This research was supported by Grant Number R01 DA023157 from the U.S. National Institute on Drug Abuse. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse or the National Institutes of Health. There are no conflicts to report. Aim: The overall goal of this study is to examine multi-level (individual, provider and environmental) risk and protective factors for ARV adherence and diversion among indigent HIV positive substance abusers; data will be used to identify salient targets for intervention to reduce patient vulnerability to diversion. Purpose: This analysis examines the contribution of serious mental illness (SMI) to ARV medication adherence among a highly marginalized sample of substance abusing HIV positive women. Methods: Guided by targeted sampling in geographic areas with high HIV prevalence and poverty indices, direct outreach was utilized to recruit 503 indigent HIV+ substance abusers in South Florida between 2010 and 2012. Following informed consent, participants completed a single face-to-face standardized interview based on the GAIN 6 instrument, assessing demographics, substance use, DSM-IV dependence and mental health status. Standardized instruments also assessed HIV diagnosis/treatment history, HIV-related stigma, and ARV attitudes. ARV adherence in the past week was measured by self report of doses missed, using the ACTG instrument. Eligibility criteria: age 18+; cocaine or heroin use 12+ times in the prior 3 months; documented HIV+ status; and, current ARV prescription. Analysis: Descriptive and bivariate statistics were computed to examine ARV adherence and its predictors. Linear regression analyses were utilized to examine multivariate relationships. This analysis presents data only for the female study participants, N=191. Background Purpose and Methods Miami is a high-incidence community for HIV, and African American women have been especially impacted. In 2010, Miami had the highest rate of new HIV infections in the U.S.. Serious mental illness (SMI) is a significant risk factor for HIV infection 1 . SMI is thought to increase HIV-related vulnerability through behavioral repertoires characterized by substance use and high risk sexual behaviors 2 . Environmental risk factors, such as poverty and homelessness, are also more prevalent among persons with SMI 1 , and these factors indirectly increase vulnerability to HIV 3 . Among HIV positive individuals, depression, anxiety, and substance use disorders are key factors influencing antiretroviral (ARV) medication adherence. The severity of symptoms related to these disorders is inversely related to ARV adherence 4 . Reports suggest that ARV diversion (selling or trading) is active in South Florida among highly vulnerable HIV+ patients 5 . The health implications of ARV diversion are substantial: Many individuals are not consistently adhering to their medication regimens, and fail to achieve the full benefits of ARV treatment. Serious Mental Illness and Medication Adherence among Vulnerable HIV+ Women In the bivariate analyses, past week ARV adherence was negatively associated with current mental health problems, substance problems, and homelessness; adherence was positively associated with favorable attitudes toward ARV medications. Multivariate analyses pointed to the impact of two key factors on adherence: ARV medication attitudes and current homelessness. These findings support the notion that both intrapersonal and environment factors are important contributors to medication adherence among HIV+ patients with high levels of competing needs. Economic vulnerability, unstable environments, and low levels of knowledge and attitudes about ARV treatment regimens must be addressed in community and practitioner-based intervention initiatives with this highly marginalized population. From a public health perspective, the provision of mental health services and housing support would appear to be important components of effective HIV treatment among this vulnerable group of women, and should form part of a compendium of services offered to marginalized HIV+ women. A primary recommendation would involve the integration of mental health care into locations where drug-involved women routinely visit, such as shelters and community HIV clinics. Co-location of services may be especially important for this group, given their economic need and difficulties in navigating the health care system. ARV diversion (sale or trading of medications) was reported by 38.7% of the women in this sample at least once in the past 90 days. Women reported being routinely targeted by “pill brokers” offering small financial incentives to purchase their ARV medications. HIV care providers should be made aware of this phenomenon in order to better educate their patients about the importance of consistent adherence to ARV medications. Hilary L. Surratt, Ph.D. [email protected] arsh.nova.edu 2 NE 40 th Street, Suite 404 Miami, FL , USA 33137 Hilary L. Surratt Steven P. Kurtz Catherine E. O’Grady Discussion and Conclusions Sample Characteristics, N=191 Age (median) 47.0 years Race/Ethnicity Hispanic 9.5% African American 77.9% White/Anglo 12.6% Education High School or more 48.2% Monthly income ≤ $1,000 86.4% Homeless (Past week) 20.4% Substance dependence (Past year) 53.9% HIV Diagnosis (median) 12.0 years ARV adherence level (Past week) below 80% 29.3% 80-94% 16.2% 95% or better 54.5% 70.2% of the sample met criteria for SMI (past year severe depression, anxiety, and/or traumatic stress). 52.6% were bothered by a serious mental health problem in the past week. The sample reported a mean HIV-related stigma score of 24.0, range 10-40. Sample Item: “People think I am a bad person because I have HIV.” The sample reported a mean ARV medication attitudes score of 8.2, range 2-16. Sample Item: “Taking HIV medication strengthens my immune system.” Linear Regression Analyses Predicting Past Week % ARV Adherence Bivariate Multivariate Unstandardized B (SE) t –score p-value Unstandardized B (SE) t –score p-value Homeless (past week) -.168 (.05) -3.14 .002 -.155 (.05) -2.95 .004 Substance problem (past week) -.094 (.03) -2.82 .005 -.043 (.04) -1.24 .216 HIV-related stigma -.005 (.003) -1.87 .063 ARV medication attitudes .032 (.01) 2.76 .000 .024 (.01) 2.07 .040 Mental health problem (past week) -.108 (.04) -2.51 .013 -.065 (.04) -1.48 .141 Results Acknowledgements References Contact Blank, M.B. & Eisenberg, M.M. (2007). HIV and mental illness: Opportunities for prevention. Journal of Prevention and Intervention in the Community,33, 1-4. Meade, C.S., Kershaw, T.S., Hansen, N., & Sikkema, K.J. (2009). Long-term correlates of child abuse among adults with severe mental illness: Adult victimization, substance abuse, and HIV sexual risk behavior. AIDS and Behavior, 13, 207-216. Surratt, H.L. & Inciardi, J.A. (2004). HIV risk, seropositivity and predictors of infection among homeless and non-homeless women sex workers in Miami, Florida, USA. AIDS Care, 16, 594-604. Nel, A., & Kagee A. (2011). Common mental health problems and antiretroviral adherence. AIDS Care, 23, 1360-1365. Surratt, Hilary L., Steven P. Kurtz, Theodore J. Cicero, Catherine O’Grady and Maria Levi -Minzi. In press. “Antiretroviral Medi cation Diversion among HIV-positive Substance Abusers in South Florida.” American Journal of Public Health. Dennis, M. L., Titus, J. C., White, M. K., Unsicker, J. I., & Hodgkins, D. (2002). Global Appraisal of Individual Needs - Initial (GAIN-I). Bloomington, IL, Chestnut Health Systems.
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
This research was supported by Grant Number R01 DA023157
from the U.S. National Institute on Drug Abuse. The content is
solely the responsibility of the authors and does not necessarily
represent the official views of the National Institute on Drug
Abuse or the National Institutes of Health.
There are no conflicts to report.
Aim: The overall goal of this study is to examine multi-level (individual, provider and environmental) risk and protective factors for ARV
adherence and diversion among indigent HIV positive substance abusers; data will be used to identify salient targets for intervention to
reduce patient vulnerability to diversion.
Purpose: This analysis examines the contribution of serious mental illness (SMI) to ARV medication adherence among a highly marginalized
sample of substance abusing HIV positive women.
Methods: Guided by targeted sampling in geographic areas with high HIV prevalence and poverty indices, direct outreach was utilized to
recruit 503 indigent HIV+ substance abusers in South Florida between 2010 and 2012. Following informed consent, participants completed a
single face-to-face standardized interview based on the GAIN6 instrument, assessing demographics, substance use, DSM-IV dependence
and mental health status. Standardized instruments also assessed HIV diagnosis/treatment history, HIV-related stigma, and ARV attitudes.
ARV adherence in the past week was measured by self report of doses missed, using the ACTG instrument.
Eligibility criteria: age 18+; cocaine or heroin use 12+ times in the prior 3 months; documented HIV+ status; and, current ARV prescription.
Analysis: Descriptive and bivariate statistics were computed to examine ARV adherence and its predictors. Linear regression analyses
were utilized to examine multivariate relationships. This analysis presents data only for the female study participants, N=191.
Background
Purpose and Methods
Miami is a high-incidence community for HIV, and African American women have been especially impacted. In 2010, Miami had the highest
rate of new HIV infections in the U.S..
Serious mental illness (SMI) is a significant risk factor for HIV infection1 . SMI is thought to increase HIV-related vulnerability through
behavioral repertoires characterized by substance use and high risk sexual behaviors 2. Environmental risk factors, such as poverty and
homelessness, are also more prevalent among persons with SMI1, and these factors indirectly increase vulnerability to HIV3.
Among HIV positive individuals, depression, anxiety, and substance use disorders are key factors influencing antiretroviral (ARV)
medication adherence. The severity of symptoms related to these disorders is inversely related to ARV adherence4.
Reports suggest that ARV diversion (selling or trading) is active in South Florida among highly vulnerable HIV+ patients5. The health
implications of ARV diversion are substantial: Many individuals are not consistently adhering to their medication regimens, and fail to achieve
the full benefits of ARV treatment.
Serious Mental Illness and
Medication Adherence among
Vulnerable HIV+ Women
In the bivariate analyses, past week ARV adherence was negatively associated with current mental health problems, substance problems, and homelessness; adherence was positively associated with favorable attitudes toward
ARV medications.
Multivariate analyses pointed to the impact of two key factors on adherence: ARV medication attitudes and current homelessness. These findings support the notion that both intrapersonal and environment factors are important
contributors to medication adherence among HIV+ patients with high levels of competing needs.
Economic vulnerability, unstable environments, and low levels of knowledge and attitudes about ARV treatment regimens must be addressed in community and practitioner-based intervention initiatives with this highly marginalized
population.
From a public health perspective, the provision of mental health services and housing support would appear to be important components of effective HIV treatment among this vulnerable group of women, and should form part of a
compendium of services offered to marginalized HIV+ women. A primary recommendation would involve the integration of mental health care into locations where drug-involved women routinely visit, such as shelters and community
HIV clinics. Co-location of services may be especially important for this group, given their economic need and difficulties in navigating the health care system.
ARV diversion (sale or trading of medications) was reported by 38.7% of the women in this sample at least once in the past 90 days. Women reported being routinely targeted by “pill brokers” offering small financial incentives to
purchase their ARV medications. HIV care providers should be made aware of this phenomenon in order to better educate their patients about the importance of consistent adherence to ARV medications.
Hilary L. Surratt, Ph.D.
arsh.nova.edu
2 NE 40th Street, Suite 404
Miami, FL , USA 33137
Hilary L. Surratt
Steven P. Kurtz
Catherine E. O’Grady
Discussion and Conclusions
Sample Characteristics, N=191
Age (median) 47.0 years
Race/Ethnicity
Hispanic 9.5%
African American 77.9%
White/Anglo 12.6%
Education
High School or more 48.2%
Monthly income ≤ $1,000 86.4%
Homeless (Past week) 20.4%
Substance dependence (Past year) 53.9%
HIV Diagnosis (median) 12.0 years
ARV adherence level (Past week)
below 80% 29.3%
80-94% 16.2%
95% or better 54.5%
70.2% of the sample met criteria for SMI (past year severe depression, anxiety, and/or traumatic stress).
52.6% were bothered by a serious mental health problem in the past week.
The sample reported a mean HIV-related stigma score of 24.0, range 10-40. Sample Item: “People think I am a bad person because I
have HIV.”
The sample reported a mean ARV medication attitudes score of 8.2, range 2-16. Sample Item: “Taking HIV medication strengthens my
immune system.”
Linear Regression Analyses Predicting Past Week % ARV Adherence
Bivariate Multivariate
Unstandardized B (SE) t –score p-value Unstandardized B (SE) t –score p-value
Homeless (past week) -.168 (.05) -3.14 .002 -.155 (.05) -2.95 .004
Substance problem (past week) -.094 (.03) -2.82 .005 -.043 (.04) -1.24 .216
HIV-related stigma -.005 (.003) -1.87 .063
ARV medication attitudes .032 (.01) 2.76 .000 .024 (.01) 2.07 .040
Mental health problem (past week) -.108 (.04) -2.51 .013 -.065 (.04) -1.48 .141
Results
Acknowledgements References Contact Blank, M.B. & Eisenberg, M.M. (2007). HIV and mental illness: Opportunities for prevention. Journal of Prevention and Intervention in the Community,33, 1-4.
Meade, C.S., Kershaw, T.S., Hansen, N., & Sikkema, K.J. (2009). Long-term correlates of child abuse among adults with severe mental illness: Adult victimization, substance abuse, and HIV sexual risk behavior. AIDS and
Behavior, 13, 207-216.
Surratt, H.L. & Inciardi, J.A. (2004). HIV risk, seropositivity and predictors of infection among homeless and non-homeless women sex workers in Miami, Florida, USA. AIDS Care, 16, 594-604.
Nel, A., & Kagee A. (2011). Common mental health problems and antiretroviral adherence. AIDS Care, 23, 1360-1365.
Surratt, Hilary L., Steven P. Kurtz, Theodore J. Cicero, Catherine O’Grady and Maria Levi-Minzi. In press. “Antiretroviral Medication Diversion among HIV-positive Substance Abusers in South Florida.” American Journal of
Public Health.
Dennis, M. L., Titus, J. C., White, M. K., Unsicker, J. I., & Hodgkins, D. (2002). Global Appraisal of Individual Needs - Initial (GAIN-I). Bloomington, IL, Chestnut Health Systems.
Related Documents
