Whats Love Got to Do With It? Relationship Factors and HIV - PowerPoint PPT Presentation

What’s Love Got to Do With It? Relationship Factors and HIV Treatment Adherence Mallory O. Johnson, Ph.D. Mallory.Johnson@ucsf.edu Center for AIDS Prevention Studies University of California, San Francisco Center for Health, Intervention, and Prevention Nov. 18, 2010

Objectives • Why study couples and HIV treatment adherence • What have we learned • Where are we going

AIDS Cases, Deaths & Prevalence 1980 - 2006 3000 10000 Number of Persons Living with HIV 2400 8000 Number of AIDS Cases/Deaths 1800 6000 1200 4000 600 2000 0 0 80 82 84 86 88 90 92 94 96 98 00 02 04 06 Year of Diagnosis/Death Cases Deaths Persons Living with HIV/AIDS

Why Study Adherence? Adherence related to • Virologic control • Treatment resistance • Morbidity • Quality of life • Survival • Health care costs • HIV transmission – Personal and community

Predictors of Poor Adherence • Side effects • Substance use/abuse • Regimen complexity • Depression • Poor social support • Lack of knowledge • Low perceived efficacy of treatment • Memory problems • Stigma

Why Study Couples? • Social support and health • Primary relationships – Education – Diet – Exercise – Drug use – Smoking

Challenges of Studying Couples • Complicated – Definition of a couple – Design, data collection, and analysis • Expensive

Why Study Couples and Adherence? • Prior counter-intuitive findings • Can relationships promote or derail adherence?

Duo Project Relationship Factors and HIV Treatment Adherence R01NR010187

Duo Phases 2006- • Qualitative phase 2007 • Measure development 2008 • Cross-sectional 2008- 2010 • Longitudinal quantitative 2009- • Longitudinal qualitative 2013 • Intervention development 2012- • piloting 2015

Framework • Interdependence Theory • Social Control • Health Care Empowerment

Responsibility Divided He’s so pissed. He goes, “Well,” when he finds out, especially last week when I missed four days in a row, “God damn it.” And he goes, “I’m going to have to just light up your cell phone. I don’t care what you’re doing, you know, whatever you’re doing you’re going to drop what you’re doing and take your pills.” He said, “I’m going to call you between ten and one everyday, just light up your phone until you tell me you’ve taken your pills.” But ever since then I’ve been taking them so when he does call, “Yeah, I took them.” So that’s it.

Autonomy He doesn't need me to stand behind him to take it. And this is another thing why we get along so well, is because you know what, if he decides one day that he doesn't want to take it, I’m not going to push him on it, okay? Because it’s his choice whether he wants to take it, okay? It’s his body, it’s his temple.

Partner dynamics Partner A: Partner B: “I like the daddy type and “ Well, I certainly love him. he certainly is —he’s that He’s very dependent, type, looks, and which I don’t mind. I personality.” mean, I don’t mind being a parent.” “We seem to be very compatible, because he pushes me around and I let him.

Cross-sectional approach

Meet Paul and Phil • Both HIV+ • Both on meds

Paul’s Paul’s Stuff Outcomes Actor Effect Actor Effect Phil’s Phil’s Stuff Outcomes

Paul’s Paul’s Stuff Outcomes Phil’s Phil’s Stuff Outcomes

Paul’s Stuff Paul’s Outcomes Actor Effect Actor Effect Phil’s Outcomes Phil’s Stuff

Recruitment • Sought male couples – Together at least 3 months • One or both men are HIV+ • One or both taking HIV meds

Recruitment

Methods • Phone screen – Separate – “Smell check” for fake couples • Verified meds and identity • Separate ACASI interviews • Blood draw for CD4 and viral load

Explanatory Variables • Depression Relationship • Treatment Beliefs – Satisfaction – General med concerns – Autonomy – Specific concerns – Intimacy – Specific necessity – Equality – Commitment – Communication

Outcomes • Adherence Self Efficacy – Integration – Perseverance • Self Reported Adherence – 3 day – 30 day • Viral Load – Detectable v not – Log10 transformed

Analysis • Actor- Partner analyses – Multivariate using p<.25 for inclusion – All results are p<.05 in adjusted models • Control for actor’s – Relationship Length – Living Together – Time on ART – Age – Number of pills per day

Sample • 420 men • 26% HS grad or less • 91 discordant couples • 84 months as couple • 119 concordant couples • 12 years HIV+ • 45 years old • 9+ years on meds • 17% AA • 18% Latino • 91% gay

Self Efficacy Integration Scale PAUL’s Concerns about Meds (-) Autonomy Age Time on Meds (-) PAUL’s Adherence Self Efficacy INTEGRATION PHIL’s Depression (-)

Self Efficacy (Perseverance) PAUL’s General Med Concerns (-) Specific Med Concerns (-) Depression (-) Autonomy Intimacy PAUL’s Time on Meds (-) Adherence Self- Efficacy PERSEVERANCE PHIL’s Relationship Satisfaction

3 DAY ADHERENCE PAUL’s General Med Concerns (-) Fewer pills per day PAUL’s 3 DAY ADHERENCE PHIL’s Beliefs that Paul’s meds are necessary

30 DAY ADHERENCE PAUL’s Relationship Communication Time on meds (-) PAUL’s 30 DAY ADHERENCE PHIL’s General Concerns about Meds (-)

VIRAL LOAD (Detect v. not) PAUL’s NOTHING Time in relationship (-) PAUL’s Detectable Viral Load PHIL’s Commitment (-)

VIRAL LOAD (log10) PAUL’s NOTHING PAUL’s Viral Load PHIL’s Commitment (-)

Summary of Findings • Both actor and partner effects on – Self Efficacy for Adherence – Self-Reported Adherence – Viral load • Relevant constructs – Depression – Treatment beliefs (general and specific) – Relationship factors (autonomy, commitment, satisfaction, intimacy, and communication) • Partner effects w/o corresponding actor effects

Limitations • Cross-sectional data • Convenience sample • High levels of adherence • Long time with HIV • Long time on meds • Relationship length • Self-reported adherence

From here to where? • Follow couples over time – 6, 12 , 18, and 24 months – Include break up interviews • Qualitative interviews • Intervention development

Paul’s Stuff Paul’s Outcomes Actor Effect Actor Effect Phil’s Outcomes Phil’s Stuff

Paul’s Stuff Paul’s Outcomes Phil’s Outcomes Phil’s Stuff

What’s in the black box? • Tactics • Support Received • Support Provided • Substance Use?

Partner A Figure 1. Conceptual Model Support Provided á Overall Support Provided á Positive Tactics â Negative Tactics Partner A á QOL/ Well-Being á Coping/Problem solving â Substance Use Partner A Support Received á Overall Support Received á Positive Tactics Partner A Partner A â Negative Tactics á CD 4 á Adherence â Viral Load Couple á Relationship Quality á Relationship Satisfaction Partner B á Intimacy Support Received á Communication á Overall Support Received â Conflict á Positive Tactics â Negative Tactics Partner B Partner B á CD 4 á Adherence â Viral Load Partner B Support Provided á Overall Support Provided Partner B á QOL/ Well-Being á Positive Tactics á Coping/Problem Solving â Negative Tactics â Substance Use

Duo Phases 2006- • Qualitative phase 2007 • Measure development 2008 • Cross-sectional 2008- 2010 • Longitudinal quantitative 2009- • Longitudinal qualitative 2013 • Intervention development 2012- • piloting 2015

Tactics • Reassure (36%) • Ask (76%) • Express concern (35%) • Check in (72%) • Watch, monitor, verify (35%) • Model (65%) • Nag (31%) • Remind (61%) • Give meds directly (27%) • Encourage (56%) • Offer advice (27%) • Fill Rx (43%) • Point out conseq. (26%) • Point out importance (37%)

‘Invisible’ Tactics Watch, Monitor, Verify • 34% received • 48% provided

Perceived effects of tactics • Affective response – Loved, valued, pleased, inspired? – Anxious, irritated? • On adherence (positive or negative) • On relationship (positive or negative)

Partner Support/Involvement • Communication • Knowledge • Involvement • Support • Regimen knowledge

Dyadic Data Analysis • Actor-Partner Effects • Sums and Differences Analysis Doctors prescribe too many medications. 0 = not true to 10= very true Peter says 6 Paul says 10 Ned says 6 Phil says 2 Sum = 12 Sum = 12 Difference = 0 Difference = 8

What about other couples?

• NIH Grant R01NR010187 • The DUO men • The DUO Project team – Tor Neilands – Lynae Darbes – Megan Comfort – Joey Taylor – Fantastic recruiters, interviewers and phlebotomists • My mentor: Susan Folkman

What’s Love Got to Do With It? Relationship Factors and HIV Treatment Adherence Mallory O. Johnson, Ph.D. Mallory.Johnson@ucsf.edu Center for Health, Intervention, and Prevention Nov. 18, 2010