The face of HIV/AIDS has changed dramatically in the last 30 years, from a disease contracted largely by gay white men to one that is increasingly transmitted among low-income minority young people. While gay and bisexual men remain the largest group affected by HIV — particularly young African-American men — ethnic-minority women are increasingly represented among those diagnosed with the disease. Middle-aged people, both gay and straight, also continue to struggle with HIV, attempting to find meaning and purpose in their lives when having the virus is no longer considered a death sentence but remains a medical and social albatross (see "Questionnaire").
Psychology is well-positioned to help in both the prevention and treatment of this continuing though less-lethal scourge, thanks to the field's strong evidence base and decades of work on the behavioral aspects of HIV/AIDS, says David J. Martin, PhD, the new director of APA's Office on AIDS.
"The use of social science data to inform the activities of our office and public policy is essential to ensuring that monies spent on HIV-related services are used wisely, and that they benefit the people they are supposed to serve," he says.
New realities, new plans
Martin brings a wealth of experience to his position. In the 1980s, he was among the first psychologists to advocate for more and better mental health services for people in the Los Angeles area who were dealing with the then-mysterious virus. He started by consulting to the team that provided medical treatment to patients hospitalized with AIDS at Harbor-UCLA Medical Center. He then served on several committees and boards of directors of AIDS organizations, and eventually established a mental health treatment program for people with AIDS at Harbor-UCLA.
For the next 30 years he directed that program and served on boards and commissions related to the mission of serving the mental health needs of those with HIV/AIDS. He was also chief psychologist and director of training in the psychology division at Harbor-UCLA Medical Center, held an appointment as clinical professor in the department of psychiatry and biobehavioral sciences in the David Geffen School of Medicine at UCLA, and was principal investigator on several federal grants related to HIV/AIDS, including HIV-risk reduction, mental health and workforce issues.
Martin also served as a member of APA's Committee on Psychology and AIDS (COPA), whose aim is to guide the development and implementation of APA's organizational response to the HIV/AIDS epidemic. He's volunteered for the Office on AIDS flagship programs he now oversees, including the HIV Office for Psychology Education (HOPE) program, and the Behavioral and Social Sciences Volunteer Program, known as BSSV.
"I had a sense of what the office was doing, and I thought I could make a contribution," he explains.
Martin brings high-level expertise to HIV's new challenges, says Emory University School of Medicine Associate Professor Eugene W. Farber, PhD, who chairs COPA. "Dave's substantive and well-rounded knowledge of the psychological aspects of HIV disease through his experiences as a clinician, researcher and educator make him excellently suited for directing the APA Office on AIDS," says Farber.
Updating great programs
One of Martin's first goals is to update elements of the HOPE and BSSV programs. HOPE trains volunteer mental health providers across the country to work with people living with or affected by HIV/AIDS. Since 1991, it has trained and certified more than 490 volunteers, who in turn have trained more than 32,000 mental health professionals. Martin is in the process of updating HOPE's curriculum to reflect the latest knowledge on the disease and its prevention and treatment, he says, noting that information in the area changes quickly. For example, he'd like to further educate HOPE volunteers about the challenges people with HIV/AIDS face when they seek to re-enter the workforce, a topic he has been studying since the mid-1990s. In his research, he found that HIV-infected people who received an evidence-based intervention that included elements of motivational interviewing, dialectical behavior therapy techniques and job skills training were more likely than those who received standard community services to engage in employment-related activities and to stay employed once back on the job.
Because the virus has now spread to young minority populations who may never have held a job, may have dropped out of school and may have problems with substance abuse, APA's program should also begin to address workplace entry help for a group that may lack job skills, Martin adds.
That, he says, "represents a far greater challenge than taking someone with a history of gainful employment and re-introducing skills that might have gotten rusty."
Research also suggests that helping those with the illness return to or enter the workplace is vital, since people feel better about themselves when they are employed.
Martin also is looking at ways to move part of HOPE's training program to the Web, while retaining a team of volunteers who can consult with trainees in person after they receive online training. BSSV is a national network of psychologists and other social scientists and providers that offers free, ongoing technical assistance to organizations that seek to implement cutting-edge prevention programs in their communities. Martin wants to update it in a way that reflects the needs and demographics of the newer groups affected by HIV/AIDS, as well as the changing approaches to prevention currently underway. For example, recent research findings on pre-exposure prophylaxis, known as PrEP, have been interpreted by some to suggest that providing antiretroviral medication to uninfected individuals may protect them from infection. However, a review of these findings clearly indicates that all of these studies included strong behavioral components — that medication alone will not reduce the continued spread of HIV infection. A resolution adopted by APA's Council of Representatives in February 2012, "Combination Biomedical and Behavioral Approaches to Optimize HIV Prevention," elaborates on this position.
"Ongoing efforts at risk reduction must stress behavioral interventions, such as condom use and medication adherence, not just medication itself," Martin says.
In addition, Martin wants the office to continue to share psychology's knowledge on HIV/AIDS to help shape policy. In April, just six weeks into his new APA position, he testified before the Presidential Advisory Council on HIV/AIDS on a range of social science issues related to HIV, including the importance of behavioral interventions in helping to prevent HIV transmission; the reauthorization of the Ryan White Care Act, which provides AIDS-related services that are not reimbursable under the Affordable Care Act; and HIV and employment.
"I really welcome the opportunity to take things to the next level by using data to inform policy and try and make meaningful policy changes," Martin says.
He may already be having an important impact: On July 15, a little less than two months after Martin gave his testimony, President Obama issued an executive order establishing a committee to speed up improvements in HIV prevention and care that included representation from the Department of Labor, meaning that the president heard the message about the importance of addressing workforce issues in dealing with the epidemic. "I can't claim credit for that — there are certainly others who have advocated for this initiative," says Martin. "But the timing was right."
The bigger picture
Martin also is considering the office's work from a more global perspective — whether or how much to emphasize domestic versus international issues, for example.
"It seems that everyone wants to go overseas to do HIV-related work," he says. "But right here in Washington, D.C., we have an HIV seroprevalence rate that looks like that of South Africa" — some 3 percent of the city's population. "While I'd definitely like to see APA bringing our expertise overseas, I think we need to be involved here at home as well."
Finally, Martin understands that the biggest challenge of his new role may be a perceptual one. The HOPE and BSSV programs "both have their origins in a time when there was a sense of urgency to do something about AIDS and HIV disease," he says, while today, the issue is less politically potent.
Martin adds he wants the Office on AIDS to help realize the theme of this year's World AIDS Day, which takes place Dec. 1: "Getting to zero: Zero new HIV infections. Zero discrimination. Zero AIDS-related deaths."
Tori DeAngelis is a writer in Syracuse, N.Y.
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