HIV/AIDS in Women and Racial/Ethnic Minorities in the U.S

Comparison of HIV Viral Suppression Between a Sample of Foreign-Born and U.S.-Born Women of Color in the United States

We investigate the association between nativity status (U.S.- vs foreignborn) and viral suppression among women of color (WOC) with HIV (HIV +) and whether this association was modified by education and housing.

METHODS

Data were from 549 HIV + WOC, who participated in the Health Resources and Services Administration-funded WOC Initiative 2009-2013. We used generalized estimating equation models to quantify the association between the respondents' nativity status and viral suppression.

RESULTS

After adjusting for covariates, foreign-born WOC were 2.2 times (95% confidence interval: 1.25, 3.85) more likely to achieve viral suppression than U.S.-born WOC. This association was not modified by education or housing status.

CONCLUSIONS

Despite facing barriers to care, foreign-born WOC were more likely to achieve viral suppression than U.S.-born WOC. Programs aiming to end the HIV epidemic and reduce HIV disparities in the U.S. should consider these findings as they provide a more nuanced understanding of HIV + WOC.

HIV knowledge and attitudes among minority pregnant patients and their non-pregnant partners in an urban hospital clinic

OBJECTIVE

HIV seroconversion during pregnancy disproportionately affects urban, minority pregnant individuals. In order to prevent perinatal HIV transmission, it is essential that individuals are aware of HIV risk factors and effective transmission prevention strategies are employed. Thus, we aimed to examine knowledge about HIV transmission and attitudes about HIV among low-income, minority pregnant individuals and their partners living in a high HIV prevalence area.

METHODS

In this qualitative study, pregnant participants were HIV-seronegative individuals receiving publicly-funded prenatal care in an urban academic center in the United States. Pregnant individuals and their partners were recruited to participate in a quality improvement program offering HIV testing to partners of pregnant people. Semi-structured guides were used to conduct individual interviews about participant sources of information about HIV, knowledge about transmission, and attitudes regarding those living with HIV. Transcripts were analyzed using the constant comparative method to determine themes and subthemes.

RESULTS

Of 51 participants, 29 were pregnant individuals and 22 were non-pregnant partners. We found that inaccurate knowledge about perinatal HIV transmission was prevalent. Sources of information about HIV included reputable literary information or educational experiences, broadcast media, and word-of-mouth sources. Participants held dichotomous perceptions of people living with HIV.

CONCLUSIONS

Among low-income, minority pregnant people and their partners in a high HIV prevalence area, inaccuracies and lack of knowledge about HIV transmission were common. Efforts to educate pregnant individuals and their partners about HIV and perinatal HIV transmission should address common misconceptions and use popular sources of information.

Racial Disparities in Adult Cochlear Implantation

OBJECTIVE

To compare rates of cochlear implant referral and cochlear implantation across different races and to compare audiometric profiles of these patients.

STUDY DESIGN

Retrospective study.

SETTING

Academic tertiary care institution.

METHODS

Demographic and audiometric data were collected for patients who underwent cochlear implant evaluation or cochlear implantation from 2010 to 2020.

RESULTS

A total of 504 patients underwent cochlear implant evaluation; 388 met cochlear implant candidacy criteria, and 258 underwent implantation. Of the patients referred for cochlear implant evaluation, 68.5% were White, 18.5% were Black, and 12.3% were Asian, while the institution's primary service area is 46.9% White, 42.3% Black, and 7.7% Asian (P < .001). Black patients referred for cochlear implant evaluation had significantly worse hearing (mean pure-tone average [PTA] 84.5 dB, 26.1% word recognition) than White patients (mean PTA 78.2 dB, P = .005; 35.7% word recognition, P = .015) and Asians patients (mean PTA 77.9 dB, P = .04; 36.5% word recognition, P = .04). Black patients who underwent cochlear implant evaluation also had significantly worse AzBio scores than White patients: 24.5% versus 36.7% (P = .003). There was no significant difference in cochlear implantation rates between Black and White candidates (P = .06).

CONCLUSION

Black patients undergo cochlear implant evaluation and cochlear implantation at rates disproportionately lower than expected based on local demographics. In addition, Black patients have significantly worse hearing at the time of cochlear implant referral than White and Asian patients. Identifying and increasing awareness of these disparities are essential steps to improving cochlear implant access for potentially disadvantaged populations.

An Examination of Geographic Differences in Social Determinants of Health Among Women with Diagnosed HIV in the United States and Puerto Rico, 2017

Objective:

To examine differences, at the census tract level, in the distribution of human immunodeficiency virus (HIV) diagnoses and social determinants of health (SDH) among women with diagnosed HIV in 2017 in the United States and Puerto Rico.

Background:

In the United States, HIV continues to disproportionately affect women, especially minority women and women in the South.

Methods:

Data reported in the National HIV Surveillance System (NHSS) of the Centers for Disease Control and Prevention were used to determine census tract-level HIV diagnosis rates and percentages among adult women (aged ≥18 years) in 2017. Data from the American Community Survey were combined with NHSS data to examine regional differences in federal poverty status, education level, income level, employment status, and health insurance coverage among adult women with diagnosed HIV infection in the United States and Puerto Rico.

Results:

In the United States and Puerto Rico, among 6,054 women who received an HIV diagnosis in 2017, the highest rates of HIV diagnoses generally were among those who lived in census tracts where the median household income was less than $40,000; at least 19% lived below the federal poverty level, at least 18% had less than a high school diploma, and at least 16% were without health insurance.

Conclusion:

This study is the first of its kind and gives insight into how subpopulations of women are affected differently by the likelihood of an HIV diagnosis. The findings show that rates of HIV diagnosis were highest among women who lived in census tracts having the lowest income and least health coverage.

The individual, interactive, and syndemic effect of substance use, depression, education, and ethnicity on retention in HIV care

In this study, we sought to assess the individual, syndemic, and interactive associations between individual-level factors and retention in care. The sample was derived from the Miami Adult Studies on human immunodeficiency virus (HIV)/ acquired immune deficiency syndrome (AIDS) cohort from 2009 to 2014. The variables were entered into a multiple logistic regression with retention as the outcome. Backward regression, adjusting for all main effects, was conducted to determine which two-way interactions were associated with retention. Multivariable logistic regression was used to test which number of factors were associated with retention. Non-Hispanic Black race/ethnicity was associated with improved retention (odds ratio [OR] = 2.44, 95% confidence interval [CI]: 1.06-5.75, p ≤ 0.05) when compared to Non-Hispanic White persons. Black-Hispanic and Other racial/ethnic identities were associated with increased retention (OR = 4.84, 95%CI: 1.16-25.79, p ≤ 0.05 and OR = 7.24, 95%CI: 1.54-54.05, p ≤ 0.05, respectively) when compared to Non-Hispanic White persons. The interaction between depressive symptoms and Alcohol Use Disorder Identification Test (AUDIT, a test that assesses alcohol use disorder) score was significantly and negatively associated with retention in HIV care (OR = 0.14, 95%CI: 0.01-1.11, p ≤ 0.10). The interaction between age and male gender was also negatively associated with retention (OR = 0.95, 95%CI: 0.88-1.01, p ≤ 0.10), and the interaction between male gender and depression was positively associated with retention (OR = 7.17, 95%CI: 0.84-98.49, p ≤ 0.10). In conclusion, multiple races/ethnicities, specifically Non-Hispanic Black, Black-Hispanic, and Other racial/ethnic identification, were associated with increased odds of retention. Multiple interactions, specifically depressive symptoms * alcohol use disorder and male gender * age, were negatively associated with retention. The male gender * depression interaction was positively associated with retention in HIV care.

Place-based predictors of HIV viral suppression and durable suppression among heterosexuals in New York city

Scant research has explored place-based correlates of achieving and maintaining HIV viral load suppression among heterosexuals living with HIV. We conducted multilevel analyses to examine associations between United Hospital Fund (UHF)-level characteristics and individual-level viral suppression and durable viral suppression among individuals with newly diagnosed HIV in New York City (NYC) who have heterosexual HIV transmission risk. Individual-level independent and dependent variables came from NYC's HIV surveillance registry for individuals diagnosed with HIV in 2009-2013 (N = 3,159; 57% virally suppressed; 36% durably virally suppressed). UHF-level covariates included measures of food distress, demographic composition, neighborhood disadvantage and affluence, healthcare access, alcohol outlet density, residential vacancy, and police stop and frisk rates. We found that living in neighborhoods where a larger percent of residents were food distressed was associated with not maintaining viral suppression. If future research should confirm this is a causal association, community-level interventions targeting food distress may improve the health of people living with HIV and reduce the risk of forward transmission.

Factors Contributing to Missed Visits for Medical Care among Human Immunodeficiency Virus-Infected Adults in Seoul, Korea

BACKGROUND

It is important that patients with human immunodeficiency virus (HIV) remain under medical care to improve their health and to reduce the potential for HIV transmission. We explored factors associated with missed visits for HIV medical care according to age group.

METHODS

Data were derived from a city-wide, cross-sectional survey of 812 HIV-infected adults in Seoul. Multiple logistic analyses were used to explore predictors of missed visits.

RESULTS

Of the 775 subjects, 99.3% were treated with antiretroviral therapy (ART) and 12.5% had missed a scheduled appointment for HIV medical care during the past 12 months. Compared with the group aged ≥ 50 years, the 20-34-years and 35-49-years groups were strongly associated with missed visits (adjusted odds ratio [aOR], 5.0 and 2.2, respectively). When divided by age group, lower education level (aOR, 3.0) in subjects aged 20-34 years, low income (aOR, 3.5), National Medical Aid beneficiary (aOR, 0.3), and treatment interruption due to side effects of ART (aOR, 3.4) in subjects aged 35-49 years, and National Medical Aid beneficiary (aOR, 7.1) in subjects aged ≥ 50 years were associated with missed visits.

CONCLUSION

In conclusion, younger age was a strong predictor of missed visits for HIV medical care. However, the risk factors differed according to age group, and the strongest predictor in each age group was related to socioeconomic status.

Acceptability of Rapid HIV Testing Among Latinos in Washington Heights, New York City, New York, USA

In the United States, human immunodeficiency virus (HIV) has a disproportionately large impact on Latino Americans. This study assessed the acceptability of rapid HIV testing among a sample of Latinos from New York City. A cross-sectional study was conducted with 192 participants from The Washington Heights/Inwood Informatics Infrastructure for Community-Centered Comparative Effectiveness Research (WICER) study. Participants were interviewed and offered rapid HIV testing and post-test counseling. Seventy-five percent (n = 143) accepted rapid HIV testing when offered. More religious participants were less likely than less religious participants to undergo testing (RR = 0.73; 95% CI 0.54-0.99). Participants tested for HIV within the past year were less likely than those who had not been tested within the past year to agree to undergo testing (RR = 0.27; 95% CI 0.11-0.66). Community-based rapid HIV testing is feasible among Latinos in urban environments. Outreach efforts to engage religious individuals and encouraging routine testing should be reinforced.

New Faces of HIV Infection: Age, Race, and Timing of Entry into HIV Care in the Southeastern United States

Among younger men who have sex with men (MSM), the incidence of HIV is rising nationally. Of the 281 persons who entered into care at a large HIV clinic in the southeastern United States in 2010 to 2012, 78 (27.8%) were <25 years old at the time of diagnosis. Those in the younger group were more likely than those aged ≥25 to be black (59.0% versus 37.4%), MSM (78.2% versus 55.2%), and to have a longer median time from diagnosis to entry into care (71 versus 53 days; P < .05 each). In adjusted survival analysis, persons of black race were less likely to enter care after diagnosis than those of nonblack race (hazard ratio = 0.75, P = .02). Young MSM represent an important target population for prevention and HIV testing interventions, and there is a need to shorten the time from diagnosis to linkage to care, particularly in persons aged <25 and of black race.

Sex, Race, and HIV Risk Disparities in Discontinuity of HIV Care After Antiretroviral Therapy Initiation in the United States and Canada

Disruption of continuous retention in care (discontinuity) is associated with HIV disease progression. We examined sex, race, and HIV risk disparities in discontinuity after antiretroviral therapy (ART) initiation among patients in North America. Adults (≥18 years of age) initiating ART from 2000 to 2010 were included. Discontinuity was defined as first disruption of continuous retention (≥2 visits separated by >90 days in the calendar year). Relative hazard ratio (HR) and times from ART initiation until discontinuity by race, sex, and HIV risk were assessed by modeling of the cumulative incidence function (CIF) in the presence of the competing risk of death. Models were adjusted for cohort site, baseline age, and CD4+ cell count within 1 year before ART initiation; nadir CD4+ cell count after ART, but before a study event, was assessed as a mediator. Among 17,171 adults initiating ART, median follow-up time was 3.97 years, and 49% were observed to have ≥1 discontinuity of care. In adjusted regression models, the hazard of discontinuity for patients was lower for females versus males [HR: 0.84; 95% confidence interval (CI): 0.79-0.89] and higher for blacks versus nonblacks (HR: 1.17; 95% CI: 1.12-1.23) and persons with injection drug use (IDU) versus non-IDU risk (HR: 1.33; 95% CI: 1.25-1.41). Sex, racial, and HIV risk differences in clinical retention exist, even accounting for access to care and known competing risks for discontinuity. These results point to vulnerable populations at greatest risk for discontinuity in need of improved outreach to prevent disruptions of HIV care.

Gender-Related Risk Factors Improve Mortality Predictive Ability of VACS Index Among HIV-Infected Women

BACKGROUND

Adding gender-related modifiable characteristics or behaviors to the Veterans Aging Cohort Study (VACS) index might improve the accuracy of predicting mortality among HIV-infected women on treatment. We evaluated the VACS index in women with HIV, determined whether additional variables would improve mortality prediction, and quantified the potential for improved survival associated with reduction in these additional risk factors.

METHODS

The VACS index (based on age, CD4 count, HIV-1 RNA, hemoglobin, aspartate aminotransferase, alanine aminotransferase, platelets, creatinine, and Hepatitis C status) was validated in HIV-infected women in the Women's Interagency HIV Study (WIHS) who initiated antiretroviral therapy between January 1996 and December 2007. Models were constructed adding race, depression, abuse, smoking, substance use, transactional sex, and comorbidities to determine whether predictability improved. Population attributable fractions were calculated.

RESULTS

The VACS index accurately predicted 5-year mortality in 1057 WIHS women with 1 year on highly active antiretroviral therapy with c-index 0.83 [95% confidence interval (CI): 0.79 to 0.87]. In multivariate analysis, the VACS index score [adjusted hazard ratio (aHR) for a 5-point increment 1.30; 95% CI: 1.25 to 1.35], depressive symptoms (aHR 1.73; 95% CI: 1.17 to 2.56), and history of transactional sex (aHR 1.93; 95% CI: 1.33 to 1.82) were independent statistically significant predictors of mortality.

CONCLUSIONS

Both depression and transactional sex significantly improved the performance of the VACS index in predicting mortality among HIV-infected women. Providing treatment for depression and addressing economic and psychosocial instability in HIV-infected women would improve health and perhaps point to a broader public health approach to reducing HIV mortality.

Geographic Variations in Retention in Care among HIV-Infected Adults in the United States

Objective

To understand geographic variations in clinical retention, a central component of the HIV care continuum and key to improving individual- and population-level HIV outcomes.

Design

We evaluated retention by US region in a retrospective observational study.

Methods

Adults receiving care from 2000–2010 in 12 clinical cohorts of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) contributed data. Individuals were assigned to Centers for Disease Control and Prevention (CDC)-defined regions by residential data (10 cohorts) and clinic location as proxy (2 cohorts). Retention was ≥2 primary HIV outpatient visits within a calendar year, >90 days apart. Trends and regional differences were analyzed using modified Poisson regression with clustering, adjusting for time in care, age, sex, race/ethnicity, and HIV risk, and stratified by baseline CD4+ count.

Results

Among 78,993 adults with 444,212 person-years of follow-up, median time in care was 7 years (Interquartile Range: 4–9). Retention increased from 2000 to 2010: from 73% (5,000/6,875) to 85% (7,189/8,462) in the Northeast, 75% (1,778/2,356) to 87% (1,630/1,880) in the Midwest, 68% (8,451/12,417) to 80% (9,892/12,304) in the South, and 68% (5,147/7,520) to 72% (6,401/8,895) in the West. In adjusted analyses, retention improved over time in all regions (p<0.01, trend), although the average percent retained lagged in the West and South vs. the Northeast (p<0.01).

Conclusions

In our population, retention improved, though regional differences persisted even after adjusting for demographic and HIV risk factors. These data demonstrate regional differences in the US which may affect patient care, despite national care recommendations.

Age, Stigma, Adherence and Clinical Indicators in HIV-Infected Women

Stigma has become a gendered phenomenon that affects increasing numbers of HIV-infected women worldwide. This study examined the role of age as a possible moderator of the relationship between stigma and antiretroviral therapy adherence, CD4% and viral load among 120 HIV-infected women. A secondary analysis was conducted using data from the Keeping Healthy and Active with Risk Reduction and Medication Adherence (KHARMA) Project, an National Institutes of Health (NIH) funded randomized controlled trial to improve Antiretroviral treatment (ART) adherence and reduce risky behaviors in HIV-infected women at five clinical sites in a South-eastern city from 2005 to 2008. Stigma was measured using the Perceived Personal Stigma of Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV/AIDS) scale. Among participants <50 years old (n=90), age was significantly associated with viral load (rho=-.24, p=.02) and stigma was negatively associated with CD4% (r =-.26, p=.02). For the 30 participants >50 years old, age was not significantly associated with viral load, stigma or CD4%, and there was no significant association between stigma and CD4% (r=.07, p=.70). These findings indicate the need for further study regarding this potential moderating effect and possible interventions to address the susceptibility of younger women to the harmful effects of stigma.

Trends in hospital deaths among human immunodeficiency virus-infected patients during the antiretroviral therapy era, 1995 to 2011

OBJECTIVE

Mortality in hospitalized human immunodeficiency virus (HIV)-infected patients is not well described. We sought to characterize in-hospital deaths among HIV-infected patients in the antiretroviral (ART) era and identify factors associated with mortality.

METHODS

We reviewed the medical records of hospitalized HIV-infected patients who died from January 1, 1995 to December 31, 2011 at an urban teaching hospital. We evaluated trends in early and late ART use and deaths due to acquired immunodeficiency syndrome (AIDS) and non-AIDS, and identified clinical and demographic correlates of non-AIDS deaths.

RESULTS

In-hospital deaths declined significantly from 1995 to 2011 (P < 0.0001); those attributable to non-AIDS increased (43% to 70.5%, P < 0.0001). Non-AIDS deaths were most commonly caused by non-AIDS infection (20.3%), cardiovascular (11.3%) and liver disease (8.5%), and non-AIDS malignancy (7.8%). Patients with non-AIDS compared to AIDS-related deaths were older (median age 48 vs 40 years, P < 0.0001), more likely to be on ART (74.1% vs 55.8%, P = 0.0001), less likely to have a CD4 count of <200 cells/mm(3) (47.2% vs 97.1%, P < 0.0001), and more likely to have an HIV viral load of ≤400 copies/mL (38.1% vs 4.1%, P < 0.0001). Non-AIDS deaths were associated with 4.5 and 4.2 times greater likelihood of comorbid underlying liver and cardiovascular disease, respectively.

CONCLUSIONS

Non-AIDS deaths increased significantly during the ART era and are now the most common cause of in-hospital deaths; non-AIDS infection, cardiovascular and liver disease, and malignancies were major contributors to mortality. Higher CD4 cell count, liver, and cardiovascular comorbidities were most strongly associated with non-AIDS deaths. Interventions targeting non-AIDS-associated conditions are needed to reduce inpatient mortality among HIV-infected patients.

Evidence-based policy versus morality policy: the case of syringe access programs

Evidence-based practice (EBP) combines proven interventions with clinical experience, ethics, and client preferences to inform treatment and services. Although EBP is integrated into most aspects of social work and public health, at times EBP is at odds with social policy. In this article the authors explore the paradox of evidence-based policy using syringe access programs (SAP) as a case example, and review methods of bridging the gap between the emphasis on EBP and lack of evidence informing SAP policy. Analysis includes the overuse of morality policy and examines historical and current theories why this paradox exists. Action steps are highlighted for creating effective policy and opportunities for public health change. Strategies on reframing the problem and shifting target population focus to garner support for evidence-based policy change are included. This interdisciplinary understanding of the way in which these factors converge is a critical first step in moving beyond morality-based policy toward evidence-based policy.

Correlates of retention in HIV care after release from jail: results from a multi-site study

Retention in care is key to effective HIV treatment, but half of PLWHA in the US are continuously engaged in care. Incarcerated individuals are an especially challenging population to retain, and empiric data specific to jail detainees is lacking. We prospectively evaluated correlates of retention in care for 867 HIV-infected jail detainees enrolled in a 10-site demonstration project. Sustained retention in care was defined as having a clinic visit during each quarter in the 6 month post-release period. The following were independently associated with retention: being male (AOR = 2.10, p ≤ 0.01), heroin use (AOR 1.49, p = 0.04), having an HIV provider (AOR 1.67, p = 0.02), and receipt of services: discharge planning (AOR 1.50, p = 0.02) and disease management session (AOR 2.25, p ≤ 0.01) during incarceration; needs assessment (AOR 1.59, p = 0.02), HIV education (AOR 2.03, p ≤ 0.01), and transportation assistance (AOR 1.54, p = 0.02) after release. Provision of education and case management services improve retention in HIV care after release from jail.

Disparities in engagement in care and viral suppression among persons with HIV

BACKGROUND

Engagement across the spectrum of HIV care can improve health outcomes and prevent HIV transmission. We used HIV surveillance data to examine these outcomes.

METHODS

San Francisco residents who were diagnosed with HIV between 2009 and 2010 were included. We measured the characteristics and proportion of persons linked to care within 6 months of diagnosis, retained in care for second and third visits, and virally suppressed within 12 months of diagnosis.

RESULTS

Of 862 persons included, 750 (87%) entered care within 6 months of diagnosis; of these, 72% had a second visit in the following 3-6 months; and of these, 80% had a third visit in the following 3-6 months. Viral suppression was achieved in 50% of the total population and in 76% of those retained for 3 visits. Lack of health insurance and unknown housing status were associated with not entering care (P < 0.01). Persons with unknown insurance status were less likely to be retained for a second visit; those younger than 30 years were less likely to be retained for a third visit. Independent predictors of failed viral suppression included age <40 years, homelessness, unknown housing status, and having a single or 2 medical visits compared with 3 visits.

CONCLUSIONS

Socioeconomic resources and age, not race or gender, are associated with disparities in engagement in HIV care in San Francisco.

Treatment outcomes in undocumented Hispanic immigrants with HIV infection

Objective

Little is known about the treatment outcomes of undocumented Hispanic immigrants with HIV infection. We sought to compare the treatment outcomes of undocumented and documented patients 12-months after entering HIV care.

Methods

We conducted a retrospective cohort study of antiretroviral-naive patients 18 years and older attending their first visit at Thomas Street Health Center in Houston, Texas, between 1/1/2003 and 6/30/2008. The study population of 1,620 HIV-infected adults included 186 undocumented Hispanic, 278 documented Hispanic, 986 Black, and 170 White patients. The main outcome measures were retention in care (quarter years with at least one completed HIV primary care provider visit) and HIV suppression (HIV RNA <400 copies/mL), both measured 12-months after entering HIV care.

Results

Undocumented Hispanic patients had lower median initial CD₄ cell count (132 cells/mm³) than documented Hispanic patients (166 cells/mm³; P = 0.186), Black patients (226 cells/mm³; P<0.001), and White patients (264 cells/mm³; P = 0.001). However, once in care, undocumented Hispanic patients did as well or better than their documented counterparts. One year after entering HIV care, undocumented Hispanics achieved similar rates of retention in care and HIV suppression as documented Hispanic and White patients. Of note, black patients were significantly less likely to have optimal retention in care (adjusted odds ratio [aOR] 0.65, CI = 0.45–0.94) or achieve HIV suppression (aOR 0.32, CI = 0.17–0.61) than undocumented Hispanics.

Conclusions

Undocumented Hispanic persons with HIV infection enter care with more advanced disease than documented persons, suggesting testing and/or linkage to care efforts for this difficult-to-reach population need intensification. Once diagnosed, however, undocumented Hispanics have outcomes as good as or better than other racial/ethnic groups. Safety net providers for undocumented immigrants are vital for maintaining individual and public health.

Retention among North American HIV-infected persons in clinical care, 2000-2008

BACKGROUND

Retention in care is key to improving HIV outcomes. The goal of this study was to describe 'churn' in patterns of entry, exit, and retention in HIV care in the United States and Canada.

METHODS

Adults contributing ≥1 CD4 count or HIV-1 RNA (HIV-lab) from 2000 to 2008 in North American AIDS Cohort Collaboration on Research and Design clinical cohorts were included. Incomplete retention was defined as lack of 2 HIV-laboratories (≥90 days apart) within 12 months, summarized by calendar year. Beta-binomial regression models were used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI) of factors associated with incomplete retention.

RESULTS

Among 61,438 participants, 15,360 (25%) with incomplete retention significantly differed in univariate analyses (P < 0.001) from 46,078 (75%) consistently retained by age, race/ethnicity, HIV risk, CD4, antiretroviral therapy use, and country of care (United States vs. Canada). From 2000 to 2004, females (OR = 0.82, CI: 0.70 to 0.95), older individuals (OR = 0.78, CI: 0.74 to 0.83 per 10 years), and antiretroviral therapy users (OR = 0.61, CI: 0.54 to 0.68 vs. all others) were less likely to have incomplete retention, whereas black individuals (OR = 1.31, CI: 1.16 to 1.49, vs. white), those with injection drug use HIV risk (OR = 1.68, CI: 1.49 to 1.89, vs. noninjection drug use), and those in care longer (OR = 1.09, CI: 1.07 to 1.11 per year) were more likely to have incomplete retention. Results from 2005 to 2008 were similar.

DISCUSSION

From 2000 to 2008, 75% of the North American AIDS Cohort Collaboration on Research and Design population was consistently retained in care with 25% experiencing some changes in status or churn. In addition to the programmatic and policy implications, the findings of this study identify patient groups who may benefit from focused retention efforts.

Impact of gender on response to highly active antiretroviral therapy in HIV-1 infected patients: a nationwide population-based cohort study

Background

Impact of gender on time to initiation, response to and risk of modification of highly active antiretroviral therapy (HAART) in HIV-1 infected individuals is still controversial.

Methods

From a nationwide cohort of Danish HIV infected individuals we identified all heterosexually infected women (N=587) and heterosexually infected men (N=583) with no record of Hepatitis C infection diagnosed with HIV after 1 January 1997. Among these subjects, 473 women (81%) and 435 men (75%) initiated HAART from 1 January 1997 to 31 December 2009. We used Cox regression to calculate hazard ratio (HR) for time to initiation of HAART, Poisson regression to assess incidence rate ratios (IRR) of risk of treatment modification the first year, logistic regression to estimate differences in the proportion with an undetectable viral load, and linear regression to detect differences in CD4 count at year 1, 3 and 6 after start of HAART.

Results

At initiation of HAART, women were younger, predominantly of Black ethnicity and had a higher CD4 count (adjusted p=0.026) and lower viral load (adjusted p=0.0003). When repeating the analysis excluding pregnant women no difference was seen in CD4 counts (adjusted p=0.21). We observed no delay in time to initiation of HAART in women compared to men (HR 0.91, 95% CI 0.79-1.06). There were no gender differences in risk of treatment modification of the original HAART regimen during the first year of therapy for either toxicity (IRR 0.97 95% CI 0.66-1.44) or other/unknown reasons (IRR 1.18 95% CI 0.76-1.82). Finally, CD4 counts and the risk of having a detectable viral load at 1, 3 and 6 years did not differ between genders.

Conclusions

In a setting with free access to healthcare and HAART, gender does neither affect time from eligibility to HAART, modification of therapy nor virological and immunological response to HAART. Differences observed between genders are mainly attributable to initiation of HAART in pregnant women.

Measuring HIV self-management in women living with HIV/AIDS: a psychometric evaluation study of the HIV Self-management Scale

OBJECTIVE

To develop and validate the HIV Self-management Scale for women, a new measure of HIV self-management, defined as the day-to-day decisions that individuals make to manage their illness.

METHODS

The development and validation of the scale was undertaken in 3 phases: focus groups, expert review, and psychometric evaluation. Focus groups identified items describing the process and context of self-management in women living with HIV/AIDS (WLHA). Items were refined using expert review and were then administered to WLHA in 2 sites in the United States (n = 260). Validity of the scale was assessed through factor analyses, model fit statistics, reliability testing, and convergent and discriminate validity.

RESULTS

The final scale consists of 3 domains with 20 items describing the construct of HIV self-management. Daily self-management health practices, social support and HIV self-management, and chronicity of HIV self-management comprise the 3 domains. These domains explained 48.6% of the total variance in the scale. The item mean scores ranged from 1.7 to 2.8, and each domain demonstrated acceptable reliability (0.72-0.86) and stability (0.61-0.85).

CONCLUSIONS

Self-management is critical for WLHA, who constitute over 50% of people living with HIV/AIDS (PLWHA) and have poorer health outcomes than their male counterparts. Methods to assess the self-management behavior of WLHA are needed to enhance their health and wellbeing. Presently, no scales exist to measure HIV self-management. Our new 20-item HIV Self-management Scale is a valid and reliable measure of HIV self-management in this population. Differences in aspects of self-management may be related to social roles and community resources, and interventions targeting these factors may decrease morbidity in WLHA.