The Connection between Mental Health and HIV AIDS Implications

The Connection between Mental Health and HIV/AIDS: Implications for Clinical Care and Research Robert H. Remien, Ph. D. Milton L. Wainberg, M. D. Katherine S. Elkington, Ph. D. HIV Center for Clinical and Behavioral Studies, Columbia University and NYSPI

Overview • The Intersection of mental health, substance abuse and HIV/AIDS • Deployment-focused intervention development: • Three research examples

The Intersection of Mental Health, Substance Use and HIV/AIDS

Mental illness and HIV Risk Behaviors Specific Diagnoses: Inconsistently associated with risk • Symptoms: • • Positive psychotic sx cluster multiple partners; IDU excitement sx sexual activity; sex exchange; condom use Depressed/anxious sx STDs; poor condom negotiation skills; multiple partners; inconsistent condom use • High rates of co morbid substance use • High rates of childhood abuse • Problematic current interpersonal relationships • Poverty / low SES : sex exchange • Stigma and Discrimination (Meade & Sikkema, 2005, 2006; Donenberg & Pao, 2005)

Substance Use and HIV Risk Behaviors • Substance use and disorder linked to HIV/STI risk behaviors • Type of substance: alcohol, stimulants, club drugs • Amount and frequency of use: Addiction – sex exchange • Motivation for use (social anxiety; expectancy theory) • Role of environmental factors: peers, family • Method of data collection • Cross-sectional, longitudinal, event-level analysis (daily diary studies) 5

Mental Health and Substance Use Problems Among Subpopulations at High Risk for HIV • IDU: ↑ rates of SUD and other psychiatric disorders • MSM: ↑ rates of SUD and depression • SW: ↑ rates of childhood sexual abuse, SUD, and PTSD • Criminal/Juvenile justice: ↑ childhood sexual abuse; SUD and psychiatric disorders (particularly PTSD) • All groups: Stigma; legal sanctions; poor access to services; high risk interpersonal relationships — all associated with ↑ risk behaviors

Psychiatric and Substance Use Disorders among PLWHA RAND HCSUS Study: 2, 864 HIV+ Medical Patients • Any Psychiatric Disorder: Major depression Dysthymia Generalized anxiety disorder Panic attack Drug dependence Problematic alcohol use • (Bing et al Arch. Gen. Psych. 2001) • • • 48% 36% 27% 16% 11% 13% 19%

Impact of Mental Health and Substance Use Problems for PLWHA Mental health and substance use problems can: • Impair the quality of one’s life • Interfere with HIV treatment adherence • Interfere with self-care behaviors and increase risk behaviors • Result in acting out verbally or physically • Impair ability to cope with daily events, including childcare • Increases morbidity and mortality

Alcohol myopia “Social lubricant” (self medication) Acute intoxication (e. g. impaired judgement) Symptoms (e. g. paranoia, anxiety, depression, psychosis) Addiction Substance Ab/use Child abuse Stigma Strained/poor family & peer relationships Mental Illness IPV HIV RISK BEHAVIORS Non Adherence to treatment and Care Interpersonal Marginalized /risky peer groups Transportation/ access to health care Environmental/ Structural Poverty Neighborhood Disintegration Poor housing Stigma

Deployment-Focused Intervention Development Implications for Intervention, Treatment, and Care

HIV Prevention with Psychiatric Patients in Brazil: Planning a National Response Milton L. Wainberg, PRISSMA Project / NIMH R 01 -65163/ 2002 -2006 MD Associate Clinical Professor of Psychiatry, Columbia University

Background Worldwide, adults with severe mental illness (SMI) have elevated rates of HIV infection (between 0. 8% and 23. 8%) relative to the general population (3 to 5 times) Ø Few (n=7; 919 participants) HIV prevention interventions have been tested for efficacy – all of them in the US (Kalichman 1995, Kelly 1997, Susser 1998, Ø Weinhardt 1998, Otto-Salaj 2001, Carey 2004, Berkman 2006) Ø There is no single “gold standard” HIV prevention intervention for the SMI PRISSMA Project / NIMH R 01 -65163/ 2002 -2006 & 2006 -2011

Summary of HIV Prevention Research among SMI - 2001 US and Other Countries 1. Are at disproportionate risk Brazil Yes? 2. Are willing to talk about and are reliable when reporting their sexual activities and use of alcohol/drugs ? 3. Do not experience adverse reactions when participating in HIV prevention efforts (e. g. , increase in sexual activity or psychiatric symptoms) ? 4. Can benefit from participating of HIV prevention interventions 5. Are seldom offered HIV prevention interventions PRISSMA Project / NIMH R 01 -65163/ 2002 -2006 & 2006 -2011 ? ?

PRISSMA I Model AIDS and Behavior, 2007 1) Optimizing Fidelity: HIV Prevention Principles 3) Balancing Fidelity and Fit: Intervention Adaptation 2) Optimizing Fit: Adaptation Principles 4) Pilot Testing and Refining: Final Intervention PRISSMA Project / NIMH R 01 -65163/ 2002 -2006 & 2006 -2011

RCT Study Design Screen Baseline assessment* Orientation HIV – 8 sessions Health – 8 sessions Post-intervention assessment** 3 - & 6 -months follow-up assessments* HIV – 3 boosters Health – 3 boosters Post -booster assessment** 12 -months follow-up assessment* PRISSMA Project / NIMH R 01 -65163/ 2002 -2006 & 2006 -2011 * Diagnoses, risk behaviors, mediators/moderators ** Process measures, mediators/moderators

Total screened 3811 Recruitment Total eligible 1579 Interested 1348 Baseline done 916 Consented & Eligible 609 Recruitment ended 7 months early!!!!!! 464 Randomized Into 37 waves (HIV vs Health)

PRISSMA Implementation Month Jan Feb March April Intervention Booster HIV Saúde May HIV June Saúde July Augost Sept Oct HIV Saúde Nov HIV Dec Saúde

Summary of HIV Prevention Research among SMI – 2011/2014 US and Other Countries Brazil 1. Are at disproportionate risk Yes 2. Are willing to talk about and are reliable when reporting their sexual activities and use of alcohol/drugs Yes 3. Do not experience adverse reactions when participating in HIV prevention efforts (e. g. , increase in sexual activity or psychiatric symptoms) Yes 4. Can benefit from participating of HIV prevention interventions 5. Are seldom offered HIV prevention interventions PRISSMA Project / NIMH R 01 -65163/ 2002 -2006 & 2006 -2011 Hopefully No

Working with systems from the beginning: A Case example with JJS youth K 01 MH 089832 ; PI: Elkington

What’s Unique about JJS Youth? • Juvenile detainees are at high risk for HIV/STIs: l l l Higher rates of HIV/STI risk behaviors Higher rates of substance use and mental health (MH) disorders Numerous contextual factors that increase risk • Peers, families, neighborhoods

Intervening with Just the Youth…. …is that Enough? • Need to involve other domains or systems of risk and protection • • • Systems may act directly (e. g. family, peer group) or may be more distal (neighborhood, JJS) Family is key to promoting or off-setting risk GOAL: Target HIV/STI risk by addressing MH and SU problems and improving family functioning within context of the JJS

Modified Ecodevelopmental Model MACROSYSTEM Social-Cultural Context Immigration Policy Exosystem • Parents’ social support • Parents’ stress Language Poverty Cultural Family MICROSYSTEM • Family functioning (conflict/support) • Caregiver monitoring/supervision • Caregiver discipline • Caregiver-youth communication • Caregiver-youth relationship satisfaction Family-School Mesosytem Parental monitoring homework School Microsystem School Bonding Academic Achievement Family-Peer Mesosytem Parental monitoring of peer activities Youth • Substance use • Mental Health • HIV/STI knowledge • Safer sex and drug use attitudes • Safer sex self-efficacy • Perceived HIV risk • Safer sex behavior skills HIV/STI sexual risk behavior Szapocznik & Coatsworth, 1999) Peer Microsystem Perceived peer HIV/STI behavior Perceived peer HIV/STI norms

Developing the intervention • To develop and implement effective interventions that are targeted and sustainable: 1. Achieve buy in from treatment system and keystakeholders involved • Probation, staff, families, youth 2. Formative work • Understand logistic and institutional-cultural contextual factors of the probation center and staff • Understand context of sexual risk for JJS youth including the role of the family

Modified Ecodevelopmental Model MACROSYSTEM Social-Cultural Context Immigration Policy Cultural Exosystem • Parents’ social support • Parents’ stress Language Poverty Family MICROSYSTEM • Family functioning (conflict/support) • Caregiver monitoring/supervision • Caregiver discipline • Caregiver-youth communication • Caregiver-youth relationship satisfaction Family-School Mesosytem Parental monitoring homework School Microsystem School Bonding Academic Achievement JJS Family-Peer Mesosytem Parental monitoring of peer activities Youth • Substance use • Mental Health • HIV/STI knowledge • Safer sex and drug use attitudes • Safer sex self-efficacy • Perceived HIV risk • Safer sex behavior skills Peer Microsystem Perceived peer HIV/STI behavior Perceived peer HIV/STI norms HIV/STI sexual risk behavior 24

Phase 1 – Formative phase • Interview probation staff (n=12) l l l What is their perception of youth HIV/STI risk? What is role of probation department in providing HIV/STI programming? How would an intervention fit into current programming…. . climate…… culture?

• All staff perceived their youth to be at considerable risk for HIV/STIs and needed intervention program: l Sexually active at young ages; ↑ pregnancies l Impulsive; MH and SA abuse problems l Limited supervision and problematic role models (peers and family) l Implications for intervention development and delivery: • Great – we are on the right track, sexual risk is a problem • Addressing MH issues and SA is key • Staff think this is important to address • Staff recommend program to families and talk up program to get resistant families involved

• Providers struggled to reconcile their role as POs with their responsibility of providing youth with services l l l “It’s not on the form so we don’t ask” Address presenting problem rather than provide prevention for a potential problem Social work vs. law enforcement: Differing views held by staff Sex risk, HIV/STI rarely bought up - believe youth will not talk Staff do not feel adequately trained to address sexual risk but would if they were trained Implications for intervention development: • Add a sex risk screening question to intake assessment? • Alter culture: promote prevention for non-probation related issues • Task shifting: train subset of POs in youth sexuality and sexual risk reduction to deliver intervention

• How would an intervention fit into current programming…. . climate…… culture? l POs currently co-lead groups onsite at the probation department On-site vs. off-site programming: Both services are available. POs busy schedule: is there time to additional programs Family engagement always tricky l Implications for intervention development: l l l • • • Build intervention into existing services and bundle Work with community providers Build in participation in HIV program as mandatory part of their probation

Developing the intervention cont’d 3. Develop a family-based intervention building on an existing efficacious youth-only intervention designed for youth on probation • 1 st work group : youth and caregivers • Review interview data and existing interventions; role play and suggest changes • 2 nd work group: probation staff • Work together to create actual intervention sessions drawing from other family-based interventions 4. Pilot test the intervention in department of probation • • Deliver as part of co-located services offered Work with CBOs to deliver to JJS families