Publications

The following is a partial list of research articles generated from the Unity Project /The Healthy Living Project.

Johnson MO, Elliott TR, Neilands TB, Morin SF, Chesney MA. A Social Problem-Solving Model of Adherence to HIV Medications. Health Psychol. 2006 May;25(3):355-63.

Center for AIDS Prevention Studies, University of California, San Francisco, CA, US. Mallory.Johnson@ucsf.edu.

HIV medication adherence remains a challenge and limits the degree to which treatment benefit can be maximized. This study tested an explanatory model of HIV medication adherence using a social problem-solving (SPS) framework. Associations of SPS with adherence are hypothesized to be direct and/or indirect via psychological health. HIV+ adults were interviewed using validated measures of SPS, psychological health, and antiretroviral therapy (ART) medication adherence. Structural equation modeling (SEM) techniques were used to test hypothesized relationships and to evaluate overall fit of the model to the data. SEM supported an indirect association (but not direct) of SPS on adherence via psychological health among the 545 HIV+ adults included in the analyses. Overall, the findings resulted in a model of adherence that offered very good fit to the data and correctly classified 97% of the cases as adherent versus nonadherent. Results support the use of SPS as a conceptual framework for understanding adherence to ART. Findings offer rationale and direction for SPS interventions to enhance adherence by improving psychological health. Such approaches, if effective, have the potential to positively impact psychological well being and adherence, thereby maximizing clinical benefit from treatment, which is linked to lower mortality from AIDS. 2006 APA, all rights reserved


Johnson MO, Chesney MA, Goldstein RB, Remien RH, Catz S, Gore-Felton C, Charlebois E, Morin SF; NIMH Healthy Living Project Team. Positive provider interactions, adherence self-efficacy, and adherence to antiretroviral medications among HIV-infected adults: A mediation model. AIDS Patient Care STDS. 2006 Apr;20(4):258-68.

Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California 94105, USA. Mallory.Johnson@ucsf.edu

Adherence to antiretroviral (ARV) therapy for HIV infection is critical for maximum benefit from treatment and for the prevention of HIV-related complications. There is evidence that many factors determine medication adherence, including adherence self-efficacy (confidence in one’s ability to adhere) and relations with health care providers. However, there are no studies that examine how these two factors relate to each other and their subsequent influence on HIV medication adherence. The goal of the current analysis was to explore a model of medication adherence in which the relationship between positive provider interactions and adherence is mediated by adherence self-efficacy. Computerized self-administered and interviewer-administered self reported measures of medication adherence, demographic and treatment variables, provider interactions, and adherence self-efficacy were administered to 2765 HIV-infected adults on ARV. Criteria for mediation were met, supporting a model in which adherence self-efficacy is the mechanism for the relationship between positive provider interactions and adherence. The finding was consistent when the sample was stratified by gender, race, injection drug use history, and whether the participant reported receipt of HIV specialty care. Positive provider interactions may foster greater adherence self-efficacy, which is associated with better adherence to medications. Results suggest implications for improving provider interactions in clinical care, and future directions for clarifying interrelationships among provider interactions, adherence self-efficacy, and medication adherence are supported.


Morin SF, Steward WT, Charlebois ED, Remien RH, Pinkerton SD, Johnson MO, Rotheram-Borus MJ, Lightfoot M, Goldstein RB, Kittel L, Samimy-Muzaffar F, Weinhardt L, Kelly JA, Chesney MA. Predicting HIV transmission risk among HIV-infected men who have sex with men: findings from the healthy living project. J Acquir Immune Defic Syndr. 2005 Oct 1;40(2):226-35.

Center for AIDS Prevention Studies, University of California, San Francisco, CA 94105, USA. smorin@psg.ucsf.edu

OBJECTIVE: To examine the predictors of transmission risk among HIV-infected men who have sex with men (MSM) in 4 US cities. METHOD: Individual computer-assisted interviews assessing psychologic measures and sexual behavior with the 5 most recent male and female partners were conducted with a diverse sample of 1910 HIV-infected MSM recruited from community and clinic settings in San Francisco, New York, Los Angeles, and Milwaukee. Transmission-risk events were defined as unprotected vaginal or anal sex with a partner who was HIV negative or of unknown status. RESULTS: A small but not insignificant proportion of MSM (12.7%) reported at least 1 transmission-risk event in the previous 3 months, with 57% of those events taking place with casual as opposed to steady partners. Multivariate predictors of transmission risk with casual partners were stimulant (eg, crystal methamphetamine) and other drug use, having low coping self-efficacy, and not having disclosed one’s HIV serostatus to all partners. Stimulant use and failing to disclosing one’s serostatus to all partners were associated with risk in primary relationships. CONCLUSIONS: Responding to HIV transmission risk in MSM requires different strategies for primary and casual partners.


Gore-Felton C, Rotheram-Borus MJ, Weinhardt LS, Kelly JA, Lightfoot M, Kirshenbaum SB, Johnson MO, Chesney MA, Catz SL, Ehrhardt AA, Remien RH, Morin SF; NIMH Healthy Living Project Team. The Healthy Living Project: an individually tailored, multidimensional intervention for HIV-infected persons. AIDS Educ Prev. 2005 Feb;17(1 Suppl A):21-39.

Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee 53202, USA. cgore@mcw.edu

The NIMH Healthy Living Project (HLP), a randomized behavioral intervention trial for people living with HIV, enrolled 943 individuals, including women, heterosexual men, injection drug users, and men who have sex with men from Los Angeles, Milwaukee, New York, and San Francisco. The intervention, which is based on qualitative formative research and Ewart’s Social Action Theory, addresses three interrelated aspects of living with HIV: stress and coping, transmission risk behavior, and medication adherence. Fifteen 90-minute structured sessions, divided into 3 modules of five sessions each, are delivered to individuals. Sessions are tailored to individuals within a structure that uses role-plays, problem solving, and goal setting techniques. A ‘Life Project’–or overarching goal related to personal striving-provides continuity throughout sessions. Because this is an ongoing project with efficacy yet to be established, we do not report intervention outcomes. However, the intervention was designed to be useful for prevention case management, settings where repeated one-on-one contact is possible, and where a structured but highly individualized intervention approach is desired.


Johnson MO, Charlebois E, Morin SF, Catz SL, Goldstein RB, Remien RH, Rotheram-Borus MJ, Mickalian JD, Kittel L, Samimy-Muzaffar F, Lightfoot MA, Gore-Felton C, Chesney A; NIMH Healthy Living Project Team. Perceived adverse effects of antiretroviral therapy. J Pain Symptom Manage. 2005 Feb;29(2):193-205.

Center for AIDS Prevention Studies, University of California, San Francisco, 74 New Montgomery, Suite 600, San Francisco, CA 94105, USA.

Adverse effects from antiretroviral therapy (ARV) for HIV are associated with medication nonadherence. The purposes of this study were to explore group differences in the reporting of adverse effects, identify individual adverse effects that are linked to nonadherence, and to explore the role of coping in the relationship between adverse effects and adherence. Cross-sectional interviews of 2,765 HIV-positive adults on ARV therapies in four U.S. cities were performed using a computerized assessment of self-reported adverse effects, coping self-efficacy, and adherence. There were no gender differences in the rate or severity of adverse effects reported. Latino respondents reported more adverse effects than either White or African Americans. Those taking a protease inhibitor (PI) reported a higher rate and greater severity of adverse effects. Older participants reported fewer adverse effects despite being more likely to be on a regimen containing a PI. Respondents with less than 90% adherence reported greater numbers and severity of adverse effects overall. In multivariate analyses, nausea, skin problems, vomiting, and memory adverse effects were independently related to less than 90% adherence over the prior three days. Coping moderated the relationship between nausea and adherence such that individuals who reported lower coping self-efficacy and experienced nausea were at increased risk for nonadherence, regardless of the length of time on the current ARV regimen. Women and men are similar in their overall reports of adverse effects, and Latinos report more adverse effects to ARVs than White or African American patients. Specific adverse effects (skin problems, memory problems, vomiting, and nausea) are more likely than others to be associated with missing ARV medications. Increasing adaptive coping self-efficacy among patients experiencing nausea may be a particularly effective strategy in increasing medication adherence.


Kirshenbaum SB, Hirky AE, Correale J, Goldstein RB, Johnson MO, Rotheram-Borus MJ, Ehrhardt AA. “Throwing the dice”: pregnancy decision-making among HIV-positive women in four U.S. cities. Perspect Sex Reprod Health. 2004 May-Jun;36(3):106-13.

HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, USA.

CONTEXT: Although AIDS-related deaths among U.S. women have decreased, the number of HIV-positive women, especially of reproductive age, has increased. A better understanding of the interaction between HIV and family planning is needed, especially as antiretroviral medications allow HIV-positive women to live longer, healthier lives. METHODS: Qualitative methods were used to examine pregnancy decision-making among 56 HIV-positive women in four U.S. cities. Biomedical, individual and sociocultural themes were analyzed in groups of women, categorized by their pregnancy experiences and intentions. RESULTS: Regardless of women’s pregnancy experiences or intentions, reproductive decision-making themes included the perceived risk of vertical transmission, which was often overestimated; beliefs about vertical transmission risk reduction strategies; desire for motherhood; stigma; religious values; attitudes of partners and health care providers; and the impact of the mother’s health and longevity on the child. Most women who did not want children after their diagnosis cited vertical transmission risk as the reason, and most of these women already had children. Those who became pregnant or desired children after their diagnosis seemed more confident in the efficacy of risk reduction strategies and often did not already have children. CONCLUSIONS: Future studies may help clarify the relationship between factors that influence pregnancy decision-making among HIV-positive women. HIV-positive and at-risk women of childbearing age may benefit from counseling interventions sensitive to factors that influence infected women’s pregnancy decisions.


Weinhardt LS, Kelly JA, Brondino MJ, Rotheram-Borus MJ, Kirshenbaum SB, Chesney MA, Remien RH, Morin SF, Lightfoot M, Ehrhardt AA, Johnson MO, Catz SL, Pinkerton SD, Benotsch EG, Hong D, Gore-Felton C; National Institute of Mental Health Healthy Living Project Team. HIV transmission risk behavior among men and women living with HIV in 4 cities in the United States. J Acquir Immune Defic Syndr. 2004 Aug 15;36(5):1057-66.

Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee, WI 53202, USA. lsw@mcw.edu

Determining rates of HIV transmission risk behavior among HIV-positive individuals is a public health priority, especially as infected persons live longer because of improved medical treatments. Few studies have assessed the potential for transmission to the partners of HIV-positive persons who engage in high-risk activities. A total of 3723 HIV-infected persons (1918 men who have sex with men [MSM], 978 women, and 827 heterosexual men) were interviewed in clinics and community-based agencies in Los Angeles, Milwaukee, New York City, and San Francisco from June 2000 to January 2002 regarding sexual and drug use behaviors that confer risk for transmitting HIV. Less than one quarter of women and heterosexual men had 2 or more sexual partners, whereas 59% of MSM reported having multiple partners. Most unprotected vaginal and anal sexual activity took place in the context of relationships with other HIV-positive individuals. Approximately 19% of women, 15.6% of MSM, and 13.1% of heterosexual men engaged in unprotected vaginal or anal intercourse with partners who were HIV-negative or whose serostatus was unknown. The majority of sexually active participants disclosed their serostatus to all partners with whom they engaged in unprotected intercourse. An estimated 30.4 new infections (79.7% as a result of sexual interactions with MSM) would be expected among the sex partners of study participants during the 3-month reporting period. Eighteen percent of 304 participants who injected drugs in the past 3 months reported lending their used injection equipment to others. In addition to the more traditional approaches of HIV test counseling and of focusing on persons not infected, intensive prevention programs for persons with HIV infection are needed to stem the future spread of the virus.


Johnson MO, Catz SL, Remien RH, Rotheram-Borus MJ, Morin SF, Charlebois E, Gore-Felton C, Goldsten RB, Wolfe H, Lightfoot M, Chesney MA; NIMH Healthy Living Project Team. Theory-guided, empirically supported avenues for intervention on HIV medication nonadherence: findings from the Healthy Living Project. AIDS Patient Care STDS. 2003 Dec;17(12):645-56.

Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California 94105, USA. Mjohnson@psg.ucsf.edu

OBJECTIVES: Adherence to antiretroviral therapy (ART) remains a challenge in efforts to maximize HIV treatment benefits. Previous studies of antiretroviral adherence are limited by low statistical power, homogeneous samples, and biased assessment methods. Based on Social Action Theory and using a large, diverse sample of men and women living with HIV, the objectives of the current study are to clarify correlates of nonadherence to ART and to provide theory-guided, empirically supported direction for intervening on ART nonadherence. DESIGN: Cross-sectional interview study utilizing a computerized interview. SETTING: Recruited from clinics, agencies, and via media ads in four U.S. cities from June 2000 to January 2002. PARTICIPANTS: Two thousand seven hundred and sixty-five HIV-positive adults taking ART. MAIN OUTCOME MEASURE: Computer-assessed self-reported antiretroviral adherence. RESULTS: Thirty-two percent reported less than 90% adherence to ART in the prior 3 days. A number of factors were related to nonadherence in univariate analysis. Multivariate analyses identified that being African American, being in a primary relationship, and a history of injection drug use or homelessness in the past year were associated with greater likelihood of nonadherence. Furthermore, adherence self-efficacy, and being able to manage side effects and fit medications into daily routines were protective against nonadherence. Being tired of taking medications was associated with poorer adherence whereas a belief that nonadherence can make the virus stronger was associated with better adherence. CONCLUSIONS: Results support the need for multifocused interventions to improve medication adherence that address logistical barriers, substance use, attitudes and expectancies, as well as skills building and self-efficacy enhancement. Further exploration of issues related to adherence for African Americans and men in primary relationships is warranted.


Remien RH, Hirky AE, Johnson MO, Weinhardt LS, Whittier D, Le GM. Adherence to medication treatment: a qualitative study of facilitators and barriers among a diverse sample of HIV+ men and women in four US cities. AIDS Behav. 2003 Mar;7(1):61-72.

HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY 10036, USA. rhr1@columbia.edu

Most studies examining HIV antiretroviral medication treatment adherence involve quantitative surveys. Although these studies have identified factors associated with medical adherence, no single variable or combination of variables is sufficiently consistent to apply to any individual or group of people. Using qualitative methods, an ethnically diverse sample (N=110) of HIV+ women, men who have sex with men, and male injecting drug users in four U.S. cities were interviewed in depth to elicit their experiences, perspectives, and life contexts regarding knowledge, attitudes, beliefs, and experiences with HIV medication adherence. Most described multiple influences on medication-taking behavior, describing adherence as a dynamic phenomenon that changes over time with their changing beliefs, attitudes, emotions, and daily and larger life events. Prevalent themes include ambivalence toward HIV medication and intentional nonadherence, usually to address physical side effects. Factors from different domains (e.g., cognitive, emotional, interpersonal) can have compensatory influences on behavioral outcomes. Findings are discussed in terms of social action theory, contributing to our theoretical understanding of the phenomenon of adherence.


Johnson MO, Remien RH. Adherence to research protocols in a clinical context: challenges and recommendations from behavioral intervention trials. Am J Psychother. 2003;57(3):348-60.

Center for AIDS Prevention Studies, University of California, San Francisco, USA.

Conducting clinical interventions in a research setting poses numerous challenges to clinicians, researchers, supervisors, and research participants. These issues often reflect a tension between the rigorous demands of a research protocol needed to ensure internal validity of the research and clinical flexibility that is representative of an externally valid intervention. In this paper, we explore difficulties in defining the roles of clinicians and research participants, delineating the scope of the intervention, and problems encountered at the intersection of clinical intervention delivery and such methodological techniques as randomization, blinding, and incentive payments. We provide guidance for setting frames for the intervention and clinical relationship, conducting training and supervision of clinical staff, and structuring quality-assurance procedures in order to meet these challenges.

Last modified: January 20, 2011