MedicalResearch.com Interview with:
Marya Viorst Gwadz, Ph.D
Senior Research Scientist Director,
Transdisciplinary Methods Core
Center for Drug Use and HIV Research (CDUHR)
New York University College of Nursing
New York, NY 10010
Medical Research: What is the background for this study?
Dr. Gwadz: HIV is a major success story in that the tolerability, convenience, and efficacy of antiretroviral medications have improved dramatically over the last decade. A number of years ago in the course of another research study with vulnerable individuals infected with HIV in New York City, and we noticed that a substantial proportion of study participants were medically eligible for HIV medications, and had access to medications, but had declined or stopped taking them. We then turned our attention to understanding why this is the case, that is, to identify the individual, social, and structural barriers that persons living with HIV/AIDS (PLHA) experience to antiretroviral therapy. We focused in particular on African American/Black and Latino/Hispanic PLHA, because the overall emphasis of our research group at the NYU College of Nursing is the development and evaluation of culturally targeted intervention approaches to address health disparities. Around 2011, studies of the “HIV cascade of care” began to emerge, which highlighted the problem of poor engagement in HIV care and antiretroviral therapy nationally. The ultimate goal of HIV treatment is viral suppression, but at present, the Centers for Disease Control and Prevention (CDC) estimates that we have achieved that goal with only 30% of PLHA.
Medical Research: What kind of intervention approach that emerged from these background findings?
Dr. Gwadz: We found that barriers to HIV medication are complex and multi-faceted for PLHA from African American/Black and Latino/Hispanic backgrounds. In particular, PLHA experience serious emotional barriers to the uptake of HIV medications, such as fear of side effects, stigma, and disclosure of HIV status. Further, high rates of substance use and mental health distress, and barriers to accessing services for these concerns, impede medication uptake. Moreover, PLHA who are wary of HIV medication tend to avoid HIV primary care, often because they do not want to feel pressured to take medications, or explain to their providers why they are not taking them. So poor engagement in HIV care, which is very common among PLHA, and low uptake of HIV medication are actually related problems.
With funding from the National Institute of Mental Health (grant #R34MH093352), and in collaboration with Mount Sinai Beth Israel and Mount Sinai St. Luke’s-Roosevelt Hospital Center, we developed a multi-component culturally targeted intervention grounded in the Motivational Interviewing approach that included three individual sessions, 12-24 weeks of patient navigation (as needed), up to five support groups with other PLHA who had declined medication, which were co-led by a “successful” peer who was engaged in HIV care and were taking HIV medication with good adherence. One novel aspect of the intervention was its focus on emotional barriers to HIV medication, and the program’s “no pressure, no judgment” stance, congruent with the Motivational Interviewing approach, was key to engaging participants into the study to talk about these difficult issues.
Medical Research: What are the main findings?
Dr. Gwadz: This was a small and exploratory study to develop and evaluate the acceptability, feasibility, and evidence of efficacy of the intervention, called “Heart to Heart.” Nonetheless, we found that the intervention was quite promising compared to a control arm. Eight months post-baseline, intervention participants tended to be more likely to evidence “good” (that is, 7 day a week) adherence assessed via hair sample analysis (60% among intervention arm participants vs. 26.7% among controls), and also had lower HIV viral load levels based on the medical record than controls, at a statistically significant level (a difference of 0.88 log10 viral load), both large effect sizes. Adherence to HIV medication is considered the “Achilles’ heel” of treatment. The field has produced a lot of good adherence interventions, but their effects do not tend to last once the intervention ends. One hypothesis we have is that the Heart to Heart intervention was successful in fostering high quality, durable intrinsic motivation for behavior change among participants. However, we need a study with a longer follow-up period to explore that issue.
Medical Research: What should clinicians and patients take away from your report?
Dr. Gwadz: Patients should know they are not alone: many PLHA are struggling with the issue of whether to take HIV medication or not, and have stopped medication and are avoiding HIV care because they don’t want to talk about that with their health care providers. We know it’s a long and hard road. We know HIV is a roller coaster. On the other hand, there are compassionate, evidence-based services in HIV clinics to help you achieve your health goals, whether you choose to take medication or not. So come to your HIV care setting and talk about it with a health care provider or social worker, whomever you feel most comfortable with.
Clinicians should know that interventions such as Heart to Heart can be implemented in clinic settings to complement HIV primary care. Health care providers simply do not have the time to address complex barriers to HIV medication in the course of treating a serious disease such as HIV. That’s where behavioral interventions such as Heart to Heart can help. Further, clinical settings can and should conduct active outreach efforts to engage patients who have dropped out or who are avoiding HIV care, because they rarely present in clinical settings. But we have found these patients can be reached though peers and outreach efforts. Last, clinic settings may benefit from training in Motivational Interviewing and other similar approaches to better engage fearful and wary patients.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Gwadz: We learned a great deal in the Heart to Heart intervention study. Modifications to the intervention are needed for the next phase of this research program, and future studies with a longer follow up period and a study of intervention mediators may shed light on whether the Heart to Heart approach has enduring effects, and on its specific mechanisms of action.
Marya Gwadz, Charles M. Cleland, Elizabeth Applegate, Mindy Belkin, Monica Gandhi, Nadim Salomon, Angela Banfield, Noelle Leonard, Marion Riedel, Hannah Wolfe, Isaiah Pickens, Kelly Bolger, DeShannon Bowens, David Perlman, Donna Mildvan. Behavioral Intervention Improves Treatment Outcomes Among HIV-Infected Individuals Who Have Delayed, Declined, or Discontinued Antiretroviral Therapy: A Randomized Controlled Trial of a Novel Intervention. AIDS and Behavior, 2015;
MedicalResearch.com Interview with: Marya Viorst Gwadz, Ph.D (2015). ‘Heart To Heart’ Aims To Improve Adherence to HIV Medications