The sample consisted of participants recruited for Project STEP (Steps Toward Embodying Positivity), an intervention designed to address HIV treatment adherence and depressive symptoms among African-American and Latino young men living with HIV in the Los Angeles metropolitan area. Participants in the intervention, which combined individualized web-based attention training with evidence-based counseling, were recruited primarily through referrals from health and social service providers and through postings on social media used by the target population (eg, Adam4Adam, Craigslist, Grindr).

Individuals who expressed interest in joining the study were screened in person or by phone to determine if they met the following 4 eligibility criteria: (1) African American or Latino male living with HIV; (2) 18- 29 years old, inclusive; (3) self-identified as gay, bisexual, or same-gender loving; and (4) depressive symptoms at mild or higher levels of severity based on self-report measures or suboptimal antiretroviral therapy adherence, two psychological and behavioral risk factors for poor HIV treatment outcomes that the intervention was designed to address.

Upon meeting the inclusion criteria, participants were administered informed consent and then enrolled in the study. Assessments and interviews with participants were conducted by a study team member during face-to-face meetings. After completing procedures to elicit and assess their individualized stimuli (ie, brief thoughts related to treatment and mood changes), participants were scheduled for a second study meeting in which they were given an attention training tutorial and assessed for baseline reaction time performance. Upon finishing 4 weeks of attention training, participants were scheduled for a posttraining assessment within a week of their final training session. Participants received $50 each for completion of the baseline and final assessments and $5 for each weekly meeting attended. All procedures for recruitment, data collection, and confidentiality were reviewed and approved by the Institutional Review Board of Charles R. Drew University of Medicine and Science.

The goal of attention training through Project STEP was twofold. First, it was designed to increase treatment adherence by teaching participants how to maintain their focus on thoughts that were approach-oriented with regard to treatment and to direct their focus away from thoughts that were avoidance-oriented. Second, to reduce depressive symptoms, attention training also sought to increase a participant’s skill in quickly diverting attention away from those thoughts perceived as having an emotionally-negative valence and directing attention toward thoughts that were perceived as neutral or having an emotionally-positive valence. Attention training, delivered via a web-based app, used the participant’s own thoughts identified during an individualized assessment procedure.

During the assessment procedure, we elicited a wide range of personal thoughts and perceptions about treatment from participants through individual interviews. Thoughts related to positive and negative changes in the participants’ emotional states were also elicited. Individual interviews were followed by administration of a computerized program in which participants were asked to quickly rate the similarity of paired combinations of their treatment-related thoughts as they appeared in random order on the computer screen. The computerized rating procedure is consistent with other research designed to identify implicit cognitive processes [42-44]. Ratings were subjected to multidimensional scaling analysis to generate 2D mappings that depicted how a participant’s treatment-related thoughts, memories, and mental associations were associated with either treatment adherence or treatment avoidance. Multidimensional scaling analysis has been used and evaluated as an approach for the assessment of implicit cognitive processes [8,43,45]. Both implicit and explicit cognitive processes were captured through the assessment procedure.

Data analysis was performed using IBM SPSS 22.0. Due to the exploratory nature of the study and the corresponding small sample size, data analysis focused primarily on descriptive statistics. The full sample consisted of individuals who were enrolled into the study and completed baseline questionnaires. We examined data from the full sample (N=20) to characterize participants who met eligibility criteria and completed baseline measures. Most analyses presented in this report, however, are based on data from participants who completed the attention training intervention and final assessments (n=12). To compare participant characteristics based on study completion status, we used the Chi-square statistic for categorical variables and independent samples t-test for continuous variables. The Chi-square statistic was also used to examine changes in adherence among participants from pre- to posttraining assessments.

We used t-tests to examine changes in mean numbers of depressive symptoms, reaction times, and accuracy scores. Reaction time analyses included reaction times only from correct responses. To reduce the influence of outliers, we eliminated reaction times that were 1.5 standard deviations above or below a participant’s mean response time. This approach is consistent with other published research [49]. Effect sizes were calculated using the phi statistic for categorical variables (small effect=0.1; medium effect=0.3; large effect=0.5) and Cohen d for comparisons of means (small effect=0.2; medium effect=0.5; large effect=0.8) [50].The alpha level for all statistical tests was set at .05.

African Americans comprised the majority of the full sample (12/20, 60%) and Latinos represented 40% (8/20). Mean participant age was 27 years (SD 1.7). Study participants identified as gay (15/20, 75%) or bisexual (5/20, 25%). Sixty-five percent of participants (13/20) indicated that they had completed high school, a high school equivalency credential, or some college, and 20% (4/20) reported graduating from college. Fifty-five percent of the full sample (11/20) had annual incomes below $20,000.

Adherence in the full sample was considerably below optimal levels, with the majority of participants (12/20, 60%) reporting adherence rates less than or equal to 75%. Participants experienced high levels of psychological distress. The mean depressive symptom score was 11.95 (SD 6.6), which is in the moderate range based on the PHQ-9 and is above the threshold widely used to suggest further evaluation for major depression. Fifty-five percent of participants in the full sample (11/20) reported elevated symptoms of anxiety. With regard to trauma symptoms, 40 percent (8/20) had symptoms at or above recommended screening level cutoffs for PTSD. Forty-five percent (9/20) reported unwanted sexual events, sexual abuse, or molestation before the age of 18. Eighty percent (16/20) reported experiencing internalized HIV stigma.

Of the 20 participants enrolled, 6 were excluded as they failed to attend a required study meeting for orientation to attention training procedures. Based on the remaining 14 participants who began attention training, the study completion rate was 86% (2 participants dropped out for unknown reasons before completing the protocol). There were no statistically significant differences between enrolled participants who completed the intervention and those who were excluded or dropped out with regard to demographics, adherence, depressive symptoms, or other assessed variables.

Participants were encouraged to complete at least three attention training sessions on a daily basis, for a total of 84 sessions during the intervention. The median number of training sessions among intervention completers was 48. All 12 study participants who completed the intervention attended each of the 4 weekly meetings with a study counselor.

Table 1 shows changes in attentional processing speed among study participants. Attentional processing was based on mean reaction times scores grouped by assessment period (baseline vs posttraining) and by stimuli pairing type (ie, positive-neutral, negative-neutral, positive-negative, and neutral-neutral). Participant reaction times to correctly identify the location of the dot-probe in each of the 4 stimuli pairings significantly declined from baseline to posttraining assessments, with large Cohen d effect sizes ranging 0.78 to 1.0. Participants experienced the greatest mean reduction in reaction times for the positive-negative stimulus pairings (369 ms), followed by positive-neutral pairings (353 ms).

Accuracy scores for each of the 4 types of stimuli pairings during the baseline and posttraining assessments were calculated to provide a measure of the rate at which participants correctly responded when prompted to indicate the location of the dot-probe. The only statistically significant change in accuracy scores from baseline to posttraining assessments, however, occurred when participants responded to positive-negative stimuli pairings (94% vs 98%, respectively; t₁₀=4.05, P=.002).

We examined the relationship between attention training and antiretroviral therapy adherence before and after the intervention by examining participant adherence rates based on a threshold of 75%. We categorized participants with adherence at or below this threshold as having “low” adherence and those with adherence above the threshold as having “moderate/high” adherence. In the current study, participants with low adherence reported rates between 50% to 75%. At baseline, 42% (5/12) of participants who completed the intervention had low adherence versus 58% (7/12) with moderate/high adherence. During the posttraining assessment, however, these percentages had shifted significantly with 75% (9/12) reporting adherence in the moderate/high range (Table 2). This change in adherence represented a large effect size (phi coefficient=.68).

Mean depressive symptoms among participants who completed the intervention declined significantly by 36% based on the PHQ-9, from 13.4 (SD 6.8) at baseline to 8.6 (SD 7.5) posttraining, (t₁₁= 4.16, P=.002; Cohen d=1.2, indicating a large effect size). The mean baseline score, which was in the moderate range with regard to depressive symptom severity, exceeded the cutoff of 10 widely used to suggest further diagnostic evaluation for major depression. The mean posttraining score, which fell below this cutoff, was clinically significant in that it represented an overall downward shift in symptom severity from the moderate to the mild range. As Table 2 shows, compared to baseline levels, there was a marked drop in the percentages of participants who experienced depressive symptoms in the moderate, moderate-severe, and severe ranges upon completing the study.

In this exploratory pilot study, we aimed to develop and implement an intervention consisting of individualized, web-based attention training combined with evidence-based counseling to promote adherence to antiretroviral therapy and reduce depressive symptoms among HIV patients experiencing elevated levels of psychological distress. Findings indicate that web-based attention training in addition to counseling can be efficiently deployed and conveniently delivered to a vulnerable HIV patient population with suboptimal antiretroviral therapy adherence and disproportionately high rates of depressive and PTSD symptoms. The intervention implemented in this study had a high completion rate (12/14, 86%), indicating strong viability as a clinical approach. Participants were able to access an individualized attention training program through their own mobile devices or computers, completing a median of 48 sessions during the 4-week attention training program, or the equivalent of approximately two sessions per day. Attention training combined with evidence-based counseling yielded considerable therapeutic benefits to intervention participants. We found statistically significant improvements among participants in antiretroviral therapy adherence from pre- to posttraining. In addition, we found both statistically and clinically significant reductions in depressive symptoms. Findings also showed notable improvements in attentional processing speed based on reaction time measures. Research suggests that improvements in processing speed play an important role in promoting everyday functioning and quality of life [51,52].

While participants in this study were assessed at only two time intervals, the study effectively employed strategies that could be used to maximize the benefits of attention training and strengthen the long-term durability of intervention outcomes. Our intervention used specific strategies (eg, performance feedback) to enhance the learning experience of study participants, drawing from recent research involving attention training [53-62]. Based on goal setting theory [63], these strategies included providing participants with explicit instructions, a clear statement of the training goal, and trial-by-trial feedback on performance (eg, reaction time changes; response accuracy rate). This study illustrates how individualized, web-based attention training for HIV patients with psychological distress could be employed in combination with psychotherapy.

Participants represented individuals who could most benefit from attention training due to the cognitive burden posed by multiple psychosocial stressors (eg, clinically-significant depressive symptoms, experiences of trauma and abuse, and internalized HIV stigma). Future studies, however, should be based on larger samples that include women and individuals representing a wider range of ages, geographic locations, and behavioral risk groups. Although studies support the validity of self-report measures of adherence [64], findings in this investigation could be bolstered by future research that incorporates biomedical measures of adherence. In addition, future studies should be designed to examine measures of cognitive self-regulation related to attention control, cognitive flexibility, and attention bias. Such measures would be derived based on administration of a standard dot-probe task where all stimuli are targeted with equal probability. This preliminary pilot study did not administer the standard dot-probe task. Finally, to better understand the role of attention training in HIV patient outcomes, research should be conducted that tracks participants over longer time intervals with a design that incorporates other approaches and a control group.

Attention training has shown much promise as an approach to improve outcomes associated with a range of health behaviors and psychological disorders [15-21,24,65]. This exploratory study contributes to the literature on attention training by showing its clinical applications in addressing the impact of depressive and trauma symptoms on HIV treatment adherence. We were able to provide evidence of the ability of individualized, web-based attention training to yield favorable improvements in adherence and psychological distress in two vulnerable populations of HIV patients. Our findings provide support for additional exploration of this promising application.

The raw data supporting the conclusions of this manuscript will be made available by the authors, without undue reservation, to any qualified researcher.