Analyzing HADS data for two different participant strata (baseline scores above versus below the cut-off separating normal and pathological values) indicated that significant CBSM training effects were only observable in subjects above the cut-off score (Fig. 3). Effect sizes (d values) for differences between baseline and 12-month follow-up scores indicated a significant benefit for the CBSM group above the respective cut-off score (HADS anxiety, 1.2; HADS depression, 1.5), whereas effect size scores were all d < 0.2 in controls and in the CBSM group below cut-off.
We found no effects of CBSM training on morbidity, viral load and CD4 cell counts, and adherence to cART compared with standard medical care. However, we did observe benefits of CBSM training on quality of life and psychological distress. Notably, significant improvements in distress were only observable in individuals with high distress at baseline.
A strength of this trial was the inclusion of a group of HIV-infected persons from a routine practice clinical setting who were taking stable antiretroviral therapy and had restored cellular immunity. Further strengths include the longitudinal assessment of the clinically relevant markers of HIV infection, the use of an intervention according to a manual, and the recruitment at multiple study centers. Limitations are that the mode of group training might have affected the acceptability of the intervention, which would explain the fact that only a small proportion (6.1%) of eligible individuals actually agreed to participate. Other routes of administration with known efficacy, such as individual psychotherapy, might prove to be more accessible to HIV-infected persons who are unwilling to participate in group therapy sessions [31,32].
Our findings endorse previous reports on the efficacy of CBSM training in reducing psychological distress and enhancing quality of life in HIV-infected individuals [19,23], extending these findings to persons receiving cART. However, we were unable to find evidence for beneficial short- or long-term CBSM training effects on surrogate markers of HIV infection as previously reported by others [16,33,34]. These discrepancies between earlier studies and our controlled trial are unlikely to result from differences in the efficacy of the employed CBSM training, since effect sizes in the psychosocial outcome parameters were comparable. Although not directly comparable to our viral load effect size estimate, Antoni et al. reported a 0.56 log10 copies/ml decrease in HIV viral load over 15 months in a CBSM training group after controlling for HIV medication adherence. However, these results were obtained in persons with substantial morbidity, including 54% with previous AIDS and 77.6% with detectable plasma HIV levels at baseline, who were on heterogeneous and nonsuppressive antiretroviral regimens.
The absence of an effect of CBSM on clinical markers may be explained by the relatively small contribution of psychosocial factors to HIV progression among persons on cART with complete viral suppression and restored immune function. Since a negative impact of psychological distress on HIV disease progression has been demonstrated in prospective studies with a follow-up of up to 9 years [1,2], effects of CBSM training on the clinical status might be observed in the long-term observation of HIV-infected individuals with high levels of psychological distress.
Our results indicate that CBSM group training is an efficacious and effective intervention for enhancing quality of life and psychological well-being in HIV-infected persons taking stable antiretroviral therapy with restored immunity and little somatic morbidity. Its beneficial effects are particularly observed among persons who present with depression and anxiety scores at baseline, which indicate high psychological distress. Therefore, screening for psychological distress  and referral to individually acceptable psychotherapeutic interventions should be integral to HIV management, if not all somatic diseases .
We are indebted to the participants and to the study nurses (Christina Grube, Anna Christen, Miriam Unger, Nicca Dunja, Susanne Stoelzl, and Andreas Egger) and the physicians of the participating HIV outpatient clinic at the University Hospital Zurich, the University Hospital Basel, University Hospital Bern, and the Cantonal Hospital St. Gallen, Switzerland, for patient care and data collection.
Members of the Swiss HIV Cohort Study group: M. Battegay, E. Bernasconi, H. Bucher, Ph. Bürgisser, M. Egger, P. Erb, W. Fierz, M. Fischer, M. Flepp (Chairman of the Clinical and Laboratory Committee), P. Francioli (President of the SHCS), H.J. Furrer, M. Gorgievski, H. Günthard, P. Grob, B. Hirschel, L. Kaiser, C. Kind, Th. Klimkait, B. Ledergerber, U. Lauper, M. Opravil, F. Paccaud, G. Pantaleo, L. Perrin, J.-C. Piffaretti, M. Rickenbach (Head of Data Centre), C. Rudin (Chairman of the Mother & Child Substudy), J. Schupbach, R. Speck, A. Telenti, A. Trkola, P. Vernazza (Chairman of the Scientific Board), Th. Wagels, R. Weber, and S. Yerly.
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