AIDS PATIENT CARE and STDs

Volume 21, Number 3, 2007

© Mary Ann Liebert, Inc.
DOI: 10.1089/apc.2006.0077

Improvement of Psychosocial Adjustment to HIV-1

Infection through a Cognitive-Behavioral Oriented
Group Psychotherapy Program: A Pilot Study

ARACELI ROUSAUD, Psych.,1 JORDI BLANCH, M.D., Ph.D.,2

MARTIN HAUTZINGER, Ph.D.,3 ELISA DE LAZZARI, Ph.D.,4 JOSEP MARIA PERI, Ph.D.,2
OLGA PUIG, Psych.,2 ESTEBAN MARTINEZ, M.D., Ph.D.,5
GUILLEM MASANA, M.D., Ph.D.,2 JOAN DE PABLO, M.D., Ph.D.,2
and JOSEP MARIA GATELL, M.D., Ph.D.5

ABSTRACT

The present study evaluated the efficacy of a group therapy program in improving psychosocial
adjustment to HIV infection, and tried to identify variables predictive of greater improvement.
The outcome of 47 completing patients was analyzed, comparing the measures between T1 (1
month before therapy), and T2 (first session), and between T2 and T3 (last session) using the
Wilcoxon matched-pairs signed-ranks test for each dimension of the Psychosocial Adjustment
to Illness Scale (PAIS). The therapy consisted of 16 weekly 2-hour sessions following a struc-
tured time-limited cognitive-behavioral group psychotherapy program. During the intervention
(between T2 and T3) a significant improvement was observed in health care orientation, voca-
tional environment, domestic environment, sexual relation, extended family relationships, social
environment, and total PAIS. There were no changes during baseline (between T1 and T2) in
any of the PAIS subscales, or in the total PAIS score. Sexual route of transmission was inde-
pendently associated with an improvement in health care orientation (  2.525). Time since HIV
diagnosis (  0.022) and being employed (  2.548) were independently associated with an
improvement in adjustment to vocational environment. Men who have sex with men showed a
poorer improvement in adjusting to family relations after the intervention (  2.548). Finally,
a lower CD4 count (  0.005) and being employed (  3.054) were independently associated
with an improvement in adjustment to social environment. Our psychotherapy program im-
proved psychosocial functioning in a heterogeneous sample of HIV-1–infected patients referred
to a consultation-liaison psychiatry unit.

INTRODUCTION life expectancies for persons living with HIV in

industrialized countries,1 quality of life and

S INCE RECENT PHARMACOLOGIC ADVANCES, par-

ticularly the advent of highly active anti-
retroviral therapy (HAART), have increased
psychosocial functioning have become impor-
tant concerns.2,3 Psychosocial adjustment is de-
fined as the capacity of an individual to per-

1Fundació Clínic per la Recerca Biomèdica-IDIBAPS, Institut d’Investigacions Biomèdiques Agustí Pi i Sunyer, Hos-

pital Clínic de Barcelona, Barcelona, Spain.

2Clinical Institute of Neurosciences, Hospital Clínic de Barcelona, Barcelona, Spain.
3Clinical and Physiological Psychology Department, Eberhard-Karls-University of Tübingen, Tübingen, Germany
4Epidemiology and Biostatistics Unit, Hospital Clínic de Barcelona, Barcelona, Spain.
5Infectious Diseases and Microbiology Department, Hospital Clínic de Barcelona, Barcelona, Spain.

212
IMPROVING ADJUSTMENT TO HIV THROUGH GROUP THERAPY
form social and domestic roles so as to meet the
challenges of every day living without emo-
tional distress or physical disability.4 The con-
cept includes interactions between the individ-
ual and other individuals and the institutions
that make up his or her sociocultural environ-
ment. Such interactions are usually achieved
through loosely prescribed behavioral patterns
termed “roles.” The functional efficiencies of an
individual’s role behavior (e.g., as spouse, par-
ent, professional) tend to be highly correlated
with judgments concerning his or her level of
psychosocial adjustment. Furthermore, it has
been consistently observed in many major dis-
eases that the nature of the patient’s psychoso-
cial adjustment can be just as important as the
status of his or her physical disease in deter-
mining the quality of an illness experience.5
Although there is substantial evidence that
psychotherapy interventions improve mood,6
adherence to treatment,7 and quality of life,8
few studies have specifically focused on the as-
sessment of the improvement of psychosocial
adjustment through a psychotherapy interven-
tion.9–10 This is the case in spite of the consid-
erable demand from HIV-infected patients for
public mental health assistance, especially from
those referred to a consultation-liaison psychi-
atry department. To optimize use of public
mental health resources and to benefit as many
patients as possible, short but efficient struc-
tured interventions are needed.
As a continuation of a previous study pub-
lished elsewhere by our group,6 the aim of the
present study is to evaluate the efficacy of a struc-
tured time-limited, cognitive-behavioral oriented
group therapy for HIV-infected patients who
were referred to a consultation-liaison psychiatry
unit from the infectious disease department and
who presented difficulties in the psychosocial ad-
justment to the HIV infection. The study also aims
to identify baseline characteristics associated with
improvement and successful outcome.
MATERIALS AND METHODS
Subjects’ recruitment, type of intervention,
and study design were described in detail in a
previous publication6 and will be summarized
as follows.
213
Subjects
Patients were recruited from August 1998 to
July 2003. Inclusion criteria were proven HIV-
positive status for at least 3 months and a clin-
ical judgment of significant psychosocial dis-
tress due to HIV-infection established by both
the psychiatrist (J.B.) and the psychologist
(A.R.), and based on their clinical experience.
Exclusion criteria were nonstabilized axis-I
psychiatric disorders where patients had to be
ascribed mainly to psychopharmacologic treat-
ment (for example, mood disorders with risk
of suicide, presence of psychotic symptoms,
current frequent panic attacks), organic mental
disorders, substance abuse during the last 6
months, symptomatic non-HIV medical dis-
ease, significant cognitive impairment, and any
medical conditions that could interfere with at-
tendance at the therapy sessions.
Intervention
Each group was closed and consisted of 8 to
12 participants, a leader or therapist (A.R.) who
was a psychologist, and a coleader or cothera-
pist who was a psychiatrist (J.B.) or a psychol-
ogist (O.P., J.M.P.). The therapy consisted of 16
weekly 2-hour sessions following a structured
time-limited cognitive-behavioral psychother-
apy program. The intervention program has
been described elsewhere, and was based on a
treatment manual.6,12 The main objectives of
the therapy were to teach the participants to
use cognitive and behavioral skills and strate-
gies. Patients were introduced to exercises for
training in problem-solving skills focused on
specific HIV-related concerns, and shown edu-
cational presentations on HIV and mental
health. Concerns and problems that are com-
mon in the context of the illness13 were han-
dled from a cognitive problem-solving per-
spective: disclosure of serostatus, safer sex
practices if sexually active, treatment compli-
ance and adherence to medical controls, and
dealing with adverse effects such as lipodys-
trophy, isolation, lack of future plans, etc.
Measures
Measures were performed at three time
points: T1 or baseline (at least 1 to 2 months be-
214 ROUSAUD ET AL.

fore beginning of the therapy), T2 (during the could not implement a control group design. Pa-
first session of the group-therapy), and T3 (dur- tients were referred to our unit from the infec-
ing the last session). tious disease department for psychopharmaco-
At baseline, all recruited patients were inter- logic treatment or general psychotherapy. Most
viewed using the Spanish adaptation of the of the patients who were not permitted to enter
Structured Clinical Interview for DSM-III-R, a group because it was complete or already on-
patient version.14 The psychiatric interview going were not able to remain on a waiting list
also included questions about patient charac- for a long time, so they received interpersonal
teristics, as well as about HIV-related data such psychotherapy or psychopharmacologic treat-
as the date of knowledge of their serostatus, ment. This meant that we were unable to com-
route of transmission, current CD4 cell count pile a control group from a waiting list. For com-
and viral load, and opportunistic diseases. At parisons, we decided to use the patients
all time points (T1, T2, and T3) patients com- themselves as their own controls by performing
pleted the Psychosocial Adjustment to Illness two preintervention measures (T1 and T2).
Scale (PAIS).15
Given the predominance of physical dimen- Statistics
sions in most of the instruments used to measure
Patients who did not finish the study
quality of life in HIV infection, and the need to
(dropouts) were compared to those who did
provide a greater emphasis on psychosocial do-
(completers) using the Wilcoxon rank sum test
mains, we decided to use the PAIS, because it
for continuous variables and the 2 test or
was designed to assess functional, emotional,
Fisher’s exact test for categorical variables. The
and social dimensions of quality of life in patients
outcome of completing patients was analyzed
with medical illnesses.16 It evaluates the psy-
comparing the measures between T1 and T2,
chological and social adjustment to illness dur-
and between T2 and T3 using the Wilcoxon
ing the previous 4 weeks. We used the Spanish
matched-pairs signed-ranks test for each di-
validation of the questionnaire17 replacing the
mension of the PAIS. No outcome data were
original term “illness” with the term “HIV in-
collected on patients who withdrew from the
fection.” The PAIS comprises 46 questions that
study. Univariate and multivariate logistic re-
were divided into seven assessment domains: (1)
gression analysis were performed to identify
health care orientation; (2) vocational environ-
patient characteristics or baseline measures
ment, (3) domestic environment; (4) sexual rela-
able to predict better outcome, in terms of de-
tions; (5) extended family relationships, (6) social
creases on dimension scores between T2 and
environment; and (7) psychological distress. All
T3. Univariate logistic regression analysis was
items were also summed together for the total
used initially to screen for association between
score. This instrument has shown a good degree
each outcome variable and each of the baseline
of reliability for both individuals and groups.15
independent variables considered individu-
The seven domains are relatively independent of
ally. A stepwise multivariate logistic regression
each other in the assessment of the overall score,
analysis was used to create a multivariate
and each gives a measure of the PAIS validity.
model for the baseline factors associated with
Higher scores indicate poorer functioning.
changes on the PAIS dimension scores. All p
values were two-tailed and statistical signifi-
Design
cance was set at 0.05. All calculations were per-
Participants were followed for 20 weeks: 4 formed with the STATA 7.0 software.18
weeks of baseline (between T1 and T2) and 16
weeks of therapy (between T2 and T3). Be-
tween T1 and T2 the patients did not receive
psychotherapy of any kind, and this period RESULTS
served as a control condition in which no
Subjects’ characteristics
changes in the measures were expected. The
group therapy took place between T2 and T3. During the period of recruitment, of 82 out-
For ethical, clinical, and practical reasons we patients sent to our consultation-liaison psychi-
IMPROVING ADJUSTMENT TO HIV THROUGH GROUP THERAPY 215

atry unit from the infectious disease service,
who were offered to participate in our study, 66
(80.5%) agreed, though only 47 finished the en-
tire program. Subjects were assigned to partici-
pate in 6 different groups. The mean number of
participants per group was 11. Table 1 shows
the characteristics of the patients who agreed to
participate in the study, divided as follows: pa-
tients who finished the whole follow-up period
(completers) and patients who were recruited
but abandoned the study (dropouts).
Dropouts
Of the 66 participants, 47 (31 men and 16
women) finished the complete follow-up pe-
riod. Most dropouts (19 patients, 29%) left the
study during the intervention period. One pa-
tient did not come to the first visit because he
had started work 1 week before the first ses-
sion of the therapy; 4 patients did not answer
the PAIS questionnaire correctly or did not
complete it inside the established time-limits.
Reasons for dropping out during the therapy
included medical complications (6 patients),
beginning a new job (4 patients), not feeling
comfortable with the group (3 patients), and
imprisonment (1 patient).
Comparison of variables at baseline be-
tween dropouts and patients who finished the
follow-up period (completers) did not show
significant differences on any of the following
variables at baseline: age, gender, sexual ori-
entation, route of transmission of HIV infec-
tion, time since HIV diagnosis, CD4 count,
presence or absence of opportunistic diseases,
psychiatric diagnosis and PAIS dimension
scores (p  0.05 for each; Table 1).

TABLE 1. DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF STUDY PATIENTS:

DIFFERENCES BETWEEN COMPLETERS AND DROPOUTS (N  66)

Completers Dropouts Total

(n  47) (n  19) (n  66) p value

Age (years), median (IQR) 39 (35–46) 37 (33–44) 39 (35–45) n.s.

Gender (male), n (%) 31 (66) 11 (58) 42 (64) n.s.
Sexual orientation, n (%) n.s.
Heterosexual 28 (60) 10 (53) 38 (58)
MSM 19 (40) 9 (47) 24 (36)
With partner, n (%) 13 (28) 8 (42) 21 (32) n.s.
Route of transmission, n (%) n.s.
Sexual 34 (72) 18 (95) 52 (79)
Intravenous drug users 13 (28) 1 (5) 14 (21)
Time since HIV diagnose (months), median (IQR) 64 (18–110) 72 (26–104) 70 (19–104) n.s.
Previous opportunistic diseases, n (%) 8 (17) 6 (32) 14 (21) n.s.
Good compliance with HAART, n (%) 42 (89) 16 (84) 58 (88) n.s.
Psychiatric diagnoses, n (%) n.s.
Major depression 6 (13) 1 (5) 7 (11)
Dysthymia 9 (19) 0 9
Adjustment disorder 28 (60) 17 (89) 45 (68)
Generalized anxiety disorder 4 (9) 1 (5) 5 (8)
PAISa subscales (baseline) n.s.
Health care orientation, median (IQR) 8 (6–11) 8 (6–10) 8 (6–11) n.s.
Vocational environment, median (IQR) 9 (5–12) 7 (5–9) 8 (5–12) n.s.
Domestic environment, median (IQR) 5 (2–10) 9 (6–12) 5 (2–10) n.s.
Sexual relations, median (IQR) 9 (5–12) 11 (5–13) 9.5 (5–12) n.s.
Extended family relations, median (IQR) 2 (0–6) 2 (0–7) 2 (0–6) n.s.
Social environment, median (IQR) 12 (6–15) 13 (3–15) 12 (6–15) n.s.
Psychological distress, median (IQR) 12 (8–14) 10 (8–16) 12 (8–14)
Total, median (IQR) 59 (38–76) 52 (33–72) 57 (37–78) n.s.

Referred patients were divided into those who finished the whole follow-up period (completers), patients who were
recruited to participate, but abandoned during the study (dropouts). Proportions were compared by using Fisher’s
exact test; continuous variables were compared by Wilcoxon rank sum test. Only significant p values (p  0.05) were
presented.
PAIS, Psychosocial Adjustment to Illness Scale; n: number of patients (rate value in brackets); IQR, interquartile
range; MSM, men who have sex with men; n.s., not significant.
216 ROUSAUD ET AL.

Participants’ characteristics 0.001), and total PAIS score (z  4.155, p 

Median scores and interquartile range on the
PAIS subscales and the rest of the characteris-
tics of the participants (64% men, n  42; 36%
women, n  24) are presented in Table 1. The
most frequent psychiatric condition was ad-
justment disorder (60%) (with depressed mood
(13%), with anxiety (15%), or mixed (32%), fol-
lowed by dysthymia (19%), and major depres-
sion (single episode or recurrent) (13%).
The mean number of sessions attended dur-
ing the period of therapy was 14.
Effect of intervention
Wilcoxon matched-pairs signed-ranks test
showed significant changes during the inter-
vention period (between T2 and T3) in health
care orientation (z  2.771, p  0.006), voca-
tional environment (z  2.062, p  0.039), do-
mestic environment (z  2.409, p  0.016),
sexual relations (z  3.723, p  0.001), ex-
tended family relationships (z  2.087, p 
0.037), social environment (z  3.671, p 
0.001). There were no changes during baseline
(between T1 and T2) in any of the PAIS sub-
scales, or in the total PAIS score. Table 2 shows
the degree of improvement for each subscale
and the total PAIS score (Table 2).
Predictors of improvement
The impact of the variables of age, gender,
sexual orientation, route of transmission, time
since HIV diagnosis, CD4 count, viral load,
presence of opportunistic diseases, employ-
ment, partnership, TARV compliance, and psy-
chiatric diagnosis in each PAIS subscale is
shown in Tables 3 and 4.
For example, compared to heterosexuals,
men who have sex with men (MSM) showed
more improvement in adjustment to health
care (p  0.041), but less improvement in fam-
ily relationships (p  0.049). Employed patients
reported more improvement in their vocational
environment (p  0.023) and patients infected
through sexual intercourse showed a greater

TABLE 2. MEDIANS, INTERQUARTILE RANGES, WILCOXON MATCHED-PAIRS SIGNED-RANKS TEST,

AND DEGREE OF IMPROVEMENT FOR EACH PAIS SUBSCALE AND TOTAL PAIS SCORE
OF PATIENTS COMPLETING THE COGNITIVE-BEHAVIORAL GROUP THERAPY (N  46)

Time-point of measure Statistical data

T1 T2 T3 Differencea Differencea
(1 month (first (last between T1 between T2 Degree of
before) session) session) and T2 and T3 improvement
between T2
Median Median Median p p and T3
PAIS (IQR) (IQR) (IQR) z value z value %

Health care 8 9 7 0.085 n.s. 2.771 0.006 8.3

orientation (6–11) (6–12) (5–10)
Vocational 9 8 5 0.984 n.s. 2.062 0.039 16.6
environment (5–12) (4–12) (2–11)
Domestic 5 5 4 0.215 n.s. 2.409 0.016 4.1
environment (2–10) (2–10) (1–8)
Sexual relations 9 9 7 0.236 n.s. 3.723  0.001 10.1
(5–12) (5–12) (4–9)
Extended family 2 3 1 1.230 n.s. 2.087 0.037 11.1
relations (0–6) (1–7) (0–5)
Social 12 10 6 0.986 n.s. 3.671  0.001 22.3
environment (6–15) (5–15) (2–11)
Psychological 12 11 7 0.495 n.s. 4.690  0.001 19.1
distress (8–14) (9–14) (4–10)
Total 59 54 39 0.657 n.s. 4.155  0.001 10.8
(38–79) (35–76) (25–62)
aWilcoxon matched-pairs signed ranks test.
PAIS, Psychosocial Adjustment to Illness Scale; IQR, interquartile range; n.s., not significant; MSM, men who have
sex with men.
 TABLE 3. UNIVARIATE LOGISTIC REGRESSION ANALYSIS OF THE FACTORS ASSOCIATED WITH IMPROVEMENT
IN EACH SUBSCALE OF THE PSYCHOSOCIAL ADJUSTMENT TO ILLNESS SCALE (N  47)

Items of the Psychosocial Adjustment to Illness Scale

Factors used in
the multivariate Statistical Health care Vocational Domestic Sexual Family Social Psychological
analysis parameters orientation environment environment relations relationships environment distress Total

Agea Coefficient NS NS NS NS NS NS NS NS
95% CI
p-value
Gender (female) Coefficient NS NS NS NS NS NS NS NS
95% CI
p-value
Sexual Coefficient 1.827 NS NS NS 2.814 NS NS NS
orientation 95% CI (0.126–3.528) (0.091–5.537)
(MSM) p-value 0.041 0.049
Employed Coefficient NS 2.407 NS NS NS NS NS NS
95% CI (0.408–4.406) (0.283–4.968)
p-value 0.023 0.087
With partner Coefficient NS NS NS NS NS NS NS NS
95% CI
p-value
HIV Coefficient 2.525 NS NS NS NS NS NS NS
transmission 95% CI (0.714–4.336)
(sexual) p-value 0.009
Time since HIV Coefficient NS 0.020 NS NS NS NS NS NS
diagnosisb 95% CI (0.002–0.038)
p-value 0.032
CD4 counta Coefficient NS NS NS NS NS 0.004 NS NS
95% CI (0.008–0)
p-value 0.062
Viral loada Coefficient NS NS NS NS NS NS NS NS
95% CI
p-value
Opportunistic Coefficient NS NS NS NS NS NS NS NS
diseases 95% CI
p-value
TARV compliance Coefficient NS NS NS NS NS NS NS NS
95% CI
p-value
Psychiatric Coefficient NS NS NS NS NS NS NS NS
diagnosis 95% CI
p-value
aContinuous variable.
CI, confidence interval; NS, not statistically significant; IVDU, intravenous drug users; MSM, men who have sex with men.
218
TABLE 4. RESULTS OF STEPWISE MULTIVARIATE LOGISTIC REGRESSION: EFFECT OF BASSELINE VARIABLES ON THE RATE
IMPROVEMENT BETWEEN T2 (FIRST SESSION) AND T3 (LAST SESSION) IN EACH PAIS SUBSCALE (N  47)
PAIS subscales Variable Categories
Health care Route of Sexual
transmission IVDU
Vocational Time since
environment HIV
diagnosis
Employed
Family Sexual MSM
relations orientation heterosexual
Social Employed
environment CD4 count
PAIS, Psychosocial Adjustment to Illness Scale; IVDU, intravenous drug users; MSM, men who have sex with men.
improvement in health care (p  0.009) than
patients infected through intravenous drug
use. Time since HIV diagnosis was associated
with a greater improvement in adjustment
to the vocational environment (p  0.032),
whereas CD4 count was inversely associated
with a greater improvement in adjustment to
the social environment (p  0.062) (Table 3).
The multivariate linear regression analysis of
each subscale of the PAIS is shown in Table 4.
Sexual route of transmission was indepen-
dently associated with an improvement in
health care orientation through the psycho-
therapy intervention (  2.525, p  0.009).
Time since HIV diagnosis (  0.022, p 
0.016) and being employed (  2.548, p 
0.012) were independently associated with an
improvement in adjustment to vocational en-
vironment. MSM showed a poorer improve-
ment in adjusting to family relations after the
intervention (  2.548, p  0.049). Finally, a
lower CD4 count (  0.005, p  0.002) and
being employed (  3.054, p  0.024) were in-
dependently associated with an improvement
in the adjustment to social environment.
DISCUSSION
Although HIV-1 infection in first world is
no longer regarded as a fatal illness, it is still
considered a long-term process with a great
many stressful factors that patients have to
confront. Psychotherapeutic intervention is
ROUSAUD ET AL.
OF
Adjusted
coefficient 95% confidence interval p value
2.525 0.714–4.336 0.009
0.022 0.005–0.038 0.016
2.548 0.654–4.442 0.012
2.814 0.091–5.537 0.049
3.054 0.491–5.618 0.024
0.005 0.009–0.001 0.022
needed when patients have problems in ad-
justing with the new situations caused by the
infection. In a previous report we demon-
strated the immediate and long-term efficacy
of a cognitive-behavioral oriented group psy-
chotherapy program for HIV-infected pa-
tients with anxiety and depressive symptoms
referred to a consultation-liaison psychiatry
department.6 The present study seeks to show
the ability of this psychotherapy program to
improve the psychosocial functioning of a
heterogeneous sample of patients with HIV-
1 infection. Many previous studies suggest
that cognitive-behavioral group interventions
in HIV-positive patients reduce depression,
anxiety and generalized psychiatric distress
indicators,13 although to our knowledge,
only two published studies have examined
the efficacy of psychotherapy in improving
psychosocial functioning in HIV-1–positive
patients.10,11 Molassiotis and coworkers10
demonstrated the efficacy of a cognitive-be-
havioral group therapy in improving quality
of life in Chinese patients with symptomatic
HIV disease compared to a peer support/
counseling group therapy and to a group re-
ceiving routine treatment with no formal psy-
chosocial intervention. In contrast, in a ran-
domized 3  3 block design study, Eller and
coworkers11 found no significant improve-
ment in quality of life in a sample of patients
receiving guided imagery or progressive
muscle relaxation compared to a control
group.
IMPROVING ADJUSTMENT TO HIV THROUGH GROUP THERAPY
PAIS subscale improvement during therapy
The present study shows that a structured,
time-limited, cognitive–behavioral oriented
group therapy program may be clinically use-
ful for improving psychosocial adjustment to
HIV-infection in a heterogeneous sample of pa-
tients referred to a consultation-liaison psychi-
atry unit. All PAIS dimensions improved dur-
ing the intervention period, but not during the
waiting period (baseline). The dimension that
showed the greatest improvement was social
environment, followed by vocational function-
ing and psychological distress.
Given the lack of scientific evidence for these
phenomena, we suggest the following expla-
nations on the strength of our clinical experi-
ence:
• The Social Environment subscale reflects
the status of the patient’s current social
and leisure time activities, and the degree
to which the patient has suffered impair-
ment or constriction of these activities as a
result of the HIV infection and/or its treat-
ment.15 Therapy allows the improvement
of social functioning via the planned in-
crease in social activities. Patients are also
trained to use strategies to confront the
disclosure of serostatus to significant oth-
ers. These strategies are complemented by
the group effect, which enables subjects to
meet others in the same situation as them-
selves.
• The Vocational Environment subscale ad-
dresses the impact that a medical disorder
may have on vocational adjustment, defin-
ing “vocational” flexibly to indicate work,
school, or home, whichever is most appro-
priate.15 The therapy promotes the onset of
new projects and the acquisition of problem
solving-strategies.
• The Psychological Distress subscale is de-
signed to measure dysphoric thoughts and
feelings that accompany the patient’s disor-
der, or are a direct result of the illness and
its sequelae.15 Anxiety is improved through
the presentation of relaxation exercises,19
and depression is improved through the ac-
quisition of strategies following Beck’s in-
tervention model.20
219
Factors associated with better outcome
Analyzing the different domains separately
we were able to obtain more information on the
effect of the therapy on the psychosocial func-
tioning of patients with specific characteristics.
In the multivariate regression analysis, pa-
tients who were infected through sexual inter-
course showed a greater improvement in the
health care orientation dimension than patients
infected through intravenous drug use. The
health care orientation dimension of the PAIS
addresses the nature of the respondent’s health
care posture, and whether it will function to pro-
mote a positive or negative adjustment to the
HIV infection. It is generally accepted that per-
sons infected through intravenous drug use fol-
low antiretroviral treatment and medical con-
trols worse than patients infected via other
routes. In a study by Mizuno and coworkers21
in a sample of patients almost all of whom were
drug users, more than two thirds (63%) of the
participants did not rank HIV as their top life
priority. For the participants of Mizuno’s study,
housing, money, and safety from violence were
particularly salient. It is also noteworthy that
HIV was not necessarily ranked as the second
or third most important by significant numbers
of participants, in fact, nearly half the subjects
ranked HIV as fourth priority or lower, and
more than 1 in 10 ranked HIV as the least im-
portant life issue.21 Furthermore, it seems that
the participants who were drug users did not
benefit from our therapy program in the same
way as the rest of the participants, possibly be-
cause cognitive–behavioral interventions pres-
ent only limited advantages over the standard
interventions in terms of both magnitude and
frequency of HIV risk reduction in drug users.22
Participants who were employed when they
began the therapy showed a significant im-
provement both in their functioning at work or
at home and in their social relationships. In a
previous longitudinal study, most HIV-in-
fected men who were unemployed at baseline
did not return to work after 30 months of fol-
low-up.23 Those authors concluded that spe-
cific interventions may be needed to promote
return to work for people with HIV/AIDS. Our
results suggest that specific psychotherapy
programs are also useful for patients who are
220
still working. HIV-infected patients have many
limitations at work and in their social relations,
especially those who are afraid of disclosing
their serostatus, and who have to take their
medication and attend the control visits with-
out disrupting their everyday professional and
social activities. Through our psychotherapy
program participants were trained to use
strategies to solve these limitations at work and
in their social relations. Our results suggest that
these strategies were more useful for those em-
ployed than for those unemployed. We should
recall at this point that the vocational dimen-
sion assessed by the PAIS also applies to stu-
dents and housewives, given the special defi-
nition of the term used by the designer of the
instrument.5
Time since HIV infection was also signifi-
cantly associated with an improvement in vo-
cational environment. In former times HIV-in-
fected patients stopped working either because
they were physically limited or because they
were considered permanently disabled by our
National Health Service. With the introduc-
tion of highly active antiretroviral treatments
(HAART) many patients improved their phys-
ical status, although they continued to be con-
sidered as patients. Through our psychother-
apy program many patients returned to
activities they had given up many years before
when their HIV positive status was diagnosed.
In our study, MSM showed a lower im-
provement in family relationships than hetero-
sexuals. In fact, family relationship is shown to
be the second most endorsed area of impaired
functioning in MSM.24 HIV-seropositive gay
and bisexual men tend to disclose their HIV
serostatus less frequently to family members
than to friends and partners.25,26 This may be
because disclosing their serostatus often im-
plies revealing their homosexuality to their
family for the first time. Furthermore, HIV-in-
fected MSM reported that friends and lovers
responded more helpfully than relatives.26
They seem to withhold their serostatus from
the family both to avoid personal rejection and
to avoid worrying them.27 Although the ther-
apy may help MSM to deal with their HIV con-
dition in a social environment, it does not seem
to help to improve family relations, as is the
case in heterosexual patients. Heterosexuals do
ROUSAUD ET AL.
not tend to have as much opportunity as MSM
to speak about their infection with friends. Dur-
ing therapy, the heterosexual participants are
able to share impressions with other HIV-pos-
itive persons. This may reduce their feelings of
guilt and encourages them to confront the fam-
ily reaction.
Similar to our previous report,6 the present
study avoids the frequent limitations observed
in other publications. Our patients had all been
referred to a Consultation-Liaison Psychiatry
Department, unlike most previous studies,28–30
in which community announcements or ad-
vertisements were used to recruit patients in
order to obtain large participant samples. This
type of recruitment produces a selection bias,
because people who volunteer for this type of
study may have a special motivation and may
be more receptive to intervention of any kind.
Our patient sample was heterogeneous,
whereas in previous studies most of the pa-
tients were MSM.28–30 Public mental health set-
tings should offer an efficient psychotherapeu-
tic and supportive intervention program for a
heterogeneous group of patients.
Nevertheless, several limitations of this
study should be mentioned. This study fol-
lowed an open-label, observational design and
no randomisation or comparison group was in-
cluded. Therefore, the problems inherent in
observational studies may be present in this in-
vestigation. The dropout rate during the inter-
vention period was very high (approximately
30%). Finally, we did not use postintervention
follow-up measures to ascertain treatment ef-
fects. An efficient therapeutical intervention
program should also aim to achieve long-last-
ing changes.
The results of this study and a review of the
most recent literature suggest that efforts
should be focused on the following areas of en-
hanced intervention development: adapting
the intervention to the client’s needs and in-
cluding a component in the intervention that
specifically targets drug users in order to im-
prove their health care, MSM to improve their
family relationships, and unemployed patients,
who seem to have more difficulties than em-
ployed patients in adjusting to HIV infection.
Our study seems to demonstrate that our
psychotherapy program for HIV infected pa-
IMPROVING ADJUSTMENT TO HIV THROUGH GROUP THERAPY
tients improves psychosocial functioning. A
therapeutic intervention program should not
only reduce distress and improve adjustment
to illness, but should also aim to achieve long-
lasting changes. Further analysis of more de-
finitive data from this ongoing study will be
presented in forthcoming studies to determine
whether this kind of psychotherapeutic inter-
vention is also effective at long-term follow-up,
and able to improve other variables such as
antiviral treatment compliance.
ACKNOWLEDGMENTS
The study was partially supported by the Eu-
ropean Commission Grant SOC 97 201135
05F02.
REFERENCES
1. Holtgrave DR. Causes of the decline in AIDS deaths,
United States, 1995–2002: Prevention, treatment or
both? Int J STD AIDS 2005;16:777–781.
2. Eller L S. Effects of cognitive-behavioral interventions
on quality of life in persons with HIV. Int J Nurs Stud
1999;36:223–233.
3. Worthington C, Myers T, O’Brien K, Nixon S, Cock-
erill R. Rehabilitation in HIV/AIDS: Development of
an expanded conceptual framework. AIDS Patient
Care STDs 2005;19:258–271.
4. Tarter RE, Switala J, Arria A. Plail J, Van Thiel D.
Quality of life before and after orthotopic hepatic
transplantation. Arch Intern Med 1991;151:1521–1526.
5. Derogatis LR, Derogatis MF. The Psychosocial Ad-
justment to Illness Scale (PAIS & PAIS-SR). Adminis-
tration, Scoring, and Procedures Manual II. Townson,
MD: Clinical Psychometric Research, 1990.
6. Blanch J, Rousaud A, Hautzinger M, et al. Assessment
of the efficacy of a cognitive-behavioural oriented group
psychotherapy program for HIV-infected patients re-
ferred to a consultation-liaison psychiatry department.
Psychotherapy and Psychosomatics 2002;71:77–84.
7. Weber R, Christen L, Christen S, et al. Effect of indi-
vuidual cognitive behaviour intervention on adher-
ence to antiretroviral therapy: prospective, random-
ized trial. Antivir Ther 2004;9:85–95.
8. Lechner SC, Antoni MH, Lydston D, et al. Cognitive-
behavioral interventions improve quality of life in
women with AIDS. J Psychosom Res 2003;54:253–261.
9. Sherman AC, Mosier J, Leszcz M, et al. Group inter-
ventions for patients with cancer and HIV disease.
Part I: Effects on psychosocial and functional out-
comes at different phases of illness. Int J Group Psy-
chother 2004;54:29–82.
221
10. Molassiotis A, Callaghan P, Twinn SF, Lam SW,
Chung WY, Li CK. A pilot study of cognitive-
behavioral group therapy and peer support/counsel-
ing in decreasing psychologic distress and improving
quality of life in Chinese patients with symptomatic
HIV disease. AIDS Patient Care STDs 2002;16:83–96.
11. Eller LS. Effects of cognitive-behavioral interventions
on quality of life in persons with HIV. Int J Nurs Stud
1999;36:223–233.
12. Riemer D, Bock J, Escobar LC, Hautzinger M. Grup-
pen-Psychotherapie für Menschen mit HIV/AIDS.
Psychotherapeutics 1998;43:198–204.
13. Kelly JA. Group psychotherapy for persons with HIV
and AIDS-related illnesses. International J Group Psy-
chother 1998;48:143–1626.
14. Spitzer RL, Williams JBW. Structured Clinical Inter-
view for DSM-III-R, patient version with psychotic
symptoms. New York, NY: New York Psychiatric In-
stitute, 1987.
15. Derogatis LR. The psychosocial adjustment to illness
scale (PAIS). J Psychom Research 1986;30:77–91.
16. Wright C, Feurer ID, Payne JL, Wise PE, Shockley S,
Speroff T. Health-related quality of life after different
types of solid organ transplantation. Ann Surg 2000;
232:597–607.
17. Crespo MD, Ferre F. Versión española del PAIS-SR:
Un instrumento de medida para la adaptación psi-
cosocial a la enfermedad física. Psiquis 1992;13:38–44.
18. StataCorp. 2001 Stata Statistical Software: Release 7.0.
College Station, TX: Stata Corporation.
19. Jacobson E. Progressive Relaxation. Chicago: Univer-
sity of Chicago Press, Chicago, 1938.
20. Beck AT. Cognitive models of depression. J Cogn Psy-
cother 1987;1:5–37.
21. Mizuno Y, Purcell D, Borkowski M, Knight K, and the
SUDIS team. The life prorities of HIV-seropositive in-
jection drug users: Findings from a community-based
sample. AIDS Behav 2003;7:395–403.
22. Hershberger SL, Wood M, Fisher G. A cognitive-behav-
ioral intervention to reduce HIV risk behaviors in crack
and injection drug users. AIDS Behav 2003;7:229–243.
23. Rabkin JG, McElhiney M, Ferrando SJ, Van Gorp W,
Lin SH. Predictors of employement of men with
HIV/AIDS: a longitudinal study. Psychosom Med
2004;66:72–78.
24. Berg M, Mimiaga M, Safren S. Mental health concerns
of HIV-infected gay and bisexual men seeking men-
tal health services: An observational study. AIDS Pa-
tient Care STDs 2004;18:635–643.
25. Wolitski RJ, Rietmeijer CA, Goldbaum GM, Wilson RM.
HIV serostatus disclosure among gay and bisexual man
in four American cities: General patterns and relation to
sexual practices. AIDS Care 1998;10:599–610.
26. Hays RB, McKusick L, Pollack L, Hilliard R, Hoff C,
Coates TJ. Disclosing HIV seropositivity to significant
others. AIDS 1993;7:425–431.
27. Mason HR, Marks G, Simoni JM, Ruiz MS, Richard-
son JL. Culturally sanctioned secrets? Latino men’s
nondisclosure of HIV infection to family, friends,
lovers. Health Psychol 1995;14:4–5.
222 ROUSAUD ET AL.

28. Weiss JJ, Mulder CL, Antoni MH, De Vroome, Address reprint requests to:
Garssen B, Goodkin K. Effects of supportive-expres- Araceli Rousaud
sive group intervention on long-term psychosocial
Fundació Clínic per la Recerca
adjustment in HIV-infected gay men. Psychother Psy-
chosom 2003; 72:132–140. Biomèdica-IDIBAPS
29. Lee MR, Cohen L, Hadley SW, Goodwin FK. Cogni- Institut d’Investigacions Biomèdiques Agustí
tive-behavioural group therapy with medication for Pi i Sunyer
depressed gay men with AIDS or symptomatic HIV Hospital Clínic de Barcelona
infection. Psychiatr Serv 1999;50:948–952. Rosellon 140
30. Goodkin K, Blaney NT, Feaster DJ, Baldewicz T,
Burkhalter JE, Leeds B. A randomised controlled clin-
Barcelona 08036
ical trial of a bereavement support group intervention Spain
in Human Immunodeficiency Virus type 1-serposi-
tive and –seronegative homosexual men. Arch Gen
Psychiatry 1999;56:52–59. E-mail: arousaud@hotmail.com