UNDERSTANDING THE PSYCHOSOCIAL DYNAMICS OF HIVAIDS PREVENTION AND CARE IN THE COMMUNITY: BASE CASE M

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UNDERSTANDING THE PSYCHOSOCIAL DYNAMICS OF
HIV/AIDS PREVENTION AND CARE IN THE COMMUNITY
BASE CASE MODEL FINDINGS AND IMPLICATIONS

• SAMPLE SLIDES FOR SDS CONF.
• David Lounsbury, Ph.D.
• Department of Psychiatry Behavioral Sciences,
  Memorial Sloan-Kettering Cancer Center, NYC
• Ralph Levine, Ph.D.
• Department of Resource Development,
• Michigan State University, Lansing, MI

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Overview

• Problem Focus
• Need for a Systems Approach
• Building the Model
• Validating the Model
• Key Findings
• Preliminary Policy Review
• Next Steps
• Conclusion

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Problem Focus
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PF1
HIV/AIDS is a complex problem

• Compelling nature of sex and drugs
• Institutional ineptitude
• Racism
• Homophobia/Heterosexism
• Gender inequities
• Politics
• Religious intolerance
• Poverty

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PF2
HIV/AIDS is a simple problem

• There are two general approaches
• Prevention
• Care
• Both have been proven to work if the right mix
  is deployed.
• In general, we want to prevent new cases of HIV
  infection and we want to develop and make
  accessible treatments that sustain quality of
  life for those who may already be positive.

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PF3
Stages of intervention

• Epidemic can be thought of as process comprised
  of a series of discrete periods, or stages, of
  intervention.
• Historically, these periods have been centered on
  either prevention (community-focused) or care
  (person-focused).

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PF4
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PF5
Conceptual framework

• Psychosocial effects as dynamic interface between
  prevention and care in the community
• Three main components
• Change over time

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PF6
Figure 1.1 - Conceptual framework for the current
study
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Need for a Systems Approach
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SA1
General assumptions

• Natural and human systems have dynamic complexity
• Systems are goal-seeking
• Systems can be changed for the better by human
  action

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SA2
Sources of data

• Primary sources
• Michigan's Statewide Coordinated Statement of
  Need SCSN (Lounsbury, 2001b)
• 48 documents were reviewed.
• 34 key informants were interviewed about the
  service needs of persons living with and affected
  by HIV/AIDS in the state.
• MDCH epidemiological data (1983 - 2001)
• Core key informants
• Active members of Michigans HIV community.
• N 10.

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SA3
Sources of data

• HIV/AIDS-focused peer-reviewed literature
• Mann and Tarantola (1996)
• Smith (2001)
• Institute of Medicine, National Science
  Foundation (2001)
• 400 individual articles

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SA4
Research questions
1. How does stigma caused by HIV/AIDS affect the
dynamics of prevention and care in the
community? 2. How does complacency caused by
HIV/AIDS affect the dynamics of prevention and
care in the community? 3. How does
disempowerment of PLWHA affect the dynamics of
prevention and care in the community? 4. How does
care affect the dynamics of prevention? and/or
How does prevention affect the dynamics of care?
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Building the Model
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MOD1
Future work
Figure 3.1 - The process o
f modeling for understanding
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MOD2
Reference modes
1. Prevalence, incidence, and mortality 2.
Prevention and care funding 3. Prevention and
care service system quality 4. Stigma and
complacency
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MOD3
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MOD4
Key constructs

• Epidemiology sector
• HIV/AIDS epi burden
• HIV/AIDS symptoms

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MOD5
Figure 4.9 - Disaggregated stock-and-flow of
HIV/AIDS epidemiological subpopulations
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MOD6
Key constructs

• Psychosocial sector
• Satisfact care sys qual
• Satisfact prev sys qual
• Percvd treatment efficacy
• Percvd HIV-related stigma
• Self-concept
• System awareness

• Service sector
• Care system quality
• Prevention sys quality
• Care resources
• Prevention resources

• Behavioral sector
• Sys change action
• Care complacency
• Prev complacency

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MOD7
Limitations

• Epidemiology sector
• Does not expressly model SES, age, gender, race,
  or sexual identity.
• Does not expressly model the dynamics of
  co-morbidy (e.g., HCV, substance addiction).
• Does not expressly explain the dynamics of HAART.

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MOD8
Limitations

• Services sector
• Does not expressly model the effects of social
  interventions (e.g., PSAs).
• Does not expressly model the effects of access to
  primary care or ability to pay for health care.
• Does not expressly model quality of essential
  support services (e.g., housing, transportation,
  and child and family support).
• Units of quantification are arbitrary.

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MOD9
Limitations

• Psychosocial and behavioral sectors
• Provider psychosocial and behavioral dynamics are
  not expressly modeled.
• Leadership dynamics are not expressly modeled.
• Units of quantification are arbitrary.

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Validating the Model
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VM1
Figure 5.1 - Hypothesized and simulated reference
mode for HIV/AIDS prevalence in Michigan, 1983 -
2001
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VM2
Figure 5.2 - Hypothesized and simulated reference
mode for HIV/AIDS mortality rate per year in
Michigan, 1983 - 2001
1983 - 2001
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VM3
Figure 5.3 - Hypothesized and simulated reference
mode for HIV/AIDS cumulative mortality in
Michigan, 1983 - 2001
Michigan, 1983 - 2001
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VM4
Figure 5.4 - Hypothesized and simulated reference
mode for HIV/AIDS incidence per year in
Michigan, 1983 - 2001
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VM5
Figure 5.5 - Hypothesized and simulated reference
mode for HIV/AIDS incidence per year in Michigan,
1990 - 1999
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VM6
Figure 5.6 - Hypothesized and simulated reference
mode for HIV/AIDS-related care and prevention
funding in the United States, 1983 -2001
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VM7
Figure 5.7 - Hypothesized and simulated reference
mode for HIV/AIDS system quality in Michigan,
1983 - 2001
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VM8
Figure 5.8 - Hypothesized and simulated reference
mode for HIV/AIDS stigma and complacency in
Michigan, 1983 - 2001
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Key Findings
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KF1
Key dynamic processes

• Perceived stigma process
• Care complacency process
• Prevention complacency process
• Community empowerment process
• Resource allocation process

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KF2
Why bother?
Too sad to care
Figure 5.14 - Causal loop diagram for care
complacency process
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KF3
Overall, a downward trend. Indication that
treatments are easier to take these days?
and/or a resurgence of symptoms due to
treatment failure?
Figure 5.15 - Care complacency process simulations
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KF4
Figure 5.16 - Care complacency process simulations
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KF5
AIDS is over
Were worth it
Figure 5.17 - Causal loop diagram for prevention
complacency process
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KF6
Aggregate PC is flat, but high, after discovery
period
Figure 5.18 - Prevention complacency process
simulations
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KF7
Figure 5.19 - Prevention complacency process
simulations
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KF8
Figure 5.21 - Prevention complacency process
simulations
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KF9
Care is stronger at reducing CC than prev is at
reducing PC?
Figure 5.24 - Prevention complacency process
simulations
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KF10
We have something to give prev
We can make a difference prev
You go for it girl
Somebodys got to do it care
We have something to give care
Figure 5.25 - Causal loop diagram for community
empowerment process
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KF11
Empowerment has never really gotten off the
ground.
How is SCA related to resources?
Figure 5.26 - Community empowerment process
simulations
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KF12
Pretty low.
Lower.
Lower still.
Lowest.
Figure 5.27 - Community empowerment process
simulations
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KF13
Figure 5.28 - Community empowerment process
simulations
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KF14
Figure 5.29 - Community empowerment process
simulations
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KF15
Figure 5.30 - Community empowerment process
simulations
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KF16
Figure 5.31 - Community empowerment process
simulations
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Preliminary Policy Review
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PPR1
Care complacency process Preliminary policy review

• Target subpopulations Diagnosed persons (i.e.,
  MHD, LHD, MHDWC, and LHDWC).
• Implications Need policies that promote care
  education programs that help clients maintain a
  circumspect attitude about the potential benefits
  of existing care and treatment, since lower PTE
  appears to reduce care complacency. However,
  education programs should not allow PTE to drop
  too low. It such situations, PLWHA may 'lose
  faith,' which could send CC back up.

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PPR2
Prevention complacency process Preliminary
policy review

• Target subpopulations NI and EHU to address
  relatively low levels of PC that still lead to
  high rates of infection. All diagnosed persons in
  order to address the high levels of PC.
• Implications Aggressively target NI and EHU with
  interventions that facilitate safer sex and HIV
  testing. Address what may be referred to as the
  nothing to lose phenomena among diagnosed
  persons and persons with care.

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PPR3
Community empowerment process Preliminary policy
review

• Target subpopulations All undiagnosed persons
  (i.e., NI, EHU, MDU, and LHU).
• Implications With respect to the objective of
  promoting SCA, the most problematic dynamics
  involve undiagnosed persons. There is a need for
  interventions that help undiagnosed persons learn
  about their serostatus AND that effectively
  brings them into the care system. There is a need
  for interventions that are not reliant on the
  negative condition of dissatisfaction in order to
  promote SCA. In other words, we need policies
  that promote positive empowerment.

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Next Steps
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NS1
Next steps

• Sensitivity analyses
• Identify levers of change within the system.
• Run scenarios based on results of preliminary
  policy review and input from core key informants.
• Policy tests
• Add new structures (interventions) and/or
  substitute new subpopulation definitions to the
  model and test to explore policy implications
  (i.e. how system performance is affected over
  time).
• Add system indicators to the model that can be
  used to affirm whether or not the intervention is
  having the desired effect in the real world.

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NS2
Next steps

• Community action
• Share and discuss each others mental models.
• Design and implement actual interventions/
  empirical studies that are grounded by
  model-generated insights.
• Evaluate the intervention(s) . . . give each
  other feedback!

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Conclusion
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C1
What does this study give us?

• Deeper insight into things that many of us
  already have an intuitive sense about.
• A picture of dynamic complexity.
• An opportunity to foster a common understanding.
• or At least an opportunity to build a common
  space from which to exchange ideas about the
  nature of the problem and what we can to do
  address it.
• Ultimate objective To work together in a manner
  of enlightened action.