Mental Health – CHIPTS – Center for HIV Identification, Prevention and Treatment Services

12May

mHealth to Enhance & Sustain Drug Use Reduction of the QUIT BI in Primary Care

Abstract:The QUIT-Mobile study proposes to use mobile phone self-monitoring and feedback to enhance and sustain over 12-months the impacts of the Quit Using Drugs Intervention Trial (QUIT), an ef- fective screening and brief intervention (SBI) previously successful in reducing risky drug use (i.e., moderate use) in low-income, diverse patients over a 3-month follow up. We propose to conduct the QUIT-Mobile study for primary care patients who receive care in 8 clinics of federally qualified health centers (FQHC) in Southern California over 12-months follow up, comparing to QUIT and Usual Care (UC). The proposed study is an Effec- tiveness-Implementation Hybrid Type 1 design consisting of a single-blind, 3-arm, RCT with adult, mostly La- tino FQHC primary care patients with risky drug use (ASSIST score 4-26), randomized to 3 conditions (n=320/arm, n=960 total): 1) QUIT-Mobile; 2) standard QUIT; 3) Usual Care. Qualitative data on implementa- tion facilitators and barriers will inform future scale-up and sustainability, in addition to cost data and cost-effec- tiveness analysis. The aims are to examine effectiveness in reducing risky drug use and cost-effectiveness comparing the three arms over 3-, 6- and 12-months. Drug use measures include urine drug tests, and timeline follow-back self-reports for past 7-days and past 30-days (risky drug users have sporadic drug use patterns requiring longer self-report recalls for drug use that urine screens may not detect). The 3-arm study enables testing of the independent and synergistic effects of QUIT-Mobile compared to QUIT and both to Usual Care, acknowledging that mHealth components alone may not be effective outside of a clinical/coaching relationship. The 12-month timeline reflects anticipated scale-up scenarios of annual primary care visits when screening and brief intervention would be repeated routinely. QUIT contains 3 components: 1) patient screening with the WHO ASSIST, 2) brief clinician advice (<4 minutes) including opioid overdose prevention education, and 3) 2- and 6-week telephone drug-use health coaching sessions utilizing motivational interviewing and cognitive be- havioral techniques, delivered by paraprofessional health coaches. QUIT-Mobile proposes to test the addition of mobile phone self-monitoring, feedback, and coach monitoring dashboard to enhance and sustain QUIT’s drug use reductions using mobile app, text-messaging (SMS), or interactive voice response (IVR) to allow par- ticipation by with varying technological preferences. This study does not test which technology platform is more effective, but rather, the effectiveness of the intervention functions (i.e., self-monitoring, automated feedback, coach monitoring) that are delivered via patients’ preferred technologies. This study is novel and timely in inte- grating massively scalable mobile phone tools into an effective primary care BI to prevent substance use disor- der (SUD) in FQHC patients delivered by paraprofessionals. QUIT-Mobile is responsive to the National Opioid Crisis, and the US Mental Health Parity Act and National Academy of Medicine recommendations to integrate behavioral health SBIs into primary care settings to prevent higher level SUD requiring specialty treatment.

Project Number: 5R01DA047386-03

https://reporter.nih.gov/search/XqGvUHDw-U2JrS-UaBk2iQ/project-details/10381700

Contact PI/ Project Leader

GELBERG, LILLIAN GELBERG, GEORGE F. KNELLER PROFESSOR (lgelberg@mednet.ucla.edu)

Organization

UNIVERSITY OF CALIFORNIA LOS ANGELES

PUBLIC HEALTH RELEVANCE: Only recently has a screening and brief intervention in low-income primary care settings been shown to reduce patients’ illicit drug use over 3-months. Good as this finding is, the next challenge is to sustain patients’ drug use reductions over 12-months to coincide with routine annual primary care visits for rescreening. We propose adding mHealth tools to enhance and sustain drug use reductions in an effective SBI to reduce drug use and prevent addiction.

FOA: PA-19-055/ Study Section: Interventions to Prevent and Treat Addictions Study Section[IPTA]

Project Start Date: 01-June-2020

Project End Date:31-March-2025

Budget Start Date: 01-April-2022

Budget End Date: 31-March-2023

NIH Categorical Spending

Funding IC: NATIONAL INSTITUTE OF DRUG ABUSE / FY Total Cost by IC: $746,806

9Nov

Text Me, Girl! – Text Messaging to Improve Linkage, Retention and Health Outcomes among HIV-positive Young Transgender Women

Abstract: Young trans women experience a number of psychosocial challenges including discrimination, prejudice, stigmatization, and social/economic marginalization, which stand as obstacles to linkage and retention in HIV care and ART medication adherence. Due to these challenges, and their often transient nature, a text-messaging HIV intervention that is easily accessible, culturally competent, private and portable is a particularly salient method for engaging and retaining young trans women in HIV care. This project utilizes a text-messaging intervention to improve engagement, retention, and health outcomes along the HIV Care Continuum, with the desired outcome of viroligical suppression, among HIV-positive young trans women, aged 18-34, who are not linked to care, or not retained in care, or not prescribed ART, or nonadherent to ART, or not virologically suppressed. Over the course of the 90-day intervention, participants receive 270 theory-based text messages that are targeted, tailored, and personalized specifically for HIV-positive young trans women; participants receive three messages per day in real-time within a 10-hour graduated and automated delivery system. The text-message content is pre-written along the HIV Care Continuum (i.e., HIV positivity/physical and emotional health, linkage/retention in care, ART adherence/viral load suppression) and is based on three proven theories of behavior change (i.e., Social Support Theory, Social Cognitive Theory, and Health Belief Model). Following screening for eligibility, informed consent, and baseline assessment, participants are randomized into one of two conditions: Group A: Immediate Text Message Intervention Delivery (ID, n=60); or, Group B: Delayed Text Message Intervention (DD, n=60) whereby participants are delivered the text-messaging intervention after a delayed 90-day period. Participants in both groups receive the exact same 90-day text-messaging intervention. Following the 90-day theory-based, trans-specific text-messaging intervention, participants may opt in/opt out of continued weekly post-intervention messages for ongoing retention and engagement support derived from the HRSA-funded UCARE4LIFE library. The randomized two-group repeated measures design assesses participants at 3-, 6-, 12-, and 18-months post-randomization to determine observed intervention effects and longitudinal intervention effects.

26Oct

Resiliency Education to Reduce Depression Disparities

Abstract: Depression is the leading cause of adult disability and common among lesbian, gay, bisexual (LGB) adults. Primary care depression quality improvement (QI) programs can improve outcomes for minorities more significantly than for nonminorities, but they are seldom available in safety-net systems. We build on findings from Community Partners in Care (CPIC) and Building Resiliency and Increasing Community Hope (B-RICH). CPIC compared depression QI approaches across healthcare and social /community services in communities of color. CPIC included healthcare and “community-trusted” programs (e.g., homeless, faithbased) to work as a network to address depression, compared to individual-program technical assistance. In CPIC, both conditions improved mental wellness, mental health quality of life, and depression over 12 months. B-RICH, a randomized study, evaluated lay delivery of a seven-session, CBTinformed resiliency education class versus case management on patients’ depressive symptoms over three months, in unpublished but completed analyses. The proposed demonstration supplements the resiliency class with a mobile/interactive voice response case management tool to reinforce class content and depression care reminders (BRICH+).

24Jan

Community Health Study

There have been few attempts to monitor the risk behaviors and HIV seroprevalence among the general population.

Understanding the HIV epidemic in Los Angeles requires establishing an integrated, multilevel surveillance system for HIV, sexually transmitted diseases (STDs), and the Hepatitis C virus (HCV). Information about sexual and substance use risk behaviors, HIV seroprevalence, and public knowledge, attitudes, and norms regarding HIV are needed for public health planning. A surveillance system will be required in order for Los Angeles to maintain funding for Ryan White and other federal and state funding sources. To begin to develop a method for mounting a comprehensive surveillance system, the City of Los Angeles is planning a study examining the acceptability of anonymous HIV testing and volunteering information about one’s risk behaviors in order to allow planning for HIV-related services.

Most studies of HIV seroprevalence and risk behaviors have been conducted with subgroups identified at high risk for HIV: young gay men, injecting drug users, homeless adolescents, or seriously mentally ill adults. There have been few attempts to monitor the risk behaviors and HIV seroprevalence among the general population (not necessarily from identified high-risk groups). Before any comprehensive surveillance system can be established, the ability to monitor HIV in community settings and among households in neighborhoods with high rates of AIDS cases must be established. To fill this gap, a two-phase project is being initiated by the city in order to assess the acceptability of HIV testing and reporting one’s risk behaviors when approached: 1) in a household survey; or 2) in a neighborhood setting such as a shopping mall, grocery center, theater, or church.

First, the acceptability of gathering HIV-related information from a household will be examined by conducting a supplement to the Los Angeles Health Survey that will be mounted this summer. An anonymous telephone interview will be conducted with random digit dialing of households within the City of Los Angeles. Randomly selected telephone numbers (n=100) will be surveyed on knowledge of transmission of HIV, attitudes and norms towards members of high-risk groups (e.g., gay men) and infected persons, and willingness to anonymously be tested for HIV. All responses will be recorded unlinked from telephone numbers selected by random digit dialing; therefore the identify of all respondents will be unknown and can never be traced. From gathering this information, the acceptability of a household approach as a method of gathering information about HIV-related information will be assessed.

Second, a community with a high rate of AIDS cases will be selected. In this neighborhood, local leaders will be consulted to identify a strategy for sampling community members anonymously and in settings accessible to all community members. In shopping malls in both communities, adults will be asked to anonymously volunteer to participate in a survey of attitudes and norms regarding HIV prevention activities, recent sexual and substance use risks acts, and consent to a saliva-based HIV test. The results of any individual test results will not be available; unmarked samples will be collected in order to indicate a community seroprevalence rate. Interested individuals will be offered an incentive for participating in the survey and test. The willingness of adult members of the community to participate in a study anonymously will be evaluated. Similar to the telephone household survey, no identity of any participant will be obtained. Overall, community rates will be obtained, but no individual information regarding risk or infection status.

The results of these two activities will be used to inform the Los Angeles County Board of Supervisor’s decisions regarding the best method for establishing surveillance methods for HIV infection and predictions regarding the future routes and subgroups for HIV infection. Currently, the County is considering adopting a method of practitioners informing public health officials of all persons testing seropositive for HIV or for a system of unique identifiers for persons who test seropositive for HIV. Both of these systems rely on the identification of seropositive persons, an event that typically occurs about 10 years after a person has become infected. Alternative strategies for monitoring the epidemic, especially among communities with an emerging epidemic must be identified. These studies will inform the strategy selected by the County and may become a national model.

23Jan

Teens and Adults Learning to Communicate (TALC: LA)

Project TALC was funded by the National Institute of Mental Health (NIMH) to evaluate the efficacy of a family-based intervention over time and to contrast the life adjustments of HIV-affected families and their non-HIV-affected neighbors in the current treatment era. Mothers living with HIV (MLH; n = 339) and their school-age children (n = 259) were randomly assigned to receive a behavioral intervention or standard care as the control condition. MLH and their children were compared to non-HIV-affected families recruited at neighborhood shopping markets.

Targeted Risk Group:

HIV-positive mothers and their adolescent children

Published Journal Articles:

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Links to Interventions, Training Manuals, etc. :

Phase 1 – Taking Care Of Myself

Parents’ Curriculum

Phase 2 – Illness

Parents’ Curriculum

Adolescents’ Curriculum

Phase 3 – Adjustment

New Caregivers and Teens’ Curriculum

Young Adults’ Curriculum

Intervention Model:

Mothers and their adolescents attended a 16-session cognitive behavioral intervention over eight weeks. For MLH, intervention goals aimed to: 1) improve parenting while ill (i.e., reduce family conflict, improve communication, clarify family roles); 2) reduce mental health symptoms; 3) reduce sexual and drug transmission acts; and 4) increase medical adherence and assertiveness with medical providers. For adolescents, the intervention goals were to: 1) improve family relationships; 2) reduce mental health symptoms; 3) reduce multiple problem behaviors (e.g., drug use, criminal justice acts, school problems, teenage pregnancy); and 4) school retention.

Research Methods:

In a random assignment study, families assigned to take part in Project TALC were compared with families assigned to a control group on mental health and health behaviors, including sexual behavior and substance use. Both intervention and control families were compared to a neighborhood cohort, matched on sociodemographics. Because study participants were followed over two years, longitudinal random effect regression models were used to test the efficacy of the intervention.

Surveys and Scales Used:

Local Significance:

There was a lack of significant findings for an intervention effect on HIV-transmission behaviors and mental health. HIV-transmission behaviors were low to begin with and participants had little room for improvement. The populations affected by the HIV epidemic in the U.S. have shifted over the past number of years since a similarly mounted intervention in New York City led to improvements. HIV interventions in the U.S. need to shift their focus to persons living with HIV who are experiencing substantial problems.

International Significance:

While the focus of U.S.-based HIV interventions need to shift, interventions for the general HIV population may be effective outside the U.S.

23Jan

Los Angeles County Methamphetamine Prevention Initiative

There is a significant unmet need in Los Angeles County for methamphetamine-specific training, and community service agencies and outreach workers need education and training on effective approaches to engage and serve persons in the community at risk. Training and technical assistance is also needed for service providers on the latest evidence-based methamphetamine treatment approaches.

More specifically, trainings are needed that cover methamphetamine-specific issues crucial for the development of skills by medical providers, clinicians and outreach workers serving clients who use methamphetamine and address specific concerns around providing culturally appropriate care for specific populations. These trainings address issues such as: mental health considerations, psychological complications, sexual and cybersex addiction and current evidence based treatments.

This training project included the following activities:

Providing consultation and technical assistance to the Los Angeles County Alcohol and Drug Program Administration (ADPA) and the Office of AIDS Programs and Policy (OAPP)
Developing training curricula and module for ADPA or OAPP-funded substance abuse or HIV/AIDS treatment providers
Developing and disseminating web-based training module
Providing in-service trainings for Los Angeles County Methamphetamine Task Forces
Providing in-service trainings for ADPA and OAPP-funded Drug Abuse and HIV prevention agencies serving young women
Providing tailored technical assistance

23Jan

Mamekhaya

In South Africa, where a large portion of pregnant women are HIV positive, prevention of mother-to-child transmission of HIV (PMTCT) is an important endeavor. To improve the effectiveness of the standard PMTCT programs, the Mamekhaya program used peer mentoring and a culturally adapted cognitive behavioral intervention (CBI).

Research Methods:

HIV-positive pregnant women at the Gugulethu Midwife Obstetric Unit and at the Vanguard Community Health Center in Cape Town were invited to participate in the study. Participants at both sites received the standard PMTCT care; however, participants at the Gugulethu site received the Mamekhaya intervention.The first part of the intervention consisted of assigning a participant with a mentor mother through Mothers2mothers. The mentor mother was a woman who was HIV-positive, had recently had a child, and had received PMTCT and was doing well. Participants also attended group sessions of a cognitive-behavioral intervention. The sessions included information on living with HIV, preventing HIV transmission, parenting, social support, and mental health.

Local Significance:

Participants in the Mamekhaya intervention had increased HIV knowledge scores, significantly increased social support, and significantly decreased depression scores compared to women in the control group.

20Jan

Vietnam – Development of a Family Intervention to Address Drug Use and HIV in Vietnam

This two-year study will be conducted in Phu Tho Province, Vietnam in collaboration with the Vietnam National Institute of Hygiene & Epidemiology (NIHE). This study will develop and pilot an intervention aimed at increasing family support for IDU’s behavior change and family capacities to effectively cope with the impact of IDUs and HIV.

Targeted Risk Group:

IDUs, family members

Intervention model:

Planned behavior change, Stages of change, and Psych-education

Research Methods:

• Focus group to develop the content, format and delivery plan for the intervention
• Intervention will be delivered to 40 IDUs and 40 their family members
• Assessments will be conducted with 80 IDUs and 80 Family members at baseline, 3-month and 6-month follow-ups.

Local Significance:

The findings from the study will inform the design of the full-scale intervention trial for families coping with IDU and/or HIV in Vietnam. By addressing HIV and IDUs, this intervention could potentially reduce the psychological, physical and emotional demands of living with chronic HIV, coping with drug use, and improve the safety of society. A dissemination of the intervention design to district hospitals in Vietnam can improve the lives of families in dealing HIV and IDUs.

International Significance:

This study demonstrates a model to combine traditional drug use treatment with psychosocial and behavioral intervention. This can be applied to other countries with different cultures.

20Jan

Grief Interventions for PLAs, Adolescents and Guardians

By the year two thousand, 80,000 children will be orphaned by AIDS in the U.S. and this number will continue to rise. Parental death during one’s childhood has been consistently associated with negative outcomes for children, however, there have been no prospective studies of adolescent bereavement from any type of parental death, including death from AIDS. This continuation study is aimed at delivering and evaluating an intervention to alleviate grief associated with the death of a parent. These results are likely to have implications for millions of AIDS orphans internationally and for the 550,000 US adolescents bereaved annually by parental death.

Scope:

Over the last two and a half years, 310 parents living with AIDS (PLAs) and their 498 adolescent children, age 12-18 were recruited. They were randomly assigned to receive: (1) a standard care condition in which extensive social welfare services are provided; or (2) an enhanced care condition in which three modules of coping skills intervention (Project TALC: Teens and Adults Learning to Communicate) plus social services are provided. Linked to the phases of parental illness, PLAs, their adolescents, and new custodial guardians are schedule to meet individually and jointly in over 32 sessions. Because the life span of women with AIDS extended from 14.3 months to 27 months over the last two years, about two thirds of the sample of PLAs continue to live longer than anticipated, delaying the delivery of the final intervention module. Over the next 18 months, the investigator anticipates that the PLAs will die, and the final, post-death module of the intervention will be delivered. The present continuation study will allow the investigator to complete the delivery and the evaluation of the intervention, and in addition, pursue the following activities: (1) follow youths of PLAs prospectively and longitudinally for four additional years to evaluate their mental health, behavioral, and social outcomes; (2) complete the delivery and evaluation of the enhanced coping skills intervention, particularly of Module 3 to new custodial guardians and youths; and (3) develop new measures of grief to describe the bereavement process over time.

Parents living with AIDS reported a mean of 3.3 (SD=1.3) areas of conflict with their adolescents and 1.5 (SD=1.7) stressful parenting events over the previous three months. The parents were very ill, with many physical symptoms and diseases. Simultaneously, substance use was common (17% used daily), but not injection drug use (3.3%). Half had a sexual partner (63% protected partners by using condoms consistently). Regression analysis revealed that parent-adolescent conflict was significantly associated with high parental drug use: stressful parent events were significantly related to the lifestyle (high drug use and frequent sex acts) of Latino and African-American parents, but not white parents. In contrast to parents with other illnesses, parent-adolescent conflict and stressful parenting events were not influenced by parents’ health status, but were significantly influenced by substance use and sexual lifestyles. Both mothers (87%) and fathers were significantly more likely to disclose their serostatus to adolescents (73%), compared to younger children (23%). Only 44% disclosed to all their children; 11% disclosed to none. Most PLAs (80%) discussed custody plans; however, only 30% initiated legal plans, typically for younger children. Adolescents informed of their PLA’s serostatus engaged in more sexual risk acts, smoked more cigarettes, reported more severe substance use, and greater emotional distress than did uninformed adolescents. Legal custody arrangements were not associated with adolescent adjustment at recruitment or followup.

National Institute of Mental Health, grant 2R01MH49958-06

20Jan

IMAGE Program

The incidence of HIV is high among women of childbearing age in the U.S., and mothers living with HIV (MLH) report their greatest source of stress is combining the maternal role with the psychological and medical demands of coping with a chronic, life-threatening condition.

The purpose of this R01 pilot study is to develop and then test the feasibility of implementing a parenting intervention for HIV-infected mothers with well children age 6–14 years old. The intervention is designed to improve parenting skills and maternal self-care skills in order to improve child and maternal outcomes. The basis for development of this intervention is work from two previous R01s (MH # 5R01MH057207, currently Yr. 12) designed to longitudinally assess HIV-positive mothers and their children.

MLH (n = 60) and their children (total N = 120) will be recruited, randomized to a theory-based, skills training intervention or a control condition, and assessed at baseline and 3, 6, and 12-month follow-ups. The intervention (“Improving Mothers’ parenting Abilities, Growth, & Effectiveness”—the IMAGE program) will consist of 5 sessions, and will be based on the Information – Motivation – Behavioral Skills (IMB) model of health behavior change, with specific skills selected based on our 10-year observational study of MLH and their children, which is on-going at UCLA. A random subset of 40% of the intervention mothers (n = 12) will be asked to participate in an in-depth qualitative interview after their last follow-up, to obtain detailed process information on their experiences in the intervention.

The main aims of this randomized pilot trial are to:

Develop the intervention and then evaluate the feasibility and acceptability of implementing the 5-week, theory based, individual behavior intervention to enhance positive parenting skills of MLH; and
Conduct preliminary evaluation of the data for effect sizes and investigate trends in the data for
- - Parenting practices outcomes (utilizing the parent practices scale), and secondary outcomes of parenting efficacy
  - Parenting behaviors targeted (parent-child communication, parental monitoring, family routines, and appropriate parentification) and the self-care skills targeted (social support, disclosure, dealing with perceived stigma)
  - Maternal outcomes for mental health indicators and physical health indicators
  - Child outcomes of mental health indicators, behavioral problems, and self-concept and coping
  - Family outcomes (family functioning, parent-child relationship)

We are now in the third decade of the HIV epidemic, and few interventions, other than for prevention or medication adherence, are available for women living with HIV; this study will be the first step in the evaluation an intervention that will assist HIV-positive mothers in dealing with the stress of parenting while coping with HIV. The pilot data will lead to a future application for a full-scale trial of the intervention to test efficacy.