51
|
Coghill AE, Suneja G, Rositch AF, Shiels MS, Engels EA. HIV Infection, Cancer Treatment Regimens, and Cancer Outcomes Among Elderly Adults in the United States. JAMA Oncol 2019; 5:e191742. [PMID: 31369037 DOI: 10.1001/jamaoncol.2019.1742] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance HIV-infected patients with cancer have an elevated cancer-specific mortality rate compared with HIV-uninfected patients with cancer. However, to our knowledge, studies describing this association have not adjusted in detail for cancer treatment, despite evidence of suboptimal cancer treatment in the setting of HIV. Objective To compare cancer-specific mortality in HIV-infected and HIV-uninfected patients with cancer after adjusting for available data on receipt of specific cancer treatments. Design, Setting, and Participants We used Surveillance, Epidemiology, and End Results-Medicare linked data to identify 308 268 patients in the United States (age, ≥65 years), including 288 with HIV infection, with nonadvanced cancers of the colorectum, lung, prostate, or breast diagnosed between 1996 and 2012 who received standard, stage-appropriate cancer treatment during the year after cancer diagnosis. Data analysis was done from August 2016 to September 2018. Exposures HIV infection identified by the presence of Medicare claims. Main outcomes Overall mortality, cancer-specific mortality, and relapse or cancer-specific mortality after initial treatment. Results In this database study of 308 268 patients with nonadvanced cancer (168 998 men and 139 270 women; age, ≥65 years), HIV-infected patients (n = 288) had significant elevations in the overall mortality rate compared with HIV-uninfected patients for cancers of the colorectum (hazard ratio [HR], 1.73; 95% CI, 1.11-2.68; P = .02), prostate (HR, 1.58; 95% CI, 1.23-2.03; P < .01), and breast (HR, 1.50; 95% CI, 1.01-2.24; P = .05). Cancer-specific mortality was elevated for prostate (HR, 1.65; 95% CI, 0.98-2.79; P = .06) and breast cancer (HR, 1.85; 95% CI, 0.96-3.55; P = .07). Compared with their HIV-uninfected counterparts, HIV-infected men with prostate cancer also experienced significantly higher rates of relapse or death (HR, 1.32; 95% CI, 1.03-1.71; P = .03) as did HIV-infected women with breast cancer (HR, 1.63; 95% CI, 1.09-2.43; P = .02). Conclusions and Relevance In the United States, elderly HIV-infected patients with cancer, particularly prostate and breast cancers, have worse outcomes than HIV-uninfected patients with cancer. This disparity persists even after adjustment for administered first-course cancer treatments and will become increasingly relevant as the HIV population in the United States continues to age.
Collapse
Affiliation(s)
- Anna E Coghill
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland.,Cancer Epidemiology Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Gita Suneja
- Radiation Oncology, Duke University, Durham, North Carolina
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Meredith S Shiels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Eric A Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| |
Collapse
|
52
|
Rositch AF, Atnafou R, Krakow M, D’Souza G. A Community-Based Qualitative Assessment of Knowledge, Barriers, and Promoters of Communicating about Family Cancer History among African-Americans. Health Commun 2019; 34:1192-1201. [PMID: 29757007 PMCID: PMC7303890 DOI: 10.1080/10410236.2018.1471335] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Family cancer history (FCH) can shape prevention and early detection behaviors to decrease cancer risk. However, many individuals are unaware of increased risk for cancers based on family patterns. For some African-American communities, communication about FCH is rare and barriers have not been well studied. To optimize the use of FCH, it is crucial to understand how patients gather and share FCH with relatives and healthcare providers. We conducted four focus groups (n = 40) and seven key informant interviews (n = 9) to investigate knowledge, experiences, and barriers/promoters of FCH in the East Baltimore African-American community. Thematic analysis identified 14 distinct themes across six communication domains: participants' understanding of FCH, past FCH communication with family and providers, barriers to FCH communication, promoters of FCH communication, suggestions for future communication, and community health priorities. FCH was most often defined by narratives of family cancer experiences, and the majority of participants had shared little FCH with family members. Five psychosocial domains were commonly reported as barriers to sharing FCH: fear/denial, pride/dignity, selflessness/self-sacrifice, cancer fatalism, and distrust/skepticism of medical care. Diagnosis/death and caregiving/social support promoted FCH communication and encouraged cancer prevention behaviors such as screening. Although most participants had experienced cancer in their families, communication about FCH was low and psychosocial barriers were common. Understanding these communication domains in minority populations is crucial to developing interventions to address disparities in cancer prevention and control, particularly where effective screening and care recommendations exist for those with positive family histories.
Collapse
Affiliation(s)
- Anne F. Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| | | | - Melinda Krakow
- Division of Cancer Control and Population Sciences, National Cancer Institute
| | - Gypsyamber D’Souza
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| |
Collapse
|
53
|
Smith AJB, Varma S, Rositch AF, Levinson K. Gynecologic cancer in HIV-positive women: a systematic review and meta-analysis. Am J Obstet Gynecol 2019; 221:194-207.e5. [PMID: 30771344 DOI: 10.1016/j.ajog.2019.02.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 01/17/2019] [Accepted: 02/07/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND While there is a significant body of literature on cervical cancer in HIV-positive women, little is known about other gynecologic cancers in this population. OBJECTIVE The objective of this systematic review and meta-analysis is to describe the incidence, presentation, treatment, and outcomes for HIV-positive women with non-acquired immunodeficiency syndrome-defining gynecologic cancers. STUDY DESIGN We searched MEDLINE, EMBASE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials for English-language studies published from 2000 to May 1, 2017. Studies containing 1 or more HIV-positive women with endometrial, ovarian, or vulvovaginal cancer and reporting incidence, treatment regimen, or survival were included. Two authors independently reviewed abstracts and full-text articles for inclusion and assessed study quality (details of the review protocol were registered as PROSPERO-CRD42017064525). Pooled estimates of incidence were calculated using random-effects models. Pooled estimates of cancer presentation and outcomes were averaged from case studies. RESULTS Of 5744 abstracts screened, we identified 70 articles on 58 studies on 292,202 women with HIV and 528 women with HIV and gynecologic cancer for inclusion. Most articles (53%) focused on incidence, and only 3, 4, and 20 articles focused on treatment and outcomes of endometrial, ovarian, and vulvovaginal cancers, respectively. The standardized incidence ratios for endometrial, ovarian, and vulvovaginal cancers were 4.38 (95% confidence interval 0.26-8.49) for endometrial cancer, 3.21 (95% confidence interval 2.29-4.13) for ovarian cancer, and 21.93 (95% confidence interval 13.50-30.35) for vulvovaginal cancer. Fifty-seven percent of women were diagnosed at an early stage, and all received cancer treatment. CONCLUSION In women with HIV, the incidence of ovarian and vulvovaginal cancer were higher than the general population, while incidence of endometrial cancer was similar. However, there was a paucity of data on treatment and outcomes for non-acquired immunodeficiency syndrome-defining gynecologic cancers. Given the increased incidence of gynecologic cancer, specific research on this population is essential to improve treatment and outcomes for HIV-positive women.
Collapse
Affiliation(s)
- Anna Jo Bodurtha Smith
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Sanskriti Varma
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins School of Medicine, Baltimore, MD
| | - Kimberly Levinson
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD; The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD.
| |
Collapse
|
54
|
Hammer A, Kahlert J, Gravitt PE, Rositch AF. Authors' response: Higher cervical cancer mortality among older women in Denmark could be due to insufficient screening coverage. Acta Obstet Gynecol Scand 2019; 98:1491. [PMID: 31433080 DOI: 10.1111/aogs.13710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 08/15/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Anne Hammer
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Johnny Kahlert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Patti E Gravitt
- Department of Global Health, Milken Institute School of Public Health, the George Washington University, Washington, DC, USA
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
55
|
Hammer A, Kahlert J, Gravitt PE, Rositch AF. Hysterectomy‐corrected cervical cancer mortality rates in Denmark during 2002‐2015: A registry‐based cohort study. Acta Obstet Gynecol Scand 2019; 98:1063-1069. [DOI: 10.1111/aogs.13608] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/08/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Anne Hammer
- Department of Obstetrics and Gynecology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Johnny Kahlert
- Department of Clinical Epidemiology Aarhus University Hospital Aarhus Denmark
| | - Patti E. Gravitt
- Department of Global Health Milken Institute School of Public Healththe George Washington University Washington District of Columbia, USA
| | - Anne F. Rositch
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore Maryland, USA
| |
Collapse
|
56
|
Rositch AF, Ginsburg OM, Huang L, Chao CA, Visvanathan K, Masalu N. Abstract P5-13-02: Not presented. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p5-13-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
This abstract was not presented at the conference.
Citation Format: Rositch AF, Ginsburg OM, Huang L, Chao CA, Visvanathan K, Masalu N. Not presented [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-02.
Collapse
Affiliation(s)
- AF Rositch
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Perlmutter Cancer Center and Section for Global Health, NYU Langone Health, New York, NY; Bugando Medical Centre, Mwanza, Tanzania, United Republic of
| | - OM Ginsburg
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Perlmutter Cancer Center and Section for Global Health, NYU Langone Health, New York, NY; Bugando Medical Centre, Mwanza, Tanzania, United Republic of
| | - L Huang
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Perlmutter Cancer Center and Section for Global Health, NYU Langone Health, New York, NY; Bugando Medical Centre, Mwanza, Tanzania, United Republic of
| | - CA Chao
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Perlmutter Cancer Center and Section for Global Health, NYU Langone Health, New York, NY; Bugando Medical Centre, Mwanza, Tanzania, United Republic of
| | - K Visvanathan
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Perlmutter Cancer Center and Section for Global Health, NYU Langone Health, New York, NY; Bugando Medical Centre, Mwanza, Tanzania, United Republic of
| | - N Masalu
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Perlmutter Cancer Center and Section for Global Health, NYU Langone Health, New York, NY; Bugando Medical Centre, Mwanza, Tanzania, United Republic of
| |
Collapse
|
57
|
Ishaque T, Massie AB, Bowring MG, Haugen CE, Ruck JM, Halpern SE, Waldram MM, Henderson ML, Wang JG, Cameron AM, Philosophe B, Ottmann S, Rositch AF, Segev DL. Liver transplantation and waitlist mortality for HCC and non-HCC candidates following the 2015 HCC exception policy change. Am J Transplant 2019; 19:564-572. [PMID: 30312530 PMCID: PMC6349527 DOI: 10.1111/ajt.15144] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 09/24/2018] [Accepted: 10/02/2018] [Indexed: 01/25/2023]
Abstract
Historically, exception points for hepatocellular carcinoma (HCC) led to higher transplant rates and lower waitlist mortality for HCC candidates compared to non-HCC candidates. As of October 2015, HCC candidates must wait 6 months after initial application to obtain exception points; the impact of this policy remains unstudied. Using 2013-2017 SRTR data, we identified 39 350 adult, first-time, active waitlist candidates and compared deceased donor liver transplant (DDLT) rates and waitlist mortality/dropout for HCC versus non-HCC candidates before (October 8, 2013-October 7, 2015, prepolicy) and after (October 8, 2015-October 7, 2017, postpolicy) the policy change using Cox and competing risks regression, respectively. Compared to non-HCC candidates with the same calculated MELD, HCC candidates had a 3.6-fold higher rate of DDLT prepolicy (aHR = 3.49 3.69 3.89 ) and a 2.2-fold higher rate of DDLT postpolicy (aHR = 2.09 2.21 2.34 ). Compared to non-HCC candidates with the same allocation priority, HCC candidates had a 37% lower risk of waitlist mortality/dropout prepolicy (asHR = 0.54 0.63 0.73 ) and a comparable risk of mortality/dropout postpolicy (asHR = 0.81 0.95 1.11 ). Following the policy change, the DDLT advantage for HCC candidates remained, albeit dramatically attenuated, without any substantial increase in waitlist mortality/dropout. In the context of sickest-first liver allocation, the revised policy seems to have established allocation equity for HCC and non-HCC candidates.
Collapse
Affiliation(s)
- Tanveen Ishaque
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mary G. Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christine E. Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jessica M. Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Samantha E. Halpern
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Madeleine M. Waldram
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Macey L. Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Benjamin Philosophe
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shane Ottmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anne F. Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| |
Collapse
|
58
|
Peprah S, Coleman JS, Rositch AF, Vanden Bussche CJ, Moore R, D'Souza G. Utilization of Pap testing among women living with HIV enrolled in primary care in Baltimore, Maryland: A 10-year longitudinal study, 2005-2014. Papillomavirus Res 2018; 6:52-57. [PMID: 30420338 PMCID: PMC6231054 DOI: 10.1016/j.pvr.2018.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/03/2018] [Accepted: 10/01/2018] [Indexed: 11/30/2022]
Abstract
Frequent Pap testing is recommended among women living with HIV (WLWH) due to their elevated risk for cervical cancer. However, there are few recent longitudinal evaluations of utilization and determinants of Pap testing among WLWH. Medical and pathology records of WLWH seen at Johns Hopkins Hospital between 2005 and 2014 were assessed using Prentice, Williams, Peterson models. Of 554 WLWH in care for ≥ 18 months, 79% received Pap testing, however only 11% consistently received Pap testing at the recommended interval. Some women (5%) were consistently under-screened (tested at longer intervals) and 21% did not receive any Pap testing at during follow-up. WLWH with decreased likelihood of screening included older women, injection drug users, whites and those who had lived for longer with HIV. In contrast, only women with a prior abnormal Pap result were more likely to receive Pap testing. CD4 cell count and health insurance were not significant determinants. Although many WLWH in care received Pap testing, some WLWH were unscreened or underscreened. Determinants of Pap testing for WLWH include socio-demographic factors and a prior abnormal result; these present potential targets in an urban HIV care setting for closer monitoring and directed interventions to improve utilization among WLWH.
Collapse
Affiliation(s)
- Sally Peprah
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, E6132B, Baltimore, MD 21205, United States
| | | | - Anne F Rositch
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, E6132B, Baltimore, MD 21205, United States
| | | | - Richard Moore
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Gypsyamber D'Souza
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, E6132B, Baltimore, MD 21205, United States.
| |
Collapse
|
59
|
Beavis A, Krakow M, Levinson K, Rositch AF. Reasons for Lack of HPV Vaccine Initiation in NIS-Teen Over Time: Shifting the Focus From Gender and Sexuality to Necessity and Safety. J Adolesc Health 2018; 63:652-656. [PMID: 30348283 DOI: 10.1016/j.jadohealth.2018.06.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/17/2018] [Accepted: 06/19/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To describe changes in parents' reasons for lack of HPV vaccine initiation in American male and female adolescents from 2010 to 2016. METHODS Log binomial regression was used to examine prevalence and trends across time in reasons parents do not intend to vaccinate from the National Immunization Survey - Teen (NIS-Teen). RESULTS In females, safety concerns were the most common reasons in 2010 (23%) and 2016 (22%). Lack of necessity (21% vs. 20%), knowledge (14% vs. 13%), and recommendation (9% vs. 10.0%) remained stable, whereas child's lack of sexual activity decreased from 19% to 10% (p<.01). For males, lack of necessity (24% vs. 22%), recommendation (22% vs. 17%), and knowledge (16% vs. 14%), and child's lack of sexual activity (16% vs. 9%) and gender (13% vs. 2%) decreased from 2010 to 2016 (p<.05). Safety concerns increased (5% vs. 14%) (p<.01). CONCLUSIONS Vaccine messages should reflect current trends and focus on persistent concerns about knowledge, safety, and necessity, rather than sexuality and gender.
Collapse
Affiliation(s)
- Anna Beavis
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, Maryland.
| | - Melinda Krakow
- Cancer Prevention Fellowship Program, National Cancer Institute, Bethesda, Maryland
| | - Kimberly Levinson
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, Maryland
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| |
Collapse
|
60
|
Dickerson LK, Rositch AF, Lucas S, Mullen LA, Harvey SC. An Educational Intervention and Feasibility Assessment of Breast Ultrasound in Rural South Africa. J Glob Oncol 2018. [DOI: 10.1200/jgo.18.10150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Breast cancer is the leading cause of cancer death in women worldwide, with a strikingly high mortality in low- and middle-income countries (LMICs) as a result of the scarcity of detection, diagnosis, and treatment. With mammography unavailable, ultrasound (US) offers a viable alternative. The literature reports successful training in various domains, but a curriculum focused on the breast is novel. We assessed the feasibility—knowledge acquisition, perceived utility, and self-efficacy—of a breast US training program for the detection of breast cancer by nonphysician providers. Methods Training was implemented for 12 providers, including professional nurses, nursing assistants, and lay counselors, at Hlokomela clinic in Hoedspruit, South Africa, over 3 weeks. Didactic presentations and example cases were followed by a presurvey (n = 12) that characterized providers’ initial attitudes toward early detection and a pretest (n = 12) that determined immediate retention of knowledge and areas for focused training. All providers received hands-on training with nurses as models. Five providers trained with patients. A post-test (n = 12) assessed overall knowledge retention and acquisition, and a postsurvey (n = 10) gauged program acceptance and provider self-efficacy with breast US. Results Pretest to post-test averages improved by 68% overall and in four competencies—foundational knowledge, descriptive categories, benign versus malignant, and lesion identification. On the postsurvey, providers expressed the belief that US could significantly affect breast cancer detection (9.1/10), treatment (7.9/10), and survival (8.7/10) in their communities and endorsed moderate confidence in their scanning (6.3/10) and interpreting abilities (5.6/10). Conclusion There is a pressing need for a paradigm shift in breast cancer care in LMICs, with early detection critical to improving outcomes. Our research supports the feasibility of breast US training as part of a breast education program in LMICs. Pretest and post-test results and observed proficiency indicate that training nonphysician providers is achievable. Postsurvey responses indicate program acceptance, provider self-efficacy with US, and community-based ownership of a breast cancer screening and awareness initiative. Follow-up work that is focused on quality improvement and sustainability is ongoing. Future work may show that breast US is viable for early detection when mammography is unavailable. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Susan C. Harvey Consulting or Advisory Role: IBM Watson, Hologic Inc Research Funding: IBM Watson
Collapse
Affiliation(s)
- Lindsay K. Dickerson
- Lindsay K. Dickerson, Johns Hopkins University School of Medicine; Anne F. Rositch, Johns Hopkins Bloomberg School of Public Health; Lisa A. Mullen and Susan C. Harvey, Johns Hopkins Medical Institutions, Baltimore, MD; and Susan Lucas, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Anne F. Rositch
- Lindsay K. Dickerson, Johns Hopkins University School of Medicine; Anne F. Rositch, Johns Hopkins Bloomberg School of Public Health; Lisa A. Mullen and Susan C. Harvey, Johns Hopkins Medical Institutions, Baltimore, MD; and Susan Lucas, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Susan Lucas
- Lindsay K. Dickerson, Johns Hopkins University School of Medicine; Anne F. Rositch, Johns Hopkins Bloomberg School of Public Health; Lisa A. Mullen and Susan C. Harvey, Johns Hopkins Medical Institutions, Baltimore, MD; and Susan Lucas, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Lisa A. Mullen
- Lindsay K. Dickerson, Johns Hopkins University School of Medicine; Anne F. Rositch, Johns Hopkins Bloomberg School of Public Health; Lisa A. Mullen and Susan C. Harvey, Johns Hopkins Medical Institutions, Baltimore, MD; and Susan Lucas, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Susan C. Harvey
- Lindsay K. Dickerson, Johns Hopkins University School of Medicine; Anne F. Rositch, Johns Hopkins Bloomberg School of Public Health; Lisa A. Mullen and Susan C. Harvey, Johns Hopkins Medical Institutions, Baltimore, MD; and Susan Lucas, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| |
Collapse
|
61
|
Sood R, Rositch AF, Ambinder E, Pool KL, Shakoor D, Pollack E, Mullen L, Harvey S. Ultrasound for Breast Cancer Detection in Low-Resource Settings: Systematic Review and Meta-Analysis. J Glob Oncol 2018. [DOI: 10.1200/jgo.18.10510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Of breast cancer–related deaths worldwide, 62.1% occur in low- and middle-income countries (LMICs). Mammography, the gold standard for screening, is largely infeasible in limited-resource settings, predominantly because of unavailability. Recent data show a dismal 0 to 12 mammography units per one million women age 50 to 69 years in most of sub-Saharan Africa. Breast ultrasound, which is used in high-resource settings to supplement mammography in certain clinical scenarios, offers a potentially viable alternative for early breast cancer detection in resource-limited areas because it is portable, economical, and a versatile technology. Methods We conducted a review of the literature to assess the potential for ultrasound alone in the detection of breast cancer. PubMed and Scopus queries with terms “breast neoplasms” and “diagnostic imaging” were systematically filtered to n = 33. Inclusion criteria were peer-reviewed studies in human participants, retrospective or prospective reviews, and a reference standard of biopsy/histopathology. Each paper was required to have extractable data with which to calculate true positives, false positives, true negatives, and false negatives. Breast imagers reviewed each paper using QUADAS and reached consensus for inclusion. Results Heterogeneity analyses confirmed a high diversity of all included studies. Pooled weighted analyses of all included studies demonstrated that the sensitivity of ultrasound for the detection of breast cancer ranged from 17% to 100%, with a 69% mean. This is higher than the known reported sensitivity of mammography for breast cancer detection of 67.8%. The specificity of ultrasound ranged from 28% to 100%, with a pooled total specificity of 97%, which is higher than the known specificity of mammography of 75%. In addition, ultrasound performed with superior sensitivity to mammography in the studies performed in LMICs that directly compared ultrasound with mammography (six of 11 studies). In the remaining five studies in LMICs, the sensitivity of ultrasound for breast cancer detection was high and ranged from 62% to 100%. Stratified analyses by age, breast density, presenting symptoms, and high-risk factors maintained the high sensitivities and specificities of ultrasound. Conclusion Sensitivities and specificities of ultrasound are comparable to mammography for the detection of invasive breast cancer. Handheld ultrasound may offer a viable alternative where mammography is not widely available as a primary detection modality for breast cancer. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Susan Harvey Honoraria: Hologic Inc, IBM Watson Imaging Consulting or Advisory Role: IBM Watson, Hologic Inc Research Funding: IBM Watson
Collapse
Affiliation(s)
- Rupali Sood
- Rupali Sood, Emily Ambinder, Delaram Shakoor, Lisa Mullen, and Susan Harvey, Johns Hopkins University School of Medicine; Anne F. Rositch, Bloomberg School of Public Health, Baltimore, MD; Kara-Lee Pool, University of California, Los Angeles, Los Angeles, CA; and Erica Pollack, Denver Health, Denver, CO
| | - Anne F. Rositch
- Rupali Sood, Emily Ambinder, Delaram Shakoor, Lisa Mullen, and Susan Harvey, Johns Hopkins University School of Medicine; Anne F. Rositch, Bloomberg School of Public Health, Baltimore, MD; Kara-Lee Pool, University of California, Los Angeles, Los Angeles, CA; and Erica Pollack, Denver Health, Denver, CO
| | - Emily Ambinder
- Rupali Sood, Emily Ambinder, Delaram Shakoor, Lisa Mullen, and Susan Harvey, Johns Hopkins University School of Medicine; Anne F. Rositch, Bloomberg School of Public Health, Baltimore, MD; Kara-Lee Pool, University of California, Los Angeles, Los Angeles, CA; and Erica Pollack, Denver Health, Denver, CO
| | - Kara-Lee Pool
- Rupali Sood, Emily Ambinder, Delaram Shakoor, Lisa Mullen, and Susan Harvey, Johns Hopkins University School of Medicine; Anne F. Rositch, Bloomberg School of Public Health, Baltimore, MD; Kara-Lee Pool, University of California, Los Angeles, Los Angeles, CA; and Erica Pollack, Denver Health, Denver, CO
| | - Delaram Shakoor
- Rupali Sood, Emily Ambinder, Delaram Shakoor, Lisa Mullen, and Susan Harvey, Johns Hopkins University School of Medicine; Anne F. Rositch, Bloomberg School of Public Health, Baltimore, MD; Kara-Lee Pool, University of California, Los Angeles, Los Angeles, CA; and Erica Pollack, Denver Health, Denver, CO
| | - Erica Pollack
- Rupali Sood, Emily Ambinder, Delaram Shakoor, Lisa Mullen, and Susan Harvey, Johns Hopkins University School of Medicine; Anne F. Rositch, Bloomberg School of Public Health, Baltimore, MD; Kara-Lee Pool, University of California, Los Angeles, Los Angeles, CA; and Erica Pollack, Denver Health, Denver, CO
| | - Lisa Mullen
- Rupali Sood, Emily Ambinder, Delaram Shakoor, Lisa Mullen, and Susan Harvey, Johns Hopkins University School of Medicine; Anne F. Rositch, Bloomberg School of Public Health, Baltimore, MD; Kara-Lee Pool, University of California, Los Angeles, Los Angeles, CA; and Erica Pollack, Denver Health, Denver, CO
| | - Susan Harvey
- Rupali Sood, Emily Ambinder, Delaram Shakoor, Lisa Mullen, and Susan Harvey, Johns Hopkins University School of Medicine; Anne F. Rositch, Bloomberg School of Public Health, Baltimore, MD; Kara-Lee Pool, University of California, Los Angeles, Los Angeles, CA; and Erica Pollack, Denver Health, Denver, CO
| |
Collapse
|
62
|
Rositch AF, Krakow M. Invited Commentary: Moving From Evidence to Impact for Human Papillomavirus Vaccination-The Critical Role of Translation and Communication in Epidemiology. Am J Epidemiol 2018; 187:1277-1280. [PMID: 29860471 DOI: 10.1093/aje/kwy024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/12/2018] [Indexed: 12/24/2022] Open
Abstract
In response to the accompanying article by Yih et al. (Am J Epidemiol. 2018;187(6):1269-1276), we highlight the importance of moving beyond epidemiologic research on human papillomavirus (HPV) vaccine safety to focus on translation of this strong evidence base into successful vaccine safety communication strategies to bolster vaccine uptake. The potential of the HPV vaccine to reduce cancer incidence is substantial, yet actual HPV vaccination rates in the United States are disappointingly low in comparison with other routine childhood vaccines with similar safety profiles. This is no doubt due, in part, to persistent parental safety concerns. In 2016, safety remained the second most common reason for lack of vaccination intent by parents of unvaccinated adolescents. While the strong study by Yih et al. makes use of a novel statistical method and a large medical claims database to confirm the low occurrence of adverse events following HPV vaccination observed globally, their study also highlights a key challenge for epidemiologists: translating our research findings to other public health domains, so that evidence-informed communication strategies can be used to disseminate the information in a way that is understandable and useful to the public. Moving forward, multidisciplinary research teams will be essential to ensure that our epidemiologic findings have a broad public health impact.
Collapse
Affiliation(s)
- Anne F Rositch
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Melinda Krakow
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| |
Collapse
|
63
|
Epeldegui M, Magpantay L, Guo Y, Halec G, Cumberland WG, Yen PK, Macatangay B, Margolick JB, Rositch AF, Wolinsky S, Martinez-Maza O, Hussain SK. A prospective study of serum microbial translocation biomarkers and risk of AIDS-related non-Hodgkin lymphoma. AIDS 2018; 32:945-954. [PMID: 29424776 PMCID: PMC5869109 DOI: 10.1097/qad.0000000000001771] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Chronic immune activation is a harbinger of AIDS-associated non-Hodgkin lymphoma (AIDS-NHL), yet the underlying basis is unclear. Microbial translocation, the passage of microbial components from the gastrointestinal tract into the systemic circulation, is a source of systemic immune activation in HIV infection and may be an important contributor to chronic B-cell activation and subsequent AIDS-NHL development. METHOD We measured biomarkers of microbial translocation including bacterial receptors/antibodies, intestinal barrier proteins, and macrophage activation-associated cytokines/chemokines, in serum from 200 HIV-infected men from the Multicenter AIDS Cohort Study prior to their AIDS-NHL diagnosis (mean = 3.9 years; SD = 1.6 years) and 200 controls. Controls were HIV-infected men who did not develop AIDS-NHL, individually matched to cases on CD4 T-cell count, prior antiretroviral drug use, and recruitment year into the cohort. RESULTS Biomarkers of bacterial translocation and intestinal permeability were significantly increased prior to AIDS-NHL. Lipopolysaccharide-binding protein (LPB), fatty acid-binding protein 2 (FABP2), and soluble CD14 were associated with 1.6-fold, 2.9-fold, and 3.7-fold increases in AIDS-NHL risk for each unit increase on the natural log scale, respectively. Haptoglobin had a 2.1-fold increase and endotoxin-core antibody a 2.0-fold decrease risk for AIDS-NHL (fourth versus first quartile). Biomarkers of macrophage activation were significantly increased prior to AIDS-NHL: B-cell activation factor (BAFF), IL18, monocyote chemoattractant protein-1 (MCP1), tumor necrosis factor-α (TNFα), and CCL17 had 2.2-fold, 2.0-fold, 1.6-fold, 2.8-fold, and 1.7-fold increases in risk for each unit increase on the natural log scale, respectively. CONCLUSION These data provide evidence for microbial translocation as a cause of the systemic immune activation in chronic HIV infection preceding AIDS-NHL development.
Collapse
Affiliation(s)
| | | | - Yu Guo
- University of California, Los Angeles, California
| | | | | | | | | | | | - Anne F Rositch
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Steven Wolinsky
- Northwestern University Feinberg School of Medicine, Chicago, Ilinois
| | | | | |
Collapse
|
64
|
Silver MI, Rositch AF, Phelan-Emrick DF, Gravitt PE. Uptake of HPV testing and extended cervical cancer screening intervals following cytology alone and Pap/HPV cotesting in women aged 30-65 years. Cancer Causes Control 2017; 29:43-50. [PMID: 29124542 DOI: 10.1007/s10552-017-0976-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 10/28/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate the adoption of HPV testing and recommended extended cervical cancer screening intervals in clinical practice, we described yearly uptake of Pap/HPV cotesting and estimated length of time between normal screens by patient characteristics. METHODS We examined 55,575 Pap/HPV records from 27,035 women aged 30-65 years from the Johns Hopkins Hospital Pathology Data System between 2006 and 2013. Cotest uptake and median times to next screening test for cotests and cytology only were calculated. Adjusted hazard ratios were estimated using Cox proportional hazards models, with random effects adjustment for clustering within clinic. RESULTS Cotest usage increased from < 10% in 2006 to 78% in 2013. The median time to next screening test following normal cytology alone remained constant around 1.5 years. Screening intervals following a dual-negative cotest increased from 1.5 years in 2006/2007 to 2.5 years in 2010, coincident with increases in the proportion of women cotested. Intervals following a dual negative cotest were longer among Medicare patients (3 years) compared with privately insured women (2.5 years), and shorter among black (2 years) compared with white women (2.8 years). CONCLUSION By mid-2013 we observed broad adoption of Pap/HPV cotesting in routine screening in a large academic medical center. Increased screening intervals were observed only among cotested women, while those screened by cytology alone continued to be screened almost annually. The influence of different combinations of race and insurance on screening intervals should be further evaluated to ensure balance of screening risks and benefits in the U.S. POPULATION
Collapse
Affiliation(s)
- Michelle I Silver
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive, 6E584, Rockville, MD, 20850, USA.
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Darcy F Phelan-Emrick
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Patti E Gravitt
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department Global Health, George Washington University, Washington, DC, USA
| |
Collapse
|
65
|
Patel EU, Rositch AF, Gravitt PE, Tobian AAR. Concordance of Penile and Oral Human Papillomavirus Infections Among Men in the United States. J Infect Dis 2017; 215:1207-1211. [PMID: 28329127 DOI: 10.1093/infdis/jix116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/02/2017] [Indexed: 01/28/2023] Open
Abstract
This study examined the concordance of penile and oral human papillomavirus (HPV) infections in the United States. A total of 1683 men aged 18-59 years who participated in the 2013-2014 National Health and Nutrition Examination Survey and had results of oral and penile HPV DNA testing were examined. The prevalence of any HPV genotype was 45.3% on the penis, 11.2% in the oral cavity, and 8.8% at both sites. The prevalence of HPV in the oral cavity was higher among those with than among those without penile HPV infection (19.3% vs 4.4%; prevalence ratio, 4.37 [95% confidence interval, 2.66-7.16]). The prevalence of ≥1 genotype-concordant HPV infection was 3.2% and was associated with sexual behavior, independent of demographic characteristics and smoking status. Sexual behavior may partly explain the observed association between penile and oral HPV infections.
Collapse
Affiliation(s)
- Eshan U Patel
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Patti E Gravitt
- Department of Global Health, George Washington University, Washington, District of Columbia
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
66
|
Dickerson LK, Rositch AF, Lucas S, Harvey SC. Pilot Educational Intervention and Feasibility Assessment of Breast Ultrasound in Rural South Africa. J Glob Oncol 2017; 3:502-508. [PMID: 29094089 PMCID: PMC5646899 DOI: 10.1200/jgo.2016.008086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Purpose Breast cancer is the leading cause of cancer death in women worldwide, with high mortality in low- and middle-income countries because of a lack of detection, diagnosis, and treatment. With mammography unavailable, ultrasound offers an alternative for downstaging. The literature reports successful training in various domains, but a focus on the breast is novel. We assessed the feasibility (knowledge acquisition, perceived usefulness, and self-efficacy) of breast ultrasound training for nonphysician providers. Methods Training was implemented for 12 providers at Hlokomela Clinic in Hoedspruit, South Africa, over 3 weeks. Didactic presentations and example cases were followed by a presurvey and test (n = 12). All providers received hands-on training with nurses as models; five providers trained with patients. A post-test (n = 12) assessed knowledge acquisition and a postsurvey (n = 10) assessed perceived program usefulness and provider self-efficacy. Results The pre- to post-test averages improved by 68% in total and in four competencies (foundational knowledge, descriptive categories, benign v malignant, and lesion identification). On the postsurvey, providers expressed that ultrasound could significantly influence breast cancer detection (9.1 out of 10), treatment (7.9 out of 10), and survival (8.7 out of 10) in their community and endorsed moderate confidence in their scanning (6.3 out of 10) and interpreting abilities (5.6 out of 10). Conclusion Our research supports the feasibility of breast ultrasound training as part of a breast education program in low- and middle-income countries. Pre- and post-test results and observed proficiency indicate that training nonphysician providers is achievable; postsurvey responses indicate program acceptance, community-based ownership, and provider self-efficacy with ultrasound. Future work may show that breast ultrasound is viable for early detection where mammography is unavailable.
Collapse
Affiliation(s)
- Lindsay K Dickerson
- , Johns Hopkins University School of Medicine; , Johns Hopkins Bloomberg School of Public Health; , Johns Hopkins Medical Institutions, Baltimore, MD; and , Chris Hani Baragwanath Academic Hospital, University of Witwatersrand School of Medicine, Johannesburg, South Africa
| | - Anne F Rositch
- , Johns Hopkins University School of Medicine; , Johns Hopkins Bloomberg School of Public Health; , Johns Hopkins Medical Institutions, Baltimore, MD; and , Chris Hani Baragwanath Academic Hospital, University of Witwatersrand School of Medicine, Johannesburg, South Africa
| | - Susan Lucas
- , Johns Hopkins University School of Medicine; , Johns Hopkins Bloomberg School of Public Health; , Johns Hopkins Medical Institutions, Baltimore, MD; and , Chris Hani Baragwanath Academic Hospital, University of Witwatersrand School of Medicine, Johannesburg, South Africa
| | - Susan C Harvey
- , Johns Hopkins University School of Medicine; , Johns Hopkins Bloomberg School of Public Health; , Johns Hopkins Medical Institutions, Baltimore, MD; and , Chris Hani Baragwanath Academic Hospital, University of Witwatersrand School of Medicine, Johannesburg, South Africa
| |
Collapse
|
67
|
Beavis AL, Gravitt PE, Rositch AF. Hysterectomy‐corrected cervical cancer mortality rates reveal a larger racial disparity in the United States. Cancer 2017; 123:1044-1050. [DOI: 10.1002/cncr.30507] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 09/27/2016] [Accepted: 09/30/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Anna L. Beavis
- Kelly Gynecologic Oncology ServiceDepartment of Gynecology and Obstetrics, Johns Hopkins MedicineBaltimore Maryland
| | - Patti E. Gravitt
- Milken Institute School of Public HealthDepartment of Global Health, George Washington UniversityWashington DC
| | - Anne F. Rositch
- Department of EpidemiologyBloomberg School of Health at Johns HopkinsBaltimore Maryland
| |
Collapse
|
68
|
Lam JO, Sugar EA, Cranston RD, Weber KM, Burk RD, Wiley DJ, Reddy S, Margolick JB, Strickler HD, Wentz A, Jacobson L, Coles CL, Bream JH, Rositch AF, Guo Y, Xiao W, Gillison ML, D'Souza G. The association of medication use with clearance or persistence of oral HPV infection. Cancer Causes Control 2016; 27:1491-1498. [PMID: 27804058 DOI: 10.1007/s10552-016-0826-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 10/25/2016] [Indexed: 12/15/2022]
Abstract
PURPOSE Persistent oral human papillomavirus (HPV) infection increases risk for oropharyngeal carcinoma, and people living with HIV have higher rates of oral HPV infection and related cancers. Some prescription medications have immunomodulatory effects, but the impact of medication use on oral HPV natural history is unknown. METHODS Scope® oral rinse-and-gargle samples were collected semi-annually from 1,666 participants and tested for 37 types of oral HPV DNA using PCR; 594 HPV-infected participants with 1,358 type-specific oral HPV infections were identified. Data were collected on recent (past 6 months) use of medications. The relationship between medication use and oral HPV clearance was evaluated using Wei-Lin-Weissfeld regression, adjusting for biologic sex, prevalent versus incident infection, age, HIV status and CD4+ T cell count. RESULTS Out of 11 medications examined, oral HPV clearance was significantly reduced in participants reporting recent use of antipsychotics (HR 0.75, 95% CI 0.57-0.99), anxiolytics/sedatives (HR 0.78, 95% CI 0.63-0.96) and antidepressants (HR 0.82, 95% CI 0.67-0.999). Among antipsychotics users, effect modification by HIV status was observed, with reduced clearance in HIV-infected (HR 0.67, 95% CI 0.49-0.91), but not HIV-uninfected participants (p-interaction = 0.009). After adjusted analysis, antipsychotic use remained significantly associated with reduced oral HPV clearance overall (aHR 0.75, 95% CI 0.57-0.99), and when restricted to only HIV-infected participants (aHR 0.66, 95% CI 0.48-0.90). After adjustment, anxiolytic/sedative use and antidepressant use were no longer significantly associated with reduced oral HPV clearance. CONCLUSIONS Some medications were associated with decreased oral HPV clearance, most notably antipsychotic medications. These medications are prescribed for conditions that may have immunomodulating effects, so characteristics of underlying illness may have partially contributed to reduced oral HPV clearance.
Collapse
Affiliation(s)
- Jennifer O Lam
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elizabeth A Sugar
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Ross D Cranston
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kathleen M Weber
- Hektoen Institute of Medicine, The CORE Center at John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA
| | - Robert D Burk
- Departments of Pediatrics, Microbiology and Immunology, and Obstetrics, Gynecology and Women's Health, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, USA
| | - Dorothy J Wiley
- School of Nursing, University of California Los Angeles, Los Angeles, CA, USA
| | - Susheel Reddy
- Division of Infectious Diseases, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Joseph B Margolick
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Howard D Strickler
- Departments of Epidemiology and Population Health, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, USA
| | - Alicia Wentz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Lisa Jacobson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Christian L Coles
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jay H Bream
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Yingshi Guo
- Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Weihong Xiao
- Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Maura L Gillison
- Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Gypsyamber D'Souza
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
| |
Collapse
|
69
|
Abstract
HIV-infected individuals are at increased risk for most types of cancer, including those typically classified as non-AIDS-defining cancers (NADCs). This increased risk is likely multifactorial, but a prominent risk factor for the increased rate of some cancers is co-infection with oncogenic viruses. Anal cancer, hepatocellular carcinoma, and Hodgkin lymphoma are three of the most common NADCs, and they are associated with co-infection with human papillomavirus, hepatitis B and C, and Epstein Barr virus, respectively. This review will examine the epidemiology, pathogenesis, and future trends around these virally associated NADCs frequently found in HIV-infected individuals.
Collapse
Affiliation(s)
- David J Riedel
- Institute of Human Virology and Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD, USA,
| | | | | |
Collapse
|
70
|
Riedel DJ, Rositch AF, Redfield RR. Patterns of HIV viremia and viral suppression before diagnosis of non-AIDS-defining cancers in HIV-infected individuals. Infect Agent Cancer 2015; 10:38. [PMID: 26535055 PMCID: PMC4631102 DOI: 10.1186/s13027-015-0033-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 09/11/2015] [Indexed: 12/30/2022] Open
Abstract
Background The association between HIV viremia and non-AIDS-defining cancers (NADCs) is not well characterized. Viremia may contribute directly or indirectly to cancer development and may have a differential impact on various cancer types. Our objective was to characterize patterns of HIV viremia in a retrospective, urban, clinical cohort (N = 320) of patients diagnosed with NADCs. Findings The most common NADC’s were lung (n = 60), prostate (n = 47), oropharyngeal (n = 32), liver (n = 29), and anal cancer (n = 20) and Hodgkin lymphoma (n = 18). In the year before cancer diagnosis, 66 % of all patients were virally suppressed. Patients with oropharyngeal (70 %) and prostate cancer (78 %) had a higher proportion of visits with suppressed viral loads. Patients diagnosed with anal cancer and Hodgkin lymphoma were infrequently virally suppressed and more frequently had viral loads ≥5 log10 copies/ml in the ten years prior to cancer diagnosis. Conclusions In this cohort of HIV-infected patients diagnosed with NADCs, there were important differences in the patterns and levels of viremia between the different NADCs in the ten years prior to cancer diagnosis. Patients with anal cancer and Hodgkin lymphoma had the highest proportion of high level viremia in the ten years before cancer and the lowest frequency of viral load suppression at cancer diagnosis.
Collapse
Affiliation(s)
- David J Riedel
- Institute of Human Virology and Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD USA.,Institute of Human Virology and Division of Infectious Diseases, University of Maryland School of Medicine, Program in Oncology, University of Maryland Marlene and Stewart Greenebaum Cancer Center, 725 W. Lombard St., N552, Baltimore, MD 21201 USA
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Robert R Redfield
- Institute of Human Virology and Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD USA
| |
Collapse
|
71
|
Hammer A, Rositch AF, Kahlert J, Gravitt PE, Blaakaer J, Søgaard M. Global epidemiology of hysterectomy: possible impact on gynecological cancer rates. Am J Obstet Gynecol 2015; 213:23-29. [PMID: 25724402 DOI: 10.1016/j.ajog.2015.02.019] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 02/03/2015] [Accepted: 02/19/2015] [Indexed: 11/26/2022]
Abstract
Despite the fact that hysterectomy is the most common surgical procedure worldwide in gynecology, national reporting of the incidence rate of gynecological cancers rarely removes the proportion no longer at risk of the disease from the population-at-risk-denominator (ie, women who have had a hysterectomy). The incidence rate of gynecological cancers is thus likely underestimated. Because hysterectomy, as well as oophorectomy, incidence varies across countries, age, and over time, meaningful comparison of gynecological cancer incidence rates may be compromised. Without accurate estimates of gynecological cancer incidence rates, performed via removing the proportion of hysterectomized or oophorectomized women from the population-at-risk-denominator, the impact of prevention strategies may be masked or misinterpreted. Furthermore, because national cervical cancer screening guidelines are at least in part based on the national reporting of cervical cancer incidence, it is important that the incidence rate reflects the true population at risk.
Collapse
|
72
|
Riedel DJ, Rositch AF, Redfield RR, Blattner WA. HIV-associated lymphoma sub-type distribution, immunophenotypes and survival in an urban clinic population. Leuk Lymphoma 2015; 57:306-312. [PMID: 26025299 DOI: 10.3109/10428194.2015.1055483] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
HIV-infected patients have an increased risk for both Hodgkin and non-Hodgkin lymphomas. A retrospective cohort of all HIV-infected patients diagnosed with lymphoma in urban clinics from 2000-2013 was evaluated to characterize the distribution and determine effects of sub-type and immunophenotype on survival. Of 160 cases identified, 131 (82%) had complete information and were analyzed. The most common sub-types were diffuse large B cell (41%), Burkitt (21%) and Hodgkin lymphoma (18%). Advanced (78% stage III/IV) and extranodal disease (82%) at presentation were common. CD20 was the most commonly expressed immunophenotypic marker (89%). Overall mortality rate was high (26.1 per 100 person-years). Lower mortality was noted in CD10 + and CD20 + lymphomas, but differences were not statistically significant. After adjustment, low CD4 count (≤ 200) at diagnosis was associated with higher mortality (adjusted hazard ration (AHR) = 1.75; 95% CI = 1.00-3.61). Mortality in this cohort of patients with HIV-associated lymphomas was high and exceeds that from published data from the general population.
Collapse
Affiliation(s)
- David J Riedel
- a Institute of Human Virology, University of Maryland School of Medicine , Baltimore , MD , USA
| | - Anne F Rositch
- b Department of Epidemiology , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Robert R Redfield
- a Institute of Human Virology, University of Maryland School of Medicine , Baltimore , MD , USA
| | - William A Blattner
- a Institute of Human Virology, University of Maryland School of Medicine , Baltimore , MD , USA
| |
Collapse
|
73
|
Silver MI, Rositch AF, Burke AE, Chang K, Viscidi R, Gravitt PE. Patient concerns about human papillomavirus testing and 5-year intervals in routine cervical cancer screening. Obstet Gynecol 2015; 125:317-329. [PMID: 25568994 DOI: 10.1097/aog.0000000000000638] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To explore attitudes toward new cervical cancer screening options and understand factors associated with those beliefs among women in routine gynecologic care. METHODS We used an interviewer-administered survey of 551 women aged 36-62 years enrolled in the HPV in Perimenopause Study. Poisson regression with robust error variance was used to estimate prevalence ratios and 95% confidence intervals (CIs) to compare women's preferences for cervical cancer screening methods and frequency. RESULTS A majority of women (55.6%, 95% CI 51.4-59.8%) were aware that screening recommendations had changed, yet 74.1% (95% CI 70.3-77.7%) still believed women should be screened annually. If recommended by their doctor, 68.4% (95% CI 64.4-72.2%) were willing to extend screening to every 3 years, but only 25.2% (95% CI 21.9-29.2%) would extend screening to 5 years. Most women (60.7%, 95% CI 56.5-65.7%) expressed a strong preference for Pap testing, and 41.4% (95% CI 37.4-45.6%) expressed at least moderate concern over having a human papillomavirus (HPV) test without a Pap test. A desire for more frequent care, higher degree of worry and perceived risk, and abnormal screening history were all associated with reduced willingness to accept HPV testing and longer screening intervals. CONCLUSION A majority of routinely screened women indicated a willingness to adopt a cervical cancer screening strategy of cytology alone or Pap-HPV cotesting every 3 years if recommended by their physician. However, they remain concerned about HPV testing and extension of screening intervals to once every 5 years. Our results suggest continued reticence to accepting newer HPV-based screening algorithms among routinely screened women older than age 35 years.
Collapse
Affiliation(s)
- Michelle I Silver
- Departments of Epidemiology, Gynecology and Obstetrics, and Pediatrics and the Center for Immunization Research, Johns Hopkins School of Public Health, Baltimore, Maryland; and the Department of Pathology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | | | | | | | | |
Collapse
|
74
|
Rositch AF, Nowak RG, Gravitt PE. Increased age and race-specific incidence of cervical cancer after correction for hysterectomy prevalence in the United States from 2000 to 2009. Cancer 2014; 120:2032-8. [PMID: 24821088 DOI: 10.1002/cncr.28548] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 11/25/2013] [Accepted: 12/02/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Invasive cervical cancer is thought to decline in women over 65 years old, the age at which cessation of routine cervical cancer screening is recommended. However, national cervical cancer incidence rates do not account for the high prevalence of hysterectomy in the United States. METHODS Using estimates of hysterectomy prevalence from the Behavioral Risk Factor Surveillance System (BRFSS), hysterectomy-corrected age-standardized and age-specific incidence rates of cervical cancer were calculated from the Surveillance, Epidemiology, and End Results (SEER) 18 registry in the United States from 2000 to 2009. Trends in corrected cervical cancer incidence across age were analyzed using Joinpoint regression. RESULTS Unlike the relative decline in uncorrected rates, corrected rates continue to increase after age 35-39 (APC(CORRECTED) = 10.43) but at a slower rate than in 20-34 years (APC(CORRECTED) = 161.29). The highest corrected incidence was among 65- to 69-year-old women, with a rate of 27.4 cases per 100,000 women as opposed to the highest uncorrected rate of 15.6 cases per 100,000 aged 40 to 44 years. Correction for hysterectomy had the largest impact on older, black women given their high prevalence of hysterectomy. CONCLUSIONS Correction for hysterectomy resulted in higher age-specific cervical cancer incidence rates, a shift in the peak incidence to older women, and an increase in the disparity in cervical cancer incidence between black and white women. Given the high and nondeclining rate of cervical cancer in women over the age of 60 to 65 years, when women are eligible to exit screening, risk and screening guidelines for cervical cancer in older women may need to be reconsidered.
Collapse
Affiliation(s)
- Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | | | | |
Collapse
|
75
|
Rositch AF, Mao L, Hudgens MG, Moses S, Agot K, Backes DM, Nyagaya E, Snijders PJ, Meijer CJ, Bailey RC, Smith JS. Risk of HIV acquisition among circumcised and uncircumcised young men with penile human papillomavirus infection. AIDS 2014; 28:745-52. [PMID: 24149088 PMCID: PMC4074250 DOI: 10.1097/qad.0000000000000092] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES There are very few data from men on the risk of HIV acquisition associated with penile human papillomavirus (HPV) infection and no data on the potential modifying effect of male circumcision. Therefore, this study evaluated whether HPV is independently associated with risk of HIV. DESIGN A cohort study of HPV natural history nested within a randomized control trial of male circumcision to reduce HIV incidence in Kisumu, Kenya. METHODS Prospective data from 2519 men were analyzed using 6-month discrete-time Cox models to determine if HIV acquisition was higher among circumcised or uncircumcised men with HPV compared to HPV-uninfected men. RESULTS Risk of HIV acquisition was nonsignificantly increased among men with any HPV [adjusted hazard ratio (aHR) 1.72; 95% confidence interval (CI) 0.94-3.15] and high-risk HPV (aHR 1.92; 95% CI 0.96-3.87) compared to HPV-uninfected men, and estimates did not differ by circumcision status. Risk of HIV increased 27% with each additional HPV genotype infection (aHR 1.27; 95% CI 1.09-1.48). Men with persistent (aHR 3.27; 95% CI 1.59-6.72) or recently cleared (aHR 3.05; 95% CI 1.34-6.97) HPV had a higher risk of HIV acquisition than HPV-uninfected men. CONCLUSIONS Consistent with the findings in women, HPV infection, clearance, and persistence were associated with an increased risk of HIV acquisition in men. Given the high prevalence of HPV in populations at risk of HIV, consideration of HPV in future HIV-prevention studies and investigation into mechanisms through which HPV might facilitate HIV acquisition are needed.
Collapse
Affiliation(s)
- Anne F. Rositch
- Department of Epidemiology, John Hopkins Bloomberg School of Public Health
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lu Mao
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michael G. Hudgens
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Stephen Moses
- Departments of Community Health Sciences, Medicine and Medical Microbiology, University of Manitoba, Winnipeg, Canada
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Danielle M. Backes
- Department of Epidemiology, Brown University, Providence, Rhode Island, USA
| | - Edith Nyagaya
- Universities of Nairobi, Illinois and Manitoba (UNIM), Kisumu, Kenya
| | - Peter J.F. Snijders
- Department of Pathology, VU University Medical Center, Amsterdam, the Netherlands
| | - Chris J.L.M. Meijer
- Department of Pathology, VU University Medical Center, Amsterdam, the Netherlands
| | - Robert C. Bailey
- Division of Epidemiology, University of Illinois at Chicago, Illinois
| | - Jennifer S. Smith
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| |
Collapse
|
76
|
Rositch AF, Soeters HM, Offutt-Powell TN, Wheeler BS, Taylor SM, Smith JS. The incidence of human papillomavirus infection following treatment for cervical neoplasia: a systematic review. Gynecol Oncol 2014; 132:767-79. [PMID: 24412508 DOI: 10.1016/j.ygyno.2013.12.040] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 12/21/2013] [Accepted: 12/31/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To systematically review the published literature in order to estimate the incidence and describe the variability of human papillomavirus (HPV) infection in women following treatment for cervical neoplasia. METHODS Several scientific literature databases (e.g. PubMed, ISI Web of Science) were searched through January 31, 2012. Eligible articles provided data on (i) baseline HPV infection status within 6 months prior to or at time of treatment (pre-treatment); and (ii) HPV test results for women's first visit after treatment occurring within 36 months (post-treatment). We abstracted and summarized the post-treatment incidence of newly detected HPV genotypes that were not present at pre-treatment, overall and stratified by study and other population characteristics. RESULTS A total of 25 studies were included, reporting post-treatment HPV incidence in nearly 2000 women. Mean patient age ranged from 31 to 43 years (median 36). Most studies used cervical exfoliated cell specimens to test for HPV DNA (n=20; 80%), using polymerase chain reaction (n=21; 84%). Cervical neoplasia treatment included loop electrical excision procedure (n=11; 44%); laser conization (n=2; 8%); laser ablation, surgical conization, cryotherapy, alpha-interferon (n=1; 4% each); or multiple treatment regimens (n=8; 32%). Follow-up times post-treatment ranged from 1.5 to 36 months (median 6). More than half of studies (n=17; 68%) estimated the incidence of any HPV type following treatment, while 7 (28%) focused specifically on high-risk (HR) HPV. HPV incidence after treatment varied widely, ranging from 0 to 47% (interquartile range: 0%-15%) in up to 3 years of follow-up after treatment. Lower HPV incidence was observed among studies that included relatively younger women, used laser conization, focused on HR-HPV rather than overall HPV infection, and had a lower proportion of recurrent cervical disease. CONCLUSIONS These modest summary incidence estimates from the published literature can guide clinicians, epidemiologists and health economists in developing best practices for post-treatment cervical cancer prevention.
Collapse
Affiliation(s)
- Anne F Rositch
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Heidi M Soeters
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Tabatha N Offutt-Powell
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Bradford S Wheeler
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Sylvia M Taylor
- GlaxoSmithKline Vaccines, Global Vaccine Development, Wavre, Belgium
| | - Jennifer S Smith
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA; Linberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| |
Collapse
|
77
|
Abstract
Anne Rositch and colleagues discuss the study by Peter Sasieni and colleagues on cervical cancer screening in older women and describe the further information needed to help inform decisions about whether to extend screening programs beyond 65 years for women with adequate negative screening. Please see later in the article for the Editors' Summary
Collapse
Affiliation(s)
- Anne F. Rositch
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
| | - Michelle I. Silver
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Patti E. Gravitt
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States of America
| |
Collapse
|
78
|
Mackelprang RD, Bosire R, Guthrie BL, Choi RY, Liu A, Gatuguta A, Rositch AF, Kiarie JN, Farquhar C. High rates of relationship dissolution among heterosexual HIV-serodiscordant couples in Kenya. AIDS Behav 2014; 18:189-93. [PMID: 23728523 DOI: 10.1007/s10461-013-0529-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
HIV-1 serodiscordant couples may experience increased risks of relationship dissolution; however, longitudinal stability of these relationships is poorly understood. We determined rates and correlates of separation among 469 serodiscordant couples in Nairobi and found that 113 (24 %) separated during 2 years of follow-up. Couples with a female HIV-1 infected partner (F+M-) and no income were more likely to separate than M+F- couples without income (HR = 5.0; 95 % CI 1.1-25.0), and F+M- and M+F- couples with income (HR = 2.4; 95 % CI 1.3-4.5 and HR = 2.3; 95 % CI 1.2-4.8, respectively). High separation rates may be important for couple support services and for conducting discordant couple studies.
Collapse
Affiliation(s)
- Romel D Mackelprang
- Department of Epidemiology, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA,
| | | | | | | | | | | | | | | | | |
Collapse
|
79
|
Liu SH, Rositch AF, Viscidi RP, Silver MI, Burke AE, Gravitt PE. Obesity and human papillomavirus infection in perimenopausal women. J Infect Dis 2013; 208:1071-80. [PMID: 23840046 PMCID: PMC3762384 DOI: 10.1093/infdis/jit297] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 03/20/2013] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Obesity is known to increase susceptibility to certain infections in men. It is unclear whether obesity increases women's risk for human papillomavirus (HPV) infection. METHODS In a prospective cohort of 696 perimenopausal women enrolled in 2008-2012, we sought to determine whether obesity predicted incident HPV detection or nondetection. Obesity was defined as body mass index (BMI) ≥ 30 kg/m(2). RESULTS Baseline any type HPV prevalence was comparable between obese and nonobese women (18.7% vs 19.1%; P > .05). Over a median follow-up period of 17.9 months (interquartile range: 12.1-24.5), 187 new HPV detections occurred among 123 women, 60 of whom subsequently lost 76 detectable infections. When compared with nonobese participants, obese women had a similar rate of new HPV detection (7.1 vs 7.8 infections per 1000 infection-years; P > .05) or loss of detection (100.3 vs 85.8 infections per 100 infection-years; P > .05). Similar results were found after adjusting for age, menopausal status, smoking habit, and sexual exposure history. CONCLUSIONS Results from the current analysis suggest little effect of obesity on HPV detection and loss of detection in mid-adult women. More research is needed to determine whether adipokines or cytokines better capture the potential immune modulating effects of obesity on HPV infection.
Collapse
Affiliation(s)
- Su-Hsun Liu
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.
| | | | | | | | | | | |
Collapse
|
80
|
Soh J, Rositch AF, Koutsky L, Guthrie BL, Choi RY, Bosire RK, Gatuguta A, Smith JS, Kiarie J, Lohman-Payne B, Farquhar C. Individual and partner risk factors associated with abnormal cervical cytology among women in HIV-discordant relationships. Int J STD AIDS 2013; 25:315-24. [PMID: 24047885 DOI: 10.1177/0956462413504554] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Individual and sexual partner characteristics may increase the risk of abnormal cervical cytology among women in human immunodeficiency virus (HIV)-discordant relationships. Papanicolaou smears were obtained in a prospective cohort of Kenyan HIV-discordant couples. Of 441 women, 283 (64%) were HIV-infected and 158 (36%) were HIV-uninfected with HIV-infected partners. Overall, 79 (18%) had low-grade and 25 (6%) high-grade cervical abnormalities. Male herpes simplex virus type 2 (HSV-2) seropositivity and lower couple socioeconomic status were associated with cervical abnormalities (p < 0.05). HIV-uninfected women with HIV-infected male sex partners (CD4 > 350 cells/µL) had the lowest prevalence of high-grade cervical lesions. HIV-infected women (CD4 > 350 cells/µL) and HIV-uninfected women with HIV-infected partners (CD4 ≤ 350 cells/µL) were at similar intermediate risk (p > 0.05), and HIV-infected women (CD4 ≤ 350 cells/µL) had significantly higher risk of high-grade cervical abnormalities (p = 0.05). Women in HIV-discordant relationships have high rates of cervical lesions and this may be influenced by couple-level factors, including HIV status and CD4 count of the infected partner.
Collapse
Affiliation(s)
- Jason Soh
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
81
|
Rositch AF, Gravitt PE, Smith JS. Growing evidence that HPV infection is associated with an increase in HIV acquisition: exploring the issue of HPV vaccination. Sex Transm Infect 2013; 89:357. [PMID: 23858496 DOI: 10.1136/sextrans-2012-050870] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
82
|
Rositch AF, Koshiol J, Hudgens MG, Razzaghi H, Backes DM, Pimenta JM, Franco EL, Poole C, Smith JS. Patterns of persistent genital human papillomavirus infection among women worldwide: a literature review and meta-analysis. Int J Cancer 2013; 133:1271-85. [PMID: 22961444 PMCID: PMC3707974 DOI: 10.1002/ijc.27828] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 08/21/2012] [Indexed: 12/14/2022]
Abstract
Persistent high-risk human papillomavirus (HR-HPV) infection is the strongest risk factor for high-grade cervical precancer. We performed a systematic review and meta-analysis of HPV persistence patterns worldwide. Medline and ISI Web of Science were searched through January 1, 2010 for articles estimating HPV persistence or duration of detection. Descriptive and meta-regression techniques were used to summarize variability and the influence of study definitions and characteristics on duration and persistence of cervical HPV infections in women. Among 86 studies providing data on over 100,000 women, 73% defined persistence as HPV positivity at a minimum of two time points. Persistence varied notably across studies and was largely mediated by study region and HPV type, with HPV-16, 31, 33 and 52 being most persistent. Weighted median duration of any-HPV detection was 9.8 months. HR-HPV (9.3 months) persisted longer than low-risk HPV (8.4 months), and HPV-16 (12.4 months) persisted longer than HPV-18 (9.8 months). Among populations of HPV-positive women with normal cytology, the median duration of any-HPV detection was 11.5 and HR-HPV detection was 10.9 months. In conclusion, we estimated that approximately half of HPV infections persist past 6 to 12 months. Repeat HPV testing at 12-month intervals could identify women at increased risk of high-grade cervical precancer due to persistent HPV infections.
Collapse
Affiliation(s)
- Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
83
|
Denslow SA, Rositch AF, Firnhaber C, Ting J, Smith JS. Incidence and progression of cervical lesions in women with HIV: a systematic global review. Int J STD AIDS 2013; 25:163-77. [PMID: 24216030 DOI: 10.1177/0956462413491735] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Global data on cervical lesion incidence and progression in HIV-positive women are essential for understanding the natural history of cervical neoplasia and informing screening policy. A systematic review was performed summarizing the incidence and progression of cervical lesions in HIV-positive women. Of 5882 HIV-positive women from 15 studies, incidence ranged from 4.9 to 21.1 cases per 100 woman-years for any cervical lesion and 0.4 to 8.8 cases per 100 woman-years for high-grade cervical lesions. HIV-positive women showed a median three-fold higher incidence of cervical lesions compared to HIV-negative women. Of 1099 HIV-positive women from 11 studies, progression from low- to high-grade lesions ranged from 1.2 to 26.2 cases per 100 woman-years. Both incidence and progression rates increased with lower CD4 counts. The effect of antiretroviral therapy on the natural history of cervical neoplasia remains unclear. HIV-positive women have higher incidence and progression of cervical neoplasia. Cervical cancer screening should be integrated into HIV treatment programmes.
Collapse
Affiliation(s)
- Sheri A Denslow
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA
| | | | | | | | | |
Collapse
|
84
|
Rositch AF, Cherutich P, Brentlinger P, Kiarie JN, Nduati R, Farquhar C. HIV infection and sexual partnerships and behaviour among adolescent girls in Nairobi, Kenya. Int J STD AIDS 2013; 23:468-74. [PMID: 22843999 DOI: 10.1258/ijsa.2012.011361] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Early sexual partnerships place young women in sub-Saharan Africa at high risk for HIV. Few studies have examined both individual- and partnership-level characteristics of sexual relationships among adolescent girls. A cross-sectional survey of sexual history and partnerships was conducted among 761 adolescent girls aged 15-19 years in Nairobi, Kenya. Rapid HIV testing was conducted and correlates of HIV infection were determined using multivariate logistic regression. The HIV prevalence was 7% and seropositive adolescents had a younger age at sexual debut (P < 0.01), more sexual partners in 12 months (P = 0.03), and were more likely to report transactional or non-consensual sex (P < 0.01). Girls who reported not knowing their partner's HIV status were 14 times as likely to be HIV-seropositive than girls who knew their partner's status (adjusted odds ratio: 14.2 [1.8, 109.3]). Public health messages to promote HIV testing and disclosure within partnerships could reduce sexual risk behaviours and HIV transmission among adolescents.
Collapse
Affiliation(s)
- A F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | | | | | | | | | | |
Collapse
|
85
|
Rositch AF, Gravitt PE, Tobian AAR, Newell K, Quinn TC, Serwadda D, Ssebbowa P, Kiggundu V, Gray RH, Reynolds SJ. Frequent detection of HPV before and after initiation of antiretroviral therapy among HIV/HSV-2 co-infected women in Uganda. PLoS One 2013; 8:e55383. [PMID: 23383171 PMCID: PMC3558485 DOI: 10.1371/journal.pone.0055383] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 12/21/2012] [Indexed: 11/29/2022] Open
Abstract
Objectives Most data on HPV and antiretroviral therapy (ART) come from high-resource countries with infrequent sampling for HPV pre- and post-ART initiation. Therefore, we examined the frequency of cervical HPV DNA detection among HIV/HSV-2 co-infected women followed monthly for 6 months both before and after initiation of ART in Rakai, Uganda. Methods Linear Array was used to detect 37 HPV genotypes in self-collected cervicovaginal swabs from 96 women who initiated ART. Random-effects log-binomial regression was used to compare the prevalence of HPV detection in the pre- and post-ART periods and determine other potential risk factors, including CD4 counts and HIV viral load. Results Nearly all women had detectable HPV in the 6 months preceding ART initiation (92%) and the cumulative prevalence remained high following initiation of therapy (90%). We found no effect of ART on monthly HPV DNA detection (prevalence ratio: 1.0; 95% confidence interval: 0.96, 1.08), regardless of immune reconstitution or HIV viral suppression. Older age and higher pre-ART CD4 counts were associated with a significantly lower risk of HPV DNA detection. Conclusions ART did not impact HPV detection within 6 months of therapy initiation, highlighting the importance of continued and consistent screening, even after ART-initiation and immune reconstitution.
Collapse
Affiliation(s)
- Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
86
|
Gravitt PE, Rositch AF, Silver MI, Marks MA, Chang K, Burke AE, Viscidi RP. A cohort effect of the sexual revolution may be masking an increase in human papillomavirus detection at menopause in the United States. J Infect Dis 2013; 207:272-80. [PMID: 23242540 PMCID: PMC3532829 DOI: 10.1093/infdis/jis660] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 09/26/2012] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cohort effects, new sex partnerships, and human papillomavirus (HPV) reactivation have been posited as explanations for the bimodal age-specific HPV prevalence observed in some populations; no studies have systematically evaluated the reasons for the lack of a second peak in the United States. METHODS A cohort of 843 women aged 35-60 years were enrolled into a 2-year, semiannual follow-up study. Age-specific HPV prevalence was estimated in strata defined by a lower risk of prior infection (<5 self-reported lifetime sex partners) and a higher risk of prior infection (≥ 5 lifetime sex partners). The interaction between age and lifetime sex partners was tested using likelihood ratio statistics. Population attributable risk (PAR) was estimated using Levin's formula. RESULTS The age-specific prevalence of 14 high-risk HPV genotypes (HR-HPV) declined with age among women with <5 lifetime sex partners but not among women with ≥ 5 lifetime sex partners (P = .01 for interaction). The PAR for HR-HPV due to ≥ 5 lifetime sex partners was higher among older women (87.2%), compared with younger women (28.0%). In contrast, the PAR associated with a new sex partner was 28% among women aged 35-49 years and 7.7% among women aged 50-60 years. CONCLUSIONS A lower cumulative probability of HPV infection among women with a sexual debut before the sexual revolution may be masking an age-related increase in HPV reactivation in the United States.
Collapse
Affiliation(s)
- Patti E Gravitt
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD21205, USA.
| | | | | | | | | | | | | |
Collapse
|
87
|
Rositch AF, Burke AE, Viscidi RP, Silver MI, Chang K, Gravitt PE. Contributions of recent and past sexual partnerships on incident human papillomavirus detection: acquisition and reactivation in older women. Cancer Res 2012; 72:6183-90. [PMID: 23019223 DOI: 10.1158/0008-5472.can-12-2635] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Understanding the fraction of newly detected human papillomavirus (HPV) infections due to acquisition and reactivation has important implications on screening strategies and prevention of HPV-associated neoplasia. Information on sexual activity and cervical samples for HPV DNA detection using Roche Linear Array were collected semiannually for two years from 700 women ages 35 to 60 years. Incidence and potential fraction of HPV associated with new and lifetime sexual partnerships were estimated using Poisson regression. Cox frailty models were used to estimate hazard ratios (HR) for potential risk factors of incident HPV detection. Recent and lifetime numbers of sexual partners were both strongly associated with incident HPV detection. However, only 13% of incident detections were attributed to new sexual partners, whereas 72% were attributed to 5 or more lifetime sexual partners. Furthermore, 155 of 183 (85%) incident HPV detections occurred during periods of sexual abstinence or monogamy, and were strongly associated with cumulative lifetime sexual exposure [HR: 4.1, 95% confidence interval (CI): 2.0-8.4). This association increased with increasing age. These data challenge the paradigm that incident HPV detection is driven by current sexual behavior and new viral acquisition in older women. Our observation that most incident HPV infection was attributable to past, not current, sexual behavior at older ages supports a natural history model of viral latency and reactivation. As the more highly exposed baby-boomer generation of women with sexual debut after the sexual revolution transition to menopause, the implications of HPV reactivation at older ages on cervical cancer risk and screening recommendations should be carefully evaluated.
Collapse
Affiliation(s)
- Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | | | | | | |
Collapse
|
88
|
Rositch AF, Hudgens MG, Backes DM, Moses S, Agot K, Nyagaya E, Snijders PJF, Meijer CJLM, Bailey RC, Smith JS. Vaccine-relevant human papillomavirus (HPV) infections and future acquisition of high-risk HPV types in men. J Infect Dis 2012; 206:669-77. [PMID: 22711906 PMCID: PMC3491740 DOI: 10.1093/infdis/jis406] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 02/22/2012] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Little is known about type-specific associations between prevalent human papillomavirus (HPV) infections and risk of acquiring other HPV types in men. Data on natural clustering of HPV types are needed as a prevaccine distribution to which postvaccine data can be compared. METHODS Using data from a randomized controlled trial of male circumcision in Kisumu, Kenya, adjusted mean survival ratios were estimated for acquisition of any-HPV, high-risk (HR) HPV, and individual HR-HPV types among men uninfected as compared to those infected with vaccine-relevant HPV types 16, 18, 31, 45, 6, or 11 at baseline. RESULTS Among 1097 human immunodeficiency virus-negative, uncircumcised men, 2303 incident HPV infections were detected over 2534 person-years of follow-up. Although acquisition of individual HR-HPV types varied by baseline HPV type, there was no clear evidence of shorter times to acquisition among men without vaccine-relevant HPV-16, -18, -31, -45, -6, or -11 infections at baseline, as compared to men who did have these infections at baseline. CONCLUSIONS These prospective data on combinations of HPV infections over time do not suggest the potential for postvaccination HPV type replacement. Future surveillance studies are needed to definitely determine whether elimination of HPV types by vaccination will alter the HPV type distribution in the population.
Collapse
Affiliation(s)
- Anne F Rositch
- Department of Epidemiology, University of North Carolina, Chapel Hill, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
89
|
Rositch AF, Poole C, Hudgens MG, Agot K, Nyagaya E, Moses S, Snijders PJF, Meijer CJLM, Bailey RC, Smith JS. Multiple human papillomavirus infections and type competition in men. J Infect Dis 2012; 205:72-81. [PMID: 22058418 PMCID: PMC3242748 DOI: 10.1093/infdis/jir709] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 08/30/2011] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There is little information on multiple human papillomavirus (HPV) infections and the potential for type competition in men, yet competition may impact the type-specific efficacy of HPV vaccination. METHODS Among 2702 uncircumcised men in Kisumu, Kenya, who were seronegative for human immunodeficiency virus, the observed numbers of HPV types detected were compared with the expected number, which was simulated under the assumption of independent infections. To assess the potential for HPV type competition, adjusted odds ratios for pairwise combinations of prevalent HPV type infections were estimated using semi-Bayesian methods. RESULTS Half of all men were HPV positive, of whom 57% had multiple HPV types. We observed men without HPV infection and with ≥4 HPV types more often than expected if infections were independent. No negative associations between individual HPV types were observed. HPV types 31, 39, 56, 58, and 59 were positively associated with both carcinogenic vaccine types HPV-16 and HPV-18 (2-sided P value <.05). CONCLUSIONS Men who were HPV infected were likely to test positive for >1 HPV type. Cross-sectional associations between individual HPV types were positive and did not appear to be type-specific. Thus, we did not identify HPV types that are candidates for potential HPV type competition in men.
Collapse
Affiliation(s)
- Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
90
|
Guthrie BL, Choi RY, Liu AY, Mackelprang RD, Rositch AF, Bosire R, Manyara L, Gatuguta A, Kiarie JN, Farquhar C. Barriers to antiretroviral initiation in HIV-1-discordant couples. J Acquir Immune Defic Syndr 2011; 58:e87-93. [PMID: 21826010 PMCID: PMC3202340 DOI: 10.1097/qai.0b013e31822f064e] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In Kenya and much of sub-Saharan Africa, nearly half of all couples affected by HIV are discordant. Antiretroviral therapy (ART) slows disease progression in HIV-1-infected individuals and reduces transmission to uninfected partners. We examined time to ART initiation and factors associated with delayed initiation in HIV-1-discordant couples in Nairobi. METHODS HIV-1-discordant couples were enrolled and followed quarterly for up to 2 years. Clinical staff administered questionnaires and conducted viral loads and CD4 counts. Participants with a CD4 count meeting ART criteria were referred to a nearby US President's Emergency Plan for AIDS Relief-funded treatment center. Barriers to ART initiation among participants with a CD4 count eligible for ART were assessed by Cox regression. RESULTS Of 439 HIV-1-infected participants (63.6% females and 36.4% males), 146 met CD4 count criteria for ART during follow-up. Median time from meeting CD4 criteria until ART initiation was 8.9 months, with 42.0% of eligible participants on ART by 6 months and 63.4% on ART by 1 year. The CD4 count at the time of eligibility was inversely associated with time to ART initiation (hazard ratio = 0.49, P < 0.001). Compared with homeowners, those paying higher rents started ART 48% more slowly (P = 0.062) and those paying lower rents started 71% more slowly (P = 0.002). CONCLUSIONS Despite access to regular health care, referrals to treatment centers, and free access to ART, over one-third of participants with an eligible CD4 count had not started ART within 1 year. Factors of lower socioeconomic status may slow ART initiation, and targeted approaches are needed to avoid delays in treatment initiation.
Collapse
Affiliation(s)
- Brandon L Guthrie
- Department of Epidemiology, University of Washington, Seattle, WA 98104-2499, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|