Whats Love Got to Do With It Relationship

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

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

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 R 01 NR 010187

Duo Phases 20062007 20082010 20092013 20122015 • Qualitative phase • Measure development • Cross-sectional • Longitudinal quantitative • Longitudinal qualitative • Intervention development • piloting

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 he certainly is—he’s that type, looks, and personality. ” “Well, I certainly love him. He’s very dependent, which I don’t mind. I 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 Stuff Actor Effect Phil’s Stuff Paul’s Outcomes Phil’s Outcomes

Paul’s Outcomes Paul’s Stuff Par Phil’s Stuff tne r Ef fect t c e ff E r e tn Phil’s Outcomes

Paul’s Stuff Actor Effect Par tne Paul’s Outcomes r Ef t fec f E r ne t Par Actor Effect Phil’s Stuff Phil’s Outcomes

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 CD 4 and viral load

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

Outcomes • Adherence Self Efficacy – Integration – Perseverance • Self Reported Adherence – 3 day – 30 day • Viral Load – Detectable v not – Log 10 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 91 discordant couples 119 concordant couples 45 years old 17% AA 18% Latino 91% gay • • 26% HS grad or less 84 months as couple 12 years HIV+ 9+ years on meds

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 Time on Meds (-) PHIL’s Relationship Satisfaction PAUL’s Adherence Self. Efficacy PERSEVERANCE

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 (log 10) 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 Actor Effect Par tne Paul’s Outcomes r Ef t fec f E r ne t Par Actor Effect Phil’s Stuff Phil’s Outcomes

Paul’s Stuff Paul’s Outcomes Par tne r Ef t fec f E r ne t Par Phil’s Stuff Phil’s Outcomes

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

Figure 1. Conceptual Model

Duo Phases 20062007 20082010 20092013 20122015 • Qualitative phase • Measure development • Cross-sectional • Longitudinal quantitative • Longitudinal qualitative • Intervention development • piloting

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

‘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 Paul says 10 Phil says 2 Sum = 12 Difference = 8 10= very true Peter says 6 Ned says 6 Sum = 12 Difference = 0

What about other couples?

• NIH Grant R 01 NR 010187 • 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