Judith A. Moskowitz, Ph.D, MPH - US grants

Description of Application (Applicant's Abstract): As HIV infection has shifted from being an imminently terminal illness to a challenging chronic illness, it has become increasingly important to know how people with HIV maintain their well being over time. The maintenance of well being is in itself an important goal, but well being is also important because it is a key to healthcare adherence, economic productivity, social satisfaction, and over-all quality of life. Previous research on coping with HIV is limited in that it is largely atheoretical; focuses on negative outcomes such as distress, ignoring positive outcomes such as well-being; and tends to be cross-sectional. This pilot study proposes to apply stress and copy theory (Folkman, 1997; Lazarus & Folkman, 1984) to longitudinal data in order to (1) develop a typology of HIV-associated stress and coping processes from two years of bimonthly narratives of 57 HIV+ men, and (2) examine the association between the typology and subsequent quantitative measures of coping, positive and negative psychological states, HIV-related symptoms, and CD4 cells at 24, 36, 48, and 60 months after entry into the study. The study participants were recruited as a comparison group of HIV+ non-caregiving men in a study of the caregiving partners of men with AIDS (MH4405, MH49985, Susan Folkman, Principle Investigator). Using an interpretive phenomenological approach, investigators plan to develop a typology of HIV-associated stress and coping processes through a three-step process of coding narratives, doing case studies, and performing a cross-case analysis. We will examine the association between the typology and quantitative measures of coping, positive and negative psychological states, and HIV-related symptoms. Demographics, use of anti-retrovirals, and length of time of known HIV serostatus treatment will be used as control variables. The 8 sub-scales from the Ways of Coping Questionnaire will be used as validation variables.

DESCRIPTION (provided by applicant): A growing body of literature indicates that positive affect may have a unique adaptive role in the process of adjustment to chronic stress, independent of the effects of negative affects like depression. The overarching goal of this research is to provide evidence and direction for the development of interventions for people with HIV that include a focus on positive affect. To this end, this study will document the occurrence, predictors, and consequences of positive affect during the 18 months post-notification of HIV+ serostatus. This is a longitudinal cohort study in which 250 participants recruited from 4 San Francisco Bay area sites will be interviewed 7 times over the course of 18 months after notification of HIV+ serostatus. Data will consist of quantitative questionnaires, qualitative interviews (audio taped), and CD4 and viral load measures. The specific aims of the study are to: 1) Document the co-occurrence of positive and negative affect in response to notification of HIV+ serostatus (and the cascade of associated stressors) over the course of 18 months in a sample of 250 men and women; 2) Explore the potential adaptational significance of positive affect by examining its unique concurrent and prospective associations with adherence, HIV risk behaviors, healthcare utilization, health behaviors, role functioning, quality of life, and symptoms of clinical depression; and 3) Identify coping processes (e.g., problem focused coping, positive reappraisal, meaningful events) and coping resources (e.g., social support, self esteem, optimism) that are uniquely associated with increases in positive affect over time. In addition, we have two secondary aims: 1) To explore the association of positive affect with progression of HIV as evidenced by CD4, viral load, and symptoms; and 2) To explore the association of positive affect with cost of HIV treatment based on healthcare utilization and medication costs.

DESCRIPTION (provided by applicant): A growing body of literature indicates that positive affect may have a unique adaptive role in the process of adjustment to chronic stress, independent of the effects of negative affects like depression. The overarching goal of this research is to provide evidence and direction for the development of interventions for people with HIV that include a focus on positive affect. To this end, this study will document the occurrence, predictors, and consequences of positive affect during the 18 months post-notification of HIV+ serostatus. This is a longitudinal cohort study in which 250 participants recruited from 4 San Francisco Bay area sites will be interviewed 7 times over the course of 18 months after notification of HIV+ serostatus. Data will consist of quantitative questionnaires, qualitative interviews (audio taped), and CD4 and viral load measures. The specific aims of the study are to: 1) Document the co-occurrence of positive and negative affect in response to notification of HIV+ serostatus (and the cascade of associated stressors) over the course of 18 months in a sample of 250 men and women; 2) Explore the potential adaptational significance of positive affect by examining its unique concurrent and prospective associations with adherence, HIV risk behaviors, healthcare utilization, health behaviors, role functioning, quality of life, and symptoms of clinical depression; and 3) Identify coping processes (e.g., problem focused coping, positive reappraisal, meaningful events) and coping resources (e.g., social support, self esteem, optimism) that are uniquely associated with increases in positive affect over time. In addition, we have two secondary aims: 1) To explore the association of positive affect with progression of HIV as evidenced by CD4, viral load, and symptoms; and 2) To explore the association of positive affect with cost of HIV treatment based on healthcare utilization and medication costs.

[unreadable] DESCRIPTION (provided by applicant): As medical treatments for HIV have improved, the number of people living with HIV has increased and prevention strategies tailored specifically to people living with HIV have become a priority. We propose to test the efficacy of a client-centered, skills-based intervention that targets a novel mechanism of change: positive affect. High levels of depressive mood are common in people with HIV. Depression, however, is only part of the emotion picture for people living with HIV. Increasing evidence suggests that positive affect plays an important role in adaptation to chronic illness, independent of levels of negative affects like depression. Data from our ongoing study of people newly diagnosed with HIV suggest that positive affect plays an adaptive role in the context of stress and may be the key to more effective interventions for people newly diagnosed with HIV. The proposed research builds on these observational findings to determine whether a 5-session theory- and evidence-based intervention designed to teach skills for increasing the frequency and intensity of daily positive affect does so, and whether this intervention has beneficial effects on subsequent psychological well being, health behaviors, and physical health up to 15 months after diagnosis with HIV. This will be a randomized controlled trial in a sample of 200 participants recruited within 12 weeks of testing positive for HIV. The control group will be attention-matched, and follow up assessments will be conducted immediately post intervention (approximately 5 months post diagnosis) and at 10 and 15 months post diagnosis. The specific aims of the study are to: (1) Determine the efficacy of the Intervention for those Recently Informed of their Seropositive Status (IRISS) for increasing the frequency and intensity of positive affect in men and women newly diagnosed with HIV, during the intervention and at 5- 10- and 15-months after diagnosis; (2) Test the effects of IRISS on HIV-related outcomes - including mental and physical health, coping, and coping resources - and determine whether increases in positive affect are responsible for improvements in these outcomes; (3) Test the effects of the individual theory-based facets of IRISS on positive affect and these HIV-related outcomes; and (4) Evaluate the extent to which personality, socioeconomic status, race/ethnicity, and stress level moderate the effects of IRISS on these outcomes. [unreadable] [unreadable] PUBLIC HEALTH RELEVANCE The first few months after HIV diagnosis provides a window of opportunity for intervention in which patients are establishing new patterns of sexual risk and health behaviors, but there are currently no interventions designed expressly for people newly diagnosed with HIV. There is a need for effective, creative, client-centered interventions that can be easily disseminated to community treatment settings. Given the increasing evidence from our research team and others that positive affect has adaptive functions in the context of health-related stress, we propose to test the efficacy of a positive affect skills-based intervention in people newly diagnosed with HIV. [unreadable] [unreadable] [unreadable]

DESCRIPTION (provided by applicant): Striking findings from recent studies in a variety of chronically ill and healthy samples demonstrate that positive affect is associated with significantly lower risk of mortality. In people with diabetes, depressive mood is common and is associated with poorer glycemic control, increased symptoms and complications, poorer adherence to exercise and diet recommendations, increased health care expenditures, and even mortality. Much less work has been done on positive affect in diabetes, even though analyses from our research team indicate that positive affect is uniquely associated with lower risk of mortality, independently of negative affect. On a broad level, these adaptive effects are consistent with theories such as Fredrickson's Broaden and Build Model and Cacioppo's Evaluative Space theory. However, very little is known about the specific cognitive, behavioral, and physiological pathways that link positive affect with improved health and psychological outcomes. Our overarching aim is to establish the benefits of positive affect in the management of type 2 diabetes, and to develop a targeted psychosocial intervention based on an understanding of the phenomenon's time-course, predictors, and mechanisms of action. In this proposal we describe a prospective observational study to document the occurrence and clinical consequences of positive affect during the 9 months after diagnosis of Type 2 diabetes in a sample of 50 participants. The specific aims of the study are to: (1) Document the adaptive physiologic functions of positive affect following a diagnosis of Type 2 diabetes by examining its unique concurrent and prospective associations with glycemic control, blood pressure, and lipids; and (2) Explore potential behavioral and psychological effects of positive affect including diabetes self management (e.g., diet, exercise, medication, self monitoring of blood glucose, and attendance at recommended health care appointments), stress-related coping resources, and coping responses. Findings will provide evidence and direction for the development of positive-affect based interventions for people with type 2 diabetes. PUBLIC HEALTH RELEVANCE: Positive affect is uniquely associated with lower risk of mortality in people with diabetes. However, the clinical, behavioral, and psychological pathways linking positive affect and poorer health in people with diabetes are unknown. The proposed study will document the clinical consequences of positive affect during the 9 months after diagnosis of Type 2 diabetes in a sample of 50 participants. Findings from the proposed study will provide evidence and direction for the development of psychosocial interventions that include a focus on positive affect for people with type 2 diabetes.

DESCRIPTION (provided by applicant): Dr. Judy Moskowitz is Associate Professor in the Department of Medicine and the Osher Center for Integrative Medicine at the University of California San Francisco. Trained as a social/health psychologist, over the past 17 years, she has mentored more than two dozen trainees and developed a thriving program of multi- disciplinary collaborative research focused on positive affect in primary and secondary HIV prevention. Dr. Moskowitz is at an ideal stage of her career for a K24 grant. Support from this award would allow her to leverage her research program to develop the careers of patient oriented researchers. She is currently funded by NIMH to conduct a randomized trial of a positive affect regulation intervention for improving psychological and physical well being in people newly diagnosed with HIV. With the support of the K24 there are two overarching questions that would be addressed by an extension of the research program: (1) for whom does the intervention work and (2) in what delivery format? Co-morbid mood disorders are a significant concern for both primary and secondary HIV prevention. The research portion of this proposal outlines an extension of Dr. Moskowitz's research program that would allow her, together with a team of mentees, to begin to address important questions of safety, efficacy, feasibility and optimal delivery format of the positive affect intervention among people with mood disorders who are at high risk for HIV. The Overall Aims of this K24 proposal are to: (1) Provide expanded mentoring of early career clinicians and trainees in patient-oriented research in the specific areas of positive affect regulation interventions, mood disorders, HIV, and, more broadly, in integration of social and behavioral sciences in patient-oriented research; and (2) Extend the current research program to tailor the content and format of a positive affect regulation intervention to maximize feasibility, safety, and efficacy for people living with mood disorders and to maximize transportability to difficult-to-reach populations who are at elevated risk of HIV by translating the modified intervention to computer-delivered format. The ultimate goal for this program of research is to amplify the public health impact for individuals living with, or at risk for, HIV, by broadening applicability of the intervention and by encouraging widespread dissemination to home and community settings. The K24 would insure sufficient time to pursue this natural progression of Dr. Moskowitz's research while protecting time to devote to mentoring future clinician investigators in patient- oriented research. The plans for development, research, and mentoring were designed to complement each other and to create a synergistic effect of mentoring and research in a new direction of patient-oriented research. The proposed mentoring, research, and career development activities actively leverage existing infrastructure, resources, and training initiatives provided by NIH, including Dr. Moskowitz's active research program, the Osher Center for Integrative Medicine, and the Clinical and Translational Science Institute (CTSI) at UCSF. PUBLIC HEALTH RELEVANCE: The short term goals of the proposed research are to tailor the content and format of the current positive affect intervention to maximize safety, feasibility, and applicability for people with mood disorders and to translate the modified intervention to computer- delivered format. The longer term objectives of this line of research are to maximize the public health impact of the positive affect intervention for people living with, or at risk for, HIV, by increasing the broad applicability of the intervention and by encouraging widespread dissemination to home and community settings. In this K24 proposal, I outline a systematic plan to make a lasting contribution to both primary and secondary HIV prevention by leveraging my current research program to facilitate the transition to independence for mentees.

DESCRIPTION (provided by applicant): Teaching adolescents effective coping skills can help them to manage stress, which is associated with health-risk behaviors including substance use and risky sexual behavior. Whereas stress reduction interventions commonly focus on reducing negative affect, there is a growing body of research that indicates that positive affect is beneficial in the context of stress. Drawing from our work (Folkman & Moskowitz, 2000) and the growing body of literature on predictors of positive affect under stress (Zautra et al., 2002, 2005), we developed a novel stress reduction intervention that has been successful in improving mood in high risk adult populations. The 5-session intervention teaches 8 skills (noticing positive events, capitalizing upon or savoring them, gratitude, mindfulness, positive reappraisal, personal strengths, attainable goals, and acts of kindness; Moskowitz, 2010; Moskowitz et al., under review). Using stress and coping theory (Lazarus & Folkman, 1984; Folkman, 1997), the broaden and build theory of positive affect (Fredrickson,1998), and the risk and protective factor framework (Hawkins, Catalano, & Miller, 1992) as our guide, we recently tailored the positive affect intervention to be delivered to adolescents as a school-based intervention: Coping and Emotional Development for Adolescents to Reduce Stress (CEDARS). In this study we propose a preliminary efficacy pilot trial of the CEDARS program in a sample of 60 students from a low resource, predominantly racial/ethnic minority public high school at high risk for engaging in risky health behaviors. The specific aims of the study are to: 1) investigate the preliminary effects of CEDARS on perceived stress, coping, and positive and negative affect; 2) determine preliminary evidence regarding whether CEDARS participation is related to reduced substance use, sexual risk behavior, and other health behaviors; and 3) determine whether affect and coping mediate the effect of the CEDARS intervention on health behaviors and attitudes. The proposed study will lay the groundwork to determine whether a more definitive R01-level randomized controlled trial to rigorously test the benefit of CEDARS as a school-based prevention program is warranted. PUBLIC HEALTH RELEVANCE: Teaching adolescents effective coping skills can help them to manage stress, which is associated with risky health behaviors including substance use and sexual risk behavior. Current programs to reduce stress tend to focus on reducing negative emotions. However, there is accumulating evidence indicating that positive emotions are uniquely beneficial in the stress and coping process. We developed a novel stress reduction intervention that has been successful in improving mood in high risk adult populations. The 5-session intervention teaches 8 skills (noticing positive events, capitalizing upon or savoring them, gratitude, mindfulness, positive reappraisal, personal strengths, attainable goals, and acts of kindness). We recently adapted the intervention to be delivered to youth as a school-based intervention: Coping and Emotional Development for Adolescents to Reduce Stress (CEDARS). In this study we propose a test of the CEDARS program in a sample of 60 students from a low resource, predominantly racial/ethnic minority public high school who are at high risk for engaging in risky health behaviors. We will test whether participating in the CEDARS program improves students' positive emotion and coping and reduces their negative emotion and stress; and reduces students' substance use, sexual risk behavior, and improves other health behaviors, such as sleep, nutrition, and exercise. We will also test whether improvements in health behavior outcomes are the result of improvements in emotion and coping. The proposed study is a pilot study that will help us to determine whether a randomized controlled trial to test CEDARS as a school-based prevention program is warranted.

DESCRIPTION (provided by applicant): Integrative medicine approaches, including meditation, yoga, tai chi, massage, and other practices are widely used by Americans in the hope of obtaining health benefits. Evidence for the health effects of these practices, however, has important limitations. The goal of the fellowship, Training for Research in Integrative Medicine (TRIM), is to train post-doctoral behavioral and social scientists, physicians, and other qualified health professionals to design and conduct rigorous clinical and translational research in CAM and integrative medicine. The program is based at the Osher Center for Integrative Medicine (OCIM) within the UCSF School of Medicine. In the present renewal, we detail the rationale for the program and our progress to date, and we propose a program incorporating improvements based on our experience in the first five years. A key change we propose is to expand the training program to include two predoctoral positions in addition to the current four post-doctoral positions. The TRIM program provides: an interdisciplinary clinical and research environment; strong mentoring by an experienced and diverse research faculty; advanced training in biological and psychological research methodologies to support clinical research in integrative medicine; rigorous training in clinical research methodologies, with special attention to issues that are particularly relevant to integrative medicine research; opportunity to conduct original research; training in research ethics; and exposure to diverse integrative approaches to patient care involving all age groups from early childhood through geriatric patients. The TRIM interdisciplinary faculty has twelve core and eight affiliated members representing internal medicine, family medicine, psychology, anthropology, biostatistics, psychoneuroendocrinology, women's health, pediatrics, health services research, medical ethics, and psychiatry. In addition, a major strength of the training program is the clinical advisory faculty who are available to provide technical assistance and consultation on specific integrative medicine approaches that trainees might want to study. TRIM faculty provide required and optional academic activities that are tailored to each trainee's individual learning objectives and are committed to being active mentors to trainees. The TRIM program will equip a new generation of researchers to expand our knowledge-base about how and whether integrative medicine approaches work for specific health conditions. PUBLIC HEALTH RELEVANCE: Integrative Medicine approaches that may improve health, including meditation, yoga, tai chi, massage, and other approaches are widely used by Americans. Evidence for the health effects of these practices, however, has important limitations. This T32 grant will train pre and postdoctoral scientists to perform rigorous research of Integrative Medicine approaches. This will help to strengthen our knowledge of how and whether these approaches work for specific health conditions.

DESCRIPTION (provided by applicant): Family members provide the vast majority of informal care to people with dementia and experience significant caregiving-related stress that contributes to mental and physical illness and increases their risk of death. As the number of people diagnosed with dementia is expected to exceed 11 million by 2050, there is a growing need for interventions that can effectively buffer these negative psychological and physical consequences in informal caregivers. The purpose of this randomized clinical trial is to test the Life Enhancing Activities for Family Caregivers (LEAF) intervention, a positive emotion skill-building program designed to improve psychological well-being (positive and negative affect, stress, burden, strain, mood) and coping. The LEAF one-hour training sessions will be conducted weekly for 5 weeks by a trained facilitator. The skills include: noticing and capitalizin on positive events, gratitude, mindfulness, positive reappraisal, personal strengths, and acts of kindness. The intervention is unique in that it is delivered via video conference, as opposed to in-person, which vastly increases the accessibility for caregivers. Also, the nature of the skills taught enable caregivers to use them at any time without needing to schedule an appointment with a provider, travel to a facility, arrange coverage for caregiving in their absence, or incur ay additional financial liability associated with service utilization. Given that sociodemographic factors, specifically age and geographic location, can influence individual caregiver's experiences, the study will test the effects of the LEAF intervention in a diverse cohort of informal caregivers of individuals with dementia. The specific aims are to: 1) Test the effect of the LEAF intervention compared to the wait list control condition on psychological well-being (positive and negative affect, stress, burden, strain, mood) and coping at end of intervention and 1 month post intervention; 2) Test the effects of caregiver age and geographic location on psychological and coping outcomes; and 3) Assess the longer-term effects of the LEAF intervention on psychological well-being and coping outcomes at 3 and 6 months post intervention. The LEAF intervention has the potential to substantially decrease the public health burden of caregiving. It is innovative in numerous respects in that it focuses on positive emotion, focuses on the caregiver, and has the potential for sustained beneficial effects. It is also easily accessible to geographically dispersed caregivers whose responsibilities and remote location often pose barriers to participation in more traditional caregiving interventions.

DESCRIPTION (provided by applicant): In the era of HIV treatment as prevention (TasP), efforts are needed to identify evidence-based combination prevention approaches that achieve greater decreases HIV viral load among populations that are more likely to engage in HIV transmission risk behavior. Because methamphetamine-using men who have sex with men (MSM) are at greater risk for acquiring and transmitting medication-resistant strains of HIV, interventions targeting stimulant use in this population of high-risk men could boost the effectiveness of TasP. At present, only conditional cash transfer approaches such as contingency management (CM) have demonstrated short- term efficacy in reducing stimulant use among substance-using MSM who are not actively seeking formal treatment. The proposed RCT will examine the efficacy of a positive affect intervention that is designed to optimize the effectiveness of CM to achieve long-term reductions in stimulant use and HIV viral load in this population. Our team will examine the efficacy of this integrative intervention in a randomized controlled trial (RCT) with 230 HIV-positive, methamphetamine-using MSM. After enrolling in CM, participants will be randomized to receive either: 1) the positive affect intervention; or 2) a attention-matched control condition. Follow-up data will be collected at 2, 3, 6, and 12 months post-randomization. This RCT will provide an opportunity to examine the efficacy of an integrative intervention designed to promote long-term reductions in HIV viral load as the primary outcome. Secondary outcomes that will be examined include: increases positive affect, reductions in stimulant use, improvements in T-helper (CD4+) count, and decreases HIV transmission risk behavior. Identifying an efficacious intervention approach to decrease HIV viral load among methamphetamine-using MSM would substantially support the goals of the National HIV/AIDS Strategy to reduce HIV incidence and mitigate HIV-related health disparities.

? DESCRIPTION (provided by applicant): The proposed work will address symptom management for patients over age 60 who are living with HIV- infection, are on combination antiretroviral therapy (cART) with suppressed viral loads, and yet continue to experience behavioral and cognitive symptoms of HIV-associated neurocognitive disorders (HAND). It is increasingly relevant that HAND persists despite cART, impacting between 30-50% of elders living with HIV. Treatment trials for adjuvant therapies in such a setting have failed, including strategies aimed at increasing central nervous system penetration effectiveness (CPE) of cART. Patients suffer symptoms that are pervasive in their impact on everyday functioning and quality of life; yet these patients are currently left with a dearth of treatment options. In this applicaton, we propose that cognitive impairment in elders living with HIV is a geriatric syndrome - a clinical condition that does not fit discreetly into a disease category because it is driven by more than one disease process and occurs with greater frequency in old age. In response to PA-13-210, we propose a randomized controlled evaluation of Mindfulness Based Stress Reduction (MBSR) to target attention, stress, anxiety, and depressive symptoms among patients over age 60 who have HAND and have maximized treatment options. We will employ intrinsic connectivity network (ICN) analyses of resting state functional magnetic resonance imaging to demonstrate increased strength of brain networks corresponding to improved symptoms. We will quantify social networks and perceived strength of social networks to determine if they moderate our main findings. Together this work employs geriatric, neuroscience and complementary medicine disciplines to reduce the symptom burden in aging HIV-infected patients.