive
therapy and pharmacotherapy on hopelessness and self-
concept. American Journal of Psychiatry, 139, 862±866.
Saah, A. J., Hoover, D. R., He, Y., Kingsley, L. A., Phair,
J. P., & the Multicenter AIDS Cohort Study (1994).
Factors influencing survival after AIDS: Report from
the Multicenter AIDS Cohort Study (MACS). Journal of
Acquired Immune Deficiency Syndromes, 7, 287±295.
Sarason, I. (1979, August). Life stress, self-preoccupation,
and social supports. Paper presented at the annual
scientific meetings of the American Psychological
Association.
Sarason, I., Potter, E., Sarason, B., & Antoni, M. H.
(1985). Life events, social support, and illnesses. Psy-
chosomatic Medicine, 47(2), 156±163.
Schneiderman, N., Antoni, M. H., & Ironson, G. (1997).
Cognitive behavioral stress management and secondary
prevention in HIV/AIDS. Psychology & AIDS Exchange,
22, 1±8.
Schneiderman, N., Antoni, M. H., Ironson, G., Fletcher,
M. A., Klimas, N., & LaPerriere, A. (1994). HIV-1,
immunity and behavior. In Glaser, R. (Ed.) Handbook
of human stress and immunity. San Diego, CA:
Academic Press.
Schneiderman, N., Antoni, M., Ironson, G., LaPerriere,
A., & Fletcher, M. A. (1992). Applied psychosocial
science and HIV-1 spectrum disease. Journal of Applied
and Preventative Psychology, 1, 67±82.
Schooley, R. (1990). Cytomegalovirus infection in the
seting of infection with the human immunodeficiency
virus. Reviews of Infectious Disease, 17, S811.
Schwartzberg, S. (1994, August). HIV as a catalyst for
personal growth: Clinical and qualitative data. Paper
presented at the annual meeting of the American
Psychological Association, Los Angeles, CA.
Seage, G., Oddleifson, S., Carr, E., Shea, B., Makarewicz-
Robert, L., vanBeuzekom, M., & DeMaria, A. (1993).
Survival with AIDS in Massachusetts, 1979 to 1989.
American Journal of Public Health, 83, 72±78.
Shine, D., Moll, B., Emerson, E., Spigland, I., Harris, C.,
Small, C. B., Friedland, G., Weiss, S. H., & Bodner, A. J.
(1987). Serologic, immunologic, and clinical features of
parental drug users from contrasting populations.
American Journal of Drug Abuse, 13, 401±412.
Sikkema, K., & Kelly, J. (1996). Behavioral medicine
interventions can improve quality of life and health of
persons with HIV disease. Annals of Behavioral Medi-
cine, 18, 40±48.
Simons, A., Garfield, S., & Murphy, G. (1984). The process
of change in cognitive therapy and pharmacotherapy:
Changes in mood and cognition. Archives of General
Psychiatry, 41, 45±51.
Smith, C., Fernengel, K., Holcroft, C., Gerald, K., &
Marien, L. (1994). Meta-analysis of the associations
between social support and health outcomes. Annals of
Behavioral Medicine, 16, 352±362.
 References
Solano, L., Costa, M., Salvati, S., Coda, R., Aiuta, F.,
Mezzaroma, I., & Bertini, M. (1993). Psychosocial
factors and clinical evolution in HIV-1 infection: A
longitudinal study. Journal of Psychosomatic Research,
37(1), 39±51.
Solomon, G., Kemeny, M., & Temoshok, L. (1991).
Psychoneuroimmunologic aspects of Human Immuno-
deficiency Virus infection. In R. Ader, D. Felten, & N.
Cohen (Eds.), Psychoneuroimmunology (2nd ed.,
pp. 1081±1114). San Diego, CA: Academic Press.
Solomon, G., Temoshok, L., O'Leary, A., & Zich, J.
(1987). An intensive psychoimmunologic study of long-
surviving persons with AIDS. Annals of the New York
Academy of Science, 496, 647±655.
Stall, R., Coates, T., & Hoff, C. (1988). Behavioral risk
reduction for HIV infection among gay and bisexual
men: A review of results from the United States.
American Psychologist, 43, 878±885.
Starr, K., Antoni, M. H., Hurwitz, B., Rodriquez, M.,
Ironson, G., Fletcher, M. A., Kumar, M., Patarca, R.,
Lutgendorf, S., Quillian, R., Klimas, N., & Schneider-
man, N. (1996). Patterns of immune, neuroendocrine,
and cardiovascular stress responses in asymptomatic
HIV seropositive and seronegative men. International
Journal of Behavioral Medicine, 3, 135±162.
Stein, M., Miller, A. H., & Trestman, R. L. (1991).
Depression, the immune system and health and illness:
Findings in search of meaning. Archives of General
Psychiatry, 48, 171±177.
Stites, D., Stobo, J., Fudenberg, H., & Wells, J. (1982).
Basic and clinical immunology (4th ed.). Los Altos, CA:
Lange.
Sumaya, C. V., Boswell, R. N., Ench, Y., Kisner, D. L.,
Hersh, E. M., Ruben, J. M., & Mansell, P. W. (1986).
Enhanced serological and virological findings of
Epstein-Barr virus in patients with AIDS and AIDS-
related complex. Journal of Infectious Disease, 154,
864±870.
Tapper, M., Rotterdam, H., Lerner, C. et al. (1984).
Adrenal necrosis in the acquired immunodeficiency
syndrome. Annals of Internal Medicine 100, 239±241.
Taylor, S. E., Falke, R. L., Shoptaw, S. J., & Lichtman, R.
R. (1986). Social support, support groups and the cancer
patient. Journal of Consulting and Clinical Psychology,
54, 608±615.
Theorell, T., Blomkvist, V., Jonsson, H., Schulman, S.,
Berntorp, E., & Stigendal, L. (1995). Social support and
the development of immune function in human immu-
nodeficiency virus infection. Psychosomatic Medicine, 57,
32±36.
Tindall, B., & Cooper, D. A. (1991). Primary HIV
infection: Host responses and intervention strategies.
AIDS, 5, 1±14.
Tisman, F., Herbert, V., Go, L. et al. (1971). In vitro
demonstration and immunosuppression without bone
marrow suppression by alcohol and bleomycin. Clinical
Research, 19, 730.
Tross, S., & Hirsch, D. A. (1988). Psychological distress
and neuropsychological complications of HIV infection
and AIDS. American Psychologist, 43, 929±934.
Turk, D., Holzman, A., & Kerns, R. (1986). Chronic pain.
In K. Holroyd, & T. Creer (Eds.), Self-management of
chronic disease: Handbook of clinical interventions and
research. Orlando, FL: Academic Press.
Turner, H. A., Hays, R. B., & Coates, T. J. (1993).
Determinants of social support among gay men: The
context of AIDS. Journal of Health and Social Behavior,
34 (March), 37±53.
Vachon, M., Lyall, W., Rogers, K., Freedman, K., &
Freeman, S. (1980). A controled study of self-help
intervention with widows. American Journal of Psychia-
try, 137(11), 1380±1384.
Viney, L., Henry, R., Walker, B., & Crooks, L. (1989). The
275
emotional reactions of HIV antibody positive men.
British Journal Medical Psychology, 62, 153±161.
Wachtel, T., Piette, M. S., Mor, V., Stein, M., Fleishman,
J., & Carpenter, C. (1992). Quality of life in persons with
Human Immunodeficiency Virus infection: Measure-
ment by the Medical Outcomes Study instrument. Annals
of Internal Medicine, 116, 129±137.
Walkey, F. H., Taylor, A. J., & Green, D. E. (1990).
Attitudes to AIDS; A comparative analysis of a new and
negative stereotype. Social Science and Medicine, 30,
549±552.
Watson, R., Eskelson, C., & Hartman, B. (1984). Severe
alcohol abuse and cellular immune functions. Arizona
Medicine, 41, 665±668.
Weber, R., Ledergerber, B., Opravil, M., Siegenthaler, W.,
& Luthy, R. (1990). Progression of HIV infection in
misusers of injected drugs who stop injecting or follow a
program of maintenance treatment with methadone.
British Medical Journal, 301, 1362±1365.
Webster, A. (1991). Cytomegalovirus as a possible co-
factor in HIV disease progression. Journal of Acquired
Immune Deficiency Syndrome, 4(Suppl.) S47±S52.
Weimer, E., Nilsson-Schonnesson, L., & Clement, U.
(1989). HIV-Infektion: Trauma und Traumaverarbei-
tung. Psyche-Zeitschrift-fur-Psychoanalyse-und-inhre-
Anwendungen, 43, 720±735.
Wiklund, I., Oden, A., Sanne, H., Ulvenstam, G.,
Wilhelmsson, C., & Wilhemsen, L. (1988). Prognostic
importance of somatic and psychosocial variables after a
first myocardial infarction. American Journal of Epide-
miology, 128, 786±795.
Williams, J., Rabkin, J., Remien, R. et al. (1991). Multi-
disciplinary baseline assessment of homosexual men with
and without human immunodeficiency virus infection II.
Standardized clinical assessment of current and lifetime
psychopathology. Archives of General Psychiatry, 48,
124±130.
Williams, R., Barefoot, J., Califf, R., Haney, T., Saunders,
W., Pryor, D., Hlatky, M., Siegler, I., & Mark, D. (1992).
Prognostic importance of social and economic resources
among medically treated patients with angiographically
documented coronary artery disease. Journal of the
American Medical Association, 267, 520±524.
Woods, T., Antoni, M. H., Ironson, G., & Kling, D.
(1996). Religiosity and its relationship to affective
distress, immune and health status in HIV-infected gay
men. Psychosomatic Medicine, 58, 84.
Workman, E. A., & La Via, M. F. (1987). T-lymphocyte
polyclonal proliferation: Effects of stress and stress
response style on medical students taking national board
examinations. Clinical Immunology and Immunopathol-
ogy, 43, 308±313.
Wortman, C. B., & Conway, T. L. (1985). The role of social
support in adaptation and recovery from physical illness.
In S. Cohen & S. L. Syme (Eds.), Social support and
health (pp. 281±302). New York: Academic Press.
Wortman, C. B., & Dunkel-Schetter, C. (1987). Conceptual
and methodological issues in the study of social support.
In A. Baum, S. Taylor, & J. E. Singer (Eds.), Handbook
of psychology and health (vol. 5, pp. 63±108). Hillsdale,
NJ: Erlbaum.
Yao, Q. Y., Rickingon, A. B., Gaston, J. S. H., & Epstein,
M. A. (1985). In vitro analysis of the Epstein-Barr virus:
Host balance in long-term renal allograft recipients.
International Journal of Cancer, 35, 43±49.
Zich, J., & Temoshok, L. (1987). Perceptions of social
support in men with AIDS and ARC: Relationships with
distress and hardiness. Journal of Applied Social Psy-
chology, 17,(3), 193±215.
Zuckerman, M., & Antoni, M. H. (1995). Social support
and its relationship to psychological physical and
immune variables in HIV infection. Clinical Psychology
and Psychotherapy, 2(4), 210±219.