In our case example, Jennifer notes the thought that she will not be able to find a partner because she has HIV. In working to restructure this thought, it is important for the therapist to acknowledge the potential truth that it may be more difficult for Jennifer to find a romantic partner due to the stigma

associated with HIV infection. Across all sessions of CBT-AD, it is important for the therapist to have an appreciation for the various ways in which HIV infection may alter the day-to-day life of the patient and therefore changes the approach to intervention. Applied to cognitive restructuring, PLX3397 in vitro certain negative thought patterns may be more difficult to challenge for an individual with HIV (e.g., “I am going to die young”; “I will never have children”; “My family will reject me”), because although these thoughts are still distorted, certain aspects of these thoughts may be true. For example, a more realistic thought for “I am going to die young” may be: “I may have more medical struggles due to my HIV infection, but taking my medication

will help me stay healthy as long as possible. Patients with chronic illness often experience multiple co-occurring mental health and psychosocial problems that necessitate ZD1839 purchase flexibility in the delivery of CBT-AD (Safren et al., 2011 and Stall et al., 2003). Specific to HIV-infected individuals, depression often co-occurs with substance use, violence, poverty, stigma, and sexual risk behavior (Safren et al., 2011 and Stall et al., 2003). While CBT-AD may not be able to treat each one of these conditions fully, the skills delivered in this protocol to manage depression and ART adherence may be generalizable to coping with other mental health symptoms and psychosocial stressors. Importantly, the presence of these multiple comorbidities and psychosocial conditions can be a barrier to effective treatment in CBT-AD. As such, it is critical that therapists working

with this population thoroughly assess all co-occurring conditions prior to initiation of treatment. Furthermore, while it is of the utmost importance to maintain treatment fidelity by not substantially altering intervention Tolmetin content, we have purposely built additional sessions into the protocol so the patient and therapist can choose to alter the course of treatment based on the needs of the patient. Being able to respond to the needs of the patient as they arise is not only important in providing the highest quality of care, but it builds trust and rapport with the patient that will facilitate the effective delivery of the CBT-AD protocol as treatment continues. We illustrate below a scenario in which substance use leads to an alteration to the course of treatment. Various other patient comorbidities and stressors may also lead to such changes in the protocol, including domestic violence, housing instability, and experiences with HIV-related stigma and victimization.