Positive Psychosocial Factors & Antiretroviral Adherence among HIV-infected African Americans Shenell D. Evans, PhD HIV Center For Clinical And Behavioral Studies New York State Psychiatric Institute And Columbia University International Positive Psychology Association June 27, 2015
Introduction HIV & Antiretroviral Adherence among African Americans (AAs) Disproportionately affected by HIV/AIDS USA: AAs are More likely to contract HIV, receive a diagnosis of AIDS, be nonadherent to antiretroviral medication regimens, and experience AIDS-related death (CDC, 2005; Heckman et al., 2004; Singh et al., 1996; Singh et al., 1999) South a : AAs account for 56% of HIV diagnoses in region (CDC, 2011) a South: AL, AR, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV
Introduction Psychosocial Risk Factors for Nonadherence Socioeconomic disparities, Racism, and Stigma Significantly contribute to barriers: Accessing care Obtaining meds Maintaining adherence (Whetten & Reif, 2006)
Introduction Protective Psychosocial Factors Less attention has been given to factors that promote adherence, perhaps with the exception of social support. Other potentially beneficial psychosocial factors may also significantly influence medication adherence: Posttraumatic growth (Tedeschi & Calhoun, 1996) Positive, transformative cognitive-emotional and social experiences individuals may report post-diagnosis. HIV+ AAs tend to report more growth than Whites (Helgeson, Reynolds, & Tomich, 2006; Sawyer, Ayers, & Field, 2010) Coping self-efficacy (Chesney et al., 2006) The degree to which an individual has confidence in his/her ability to use problem-focused, emotion-focused and supportseeking coping strategies in stressful situations.
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Introduction HIV medication nonadherence is a public health priority, given the increased risk for drug resistance and mortality. These risks coupled with continued HIV-related disparities among AAs underscore the need to identify novel psychosocial therapeutic targets to improve HIV treatment adherence. The present study explored the association of several negative and positive psychosocial factors with self-reported adherence: Negative - depression, substance use, posttraumatic stress symptoms Positive - social support, coping self-efficacy, PTG Hypothesis: PTG would be associated with adherence above and beyond other psychosocial factors.
Method Participants 104 African American adults 51% male, average age = 42.5 years Completed brief questionnaires following routine HIV primary care visit from May 2010 to August 2011 Approved by university Institutional Review Boards Procedure Consenting participants were asked to complete an audiocomputer assisted survey interview $15.00 gift card Measures Treatment adherence (100% vs. <100%), Drug use history (y/n), Center for Epidemiologic Studies Short Depression Scale, Stressful Life Events Screening Questionnaire, Posttraumatic Stress Checklist-Specific, Multidimensional Scale of Perceived Social Support, Coping Self-Efficacy scale
Results Statistical Analysis Chi-square test or correlation analyses to examine associations between adherence and binary or continuous variables. Logistic regression model. Sample Characteristics Elevated level of depressive symptomatology (M = 10.3, SD = 6.9; elevated 10) 75% lifetime stressful life event. 23% Family/friend death. Of those, 74.4% indicated that the event caused intense fear, horror, or helplessness. 14% - probable current PTSD. 43% consumed alcohol and other drugs (35%; i.e., marijuana or crack) in the past 30 days 61% endorsed optimal adherence (i.e., taken 100% of medications) over the past month 39% undetectable viral load
Results Demographic, disease-related, and psychosocial characteristics of HIV+ African American adults in Mississippi (N = 104) Demographic Age (mean, SD) 42.5 (9.2) Male (n, %) 53 (51) Sexual orientation (n,%) Heterosexual 71 (68) Homosexual 21 (20) Bisexual 7 (7) Questioning/unsure 5 (5) Education (n, %) Less than high school diploma 27 (26) High school diploma (or equivalent) 33 (32) College graduate/some college 44 (42) Employment (n, %) Full-time 17 (16) Part-time 7 (7) Unemployed 48 (46) Retired 6 (6) Public/Disability Assistance 37 (36) Disease-related Characteristics CD4 count (n = 53; median [SD]) 374 (241) Viral load (n = 54; median [SD]) 6,554 (46,845) Undetectable viral load (n, %) 41 (39) Reported 100% adherence in past 30 days (n, %) 63 (61) Adherence (mean, SD) 7.3 (2.7) Psychosocial Measures Alcohol use in past 30 days (n, % yes) 45 (43) Other drug use in past 30 days (n, %) 38 (36) Marijuana 23 (22) Cocaine/crack cocaine 15 (14) Posttraumatic stress symptoms (mean, SD) 34.8 (17.1) Probable current PTSD (n, %) 15 (14) Depression (mean, SD) 10.3 (6.9) Elevated depression (n, %) 38 (37) Social support (mean, SD) 48.7 (20.1) Coping self-efficacy (mean, SD) 196.5 (59.2) Posttraumatic growth (mean, SD) 71.9 (30.2)
Results Covariates Adherence was not significantly associated with age (p =.74), gender (p =.25), high school diploma (p =.45) Correlates Coping self-efficacy total score (r(102) =.22, p =.03) Problem-focused (r (102) =.27, p =.01) and emotion-focused (r (102) =.21, p =.03) coping strategies subscales, but not support-seeking strategies (r (102) =.12, p >.05) Depression, substance use, posttraumatic stress, social support, and PTG were not significantly associated with adherence.
Results Multivariable analysis Step 1: Risk (depression, posttraumatic stress symptoms, alcohol, and other drugs) and demographic (age, gender, and education) factors Only elevated depression scores were significantly associated with 100% adherence (OR = 4.14, p =.03) Step 2: Protective factors (social support, coping selfefficacy, and posttraumatic growth) Significant risk factor: elevated depression scores (OR = 8.03, p =.01) Significant protective factor: coping self-efficacy (OR = 1.01, p =.04) The hypothesis regarding the relationship between posttraumatic growth and treatment adherence was unsupported.
Conclusion AAs living in the Southern region of the US face significant challenges at every stage of HIV disease with greater incidence, prevalence, and deaths attributed to HIV/AIDS. The sociocultural context of the region, which is characterized by racism, discrimination, poverty, and oppression, is important to consider as AAs living in the South experience numerous health and socioeconomic disparities that significantly influence HIV prevention, treatment, and care. Empirical research among ethnic minorities living with HIV generally has focused more on poor outcomes, rather than strengths and positive changes.
Conclusion Coping self-efficacy: ONLY positive psychosocial factor associated with an increase in the odds of optimal adherence. Little attention among Southern residing African Americans living with HIV Inverse relationship with psychological distress (Evans & Williams, 2008; Evans, Williams, & Leu, 2013) High coping self-efficacy ~ less likely depressed (Rodkjaer et al. 2014) Low confidence and/or perceived deficits in the strategies identified on the coping self-efficacy scale represent important, amenable intervention targets that can enhance HIV self-management, including adherence outcomes.
Acknowledgments This research was supported in part by funding from the first author s pre-doctoral training fellowship with Brown University (T32DA13911-12) HIV and Other Infectious Consequences of Substance Abuse. Dr. Evans is supported by a NIMH training grant (T32- MH19139 Behavioral Sciences Research in HIV Infection; PI: Robert Remien, Ph.D.). Dr. Elkington is supported by a Mentored Career Development Award (K01MH089832; PI: K.S. Elkington, Ph.D.). Correspondence concerning this study should be addressed to Shenell D. Evans at shenellevans@gmail.com.