William A. Fisher

The information-motivation-behavioral skills model of ART adherence in a deep south HIV+ clinic sample

High levels of adherence to antiretroviral therapy (ART) are critical to the management of HIV, yet many people living with HIV do not achieve these levels. There is a substantial body of literature regarding correlates of adherence to ART, and theory-based multivariate models of ART adherence are emerging. The current study assessed the determinants of adherence behavior postulated by the Information–Motivation–Behavioral Skills model of ART adherence in a sample of 149 HIV-positive patients in Mississippi. Structural equation modeling indicated that ART-related information correlated with personal and social motivation, and the two sub-areas of motivation were not intercorrelated. In this Deep South sample, being better informed, socially supported, and perceiving fewer negative consequences of adherence were independently related to stronger behavioral skills for taking medications, which in turn associated with self-reported adherence. The IMB model of ART adherence appeared to well characterize the complexities of adherence for this sample.

Reasons for ART non-adherence in the Deep South: Adherence needs of a sample of HIV-positive patients in Mississippi

Abstract HIV prevalence in the American Deep South has reached crisis proportions and greater numbers of patients are enrolling in clinical care and beginning antiretroviral therapy (ART). In order to gain maximum benefit from ART, patients must sustain high levels of adherence to demanding regimens over extended periods of time. Many patients are unable to maintain high rates of adherence and may need assistance to do so, which may be based upon an understanding of barriers to adherence for a given population. The current study sought to gain understanding of barriers to adherence for a mixed urban/rural HIV-positive patient population in Mississippi and to determine whether barriers to adherence may be specific to gender, employment, depressive symptoms or educational attainment status. Seventy-two patients who missed a dose of ART medication over the last three days endorsed the top five reasons for missing a dose as: (1) not having the medication with them, (2) sleeping through the dose time, (3) running out of the medication, (4) being busy with other things and (5) other. Reported barriers were fairly consistent across different groups, although women and those classified as having moderate to severe depressive symptoms reported different patterns of adherence barriers. Results suggest that adherence interventions implemented in the Deep South must take into account specific barriers faced by individuals within this region, where stigma, gender disparities and limited resources are prevalent.

The Theory of Planned Behavior and Safer Sex Behaviors of Gay Men

Determinants of performance of 11 safer sex behaviors were examined within the framework of the theory of planned behavior in a sample of gay men. The theory of planned behavior proposes that intentions and perceived control over behavior contribute to the prediction of behavioral performance. It also theorizes that perceived control, attitudes, and subjective norm predict intentions. Results indicated that control did not contribute significantly to the prediction of any of a range of safer sex behaviors in the sample of gay men, over and above the predictive power of intentions. Control measures were, however, predictive of some safer sex intentions, together with attitudes and subjective norms. Moreover, AIDS-preventive behavioral skills (e.g., how effectively one believed he could enact the behavior), as opposed to difficulty of performing safer sex behaviors (e.g., the ease or difficulty of enacting the behavior), proved to be the control component that was most strongly related to intention. Discussion focuses on the relevance of the findings for safer sex interventions with gay men and for the theory of planned behavior.

Information–motivation–behavioral skills barriers associated with intentional versus unintentional ARV non-adherence behavior among HIV+ patients in clinical care

Abstract Since the arrival of antiretroviral (ARV) therapy, HIV has become better characterized as a chronic disease rather than a terminal illness, depending in part on ones ability to maintain relatively high levels of adherence. Despite research concerning barriers and facilitators of ARV adherence behavior, relatively little is known about specific challenges faced by HIV-positive persons who report “taking a break” from their ARV medications. The present study employed the Information–Motivation–Behavioral Skills Model of ARV adherence as a framework for understanding adherence-related barriers that may differentiate between non-adherent patients who report “taking a break” versus those who do not report “taking a break” from their ARV medications. A sample of 327 HIV-positive patients who reported less than 100% adherence at study baseline provided data for this research. Participants who reported “taking a break” from their HIV medications without first talking to their healthcare provider were classified as intentionally non-adherent, while those who did not report “taking a break” without first talking with their healthcare provider were classified as unintentionally non-adherent. Analyses examined differences between intentionally versus unintentionally non-adherent patients with respect to demographic characteristics and responses to the adherence-related information, motivation, and behavioral skills questionnaire items. Few differences were observed among the groups on demographics, adherence-related information, or adherence-related motivation; however, significant differences were observed on about half of the adherence-related behavioral skills items. Implications for future research, as well as the design of specific intervention components to reduce intentionally non-adherent behavior, are discussed.

HIV stigma and unprotected sex among PLWH in KwaZulu-Natal, South Africa: a longitudinal exploration of mediating mechanisms

Social and structural factors including HIV stigma are theorized to drive global disparities in HIV prevalence. This study tests whether HIV self-stigma, or experiences of stigma at the individual level, is associated with engagement in unprotected sex among people living with HIV (PLWH) in KwaZulu-Natal, South Africa, where 37.4% of adults are living with HIV compared with 0.8% worldwide. It further explores whether depressive symptoms, HIV status disclosure to sex partners, and/or condom use attitudes mediate potential associations between HIV self-stigma and unprotected sex. Participants, including 924 PLWH, were recruited from primary care clinics and completed baseline, 6-, 12-, and 18-month survey assessments between 2008 and 2011. Hierarchical linear modeling analyses were used to examine longitudinal within-subjects associations between HIV self-stigma, mediators, and unprotected sex with both HIV-negative/unknown and HIV-positive partners. Results demonstrate that HIV self-stigma was prospectively associated with greater likelihood of unprotected sex with HIV-negative/unknown partners. None of the variables explored significantly mediated this association. HIV self-stigma was also prospectively associated with greater likelihood of unprotected sex with HIV-positive partners via the mediators of greater depressive symptoms and more negative condom use attitudes. The current study suggests that HIV self-stigma undermines HIV secondary prevention and care efforts among PLWH in KwaZulu-Natal. It is therefore critical to address HIV stigma at the social/structural level to reduce HIV self-stigma at the individual level and ultimately curb global disparities in HIV prevalence. In the absence of widespread social/structural change, interventions that treat depressive symptoms and encourage more positive condom use attitudes despite the existence of HIV stigma may buffer associations between HIV self-stigma and unprotected sex with HIV-positive partners among PLWH in KwaZulu-Natal.

Social Psychology and the Fight Against AIDS: An Information–Motivation–Behavioral Skills Model for the Prediction and Promotion of Health Behavior Change

Abstract The sudden emergence of the AIDS epidemic in the 1980s created an urgent requirement to achieve rapid, voluntary, and sustained behavior change to protect individual and public health. Social psychologists, realizing the relevance of the research approaches and theoretical models that define the discipline, began applying existing research methodologies and conceptual models of attitude and behavior change and developed new models aimed at understanding, predicting, and promoting AIDS preventive behavior. This chapter explores the history of the AIDS epidemic, the unique behavior change challenges it poses, and the application of social psychological approaches in the fight against this disease. We review classical social psychological theories that have been applied to promote safer sex behavior change and describe a novel Information–Motivation–Behavioral Skills (IMB) conceptualization that was developed to strengthen efforts to understand, predict, and promote AIDS preventive behavior. The IMB model has been applied successfully to understanding and predicting AIDS risk and AIDS preventive behavior in diverse settings worldwide, and IMB model-based interventions have produced sustained improvements in AIDS preventive behavior in a wide variety of intervention settings. Applications of the IMB model across multiple health behavior domains, including the prediction and promotion of adherence to medical regimen, cardiac health, and diabetes self-management, have established the IMB model as a highly generalizable theoretical and applied approach to health behavior change.

Attitudes toward needle-sharing and HIV transmission risk behavior among HIV+ injection drug users in clinical care

Abstract Risky behavior related to injection drug use accounts for a considerable proportion of incident HIV infection in the United States. Large numbers of injection drug users (IDUs) currently receive antiretroviral therapy in clinical settings and are accessible for risk-reduction interventions to reduce transmission of drug-resistant HIV and spread of HIV to uninfected others. The current study examined attitudes toward needle- or equipment-sharing among 123 HIV-positive IDUs in clinical care in an effort to understand the dynamics of such behavior and to create a basis for clinic-based risk-reduction interventions. Results indicate that at baseline, participants who reported extremely negative attitudes toward needle-sharing were less likely to have shared during the past month than those with less-extreme negative attitudes. Demographic, behavioral, and attitudinal variables were entered into a logistic regression model to examine needle-sharing group membership among HIV-positive IDUs. Being female and having less-extreme negative attitudes toward sharing were independent and significant correlates of sharing behavior. Interventions targeting needle-sharing attitudes deployed within the clinical care setting may be well-positioned to reduce HIV transmission among HIV-positive IDUs.