William D. Marelich

Predictors of antiretroviral adherence

This study was conducted in order to help determine the key factors that predict adherence to antiretroviral medications. A total of 115 HIV/AIDS patients who were having trouble adhering to their antiretroviral regimens completed face-to-face interviews in which adherence levels, medication side effects, mental health, social support, patient–provider relationship characteristics, substance use and health anxiety were assessed. Three measures of adherence were used: adherence over the past three days, adherence over the past week, and adherence over the past month. Logistic regression analyses indicated strongest prediction of three-day adherence, with mental health, social support, patient–provider relationship characteristics and side effects contributing to prediction. Past week adherence was associated with age and social support measures, and showed a marginal association with side effects. Past month adherence was less strongly predicted, with social support and alcohol use contributing to prediction. Thus, a variety of factors were found to determine adherence, and implications of the findings for adherence models and interventions are discussed.

Barriers to Antiretroviral Adherence among HIV-Infected Adults

Success of highly active antiretroviral therapies (HAART) relies on HIV-infected patients being able to adhere to complicated treatment regimens for extremely long periods of time. Four focus groups with patients taking antiretrovirals (N = 39) were conducted to: (1) determine what strategies facilitate successful adherence; (2) determine what barriers prevent adherence; and (3) investigate the health-care provider and patient relationship and how it may impact adherence. Quantitative and qualitative information was gathered. Participants were prescribed an average of 15 pills per day (M = 14.7, SD = 6.3, range 4 to 36). Findings from the quantitative data revealed that the three strategies used most often to aid adherence were: carrying special containers for medication; having a health-care provider explain or clarify medication requirements; and carrying food and water for adherence to special instructions. The most difficult barriers for patients were sleeping through dose time, problems in following special instructions, and changes in daily routines. From the qualitative data, four main categories of barriers and aids to adherence emerged: patient characteristics, the health-care provider-patient relationship, the health-care system, and issues related to the medication regimen. Barriers related to the health care provider-patient relationship included patient satisfaction with their provider, as well as quality of communication with the provider. In addition, health-care system barriers caused difficulty in maintaining adherence. Implications for patient as well as provider interventions are discussed.

Mothers living with HIV/AIDS: Mental, physical, and family functioning

There has been little work assessing the psychological condition of mothers living with HIV, their home life, and how these women function as caretakers with a chronic illness. In this study, interviews were conducted with 135 HIV symptomatic or AIDS diagnosed mothers of young, well children aged 6-11. White mothers were less likely to be severely ill (CD4 counts of < 500) than all other race/ethnic groups. The mean level of depression was elevated among this sample, and was associated with poorer cohesion in the family, and with poorer family sociability. Depression also was associated with the mothers being less able to perform tasks that they typically do; children of more depressed mothers had increased responsibilities for household tasks.

Results of a Pilot Intervention Trial to Improve Antiretroviral Adherence Among HIV-Positive Patients

A small pilot trial of a multicomponent (behavioral strategies, simplified patient information, and social support) and multidisciplinary (cognitive-behavioral therapy and nursing) medication adherence intervention was conducted for HIV-infected adults prescribed antiretrovirals. Patients (N = 33) were randomly assigned to the intervention condition or standard care. Compared to the control group, patients in the intervention condition had significantly higher self-efficacy to communicate with clinic staff (p = .04) and to continue treatment (p = .04), were significantly more likely to be using behavioral and cognitive strategies (p = .01 and p = .04), reported significantly higher life satisfaction (p = .03), reported significantly increased feelings of social support (p = .04), and showed a trend toward an increase in taking their medications on schedule (p = .06). The intervention, however, did not appear to affect health-related anxiety or to significantly improve adherence to dose. Implications for future intervention planning are discussed.

Pilot Trial of a Disclosure Intervention for HIV+ Mothers: The TRACK Program.

OBJECTIVE The Teaching, Raising, And Communicating with Kids (TRACK) program was a longitudinal pilot-trial intervention designed to assist mothers living with HIV (MLHs) to disclose their serostatus to their young children (age 6-12 years). METHOD MLH and child dyads (N = 80 dyads) were recruited and randomized to intervention or control; the intervention group had 3 individual sessions and 1 follow-up phone call. The sessions focused on preparing MLHs for disclosure through behavioral exercises using Derlegas model (V. J. Derlega, B. A. Winstead, K. Greene, J. Serovich, & W. N. Elwood, 2004) of HIV disclosure. Both MLHs and their child were assessed across multiple time points (baseline, 3, 6, and 9 months) regarding disclosure of HIV status, and specific outcome variables (i.e., relationship context, mothers health, childs mental health, and family outcomes). RESULTS MLHs in the intervention group were 6 times more likely to disclose their HIV status than those in the control group (OR = 6.33, 95% CI [1.64, 24.45]), with 33% disclosing in the intervention group compared with 7.3% in the control group. MLHs in the intervention group showed increases in disclosure self-efficacy across time, increased communication with their child, and improvement in emotional functioning. Children of MLHs in the intervention group exhibited reductions in depression and anxiety, and increases in happiness. CONCLUSIONS TRACK was found to be successful in helping MLHs disclose their HIV status to their children, with positive outcomes noted for both MLHs and their children.

HIV Risk Among Homosexual, Bisexual, and Heterosexual Male and Female Youths

Variations in sexual risk acts and thesocial-cognitive mediators of sexual acts were examinedamong young homosexual, bisexual, and heterosexual malesand females (N = 478; 13-21 Years of age) from four community-based agencies in New York City, SanFrancisco, and Los Angeles (29% African American, 36%Latino, 36% White/other). The prevalence and frequencyof sexual risk acts varied by gender but were similar across youth of different sexualorientations, ethnicities, and ages. Condom use and thesocial-cognitive mediators of risk varied by sexualorientation and gender. Homosexual youths reported a gap between their positive attitudes toward HIVprevention and their skills to implement safer sex acts,particularly under social pressure. Bisexual youthsappeared at greatest risk; their reports of sexual risk were the highest, yet their perceived riskfor HIV was relatively low and skills and knowledge weremoderate (relative to their peers). Heterosexual youthsappear at high risk for HIV based on reports of low rates of condom use and HIV-relatedbeliefs and attitudes. However, heterosexual youthsdemonstrated the highestlevelofcondom skills. The numberofsexual partners was not associated with anyHIV-related social cognitive mediator, suggesting thatalternative theoretical models must be proposed forpartner selection. Longitudinal research with similarsubgroups of youths is needed.

A Longitudinal Study of the Impact on Young Children of Maternal HIV Serostatus Disclosure

A longitudinal analysis of the psychological well-being of 81 young children ages 6–11 living with their HIV symptomatic or AIDS diagnosed mothers was conducted. Specifically, the relationship among mothers’ disease severity, maternal disclosure of HIV, and children’s psychological well-being was investigated. The children were assessed over three time points (i.e. baseline assessment, 6- month and 1-year follow-up). Two categories of maternal disclosure (disclosed before baseline, no disclosure at any of the three time points over 1-year), and two categories of disease severity (< 500 T-cell count across all assessments, 500+) were created. A series of 2 × 2 × 3 repeated measures MANOVAs was used to assess the effects of the maternal disclosure and disease severity across time on children’s psychological well-being. Results showed significant within-group time effects for child depression, suggesting a decrease in depression over time. Interaction results of time and maternal disclosure revealed only a few significant changes over time. However, significant decreases over time for child depression were noted among children whose mothers’ CD4 cell counts remained at 500+ across the three assessment periods. Implications for future research and for psychosocial needs of these families are discussed.

Anxiety/stress among mothers living with HIV: effects on parenting skills and child outcomes

Abstract Parental HIV infection has been associated with negative outcomes for children, and parenting skills appear to be one mechanism operating in that association. The present study focuses on the relations between maternal stress, parenting, and child functioning among families where the mother is living with HIV. Sixty-nine mothers with at least one child between six and 12 years old completed questionnaires at the baseline assessment of an intervention designed to facilitate maternal disclosure of HIV status. Respondents were assessed using multiple measures of stress/anxiety, parenting skills, and child outcomes, including the Parenting Stress Index, the RAND Mental Health Inventory, the Family Routines Questionnaire, and the Child Behavior Checklist. Covariance structural modeling was used to assess the variable relationships, with latent constructs created for maternal anxiety/stress, parenting skills, and child problem behaviors (both direct and indirect effects were evaluated, with a model-based bootstrap used to verify model stability). Results demonstrated that maternal stress was negatively associated with a broad range of parenting skills, and that parenting skills were negatively associated with child problem behaviors. Mothers living with HIV who are anxious about their own health and functioning, and who were more stressed in their parental role, were more likely to exhibit poorer parenting skills – specifically to engage children less frequently in family routines (e.g., eating meals together, having a bedtime routine), poorer parent–child communication, and poorer and less consistent parenting discipline. Not uncommonly, mothers living with HIV experience a range of stressors above and beyond those related to their illness (e.g., poverty, residence in high risk and low resource communities, discrimination). Results demonstrate the need for interventions designed to decrease maternal stress and enhance parenting skills for families affected by HIV.

Resiliency in Young Children Whose Mothers are Living with HIV/AIDS

Abstract Resiliency was investigated among well children 6–11 years of age (N = 111) whose mothers are living with AIDS or are HIV symptomatic to determine if mothers HIV status was a risk factor that could effect child resiliency, as well as investigate other factors associated with resiliency. Assessments were conducted with mother and child dyads over four time points (baseline, 6-, 12-, and 18-month follow-ups). Maternal illness was a risk factor for resiliency: as maternal viral load increased, resiliency was found to decrease. Longitudinally, resilient children had lower levels of depressive symptoms (by both mother and child report). Resilient children also reported higher levels of satisfaction with coping self-efficacy. A majority of the children were classified as non-resilient; implications for improving resiliency among children of HIV-positive mothers are discussed.

Results of an Antiretroviral Adherence Intervention: STAR (Staying Healthy: Taking Antiretrovirals Regularly).

A randomized 2-group medication adherence intervention is evaluated with HIV-infected adults (N = 141) assessed at baseline, 3-, and 9-month follow-ups. Cognitive (self-efficacy, behavioral intent), mental health (depression, well-being), and substance use indicators were the outcome measures. In addition, a posttest-only analysis from 3 to 9 months evaluates intervention impact on antiretroviral adherence, measured through Medication Event Monitoring System and pill counts. Compared to the standard care group, the intervention group showed significant increases in adherence self-efficacy and behavioral intent at 3 and 9 months and marginal improvements in mental health. Although the standard care group had higher adherence at 3 months (no baseline data were available prior to intervention), intervention group patients showed significant increases in adherence from 3 to 9 months. Although adherence levels achieved by intervention patients may not be sufficient for virological control, this is one of the first studies to provide promising results of longer term effectiveness of a behavioral adherence intervention.