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
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6000
1200
4000
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2000
0
0
80
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92
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Year of Diagnosis/Death
Cases
Deaths
Persons Living with HIV/AIDS
06
Number of Persons Living with HIV
Number of AIDS Cases/Deaths
AIDS Cases, Deaths & Prevalence
1980 - 2006
Why Study Adherence?
Adherence related to
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Virologic control
Treatment resistance
Morbidity
Quality of life
Survival
Health care costs
HIV transmission
– Personal and community
Predictors of Poor Adherence
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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
R01NR010187
Duo Phases
20062007
• Qualitative phase
• Measure development
2008
20082010
20092013
20122015
• 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
Actor Effect
Phil’s Stuff
Paul’s
Outcomes
Phil’s
Outcomes
Paul’s Stuff
Paul’s
Outcomes
Phil’s Stuff
Phil’s
Outcomes
Paul’s Stuff
Paul’s Outcomes
Actor Effect
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 CD4 and viral load
Explanatory Variables
• Depression
• Treatment Beliefs
– General med concerns
– Specific 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
– Log10 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
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420 men
91 discordant couples
119 concordant couples
45 years old
17% AA
18% Latino
91% gay
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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 (-)
PAUL’s
Adherence SelfEfficacy
PERSEVERANCE
PHIL’s
Relationship Satisfaction
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 (log10)
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
Paul’s Outcomes
Actor Effect
Actor Effect
Phil’s Stuff
Phil’s Outcomes
Paul’s Stuff
Paul’s Outcomes
Phil’s Stuff
Phil’s Outcomes
What’s in the black box?
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Tactics
Support Received
Support Provided
Substance Use?
Figure 1. Conceptual Model
á
á
â
á
á
á
á
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á
á
â
á
á
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Partner A
Support Provided
Overall Support Provided
Positive Tactics
Negative Tactics
Partner A
QOL/ Well-Being
Coping/Problem solving
Substance Use
Couple
Relationship Quality
Relationship Satisfaction
Intimacy
Communication
Conflict
Partner B
QOL/ Well-Being
Coping/Problem Solving
Substance Use
á
á
â
Partner A
Support Received
Overall Support Received
Positive Tactics
Negative Tactics
á
á
â
Partner B
Support Received
Overall Support Received
Positive Tactics
Negative Tactics
á
á
â
Partner B
Support Provided
Overall Support Provided
Positive Tactics
Negative Tactics
Partner A
á Adherence
á
â
Partner A
CD 4
Viral Load
Partner B
á Adherence
á
â
Partner B
CD 4
Viral Load
Duo Phases
20062007
• Qualitative phase
• Measure development
2008
20082010
20092013
20122015
• Cross-sectional
• Longitudinal quantitative
• Longitudinal qualitative
• Intervention development
• piloting
Tactics
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Ask
(76%)
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Check in (72%)
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Model (65%)
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Remind (61%)
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Encourage (56%)
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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
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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 R01NR010187
• The DUO men
• The DUO Project team
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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