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Family Effects of Structural Ecosystems Therapy (SET) for HIV+ Women in Drug Recovery

Family Effects of Structural Ecosystems Therapy (SET) for HIV+ Women in Drug Recovery. Victoria Mitrani, Daniel Feaster & Brian McCabe. e, Date, 2012 State of the Science Congress on Nursing Research. Center of Excellence for Health Disparities Research.

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Family Effects of Structural Ecosystems Therapy (SET) for HIV+ Women in Drug Recovery

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  1. Family Effects of Structural Ecosystems Therapy (SET) for HIV+ Women in Drug Recovery Victoria Mitrani, Daniel Feaster & Brian McCabe e, Date, 2012 State of the Science Congress on Nursing Research Center of Excellence for Health Disparities Research Research was supported by the National Institute on Drug Abuse (R01DA16543, R01DA15004) and the National Institutes of Health Office of Research on Women’s Health. This presentation was also supported by the National Institute of Minority Health and Health Disparities (P60MD002266). The content is solely the responsibility of the authors and does not necessarily represent the views of the National Institutes of Health.

  2. Significance of HIV/AIDS for Women’s Health • Treatment advances have transformed HIV/AIDS from a mortal illness into a manageable chronic condition (Cole, Hernan, Anastos, Jamieson, & Robins, 2007). • However, HIV/AIDS remains the fifth-leading cause of death for women in the United States, and in 2004 the leading cause of death for black women aged 25-34 years (Centers for Disease Control, 2008).

  3. Mental Health and Substance Abuse Among Women with HIV/AIDS • Women living with HIV/AIDS experience elevated psychological distress (Bing et al., 2001; Catz, Gore-Felton, & McClure, 2002), which can have a detrimental impact on physical health (Ickovics et al., 2001; Leserman et al., 2002; Remien et al., 2006). • Drug use is associated with poor adherence to HIV treatments (Lucas, Cheever, Chaisson, & Moore, 2001; Sherer, 1998) • Stimulant use is associated with immune activation that hastens HIV viral replication (Carrico et al., 2008).

  4. HIV and the Family • Family stress and support impact medication adherence (Merenstein et al., 2009; Murphy, Greenwell, & Hoffman, 2002) and health (Jones, Beach, Forehand, & Foster, 2003) among women with HIV/AIDS. • HIV+ women report that communication with family about illness, the family’s denial about the woman’s HIV status, their lack of knowledge about transmission, and the woman’s past drug use contribute the most stress in family relationships (Owens, 2003). • Families dually affected by HIV/AIDS and substance abuse are vulnerable to disruptions, such as loss of child custody (Barroso & Sandelowski, 2004; Conners et al., 2004).

  5. Family Interventions for Persons with HIV/AIDS • Couples Interventions- • Remien et al.; 2005 - support-enhancing intervention resulted in improved medication adherence. • El-Bassel et al., 2010 - skill-building intervention reduced sexual risk behaviors in African American couples. • Parent/child Intervention- Rotheram-Borus et al., 2003 - coping skills intervention for parents with AIDS and their adolescent children reduced emotional distress and problem behaviors. • Whole-Family Intervention - Szapocznik et al., 2004 - SET for HIV+ African American women reduced psychological distress, drug use relapse (Feaster, Burns, et al., 2010) and improved medication adherence (Feaster, Brincks, et al., 2010).

  6. Design of Parent RCT • 126 HIV+ women in drug recovery randomized toSET or HIV Health Group (HG) • Assessments every 4 months for 1 year • Aim: To examine the impact of SET in reducing drug relapse and improving medication adherence in the target women 6

  7. Target Women’s Outcomes • The results were mixed. • Women in SET did not show better drug use or medication adherence outcomes than women in HG. • Women in SET did show better outcomes than women in HG on: • improvement in CD4 T-cell count • starting antiretroviral treatment • accessing substance abuse services in response to relapse • separating from drug-using household members Reported in Feaster, D.J., Mitrani, V. B., Burns, M.J., McCabe, B.E., Brincks, A.M., Rodriguez, A.E., Asthana, D., Robbins, M.S. (2010). A randomized controlled trial of Structural Ecosystems Therapy for HIV medication adherence and substance abuse relapse prevention. Drug and Alcohol Dependence, 111(3),227-234.

  8. AIMS of the Family Study • Examining the impact of SET in families of HIV+ women in drug recovery • Examines aggregated data of family members (>age 10) including the woman • H1 - Family functioning • H2 - Family outcomes on psychological distress and drug abstinence • H3- Effect of changes in family functioning on family outcomes • H4- Reciprocal effects between the woman’s and family-members’ (excluding the woman) outcomes Reported in Mitrani, V. B., McCabe, B. E., Burns, M. J., & Feaster, D. J. (2012, June 18). Family Mechanisms of Structural Ecosystems Therapy for HIV-Seropositive Women in Drug Recovery. Health Psychology. Advance online publication.

  9. Structural Ecosystems Therapy: SET • SET isnota drugtreatmentintervention, butrather a post-treatmentorancillaryapproach • Throughconjointsessions, SET seekstoimproverelationshipswithinthefamily and betweenthefamily and outsidesystems (e.g., healthordrugtreatmentproviders, courts, church) topreventdrugrelapse & encourage HIV medicationadherence , by: • Strengtheningfamilysupport (e.g., toencourage HIV self-care and adherence) • Strengtheningtiestosupportiveresourcesoutside of thefamily • Establishingrelationshipboundaries (e.g., helpingwomandistanceherselffromdrug-usingfamilymembers, peers) • Creating a plan forfamilytorespondtorelapse and other crises (e.g., illness, housingloss, domesticviolence) Mitrani, V.B., Robinson, C., and Szapocznik, J. (2009). Structural Ecosystems Therapy (SET) for women with HIV/AIDS. In M. Stanton and J. Bray (Eds.), Handbook of Family Psychology (pp. 355-369). West Sussex, United Kingdom: Wiley-Blackwell.

  10. 4 months of treatment: SET: 1 hour/week – woman and family Health Group: 2 hours/bi-weekly – woman only Location of treatment: SET: Home-based Health Group: Office w/$ for transportation Manualized treatments Therapists with master’s degrees & comparable experience in modality Treatment Parameters for SET and Health Group

  11. English or Spanish speaking HIV+ and meets criteria for ART (viral load over 100,000 or CD4 T-cell count under 350 or any AIDS-defining illness) ≥18 years Meets DSM-IV critera for abuse or dependence on an illegal substance in the last year ≤1 year since exit from drug treatment Willing to disclose HIV status to at least one health care professional Having an eligible family member enroll in the family study Inclusion Criteria for Women 11

  12. Identifying the Family • Used a flexible butstandardizeddefinitionto capture therichness and variety of familyconstellations (includingnontraditional “kin”) • Focusedonfamilyrelationshipsthatwouldpotentiallyinfluence, and beinfluencedby, thewoman’scondition Inclusion criteria for family members: • Must meet ≥1 of the following: • Live in the woman’s household (but not strictly as boarder) • Her children (>5 yrs) with at least monthly contact • Has a role in helping to raise her children • Is her spouse or partner • Is a major source of support to the woman • Individuals were excluded if the woman did not want them in the study 13

  13. Randomization Health Group Allocated to intervention (n = 67 women; n = 150 family members) Received allocated intervention (n = 42 women) Did not receive allocated intervention (n = 25 women) SET Allocated to intervention (n = 59 families; n = 119 family members) Received allocated intervention (n = 33 families) Did not receive allocated intervention (n = 26 families) Allocation Families 52 (88%) present at 4 month 45 (76%) present at 8 month 42 (71%) present at 12 month Women + Family Members 111 present at 4 month 103 present at 8 month 110 present at 12 month Families 64 (96%) present at 4 month 61 (91%) present at 8 month 57 (85%) present at 12 month Women + Family Members 145 present at 4 month 152 present at 8 month 148 present at 12 month Follow-Up Analyzed (n = 59 families, n = 119 family members) Excluded from analysis (n = 0) Analyzed (n = 67 families, n = 150 family members) Excluded from analysis (n = 0) Analysis Family Flow in the Study 14

  14. Measurement of Family Functioning Family Cohesion Family Support Family Functioning Significant Other Support Acquiring Social Support Reframing Family Environment Scale (Moos & Moos, 1994) Multidimensional Scale of Perceived Social Support(Zimet, Dahlem, Zimet, & Farley, 1988) Family-Crisis Oriented Evaluation Scales (F-COPES; McCubbin, Larsen, & Olsen, 1981) 15

  15. H1: Effect of SET on Family Functioning The GEE analysis for family functioning revealed a significant time by treatment interaction (B = -0.05, SE = 0.02, p < .01). . 16

  16. Effect of SET and Family Functioning on Family Member Outcomes • H2: No effect of SET on family psychological distress or drug abstinence • H3: Effect of Changes in Family Functioning on psychological distress and drug abstinence • Changes in family functioning were not related to changes in family level drug abstinence • Changes in family functioning were related to changes in psychological distress of family members (B = -6.26, SE = 1.49, p < .001). (see next slide)

  17. Effect of Family Functioning on Psychological Distress • Psychological distress was reduced in both SET and HG, so there was no direct effect of SET on distress. • However, change in family functioning was related to change in psychological distress (B=-6.26, SE= 1.49, p< .001). • After controlling for change in family functioning, there was a • significant difference in the trajectory of psychological distress • between SET and HG (B=-0.28,SE= 0.13, p<.05). • There was an indirect effect from treatment to change in psychological distress such that when SET helped to reduce distress in the family it was acting through the mechanism of family functioning. • There was likely some other mechanism that reduced distress among family members of women in HG and caused the two groups to look similar on distress (Shrout & Bolger, 2002; Krause et al., 2010).

  18. H4: Reciprocal Effects Between Woman and their Family Members • Cross-lag models were used to test reciprocal effects. • Model fit for psychological distress was not acceptable so effect could not be tested. • Family drug abstinence significantly predicted the woman’s drug abstinence at the next timepoint (B = 0.19, SE = 0.06, p < .001). 19 19

  19. Conclusions • SET affected family functioning by preventing deterioration, which may be a risk for families with members post- drug treatment • Prevention of deterioration in family functioning may have led to reduced psychological distress in the women and their family members. • Reductions in drug use among family members led to abstinence in the women. • These findings demonstrate the interdependency of family members and the impact that family can have in preventing relapse. 20 20

  20. Literature Cited Barroso, J., & Sandelowski, M. (2004). Substance abuse in HIV-positive women. JANAC: Journal of the Association of Nurses in AIDS Care, 15, 48–59. Bing, E. G., Burnam, M. A., Longshore, D., Fleishman, J. A., Sherbourne, C. D., London, A. S., . . . Shapiro, M. (2001). Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Archives of General Psychiatry, 58, 721–728. Carrico, A. W., Johnson, M. O., Morin, S. F., Remien, R. H., Riley, E. D., Hecht, F. M., & Fuchs, D. (2008). Stimulant use is associated with immune activation and depleted tryptophan among HIV-positive persons on anti-retroviral therapy. Brain, Behavior, and Immunity, 22, 1257– 1262. Catz, S. L., Gore-Felton, C., & McClure, J. B. (2002). Psychological distress among minority and low-income women living with HIV. BehavioralMedicine, 28, 53–60. Centers for Disease Control. (2008, August). HIV/AIDS fact sheet: HIV/AIDS among women. Retrieved from http://www.cdc.gov/hiv/topics/ women/resources/factsheets/pdf/women.pdf Cole, S. R., Hernan, M. A., Anastos, K., Jamieson, B. D., & Robins, J. M. (2007). Determining the effect of highly active antiretroviral therapy on changes in human immunodeficiency virus type 1 RNA viral load using a marginal structural left-censored mean model. American Journal ofEpidemiology, 166, 219–227.

  21. Conners, N. A., Bradley, R. H., Mansell, L. W., Liu, J. Y., Roberts, T. J., Burgdorf, K., & Herrell, J. M. (2004). Children of mothers with serious substance abuse problems: An accumulation of risks. The AmericanJournal of Drug and Alcohol Abuse, 30, 85–100.  El-Bassel, N., Jemmott, J. B., Landis, J. R., Pequegnat, W., Wingood, G. M., Wyatt, G. E., & Bellamy, S. L. (2010). National Institute of Mental Health Multisite Eban HIV/STD prevention intervention for African American HIV serodiscordant couples: A cluster randomized trial. Archives of Internal Medicine, 170, 1594–1601. Feaster, D. J., Brincks, A. M., Mitrani, V. B., Prado, G., Schwartz, S. J., & Szapocznik, J. (2010). The efficacy of structural ecosystems therapy for HIV medication adherence with African American women. Journal ofFamily Psychology, 24, 51–59. Feaster, D. J., Burns, M. J., Brincks, A. M., Prado, G., Mitrani, V. B., Mauer, M. H., & Szapocznik, J. (2010). Structural ecosystems therapy for HIV+ African American women and drug abuse relapse. FamilyProcess, 49, 204–219. Ickovics, J. R., Hamburger, M. E., Vlahov, D., Schoenbaum, E. E., Schuman, P., Boland, R. J., . . . for the HIV Epidemiology Research Study Group. (2001). Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: Longitudinal analysis from the HIV Epidemiology Research Study. JAMA: Journal of the AmericanMedical Association, 285, 1466–1474. Jones, D. J., Beach, S. R. H., Forehand, R., & Foster, S. E. (2003). Self-reported health in HIV-positive African American women: The role of family stress and depressive symptoms. Journal of Behavioral Medicine,26, 577–599.

  22. Krause, M. R., Serlin, R. C., Ward, S. E., Rony, R. Y. Z., Ezenwa, M. O., & Naab, F. (2010). Testing mediation in nursing research: Beyond Baron and Kenny. Nursing Research, 59, 288 –294. Leserman, J., Petitto, J. M., Gu, H., Gaynes, B. N., Barroso, J., Golden, R. N., . . . Evans, D. L. (2002). Progression to AIDS, a clinical AIDS condition and mortality: Psychosocial and physiological predictors. PsychologicalMedicine, 32, 1059–1073. Lucas, G. M., Cheever, L. W., Chaisson, R. E., & Moore, R. D. (2001). Detrimental effects of continued illicit drug use on the treatment of HIV-1 infection. Journal of Acquired Immune Deficiency Syndrome, 27,251–259. McCubbin, H., Larsen, A., & Olson, D. (1996). F-COPES: Family Crisis Oriented Personal Evaluation Scales. In H. McCubbin, A. Thompson, & M. McCubbin (Eds.), Family assessment: Resiliency, coping and adaptation:Inventories for research and practice (pp. 120–133). Madison, WI: University of Wisconsin. Merenstein, D., Schneider, M. F., Cox, C., Schwartz, R., Weber, K., Robison, E., . . . Plankey, M. W. (2009). Association of child care burden and household composition with adherence to highly active antiretroviral therapy in the Women’s Interagency HIV Study. AIDSPatient Care and STDs, 23, 289–296. Moos, R., & Moos, B. (1994). Family environment scale manual: Development,applications, research (3rd ed.). Palo Alto CA: Consulting Psychology Press. Murphy, D. A., Greenwell, L., & Hoffman, D. (2002). Factors associated with antiretroviral adherence among HI infected women with children. Women & Health, 36, 97-111. Owens, S. (2003). African American women living with HIV/AIDS: Families as sources of support and of stress. Social Work, 48, 163–171.

  23. Remien, R. H., Exner, T., Kertzner, R. M., Ehrhardt, A. A., Rotheram- Borus, M. J., Johnson, M. O., . . . Kelly, J. A.; NIMH Healthy Living Project Trial Group. (2006). Depressive symptomatology among HIVpositive women in the era of HAART: A stress and coping model. American Journal of Community Psychology, 38, 275–285. Remien, R. H., Stirratt, M. J., Dolezal, C., Dognin, J. S., Wagner, G. J., Carballo-Dieguez, A., . . . Jung, T. M. (2005). Couple-focused support to improve HIV medication adherence: A randomized controlled trial. AIDS, 19, 807–814. Rotheram-Borus, M. J., Lee, M., Leonard, N., Lin, Y., Franzke, L., Turner, E., . . . Gwadz, M. (2003). Four-yea behavioral outcomes of an intervention for parents living with HIV and their adolescent children. AIDS,17, 1217–1225. Sherer, R. (1998). Adherence and antiretroviral therapy in injection drug users. JAMA: Journal of the American Medical Association, 280, 567–568. Shrout, P. E., & Bolger, N. (2002). Mediation in experimental and nonexperimental studies: New procedures and recommendations. PsychologicalMethods, 7, 422–445. Szapocznik, J., Feaster, D. J., Mitrani, V. B., Prado, G., Smith, W.,Robinson-Batista, . . . Robbins, M. S. (2004). Structural Ecosystems Therapy for HIV-seropositive African-American women: Effects on psychological distress, family hassles, and family support. Journal ofConsulting and Clinical Psychology, 72, 288–303. Zimet, G. D., Dahlem, N. W., Zimet, S. G., & Farley, G. K. (1988). The multidimensional scale of perceived social support. Journal of PersonalityAssessment, 52, 30–41.

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