This study was funded by linked cooperative agreements between NIMH and the Research Foundation for Mental Hygiene, Inc. (N.Y. State Psychiatric Institute/Columbia University, HIV Center); the Medical College of Wisconsin; the University of California, Los Angeles; and the University of California, San Francisco.  To read more about ongoing developments relating to this project, click here.

                        

Collaborating Institutions and Key Personnel:

HIV Center:
Principal Investigator: Anke A. Ehrhardt, Ph.D.
Co-Principal Investigator: Robert H. Remien, Ph.D.

Medical College of Wisconsin:
Principal Investigator: Jeffrey A. Kelly, Ph.D.

University of California, Los Angeles:
Principal Investigator: Mary Jane Rotheram-Borus, Ph.D.

University of California, San Francisco:
Principal Investigator: Margaret A. Chesney, Ph.D.
Co-Principal Investigator: Stephen F. Morin, Ph.D.

National Institute of Mental Health:
Willo Pequegnat, Ph.D.

Beth Israel Medical Center, New York:
Don C. DesJarlais, Ph.D.; Jackie Correale, M.P.H.

St. Luke's-Roosevelt Medical Center, New York:
Hannah Wolfe, Ph.D.; Rachel Wolfe, Ph.D.

Funding Source and Project Period: NIMH U10: 9/30/98-7/31/05.

 

Project Overview

More Americans than in the past are people living with HIV (PLH), and they will have longer anticipated life spans and better potential health. However, research indicates that a substantial number of HIV-infected persons continue to engage in high-risk sexual and substance use behaviors. Many studies have shown that 30% to 40% of PLH continue to engage in acts that place themselves and others at risk. Medical adherence and skills needed to interact with the medical profession are also low, especially among disenfranchised populations now most likely to become infected. The goal of this project was to design and test an intervention to reduce sexual and injection practice risk behaviors among 942 HIV-infected men and women in order to decrease the likelihood that PLH would transmit infection to others and to promote other health-related behavior changes in PLH. Although sexual and drug use transmission risk acts were the primary outcomes, the intervention also sought to a) to enhance health care behaviors that may increase individuals' prospects for long-term survival; and b) to maintain positive behavioral and mental health changes over time to enhance the quality of life of PLH. Heterosexual women and men, men who have sex with men (MSM), and injection drug users (IDUs) were the four subgroups included in the research, which was undertaken collaboratively by research teams at four sites: Los Angeles, New York City, San Francisco, and Milwaukee.

 

NY took the lead on the one-year period of formative Phase 1 studies . Interviews were conducted with 152 HIV+ women, MSM, and IDUs at each site. The formative research consisted of qualitative life-history interviews to characterize the psychical, social, and interpersonal contexts that influence risk behavior among PLH: stages of adaptation to serostatus; barriers to implementation of safer sex, positive health care acts, and quality of life; and ways to tailor the intervention's theoretical framework, the social action model (Ewart, 1990; Ewart, 1995), for each subpopulation. Based on findings of the formative studies and the constructs of the social action model, an individually-delivered intervention of 15 sessions, organized into three modules (health behavior promotion, transmission risk behavior reduction, and psychological coping enhancement) was developed.

 

In the Phase 2 main intervention trial, four subgroups of infected persons, all of whom have engaged in high-risk transmission acts in the past six months, were recruited at each site. Altogether 936 PLH's project-wide were randomly assigned in equal numbers to an immediate or lagged (control) intervention condition. Following the baseline interview, assessment interviews were conducted at 5-month intervals for the next 25 months. In addition to anticipating changes in the primary outcomes of sexual and drug use transmission risk acts over time, we examined the impact of intervention on secondary outcomes related to health care behaviors and quality of life. In response to each module, we examined the impact of mediating factors emerging from social action theory (coping skills, social support, problem solving, HIV-related attitudes/beliefs, and environmental context of risk acts), and participant background factors (gender, ethnicity, and history of transmission behaviors) on outcomes.

 

The specific aims of the study were (1) to determine the physical, social and interpersonal contexts that characterize continued risk behavior in the lives of PLH and to tailor intervention to salient factors in these contexts; (2) to evaluate the effectiveness of an individually-delivered intervention to reduce HIV-related sexual and substance use transmission acts and to improve health care practices and quality of life for PLH (women, MSM, and IDUs) who have recently engaged in high-risk practices and who are randomly assigned to an immediate or lagged (control) intervention condition; (3) to evaluate factors that may mediate the impact of the intervention including participant exposure category and background factors; the acquisition of theoretically-based targeted skills; attitudes, norms, environmental contexts; and site factors; and (4) to evaluate the cost effectiveness of the intervention and to disseminate its findings.

 

The trial is now complete. There were multiple study findings and investigators continue to utilize the large data set for further analyses.

 

Publications from this project (as of 11/1/09):

1. Rotheram-Borus, M. J., Desmond, K., Arnold, E., & Comulada, S. (2009). Reducing risky sexual behavior and drug use among currently and formerly homeless adults living with HIV. American Journal of Public Health, 99(6), 1100-1107.

2. Johnson, M. O., Chesney, M. A., Neilands, T. B., Dilworth, S. E., Remien, R. H., Weinhardt, L. S., Wong, F. L., & the NIMH Healthy Living Project Team. (2008). Disparities in reported reasons for not initiating or stopping antiretroviral treatment among a diverse sample of people living with HIV. Journal of General Internal Medicine, 24(2), 247-251. PMCID: PMC2628985

3. Morin, S. F., Shade, S. B., Steward, W. T., Carrico, A. W., Remien, R. H., Rotheram-Borus, M. J., Kelly, J. A., Charlebois, E. D., Johnson, M. O., Chesney, M. A., & the Healthy Living Project Team. (2008). A behavioral intervention reduces HIV transmission risk by promoting sustained serosorting practices among HIV-infected men who have sex with men. JAIDS, 49(5), 544-551. PMCID: PMC2659703

4. 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(8), 1257-1262. NIHMS# 94463

5. Carrico, A. W., Chesney, M. A., Johnson, M. O., Morin, S. F., Neilands, T. B., Remien, R. H., Rotheram-Borus, M. J., & Wong, F. L. (2009). Randomized controlled trial of a cognitive-behavioral intervention for HIV-positive persons: An investigation of treatment effects on psychosocial adjustment. AIDS & Behavior, 13(3), 555-563. NIHMS# 112811

6. Wong, F. L., Rotheram-Borus, M. J., Lightfoot, M., Pequegnat, W., Comulada, W. S., Cumberland, W., Weinhardt, L. S., Remien, R. H., Chesney, M., Johnson, M., & the Healthy Living Trial Group. (2008). Effects of behavioral intervention on substance use among people living with HIV: The Healthy Living Project randomized controlled study. Addiction, 103(7), 1206-1214. PMCID: PMC2665995

7. Johnson, M.O., Carrico, A.W., Chesney, M.A., & Morin, S.F. (2008). Internalized heterosexism among HIV-positive gay-identified men: Implications for HIV prevention and care. Journal of Consulting and Clinical Psychology, 76(5), 829-839.

8. Mosack, K. E., Weinhardt, L., Kelly, J. A., Gore-Felton, C., McAuliffe, T., Johnson, M. O., Remien, R. H., Rotheram-Borus, M. J., Ehrhardt, A. A., Chesney, M. A., & Morin, S. (2008). Influence of coping, social support, and depression on subjective health status among HIV-positive adults with different sexual identities. Behavioral Medicine, 34(4), 133-144. PMCID: PMC2653049

9. Steward, W. T., Charlebois, E. D., Johnson, M. O., Remien, R. H., Goldstein, R. B., Wong, F. L., & Morin, S. F. (2008). Receipt of prevention services among HIV-infected men who have sex with men. American Journal of Public Health, 98(6), 1011-1014. PMCID: PMC2377307
10. Johnson, M. O., Dilworth, S. E., Neilands, T. B., Chesney, M. A., Rotheram- Borus, M. J., Remien, R. H., Weinhardt, L. S., Ehrhardt, A. A., & Morin, S. F. (2008). Predictors of attrition among high risk HIV-infected participants enrolled in a multi-site prevention trial. AIDS & Behavior, 12(6), 974-977. PMCID: PMC2574761
11. Johnson, M. O., Charlebois, E., Morin, S. F., Remien, R. H., Chesney, M. A., & the NIMH Healthy Living Project Team. (2007). Effects of a behavioral intervention on antiretroviral medication adherence among people living with HIV: The Healthy Living Project randomized controlled study. JAIDS, 46(5), 574-580. PMCID: PMC2442469
12. Carrico, A. W., Johnson, M. O., Moskowitz, J. T., Neilands, T. B., Morin, S. F., Charlebois, E., Steward, W. T., Remien, R. H., Wong, L., Rotheram-Borus, M. J., Lightfoot, M. A., Chesney, M. A., & the NIMH Healthy Living Project Team. (2007). Affect regulation, stimulant use and viral load among HIV + persons on anti-retroviral therapy. Psychosomatic Medicine, 69, 785-792.
13. Johnson, M. O., Neilands, T. B., Dilworth, S. E., Morin, S. F., Remien, R.H., & Chesney, M. A. (2007). The role of self-efficacy in HIV treatment adherence: validation of the HIV treatment adherence self-efficacy scale (HIV-ASES). Journal of Behavioral Medicine, 30(5), 359-370. PMCID: PMC2423379

14. Remien, R. H., Exner, T. E., Morin, S. F., Ehrhardt, A. A., Johnson, M. O., Correale, J., Marhefka, S., Kirshenbaum, S. B., Weinhardt, L. S., Rotheram- Borus, R. J., Catz, S., Gore-Felton, C., Chesney, M., Kelly, J., & the NIMH Healthy Living Project Team. (2007). Medication adherence and sexual risk behavior among HIV-infected adults: Implications for transmission of resistant virus. AIDS and Behavior, 11(5), 663-675.

15. Johnson, M. O. & Neilands, T. B. (2007). Neuroticism, side effects, and health perceptions among HIV-infected individuals on antiretroviral medications. Journal of Clinical Psychology in Medical Settings, 14(1), 69-77. PMCID: PMC2435048

16. Kirshenbaum, S. B., Pinto, R. M., Correale, J., Remien, R. H., Goldstein, R. B., Catz, S. L., Johnson, M. O., Morin, S. F., Rotheram-Borus, M. J., & Ehrhardt, A. A. (2007). Opening up windows when clients keep closing doors: Key elements in engaging HIV-positive individuals in prevention interventions. Journal of HIV/AIDS & Social Services, 6(3), 5-28.

17. Carrico, A. W., Johnson, M. O., Morin, S. F., Remien, R. H., Charlebois, E. D., Steward, W. T., Chesney, M. A., & the NIMH Healthy Living Project Team. (2007). Correlates of suicidal ideation among HIV-positive persons. AIDS, 21(9), 1199- 1203.

18. The NIMH Healthy Living Project Team. (2007). Effects of a behavioral intervention to reduce risk of transmission among people living with HIV: The Healthy Living Project randomized controlled study. Journal of Acquired Immune Deficiency Syndromes, 44, 213-221.

19. Klitzman, R., Exner, T. E., Correale, J., Kirshenbaum, S. B., Remien R. H., Ehrhardt, A. A., Lightfoot, M., Catz, S. L., Weinhardt, L. S., Johnson, M. O., Morin, S. F., Rotheram-Borus, M. J., Kelly, J. A., & Charlebois, E. (2007). It’s not just what you say: Relationships of HIV disclosure and risk reduction among MSM in the post-HAART era. AIDS Care, 19(6), 749-756.

20. Remien, R. H, Exner, T. E., Kertzner, R. M., Ehrhardt, A. A., Rotheram-Borus, M. J., Johnson, M. O., Weinhardt, L. S., Kittel, L. E., Goldstein, R. B., Pinto, R. M., Morin, S. F., Chesney, M. A., Lightfoot, M., Gore-Felton, C., Dodge, B., Kelly, J. A., & the NIMH Healthy Living Project Trial Group. (2006). Depressive symptomatology among HIV-positive women in the era of HAART: A stress and coping model. American Journal of Community Psychology, 38(3-4), 275-285.

21. Melendez, R. M., Exner, T. E., Ehrhardt, A. A., Dodge, B., Remien, R. H., Rotheram-Borus, M. J., Lightfoot, M., Hong, D., & the NIMH Healthy Living Project Team. (2006). Health and health care among HIV- positive male-to-female transgenders. American Journal of Public Health, 96(6), 1034-1037. PMCID: PMC1470610

22. Johnson, M. O., Chesney, M. A, Goldstein, R. B., Remien, R. H., Catz, S., Gore-Felton, C., Charlebois, E. D., Morin, S. F., & NIMH Healthy Living Project Team. (2006). Positive provider interactions, adherence self-efficacy, and adherence to antiretroviral medications among HIV infected adults: A mediation model. AIDS Patient Care and STDs, 20(4), 258-268. PMCID: PMC2432422

23. Johnson, M. O., Elliott, T. R., Neilands, T. B., Morin, S. F., & Chesney, M. A. (2006). A social problem solving model of adherence to HIV medications. Health Psychology, 25(3), 355-363. PMCID: PMC2432423

24. Hong, D. S., Goldstein, R. B., Rotheram-Borus, M. J., Wong, F. L., & Gore-Felton, C. (2006). Perceived partner serostatus, attribution of responsibility for prevention of HIV transmission, and sexual risk behavior with “main” partner among adults living with HIV. AIDS Education and Prevention, 18, 150-162.

25. Goldstein, R. B., Rotheram-Borus, M. J., Johnson, M. O., Weinhardt, L. S., Remien, R. H., Lightfoot, M., Catz, S., Gore-Felton, C., Kirshenbaum, S. B., Morin, S. F., & the NIMH Healthy Living Project Team. (2005). Insurance coverage, usual source of care, and receipt of clinically indicated care for comorbid conditions among adults living with HIV. Medical Care, 43(4), 401-410.

26. Lightfoot, M., Rogers, T., Goldstein, R. B., Rotheram-Borus, M. J., May, S., Kirshenbaum, S. B., Weinhardt, L. S., Zadoretzky, C., Kittel, L., Johnson, M. O., Gore-Felton, C., & Morin, S. F. (2005). Predictors of substance use frequency and reductions in seriousness of use among persons living with HIV. Drug and Alcohol Dependence, 77(2), 129-138.

27. Gore-Felton, C., Rotheram-Borus, M. J., Weinhardt, L. S., Kelly, J. A., Lightfoot, M., Kirshenbaum, S. B., Johnson, M. O., Chesney, M. A., Catz, S. L., Ehrhardt, A. A., Remien, R., Morin, S. F., & the NIMH Healthy Living Project Team (2005). The Healthy Living Project: An individually-tailored, multidimensional intervention for HIV-infected persons. AIDS Education and Prevention, 17(1 Supp A), 21-39.

28. Johnson, M. O., Charlebois, E., Morin, S. F., Catz, S. L., Goldstein, G. B., Remien, R., H., Rotheram-Borus, M. J., Mickalian, J., Kittel, L., Samimy-Muzaffer, F., Lightfoot, M., Gore-Felton, C., Chesney, M. A., & the NIMH Healthy Living Project Team. (2005). Perceived adverse effects of antiretroviral. Journal of Pain and Symptom Management, 29(2), 193-205.

29. Goldstein, R. B., Johnson, M. O., Rotheram-Borus, M. J., Kirshenbaum, S. B., Pinto, R. M., Kittel, L., Pequegnat, W., Mickalian, J. D., Weinhardt, L. S., Kelly, J. A., Lightfoot, M., & the NIMH Healthy Living Team. (2005). Psychological distress, substance use, and adjustment among parents and nonparents living with HIV. Journal of the American Board of Family Practice, 18(5), 362-373. PMCID: PMC1395483

30. Morin, S. F., Steward, W. T., Charlebois E., Remien, R. H., Pinkerton, S. D., Johnson, M. O., Rotheram-Borus, M. J., Lightfoot, M., Goldstein, R. B., Kittel L., Samimy-Muzaffar, F., Weinhardt, L., Kelly, J. A., & Chesney, M. A. (2005). Predicting HIV transmission risk among HIV-Infected men who have sex with men: Finding from the Healthy Living Project. Journal of Acquired Immune Deficiency Syndromes, 40(2), 226-235.

31. Weinhardt, L. S. The effects of HIV diagnosis on sexual risk behavior. In: Kalichman S, ed. Positive prevention: Reducing HIV transmission risks among people living with HIV. New York: Kluwer; 2005: 29-60.

32. Klitzman, R. L., Kirshenbaum, S. B., Kittel, L., Morin, S. F., Daya, S., Mastrogiacomo, M., & Rotheram-Borus, M. J. (2004). Naming names: Perceptions of name-based HIV reporting, partner notification, and criminalization of non-disclosure among persons living with HIV. Sexuality Research and Social Policy, 1(3), 38-57.

33. Weinhardt, L. S., Kelly, J. A., Brondino, M. J., Rotheram-Borus, M. J., Kirshenbaum, S., Chesney, M., Remien, R. H., Morin, S., Lightfoot, M., Ehrhardt, A. A., Johnson, M. O., Catz, S. L., Pinkerton, S. D., Benotsch, E. G., Hong, D., Gore-Felton, C., & the NIMH Healthy Living Project Team. (2004). HIV transmission risk behavior among men and women living with HIV in four US cities. Journal of Acquired Immune Deficiency Syndromes, 36(5), 1057-1066.

34. Kirshenbaum, S. B., Hirky, A. E., Correale, J., Goldstein, R. B., Johnson, M. O., Rotheram-Borus, M. J., & Ehrhardt, A. A. (2004). "Throwing the Dice": Pregnancy decision making among HIV+ women in four U.S. cities. Perspectives on Sexual and Reproductive Health, 36(3), 106-113.

35. Klitzman, R. L., Kirshenbaum, S. B., Dodge, B., Remien, R. H. Ehrhardt, A. A., Johnson, M. O., Kittel, L. E., Daya, S., Morin, S. F., Kelly, J., Lightfoot, M. J., Rotheram-Borus, M. J., & the NIMH Healthy Living Trial Group (2004). Intricacies and inter-relationships between HIV disclosure and HAART: A qualitative study. AIDS Care, 16(5), 628-640.

36. Johnson, M. O., Catz, S., Remien, R. H., Rotheram-Borus, M. J., Morin, S. F., Charlebois, E., Gore-Felton, C., Goldstein, R. B., Wolfe, H., Lightfoot, M., Chesney, M. A., & the NIMH HLP Team. Theory guided, empirically supported avenues for intervention on HIV medication nonadherence: Findings from the Healthy Living Project. In: Laurence J, ed. Medication Adherence in HIV / AIDS. NY: Leibert Publishers; 2004: 355-366.

37. Johnson, M. O., Catz, S., Remien, R. H., Rotheram-Borus, M. J., Morin, S. F., Charlebois, E., Gore-Felton, C., Goldstein, R. B., Wolfe, H., Lightfoot, M., Chesney, M. A., & the NIMH HLP Team. (2003). Theory guided, empirically supported avenues for intervention on HIV medication nonadherence: Findings from the Healthy Living Project. AIDS Patient Care and STDs, 17(12), 645-656.

38. Hirky, A. E., Kirshenbaum, S. B., Melendez, R. M., Rollet, C., Perkins, S. L., & Smith, R. A. (2003). The female condom: Attitudes and experiences among HIV-positive heterosexual women and men. Women and Health, 37(1), 71-89.

39. Remien, R. H., Hirky, A. E., Johnson, M. O., Le, G. M., Whittier, D., & Weinhardt, L. S. (2003). Adherence to medication treatment: A qualitative study of facilitators and barriers among a diverse sample of HIV+ men and women in four U.S. cities. AIDS and Behavior, 7(1), 61-72.

40. Wight, R. G., Rotheram-Borus, M. J., Klosinski, L., Ramos, B., Calabro, M., & Smith, R. (2000). Screening for transmission behaviors among HIV-infected adults. AIDS Education and Prevention, 12(5), 431-441.

 

<back to top>