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The Connection between Mental Health and HIV/AIDS: Implications for Clinical Care and Research Robert H. Remien, Ph.D. Milton L. Wainberg, M.D. Katherine.

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Presentation on theme: "The Connection between Mental Health and HIV/AIDS: Implications for Clinical Care and Research Robert H. Remien, Ph.D. Milton L. Wainberg, M.D. Katherine."— Presentation transcript:

1 The Connection between Mental Health and HIV/AIDS: Implications for Clinical Care and Research Robert H. Remien, Ph.D. Milton L. Wainberg, M.D. Katherine S. Elkington, Ph.D. HIV Center for Clinical and Behavioral Studies, Columbia University and NYSPI

2 Overview The Intersection of mental health, substance abuse and HIV/AIDS The Intersection of mental health, substance abuse and HIV/AIDS Deployment-focused intervention development: Deployment-focused intervention development: Three research examples Three research examples

3 The Intersection of Mental Health, Substance Use and HIV/AIDS

4 Mental illness and HIV Risk Behaviors Specific Diagnoses: Inconsistently associated with riskSpecific Diagnoses: Inconsistently associated with risk Symptoms:Symptoms: Positive psychotic sx cluster  multiple partners; IDUPositive psychotic sx cluster  multiple partners; IDU  excitement sx  sexual activity; sex exchange;  condom use  excitement sx  sexual activity; sex exchange;  condom use Depressed/anxious sx  STDs; poor condom negotiation skills; multiple partners; inconsistent condom useDepressed/anxious sx  STDs; poor condom negotiation skills; multiple partners; inconsistent condom use High rates of co morbid substance useHigh rates of co morbid substance use High rates of childhood abuseHigh rates of childhood abuse Problematic current interpersonal relationshipsProblematic current interpersonal relationships Poverty / low SES : sex exchangePoverty / low SES : sex exchange Stigma and DiscriminationStigma and Discrimination (Meade & Sikkema, 2005, 2006; Donenberg & Pao, 2005)

5 5 Substance Use and HIV Risk Behaviors Substance use and disorder linked to HIV/STI risk behaviorsSubstance use and disorder linked to HIV/STI risk behaviors Type of substance: alcohol, stimulants, club drugs Type of substance: alcohol, stimulants, club drugs Amount and frequency of use: Addiction – sex exchange Amount and frequency of use: Addiction – sex exchange Motivation for use (social anxiety; expectancy theory) Motivation for use (social anxiety; expectancy theory) Role of environmental factors: peers, family Role of environmental factors: peers, family Method of data collection Method of data collection Cross-sectional, longitudinal, event-level analysis (daily diary studies) Cross-sectional, longitudinal, event-level analysis (daily diary studies)

6 Mental Health and Substance Use Problems Among Subpopulations at High Risk for HIV IDU: ↑ rates of SUD and other psychiatric disorders IDU: ↑ rates of SUD and other psychiatric disorders MSM: ↑ rates of SUD and depression MSM: ↑ rates of SUD and depression SW: ↑ rates of childhood sexual abuse, SUD, and PTSD SW: ↑ rates of childhood sexual abuse, SUD, and PTSD Criminal/Juvenile justice: ↑ childhood sexual abuse; SUD and psychiatric disorders (particularly PTSD) Criminal/Juvenile justice: ↑ childhood sexual abuse; SUD and psychiatric disorders (particularly PTSD) All groups: Stigma; legal sanctions; poor access to services; high risk interpersonal relationships — all associated with ↑ risk behaviors All groups: Stigma; legal sanctions; poor access to services; high risk interpersonal relationships — all associated with ↑ risk behaviors

7 RAND HCSUS Study: 2,864 HIV+ Medical Patients Any Psychiatric Disorder: 48% Any Psychiatric Disorder: 48% Major depression 36% Major depression 36% Dysthymia 27% Dysthymia 27% Generalized anxiety disorder 16% Generalized anxiety disorder 16% Panic attack 11% Panic attack 11% Drug dependence 13% Drug dependence 13% Problematic alcohol use 19% Problematic alcohol use 19% (Bing et al Arch. Gen. Psych. 2001) (Bing et al Arch. Gen. Psych. 2001) Psychiatric and Substance Use Disorders among PLWHA

8 Impact of Mental Health and Substance Use Problems for PLWHA Mental health and substance use problems can: Impair the quality of one’s life Impair the quality of one’s life Interfere with HIV treatment adherence Interfere with HIV treatment adherence Interfere with self-care behaviors and increase risk behaviors Interfere with self-care behaviors and increase risk behaviors Result in acting out verbally or physically Result in acting out verbally or physically Impair ability to cope with daily events, including childcare Impair ability to cope with daily events, including childcare Increases morbidity and mortality Increases morbidity and mortality

9 HIV RISK BEHAVIORS Non Adherence to treatment and Care Mental Illness Symptoms (e.g. paranoia, anxiety, depression, psychosis) Environmental/ Structural Poverty Neighborhood Disintegration Poor housing Stigma Substance Ab/use Interpersonal Child abuse IPV Stigma Strained/poor family & peer relationships Marginalized /risky peer groups Acute intoxication (e.g. impaired judgement) Addiction Alcohol myopia “Social lubricant” (self medication) Transportation/ access to health care

10 Deployment-Focused Intervention Development Implications for Intervention, Treatment, and Care

11 PRISSMA Project / NIMH R / HIV Prevention with Psychiatric Patients in Brazil: Planning a National Response Milton L. Wainberg, MD Associate Clinical Professor of Psychiatry, Columbia University

12 Background  Worldwide, adults with severe mental illness (SMI) have elevated rates of HIV infection (between 0.8% and 23.8%) relative to the general population (3 to 5 times)  Few (n=7; 919 participants) HIV prevention interventions have been tested for efficacy – all of them in the US (Kalichman 1995, Kelly 1997, Susser 1998, Weinhardt 1998, Otto-Salaj 2001, Carey 2004, Berkman 2006)  There is no single “gold standard” HIV prevention intervention for the SMI PRISSMA Project / NIMH R / &

13 Summary of HIV Prevention Research among SMI

14 2) Optimizing Fit: Adaptation Principles 1) Optimizing Fidelity: HIV Prevention Principles 3) Balancing Fidelity and Fit: Intervention Adaptation 4) Pilot Testing and Refining: Final Intervention PRISSMA I Model AIDS and Behavior, 2007 PRISSMA Project / NIMH R / &

15 RCT Study Design PRISSMA Project / NIMH R / & Screen Baseline assessment* * Diagnoses, risk behaviors, mediators/moderators ** Process measures, mediators/moderators Orientation HIV – 8 sessionsHealth – 8 sessions Post-intervention assessment** 3- & 6-months follow-up assessments* HIV – 3 boostersHealth – 3 boosters 12-months follow-up assessment* Post -booster assessment**

16 Recruitment Total screened 3811 Total eligible 1579 Interested 1348 Baseline done 916 Consented & Eligible Randomized Into 37 waves (HIV vs Health) Recruitment ended 7 months early!!!!!!

17 PRISSMA Implementation MonthInterventionBooster Jan HIV Feb March Saúde April MayHIV JuneSaúde July HIV Augost Sept Saúde Oct NovHIV DecSaúde

18 PRISSMA Project / NIMH R / & Summary of HIV Prevention Research among SMI – 2011/2014

19 Working with systems from the beginning: A Case example with JJS youth K01MH ; PI: Elkington

20 What’s Unique about JJS Youth? Juvenile detainees are at high risk for HIV/STIs:Juvenile detainees are at high risk for HIV/STIs: Higher rates of HIV/STI risk behaviors Higher rates of HIV/STI risk behaviors Higher rates of substance use and mental health (MH) disorders Higher rates of substance use and mental health (MH) disorders Numerous contextual factors that increase risk Numerous contextual factors that increase risk Peers, families, neighborhoodsPeers, families, neighborhoods

21 Intervening with Just the Youth…. …is that Enough? Need to involve other domains or systems of risk and protectionNeed to involve other domains or systems of risk and protection Systems may act directly (e.g. family, peer group) or may be more distal (neighborhood, JJS)Systems may act directly (e.g. family, peer group) or may be more distal (neighborhood, JJS) Family is key to promoting or off-setting riskFamily is key to promoting or off-setting risk GOAL: Target HIV/STI risk by addressing MH and SU problems and improving family functioning within context of the JJSGOAL: Target HIV/STI risk by addressing MH and SU problems and improving family functioning within context of the JJS

22 Modified Ecodevelopmental Model MACROSYSTEM Social-Cultural Context Family MICROSYSTEM Family functioning (conflict/support) Caregiver monitoring/supervision Caregiver discipline Caregiver-youth communication Caregiver-youth relationship satisfaction Peer Microsystem Perceived peer HIV/STI behavior Perceived peer HIV/STI norms School Microsystem School Bonding Academic Achievement Family-School Mesosytem Parental monitoring homework Family-Peer Mesosytem Parental monitoring of peer activities Exosystem Parents’ social support Parents’ stress Cultural Immigration Policy Poverty Language Youth Substance use Mental Health HIV/STI knowledge Safer sex and drug use attitudes Safer sex self-efficacy Perceived HIV risk Safer sex behavior skills HIV/STI sexual risk behavior Szapocznik & Coatsworth, 1999)

23 Developing the intervention To develop and implement effective interventions that are targeted and sustainable:To develop and implement effective interventions that are targeted and sustainable: 1.Achieve buy in from treatment system and key- stakeholders involved Probation, staff, families, youthProbation, staff, families, youth 2.Formative work Understand logistic and institutional-cultural contextual factors of the probation center and staffUnderstand logistic and institutional-cultural contextual factors of the probation center and staff Understand context of sexual risk for JJS youth including the role of the familyUnderstand context of sexual risk for JJS youth including the role of the family

24 JJS 24 Modified Ecodevelopmental Model MACROSYSTEM Social-Cultural Context Family MICROSYSTEM Family functioning (conflict/support) Caregiver monitoring/supervision Caregiver discipline Caregiver-youth communication Caregiver-youth relationship satisfaction Peer Microsystem Perceived peer HIV/STI behavior Perceived peer HIV/STI norms School Microsystem School Bonding Academic Achievement Family-School Mesosytem Parental monitoring homework Family-Peer Mesosytem Parental monitoring of peer activities Exosystem Parents’ social support Parents’ stress Cultural Immigration Policy Poverty Language Youth Substance use Mental Health HIV/STI knowledge Safer sex and drug use attitudes Safer sex self-efficacy Perceived HIV risk Safer sex behavior skills HIV/STI sexual risk behavior

25 Phase 1 – Formative phase Interview probation staff (n=12)Interview probation staff (n=12) What is their perception of youth HIV/STI risk? What is their perception of youth HIV/STI risk? What is role of probation department in providing HIV/STI programming? What is role of probation department in providing HIV/STI programming? How would an intervention fit into current programming….. climate…… culture? How would an intervention fit into current programming….. climate…… culture?

26 All staff perceived their youth to be at considerable risk for HIV/STIs and needed intervention program: All staff perceived their youth to be at considerable risk for HIV/STIs and needed intervention program: Sexually active at young ages; ↑ pregnancies Sexually active at young ages; ↑ pregnancies Impulsive; MH and SA abuse problems Impulsive; MH and SA abuse problems Limited supervision and problematic role models (peers and family) Limited supervision and problematic role models (peers and family) Implications for intervention development and delivery: Implications for intervention development and delivery: Great – we are on the right track, sexual risk is a problemGreat – we are on the right track, sexual risk is a problem Addressing MH issues and SA is keyAddressing MH issues and SA is key Staff think this is important to addressStaff think this is important to address Staff recommend program to families and talk up program to get resistant families involvedStaff recommend program to families and talk up program to get resistant families involved

27 Providers struggled to reconcile their role as POs with their responsibility of providing youth with services Providers struggled to reconcile their role as POs with their responsibility of providing youth with services “It’s not on the form so we don’t ask” “It’s not on the form so we don’t ask” Address presenting problem rather than provide prevention for a potential problem Address presenting problem rather than provide prevention for a potential problem Social work vs. law enforcement: Differing views held by staff Social work vs. law enforcement: Differing views held by staff Sex risk, HIV/STI rarely bought up - believe youth will not talk Sex risk, HIV/STI rarely bought up - believe youth will not talk Staff do not feel adequately trained to address sexual risk but would if they were trained Staff do not feel adequately trained to address sexual risk but would if they were trained Implications for intervention development: Implications for intervention development: Add a sex risk screening question to intake assessment?Add a sex risk screening question to intake assessment? Alter culture: promote prevention for non-probation related issuesAlter culture: promote prevention for non-probation related issues Task shifting: train subset of POs in youth sexuality and sexual risk reduction to deliver interventionTask shifting: train subset of POs in youth sexuality and sexual risk reduction to deliver intervention

28 How would an intervention fit into current programming….. climate…… culture? How would an intervention fit into current programming….. climate…… culture? POs currently co-lead groups onsite at the probation department POs currently co-lead groups onsite at the probation department On-site vs. off-site programming: Both services are available. On-site vs. off-site programming: Both services are available. POs busy schedule: is there time to add additional programs POs busy schedule: is there time to add additional programs Family engagement always tricky Family engagement always tricky Implications for intervention development: Implications for intervention development: Build intervention into existing services and bundleBuild intervention into existing services and bundle Work with community providersWork with community providers Build in participation in HIV program as mandatory part of their probationBuild in participation in HIV program as mandatory part of their probation

29 Developing the intervention cont’d 3.Develop a family-based intervention building on an existing efficacious youth-only intervention designed for youth on probation 1 st work group : youth and caregivers1 st work group : youth and caregivers Review interview data and existing interventions; role play and suggest changesReview interview data and existing interventions; role play and suggest changes 2 nd work group: probation staff2 nd work group: probation staff Work together to create actual intervention sessions drawing from other family-based interventionsWork together to create actual intervention sessions drawing from other family-based interventions 4.Pilot test the intervention in department of probation Deliver as part of co-located services offeredDeliver as part of co-located services offered Work with CBOs to deliver to JJS familiesWork with CBOs to deliver to JJS families


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