Causes of death among women with human immunodeficiency virus infection in the era of combination antiretroviral therapy

Provocative Findings From a Transdiagnostic Counseling Intervention to Improve Psychiatric Comorbidity and HIV Care Engagement Among People With HIV: A Pilot Randomized Clinical Trial

BACKGROUND

Depression, anxiety, post-traumatic stress, and alcohol/substance use disorders are prevalent among people with HIV (PWH), commonly co-occur, and predict worse HIV care outcomes. Transdiagnostic counseling approaches simultaneously address multiple co-occurring mental health disorders.

METHODS

We conducted a pilot individually randomized trial of the Common Elements Treatment Approach adapted for people with HIV (CETA-PWH), a transdiagnostic counseling intervention, compared with usual care at a large academic medical center in the southern United States. Participants were adults with HIV; at risk for HIV care disengagement; and with elevated symptoms of depression, anxiety, post-traumatic stress, and/or alcohol/substance use. Mental health and HIV care engagement were assessed at 4 and 9 months.

RESULTS

Among participants (n = 60), follow-up was high at 4 (92%) and 9 (85%) months. Intervention engagement was challenging: 93% attended ≥1 session, 43% attended ≥6 sessions in 3 months ("moderate dose"), and 30% completed treatment. Although not powered for effectiveness, mental health outcomes and HIV appointment attendance improved in CETA-PWH relative to usual care in intent-to-treat analyses; those receiving a moderate dose and completers showed progressively greater improvement. Viral load showed small differences between arms. The dose-response pattern was not explained by differences between those who did and did not complete treatment.

CONCLUSIONS

This pilot trial provides preliminary evidence for the potential of CETA-PWH to simultaneously address co-occurring mental health comorbidities and support HIV appointment attendance among PWH. Additional strategies may be an important part of ensuring that clients can engage in the full course of treatment and realize its full benefits.

Systematic review and meta-analysis on the effect of depression on ART adherence among women living with HIV

BACKGROUND

Depression is a very common psychiatric disorder in worldwide. Globally, Human Immunodeficiency Virus (HIV) is highly prevalent among women, and are disproportionately affected by depression. Antiretroviral Therapy (ART) adherence which could highly be affected by depression is yet to be explored effectively. Depression affects overall poor HIV clinical outcomes, socioeconomic and social interactions. However, it is not well understood specifically how depression affects ART adherence in women living with HIV (WLWHIV). Investigating the effects of depression on ART adherence is critical in order to develop nuanced new evidence to address non-adherence in WLWHIV.

OBJECTIVE

To conduct a meta-analysis on the correlation between depression and adherence to antiretroviral therapy among women living with HIV in the globe.

METHOD

Using population, exposed and outcome approach, we searched Scopus, PubMed, EMBASE, Cochrane Library, Psych info, Web of science and google scholar for cohort and cross-sectional studies globally. The search strategy was structured comprising terms associated with antiretroviral therapy and adherence, women living with HIV and depression. We evaluated the paper quality, using the Newcastle-Ottawa Scales (NOS). The fixed effect model was used to analysis the effect of depression on ART adherence.

RESULT

A total of 8 articles comprise 6474 participants were included in this study. There were controversial findings related to the effect of depression to ART adherence. Among three cross-sectional study, one article demonstrating, depression was associated with ART adherence. Of the five cohort studies, four cohort studies reported association. The overall pooled estimated effect of depression on ART adherence was 1.02 [RR = 1.015 with 95% CI (1.004, 1.026)] with a p-value of 0.005.

CONCLUSION AND RECOMMENDATION

Depression was the risk factor for ART adherence among women living with HIV. It is therefore, necessary for clinician to note this and perform screening for ART adherence.

TRIAL REGISTRATION

The review protocol was developed with prospero registration: CRD42023415935.

Body mass index and quality of life in people living with HIV

With advances in the treatment of HIV, people living with HIV (PLWH) are now expected to have a near-normal life expectancy, but challenges remain in the form of substantially poorer health-related quality of life (HRQoL) than the general population. Being overweight or obese may pose an additional burden in PLWH, but few studies have evaluated the relationship between body mass index (BMI) and HRQoL in PLWH. This study aimed to evaluate and describe the association between HRQoL and BMI among PLWH in the US. Data were obtained from the 2018 and 2019 US National Health and Wellness Survey, an online, self-reported, general population survey. Analyses included 575 PLWH who self-reported a physician diagnosis and prescription use for the treatment of HIV, as well as 1725 propensity score matched non-HIV controls. After adjusting for age, sex, race, and comorbidities, higher BMI was associated with poorer physical (β =  -0.18, p = 0.005) and general (β =  -0.42, p = 0.014) HRQoL among PLWH. Additionally, PLWH reported poorer mental, physical, and general HRQoL than non-HIV controls; these relationships were not moderated by BMI. The potential negative impact of higher BMI on patients' humanistic outcomes should be considered in HIV management, including selection of treatment.

Clinico-demographic and survival profile of people living with HIV on antiretroviral treatment

Objective

To assess the demographic, clinical, and survival profile of people living with HIV.

Methods

A retrospective cohort study was conducted among patients enrolled at a single antiretroviral therapy center in North Karnataka. A total of 11,099 were recruited from April 2007 to January 2020, out of which 3,676 were excluded and the final 7,423 entries were subjected to analysis. The outcome of interest was the time to death in months of people living with HIV on antiretroviral therapy (ART). The clinical and demographic characteristics were examined as potential risk factors for survival analysis. To investigate the factors that influence the mortality of patients using ART, univariate and multivariate Cox regression were performed. Hazard ratio (HR), 95% confidence interval (CI), and p-values were presented to show the significance. The log-rank test was used to determine the significance of the Kaplan-Meier survival curve.

Results

Out of 7,423 HIV-positive people, majority were female (51.4%), heterosexual typology (89.2%), and in the age group 31-45 years (45.5%). The risk of death in male patients was 1.24 times higher (95% CI: 1.14-1.35) than female patients. Patients with age >45 were 1.67 times more likely to die than patients ≤30 (95% CI: 1.50-1.91). In the multivariable analysis, the hazards of mortality increased by 3.11 times (95% CI: 2.09-2.79) in patients with baseline CD4 count ≤50 as compared to those who had baseline CD4 count >200. The risk of death in patients who were diagnosed with TB was 1.30 times more (95% CI: 1.19-1.42) than in those who did not have TB. The survival probabilities at 3 and 90 months were more in female patients (93%, 70%) compared with male patients (89, 54%), respectively.

Conclusion

This study proved that age, sex, baseline CD4 count, and tuberculosis (TB) status act as risk factors for mortality among people with HIV. Prevention strategies, control measures, and program planning should be done based on the sociodemographic determinants of mortality.

M. SP, Ku HC, Wu YL, Ko NY. Global overview of suicidal behavior and associated risk factors among people living with human immunodeficiency virus: A scoping review

Death by suicide is a major public health problem. People living with human immunodeficiency virus (PLHIV) have higher risk of suicidal behavior than the general population. The aim of this review is to summarize suicidal behavior, associated risk factors, and risk populations among PLHIV. Research studies in six databases from January 1, 1988, to July 8, 2021, were searched using keywords that included "HIV," "suicide," and "risk factors." The study design, suicide measurement techniques, risk factors, and study findings were extracted. A total of 193 studies were included. We found that the Americas, Europe, and Asia have the highest rates of suicidal behavior. Suicide risk factors include demographic factors, mental illness, and physiological, psychological, and social support. Depression is the most common risk factor for PLHIV, with suicidal ideation and attempt risk. Drug overdosage is the main cause of suicide death. In conclusion, the current study found that PLHIV had experienced a high level of suicidal status. This review provides an overview of suicidal behavior and its risk factors in PLHIV with the goal of better managing these factors and thus preventing death due to suicide.

Hypertension and one-year risk of all-cause mortality among women with treated HIV in the United States

OBJECTIVE

Hypertension is a critical cause of cardiovascular disease, and women with HIV have a higher prevalence of hypertension than women without HIV. The relationship between hypertension and mortality has not been well characterized in women with treated HIV. Here, we estimate the effect of hypertension on 1-year risk of all-cause mortality among women with HIV on antiretroviral therapy (ART) in the United States.

DESIGN

An analysis of multicenter, observational cohort data from the Women's Interagency HIV Study (WIHS) collected between 1995 and 2019.

METHODS

We included women with HIV who reported ever using ART. We used parametric g-computation to estimate the effect of hypertension (SBP ≥140  mmHg, DBP ≥90 mmHg, or use of hypertensive medication) on all-cause mortality within 1 year of a WIHS visit.

RESULTS

Among 2929 unique women, we included 57 034 visits with a median age of 45 (interquartile range: 39, 52) years. Women had hypertension at 34.5% of visits, and 641 deaths occurred within 1 year of a study visit. Comparing women at visits with hypertension to women at visits without hypertension, the standardized 1-year risk ratio for mortality was 1.16 [95% confidence interval (95% CI): 1.01-1.33]. The risk ratios were higher in Hispanic (risk ratio: 1.23, 95% CI: 0.86-1.77) and non-Hispanic black women (risk ratio: 1.19, 95% CI: 1.04-1.37) and lower in non-Hispanic white women (risk ratio: 0.93, 95% CI: 0.58-1.48).

CONCLUSION

Among women with treated HIV, those with hypertension, compared with those without, had an increased 1-year risk of all-cause mortality.

HIV Increases the Risk of Cigarette Smoke-Induced Emphysema Through MMP-9

BACKGROUND

HIV is associated with an increased risk for emphysema. Matrix metalloproteinase 9 (MMP-9) is a lung tissue remodeling enzyme associated with emphysema. We previously found MMP-9 activity increases with increases in oxidative stress and that HIV increases alveolar oxidative stress. We hypothesized that HIV proteins would increase the risk of cigarette smoke-induced emphysema due to MMP-9.

METHODS

HIV-1 transgenic rats and wild-type littermates were exposed to cigarette smoke or sham for 8 weeks. Lung compliance and histology were assessed. Bronchoalveolar lavage (BAL), primary alveolar macrophages (AM), and serum samples were obtained. A rat alveolar macrophage cell line was exposed to the HIV protein Tat, and MMP-9 levels were assessed by Western immunoblotting. MMP-9 protein expression and activity were assessed in AM from the HIV rat model by ELISA and cytoimmunofluoresence, respectively. Serum from human subjects with and without HIV and tobacco dependence was assessed for MMP-9 levels.

RESULTS

MMP-9 expression was significantly increased in rat alveolar macrophages after Tat exposure. HIV-1 transgenic rats developed emphysema while wild-type littermates did not. MMP-9 expression was also increased in the serum, BAL, and AM of HIV-1 transgenic rats after exposure to cigarette smoke compared with wild-type rats. In parallel, serum samples from HIV+ smokers had higher levels of MMP-9 than subjects without HIV and those who did not smoke.

CONCLUSION

The combination of HIV and cigarette smoke increases MMP-9 expression in experimental rat HIV models and human subjects. HIV and cigarette smoke both induce alveolar oxidative stress and thereby increase MMP-9 activity.

Development and Validation of the HIV-CARDIO-PREDICT Score to Estimate the Risk of Cardiovascular Events in HIV-Infected Patients

IMPORTANCE

Commonly used risk assessment tools for cardiovascular disease might not be accurate for HIV-infected patients.

OBJECTIVE

We aimed to develop a model to accurately predict the 10-year cardiovascular disease (CV) risk of HIV-infected patients.

DESIGN

In this retrospective cohort study, adult HIV-infected patients seen at Boston Medical Center between March 2012 and January 2017 were divided into model development and validation cohorts.

SETTING

Boston Medical Center, a tertiary, academic medical center.

PARTICIPANTS

Adult HIV-infected patients, seen in inpatient and outpatient setting.

MAIN OUTCOMES AND MEASURES

We used logistic regression to create a prediction risk model for cardiovascular events using data from the development cohort. Using a point-based risk-scoring system, we summarized the relationship between risk factors and cardiovascular disease (CVD) risk. We then used the area under the receiver operating characteristics curve (AUC) to evaluate model discrimination. Finally, we tested the model using a validation cohort.

RESULTS

1914 individuals met the inclusion criteria. The model had excellent discrimination for CVD risk [AUC 0.989; (95% CI: 0.986-0.993)] and included the following 11 variables: male sex (95% CI: 2.53-3.99), African American race/ethnicity (95% CI: 1.50-3.13), current age (95% CI: 0.07-0.13), age at HIV diagnosis (95% CI: -0.10-(-0.02)), peak HIV viral load (95% CI: 9.89 × 10-7-3.00 × 10-6), nadir CD4 lymphocyte count (95% CI: -0.03-(-0.02)), hypertension (95% CI: 0.20-1.54), hyperlipidemia (95% CI: 3.03-4.60), diabetes (95% CI: 0.61-1.89), chronic kidney disease (95% CI: 1.26-2.62), and smoking (95% CI: 0.12-2.39). The eleven-parameter multiple logistic regression model had excellent discrimination [AUC 0.957; (95% CI: 0.938-0.975)] when applied to the validation cohort.

CONCLUSIONS AND RELEVANCE

Our novel HIV-CARDIO-PREDICT Score may provide a rapid and accurate evaluation of CV disease risk among HIV-infected patients and inform prevention measures.

Predictors and Consequences of Prescription Opioid Use in Women Living With and Without HIV: 20-Year Follow-Up

Objective: To examine predictors and consequences of prescription opioid use among a cohort of women living with HIV (WLWH) and women without HIV from 2000 to 2019. Materials and Methods: The Women's Interagency HIV Study is a multisite, prospective cohort study. Cumulative proportion of visits with prescription opioid use was categorized as follows: minimal (0%-9%), intermediate (10%-39%), and chronic (>40%). Logistic regression examined independent predictors, and proportional hazards regression estimated unadjusted and adjusted hazards of all-cause mortality, comparing intermediate and chronic prescription opioid use with minimal use. Results: Annual prevalence of prescription opioid use significantly increased from 12.6% to 19.3% from 2000 to 2019 (p < 0.0001). Prescription opioid use was minimal in 75%, intermediate in 16%, and chronic in 9% of women. WLWH had 56% higher odds of chronic prescription opioid use compared with women without HIV. Even after adjusting for quality-of-life scores including ratings of pain, women with intermediate and chronic prescription opioid use had greater odds of being sexual minorities (lesbian or bisexual), unemployed, and were more likely to report benzodiazepine and nonprescription substance use compared with those with minimal use. Intermediate and chronic prescription opioid use were each associated with an almost 1.5-fold increased risk of all-cause mortality. Conclusions: Despite federally mandated opioid prescribing guidelines, prescription opioid use and related mortality significantly increased in women experiencing physical and psychosocial vulnerabilities. The higher mortality rate found among prescription opioid users may reflect the many underlying chronic medical and psychosocial conditions for which these opioids were prescribed, as well as complications of opioids themselves. Findings underscore the need for non-opioid and nonpharmacological interventions for chronic pain, particularly in sexual minorities and WLWH. Avoiding concurrent use of opioids with benzodiazepines and nonprescription drugs might reduce mortality. Clinical Trial Registration Number: NCT00000797.

Poverty, Deprivation, and Mortality Risk Among Women With HIV in the United States

BACKGROUND

Prior studies suggest neighborhood poverty and deprivation are associated with adverse health outcomes including death, but evidence is limited among persons with HIV, particularly women. We estimated changes in mortality risk from improvement in three measures of area-level socioeconomic context among participants of the Women's Interagency HIV Study.

METHODS

Starting in October 2013, we linked geocoded residential census block groups to the 2015 Area Deprivation Index (ADI) and two 2012-2016 American Community Survey poverty variables, categorized into national tertiles. We used parametric g-computation to estimate, through March 2018, impacts on mortality of improving each income or poverty measure by one and two tertiles maximum versus no improvement.

RESULTS

Of 1596 women with HIV (median age 49), 91 (5.7%) were lost to follow-up and 83 (5.2%) died. Most women (62%) lived in a block group in the tertile with the highest proportions of individuals with income:poverty <1; 13% lived in areas in the tertile with the lowest proportions. Mortality risk differences comparing a one-tertile improvement (for those in the two highest poverty tertiles) in income:poverty <1 versus no improvement increased over time; the risk difference was -2.2% (95% confidence interval [CI] = -3.7, -0.64) at 4 years. Estimates from family income below poverty level (-1.0%; 95% CI = -2.7, 0.62) and ADI (-1.5%; 95% CI = -2.8, -0.21) exposures were similar.

CONCLUSIONS

Consistent results from three distinct measures of area-level socioeconomic environment support the hypothesis that interventions to ameliorate neighborhood poverty or deprivation reduce mortality risk for US women with HIV. See video abstract at, http://links.lww.com/EDE/B863.

Barriers and facilitators to smoking cessation among HIV-infected people who inject drugs (PWID) in Hanoi, Vietnam: a qualitative study

INTRODUCTION

In Vietnam, 60% of men living with HIV smoke tobacco, and 92% of HIV-infected people who inject drugs (PWID) smoke tobacco. Tobacco use increases mortality through increased health risks including tuberculosis and malignancy in HIV-infected smokers. However, tobacco use treatment is not widely available in Vietnam. The objective was to examine current barriers and facilitators of smoking cessation and tobacco use treatment for HIV-infected PWID in Hanoi, Vietnam.

METHODS

Native speaking ethnographers conducted semi-structured qualitative interviews about tobacco use and tobacco use treatment with sixteen HIV-infected PWID and eight healthcare providers, recruited from four HIV-Methadone Maintenance Treatment (MMT) clinics in Hanoi, Vietnam. Interviews were recorded, transcribed, and translated for thematic analysis in Dedoose.

RESULTS

Clients and providers had learned the general health risks of smoking from public awareness campaigns. Half had tried to quit previously, often motivated by advice from family members but not by HIV providers' advice. Almost all clients did not want to quit, citing the low price of tobacco, prevalence of smoking in Vietnam, and physical cravings. HIV provider's counseling was brief, inconsistent, and limited by low provider knowledge and competing burdens of HIV and injection drug use. Providers recently trained by NGO-led seminars on tobacco prioritized tobacco use treatment.

CONCLUSIONS

Smoking cessation efforts for people living with HIV/AIDS (PLHA) and PWID smokers in Hanoi, Vietnam could benefit from further community public awareness campaigns, and exploring increased tobacco taxation. Tobacco use treatment at HIV clinics could benefit from involving family and friends in cessation, and training providers in treatment methods.

Women from afar: an observational study of demographic characteristics and mortality among foreign-born women living with HIV in the Women's Interagency HIV Study (WIHS) in the United States 1994-2016

INTRODUCTION

Foreign-born persons comprise ~13% of the US population. Immigrants, especially women, often face a complex set of social and structural factors that negatively impact health outcomes including greater risk of HIV infection. We described socio-demographic, clinical and immunological characteristics and AIDs and non-AIDS death among foreign-born women living with HIV (FBWLWH) participating in the US Women's Interagency HIV Study (WIHS) in the US from 1994 to 2016. We hypothesized that FBW will experience higher AIDS-related mortality compared to US-born women (USBW).

METHODS

The WIHS is a multicenter prospective observational cohort study of mostly women living with HIV (WLWH). The primary exposure in this analysis, which focused on 3626 WLWH, was self-reported country of birth collapsed into foreign-born and US born. We assessed the association of birthplace with categorized demographic, clinical and immunological characteristics, and AIDS/non-AIDS mortality of WLWH, using chi-squared tests. Proportional hazard models examined the association of birthplace with time from enrolment to AIDS and non-AIDS death.

RESULTS

Of the 628 FBW, 13% were born in Africa, 29% in the Caribbean and 49% in Latin America. We observed significant differences by HIV status in socio-demographic, clinical and immunological characteristics and mortality. For both AIDS and non-AIDS caused deaths FBW WLWH had lower rates of death. Adjusting for year of study enrolment and other demographic/clinical characteristics mitigated FBW's statistical survival advantage in AIDS deaths Relative Hazard (RH = 0.91 p = 0.53), but did not substantively change the survival advantage in non-AIDS deaths RH = 0.33, p < 0.0001).

CONCLUSION

Foreign-born WLWH exhibited demographic, clinical and immunological characteristics that are significantly different compared with women born in the US or US territory. After adjusting for these characteristics, the FB WLWH had a significantly lower hazard of non-AIDS but not AIDS mortality compared to women born in the US or a US territory. These findings of non-increased mortality can help inform models of care to optimize treatment outcomes among FBWLWH in the United States.

Association between Use of Methadone, Other Central Nervous System Depressants, and QTc Interval-Prolonging Medications and Risk of Mortality in a Large Cohort of Women Living with or at Risk for Human Immunodeficiency Virus Infection

STUDY OBJECTIVE

To evaluate the association between use of methadone, other central nervous system (CNS) depressants, and QTc interval-prolonging medications and risk of mortality among human immunodeficiency virus (HIV)-infected and at-risk HIV-uninfected women.

DESIGN

Multicenter, prospective, observational cohort study (Women's Interagency HIV Study [WIHS]).

PARTICIPANTS

A total of 4150 women enrolled in the WIHS study between 1994 and 2014 who were infected (3119 women) or not infected (1031 women) with HIV.

MEASUREMENTS AND MAIN RESULTS

Data on medication utilization were collected from all study participants via interviewer-administered surveys at 6-month intervals (1994-2014). Mortality was confirmed by National Death Index data. With age defining the time scale for the analysis, Cox proportional hazards models were used to estimate hazard ratios (HRs) for all-cause mortality in HIV-infected and -uninfected women and non-acquired immunodeficiency syndrome (AIDS) deaths in HIV-infected women. A total of 1046 deaths were identified, of which 429 were considered non-AIDS deaths. Use of benzodiazepines, CNS depressants (excluding methadone), and number of medications with conditional QTc interval-prolonging effects were each associated with all-cause mortality in multivariate models of HIV-infected women: hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.01-1.60, p=0.037; HR 1.61, 95% CI 1.35-1.92, p<0.0001; and HR 1.15 per drug, 95% CI 1.00-1.33, p=0.047, respectively. Other explanatory variables for all-cause mortality in this model included HIV viral load, CD4+  cell count, renal function, hemoglobin and albumin levels, HIV treatment era, employment status, existence of depressive symptoms, ever use of injection drugs, and tobacco smoking. Of interest, use of CNS depressants (excluding methadone) was also associated with non-AIDS deaths (HR 1.49, 95% CI 1.49-2.2, p<0.0001). Although use of benzodiazepines and conditional QT interval-prolonging medications were associated with increased risk of non-AIDS mortality (HR 1.32 and 1.25, respectively), the effect was not statistically significant (p>0.05).

CONCLUSION

In this cohort of HIV-infected and at-risk HIV-uninfected women, use of benzodiazepines, CNS depressants, and conditional QTc interval-prolonging medications were associated with a higher risk of mortality independent of methadone and other well-recognized mortality risk factors. Care must be taken to assess risk when prescribing these medications in this underserved and at-risk patient population.

The relationship between health-related variables and increases in smoking among recently diagnosed HIV+ people who inject drugs in Vietnam

BACKGROUND

In Vietnam tobacco smoking is prevalent among people living with HIV (PLHIV) and causes excess mortality in this population. Injection drug use is a driver of HIV infections in Vietnam. Changes in HIV disease state may correlate to changes in smoking among PLHIV. This study investigates the relationship between increases in smoking and health-related variables among recently diagnosed HIV+ people who inject drugs (PWID) in Vietnam.

METHODS

We analyzed longitudinal data from 323 recently diagnosed HIV+ PWID in a randomized controlled trial from 2009 to 2013 in Thai Nguyen province, Vietnam. The outcome was an increase of >one cigarette/day from baseline visit cigarette smoking. A generalized estimating equation for repeated measures was used to estimate bivariable and multivariable associations between participant characteristics and smoking increases. We collected qualitative data to enhance our understanding of quantitative results, from 16 HIV+ PWID who smoke.

RESULTS

Ninety three point 5% of participants reported some smoking at baseline. Smoking fewer cigarettes, higher health related quality of life (QOL), and higher CD4 counts were predictive of increases in smoking at future visits in a multivariable model. Qualitative data showed smoking increases were tied to improved perceived health, and counseling during respiratory illnesses may increase intention to quit.

CONCLUSION

HIV+ PWID in Vietnam smoke at a very high rate. Increases in their smoking are correlated to increases in heath-related QOL, and increases in perceptions of health. Any tobacco-use intervention should account for internal tobacco use triggers faced by HIV+ PWID.

Correlates of same-sex behavior disclosure to health care providers among Black MSM in the United States: implications for HIV prevention

Disclosure of same-sex behavior to health care providers (HCPs) by men who have sex with men (MSM) has been argued to be an important aspect of HIV prevention. However, Black MSM are less likely to disclose compared to white MSM. This analysis of data collected in the United States from 2006-2009 identified individual and social network characteristics of Black MSM (n = 226) that are associated with disclosure that may be leveraged to increase disclosure. Over two-thirds (68.1%) of the sample had ever disclosed to HCPs. Part-time employment (AOR = 0.32, 95% CI = 0.11-0.95), bisexual identity (AOR = 0.29, 95% CI = 0.12-0.70), and meeting criteria for alcohol use disorders (AOR = 0.32, 95% CI = 0.14-0.75) were negatively associated with disclosure. Disclosers were more likely to self-report being HIV-positive (AOR = 4.47, 95% CI = 1.54-12.98), having more frequent network socialization (AOR = 2.15, 95% CI = 1.24-3.73), and having a social network where all members knew the participant had sex with men (AOR = 4.94, 95% CI = 2.06-11.86). These associations were not moderated by self-reported HIV status. Future interventions to help MSM identify social network members to safely disclose their same-sex behavior may also help disclosure of same-sex behavior to HCPs among Black MSM.

The pharyngeal carriage of Haemophilus influenzae among healthy population in China: a systematic review and meta-analysis

BACKGROUND

A nationwide investigation on the carriage proportion of H. influenzae among healthy populations is lacking in China. The purpose of the study was to review the prevalence of pharyngeal carriage of H. influenzae among healthy populations in China, and explore its influencing factors. The serotypes distribution of H. influenzae was also analyzed.

METHODS

A systematic search was conducted with key words "Haemophilus influenzae", "Carriage", and "China" or "Chinese" from inception to March 2018. After careful screening, the data of included articles were extracted with a pre-designed excel form. Then, the pooled carriage proportion of H. influenzae was calculated using the random effect model.

RESULTS

A total of 42 studies with 17,388 participants were included. The overall pooled carriage proportion of H. influenzae was 0.17 (95% CI: 0.13-0.21), and the carriage proportion largely varied by province. Subgroup analysis indicated that the pooled carriage proportion was 0.17 (0.13-0.21) for children, and 0.14 (0.7-0.23) for adults. There were no statistically significant heterogeneity between subgroups by age (p = 0.65), sex (p = 0.88), and season (p = 0.10). The pooled carriage proportion of Hib was 0.01 (0-0.02), while the carriage proportion of NTHi was 0.22 (0.13-0.31).

CONCLUSION

In China, the carriage proportion of H. influenzae among healthy population was low, but it largely varied by provinces.

History of Incarceration Among Women with HIV: Impact on Prognosis and Mortality

Objectives: To identify factors associated with incarceration among women and examine the relationship between incarceration and human immunodeficiency virus (HIV)-related outcomes. Materials and Methods: We analyzed longitudinal data from 3324 women (2372 with HIV and 952 uninfected) from 2007 to 2016 in the Women's Interagency HIV Study, a U.S. cohort of women with and without HIV. Lifetime history of incarceration before first study visit was used as the outcome and then as a predictor for HIV outcomes and mortality. Using multivariable models, we assessed associations between socio-demographic, behavioral, and clinical characteristics and incarceration, and between incarceration and HIV outcomes, including mortality. Results: Overall, 1256 (38%) of women reported ever being incarcerated. Women who had a history of drug use had a 44% greater prevalence of incarceration compared with those who did not use drugs. Sexual minority women and women who experienced physical and sexual abuse had a 47% and 28%, respectively, greater prevalence of incarceration than heterosexual women and those not abused. For the 862 women with HIV and a history of incarceration, having an incarceration history was independently associated with less viral suppression (adjusted prevalence ratios = 0.95; confidence intervals [CI]:0.90-1.00 p = 0.04) and higher likelihood of death (adjusted hazard ratios = 1.39; CI:1.04-1.86 p = 0.03). Conclusions: Incarceration is common in this cohort and may put women with HIV at increased odds of worse HIV outcomes and mortality than those without a history of incarceration. Addressing the intersecting epidemics of HIV, substance use, and incarceration by providing needed treatment and resources and avoiding criminalization may improve health outcomes in vulnerable women with HIV.

Viremia Trajectories of HIV in HIV-Positive Women in the United States, 1994-2017

IMPORTANCE

Viral suppression of HIV is an important treatment goal to decrease morbidity, mortality, and risk of transmission to others.

OBJECTIVE

To characterize longitudinal HIV viral load outcomes among women enrolled in the Women's Interagency HIV Study (WIHS).

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort study of HIV-positive women with semiannual study visits and a minimum of 5 follow-up visits was conducted from 1994 to 2017. The WIHS sites included in this analysis are in Brooklyn and Bronx, New York; Chicago, Illinois; San Francisco, California; and Washington, DC.

MAIN OUTCOMES AND MEASURES

Women were categorized into groups based on their probability of achieving viral load suppression below 200 copies/mL using logistic trajectory modeling. Multinomial regression analysis was used to identify factors associated with placement in the group with the highest probability of viremia.

RESULTS

At baseline, the mean (SD) age of the 1989 women was 36.9 (8.0) years, mean CD4+ T-lymphocyte count was 467/mm3, median (interquartile range) HIV RNA was 6200.0 (384.5-41 678.0) copies/mL, and 1305 women (65.6%) were African American. Three trajectory groups were identified with low (568 [28.6%]), intermediate (784 [39.4%]), and high (637 [32.0%]) probability of viremia above 200 copies/mL. The mean (SD) cumulative years of viral suppression were 18.7 (4.0) years, 12.2 (3.1) years, and 5.8 (2.9) years in the respective groups. Factors associated with high probability of viremia included younger age (odds ratio [OR]. 0.99; 95% CI, 0.98-0.99; P = .03), African American race (odds ratio [OR], 2.43; 95% CI, 1.75-3.37), P < .001), Hispanic race/ethnicity (OR, 1.50; 95% CI, 1.03-2.19; P = .04), increased levels of depressive symptoms (OR, 1.17; 95% CI, 1.01-1.36; P = .03), drug use (OR, 1.23; 95% CI, 1.01-1.51; P = .04), lower CD4+ T-lymphocyte counts (OR, 95% CI, 0.82; 0.80-0.85; P < .001), and unstable housing (OR, 1.25, 95% CI, 1.03-1.50; P = .02). Between 2015 and 2017, 71.2% of women demonstrated sustained viral suppression: 89.6% (310 of 346) of those with low viremia, 83.4% (346 of 415) with intermediate, and 35.2% (112 of 318) with high probability of viremia.

CONCLUSIONS AND RELEVANCE

This longitudinal approach suggested that the probability of viremia decreased substantially over time for most participants, including among women with earlier histories of incomplete viral suppression. The findings from this study suggest that continued efforts are needed to address mental health, social, behavioral and structural factors that were identified as associated with high probability of HIV viremia over time.

Death after diagnosis of noncommunicable disease comorbid conditions, stratified by injection drug use

OBJECTIVE

Describe all-cause mortality associated with history of injection drug use (IDU) after a validated diagnosis of four noncommunicable disease (NCD) diagnoses: end-stage liver disease (ESLD); end-stage renal disease (ESRD); cancer; or myocardial infarction (MI) or stroke.

DESIGN

We followed four cohorts of persons in continuity HIV care in the Johns Hopkins HIV Clinic with a validated diagnosis of ESLD (n = 67), ESRD (n = 187), cancer (n = 424), and MI or stroke (n = 213) from 1996 through approximately 2014.

METHODS

Crude and adjusted Cox proportional hazards models to estimate hazard ratios for death after a validated diagnosis of one of four NCD diagnoses associated with history of IDU as an HIV acquisition risk factor.

RESULTS

History of IDU was not associated with death after ESRD (adjusted hazard ratio 0.98, 95% confidence interval (CI) 0.57-1.68). Associations between history of IDU and death after ESLD and MI or stroke were weak, imprecise and not statistically significant (hazard ratio 1.17, 95% CI 0.63-2.19; hazard ratio 1.21, 95% CI 0.80-1.83). History of IDU was not associated with death after cancer in the first 6 months, but subsequently, the adjusted hazard ratio was 2.03 (95% CI 1.26-3.27).

CONCLUSION

Persons with a history of injection drug use and non-IDU had strikingly similar risk and hazard of mortality after several major NCD diagnoses. Mortality after cancer diagnosis in this cohort was higher for persons with a history of IDU than those without; this may be because of being diagnosed with a different mix of specific sites and stages of cancers.

Cumulative Burden of Depression and All-Cause Mortality in Women Living With Human Immunodeficiency Virus

Background

Research linking depression to mortality among people living with human immunodeficiency virus (PLWH) has largely focused on binary "always vs never" characterizations of depression. However, depression is chronic and is likely to have cumulative effects on mortality over time. Quantifying depression as a cumulative exposure may provide a better indication of the clinical benefit of enhanced depression treatment protocols delivered in HIV care settings.

Methods

Women living with HIV (WLWH), naive to antiretroviral therapy, from the Women's Interagency HIV Study were followed from their first visit in or after 1998 for up to 10 semiannual visits (5 years). Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. An area-under-the-curve approach was used to translate CES-D scores into a time-updated measure of cumulative days with depression (CDWD). We estimated the effect of CDWD on all-cause mortality using marginal structural Cox proportional hazards models.

Results

Overall, 818 women contributed 3292 woman-years over a median of 4.8 years of follow-up, during which the median (interquartile range) CDWD was 366 (97-853). Ninety-four women died during follow-up (2.9 deaths/100 woman-years). A dose-response relationship was observed between CDWD and mortality. Each additional 365 days spent with depression increased mortality risk by 72% (hazard ratio, 1.72; 95% confidence interval, 1.34-2.20).

Conclusions

In this sample of WLWH, increased CDWD elevated mortality rates in a dose-response fashion. More frequent monitoring and enhanced depression treatment protocols designed to reduce CDWD may interrupt the accumulation of mortality risk among WLWH.

How do outcomes compare between women and men living with HIV in Australia? An observational study

Background Gender differences vary across geographical settings and are poorly reported in the literature. The aim of this study was to evaluate demographics and clinical characteristics of participants from the Australian HIV Observational Database (AHOD), and to explore any differences between females and males in the rate of new clinical outcomes, as well as initial immunological and virological response to antiretroviral therapy.

METHODS

Time to a new clinical end-point, all-cause mortality and/or AIDS illness was analysed using standard survival methods. Univariate and covariate adjusted Cox proportional hazard models were used to evaluate the time to plasma viral load suppression in all patients that initiated antiretroviral therapy (ART) and time to switching from a first-line ART to a second-line ART regimen.

RESULTS

There was no significant difference between females and males for the hazard of all-cause mortality [adjusted hazard ratio: 0.98 (0.51, 1.55), P=0.67], new AIDS illness [adjusted hazard ratio: 0.75 (0.38, 1.48), P=0.41] or a composite end-point [adjusted hazard ratio: 0.74 (0.45, 1.21), P=0.23]. Incident rates of all-cause mortality were similar between females and males; 1.14 (0.61, 1.95) vs 1.28 (1.12, 1.45) per 100 person years. Virological response to ART was similar for females and males when measured as time to viral suppression and/or time to virological failure.

CONCLUSION

This study supports current Australian HIV clinical care as providing equivalent standards of care for male and female HIV-positive patients. Future studies should compare ART-associated toxicity differences between ART-associated toxicity differences between men and women living with HIV in Australia.

Association of Increased Chronicity of Depression With HIV Appointment Attendance, Treatment Failure, and Mortality Among HIV-Infected Adults in the United States

IMPORTANCE

Depression commonly affects adults with HIV and complicates the management of HIV. Depression among individuals with HIV tends to be chronic and cyclical, but the association of this chronicity with HIV outcomes (and the related potential for screening and intervention to shorten depressive episodes) has received little attention.

OBJECTIVE

To examine the association between increased chronicity of depression and multiple HIV care continuum indicators (HIV appointment attendance, treatment failure, and mortality).

DESIGN, SETTING, AND PARTICIPANTS

The study comprised an observational clinical cohort of 5927 patients with 2 or more assessments of depressive severity who were receiving HIV primary care at 6 geographically dispersed US academic medical centers from September 22, 2005, to August 6, 2015.

MAIN OUTCOMES AND MEASURES

Missing a scheduled HIV primary care visit, detectable HIV RNA viral load (≥75 copies/mL), and all-cause mortality. Consecutive depressive severity measures were converted into a time-updated measure: percentage of days with depression (PDD), following established methods for determining depression-free days.

RESULTS

During 10 767 person-years of follow-up, the 5927 participants (5000 men, 926 women, and 1 intersex individual; median age, 44 years [range, 35-50 years]) had a median PDD of 14% (interquartile range, 0%-48%). During follow-up, 10 361 of 55 040 scheduled visits (18.8%) were missed, 6191 of 28 455 viral loads (21.8%) were detectable, and the mortality rate was 1.5 deaths per 100 person-years. Percentage of days with depression showed a dose-response relationship with each outcome. Each 25% increase in PDD led to an 8% increase in the risk of missing a scheduled appointment (risk ratio, 1.08; 95% CI, 1.05-1.11), a 5% increase in the risk of a detectable viral load (risk ratio, 1.05; 95% CI, 1.01-1.09), and a 19% increase in the mortality hazard (hazard ratio, 1.19; 95% CI, 1.05-1.36). These estimates imply that, compared with patients who spent no follow-up time with depression (PDD, 0%), those who spent the entire follow-up time with depression (PDD, 100%) faced a 37% increased risk of missing appointments (risk ratio, 1.37; 95% CI, 1.22-1.53), a 23% increased risk of a detectable viral load (risk ratio, 1.23; 95% CI, 1.06-1.43), and a doubled mortality rate (hazard ratio, 2.02; 95% CI, 1.20-3.42).

CONCLUSIONS AND RELEVANCE

Greater chronicity of depression increased the likelihood of failure at multiple points along the HIV care continuum. Even modest increases in the proportion of time spent with depression led to clinically meaningful increases in negative outcomes. Clinic-level trials of protocols to promptly identify and appropriately treat depression among adults living with HIV should be conducted to understand the effect of such protocols on shortening the course and preventing the recurrence of depressive illness and improving clinical outcomes.

Mortality under plausible interventions on antiretroviral treatment and depression in HIV-infected women: an application of the parametric g-formula

PURPOSE

Among HIV-infected persons, antiretroviral therapy (ART) and depression are strongly associated with mortality. We estimated reductions in 5-year mortality in Women's Interagency HIV Study participants under plausible hypothetical increases in ART initiation and reductions in depression (CES-D score≥16).

METHODS

We followed 885 ART-naïve Women's Interagency HIV Study participants for 5 years from their first study visit after April 1998 to death or censoring. We used the parametric extended g-formula to estimate cumulative mortality under the natural course (NC) and alternative exposure distributions.

RESULTS

Baseline prevalence of depression was 52% and 62% initiated ART by 5 years. Compared with mortality under NC (13.2%), immediate ART and elimination of 36% or 67% of depressive episodes were associated with risk differences (RDs) of -5.2% (95% CI: -7.7%, -2.6%) and -5.7 (95% CI: -8.7, -2.7). Compared with immediate ART and NC for depression, additionally eliminating 67% of the depressive episodes was associated with RD = -1.6 (95% CI: -3.9, 0.8). Compared with 5-year mortality under NC for ART and elimination of 67% of depression, also initiating ART immediately was associated with RD = -2.6 (95% CI: -5.0, -0.3).

CONCLUSIONS

Increasing ART initiation and reducing depression were associated with moderate reductions in 5-year mortality among HIV-infected women.

Gender differences in causes of death among persons with HIV/AIDS in San Francisco, California, 1996-2013

The objective was to examine gender differences in causes of death using the San Francisco HIV/AIDS and death registries. Data from San Francisco residents diagnosed with HIV/AIDS who died from 1996 to 2013 were analyzed. Age, race/ethnicity, year, and gender-adjusted standardized mortality ratios and Poisson 95% confidence intervals were calculated for underlying causes of death. Among the 6268 deaths, deaths attributed to drug use, mental disorders due to substance use, cerebrovascular disease, chronic obstructive pulmonary disease, renal disease, and septicemia were more likely among women than among men. Compared to the California population, women had elevated standardized mortality ratios for drug overdose (25.37), mental disorders due to substance abuse (27.21), cerebrovascular disease (2.83), chronic obstructive pulmonary disease (7.37), heart disease (2.37), and liver disease (5.54), and these were higher than the standardized mortality ratios for the men in our study. Men, but not women, had elevated standardized mortality ratios for suicide (2.70), undetermined intent (3.88), renal disease (2.29), and non-AIDS cancer (1.68) compared to population rates. Continued efforts to reduce HIV-related illnesses and an increased emphasis on diagnosing and treating preventable causes of death, including substance use, heart disease, and mental health disorders, are needed as part of comprehensive HIV care.

Predicting death over 8 years in a prospective cohort of HIV-infected women: the Women's Interagency HIV Study

OBJECTIVES

Predicting mortality in middle-aged HIV-infected (HIV+) women on antiretroviral therapies (ART) is important for understanding the impact of HIV infection. Several health indices have been used to predict mortality in women with HIV infection. We evaluated: (1) an HIV biological index, Veterans Aging Cohort Study (VACS); (2) a physical index, Fried Frailty Index (FFI); and (3) a mental health index, Center for Epidemiologic Studies-Depression (CES-D). Proportional hazards regression analyses were used to predict death and included relevant covariates.

DESIGN

Prospective, observational cohort.

SETTING

Multicentre, across six sites in the USA.

PARTICIPANTS

1385 multirace/ethnic ART-experienced HIV+ women in 2005.

PRIMARY AND SECONDARY OUTCOMES

All deaths, AIDS deaths and non-AIDS deaths up to ~8 years from baseline.

RESULTS

Included together in one model, VACS Index was the dominant, significant independent predictor of all deaths within 3 years (HR=2.20, 95% CI 1.83, 2.65, χ²=69.04, p<0.0001), and later than 3 years (HR=1.55, 95% CI 1.30, 1.84, χ²=23.88, p<0.0001); followed by FFI within 3 years (HR=2.06, 95% CI 1.19, 3.57, χ²=6.73, p=0.01) and later than 3 years (HR=2.43, 95% CI 1.58, 3.75, χ²=16.18, p=0.0001). CES-D score was not independently associated with mortality.

CONCLUSIONS AND RELEVANCE

This is the first simultaneous evaluation of three common health indices in HIV+ adults. Indices reflecting physical and biological ageing were associated with death.

In-Patient Mortality among PLHIV: A 7-Year Hospital-Based Retrospective Study in Coastal South India

BACKGROUND

With the wide usage of highly active antiretroviral therapy, the morbidity and mortality due to HIV have declined gradually. The aim of our study was to determine the cause of mortality among HIV-infected patients and the factors causing early death.

METHODS

Using medical records of 73 inpatients who are dead, data were collected and analyzed using SPSS version 19 (IBM SPSS Statistics). Chi-square test was performed to determine the factors contributing to early death. A P value <.05 was considered significant.

RESULTS

Among 73 deaths, 50 (68.5%) were AIDS related and 23 (31.5%) were non-AIDS related. The most common opportunistic infection causing death was Pneumocystis carinii pneumonia. Early deaths were strongly attributed to low CD4 counts at admission (<100 cells), antiretroviral therapy-naive status, late presentation, and fewer admissions ( P value <.05).

CONCLUSION

Although AIDS-defining illness remains the main cause of death in HIV, there is significant number of deaths due to non-HIV-related causes.

Efficacy Of Pegylated Interferon And Ribavirin Treatment In Coinfected HIV HCV Patients

The objectives of the study were to determine the efficacy of pegylated interferon alfa 2 b (PegINF) and ribavirin (RBV) treatment in co-infected HIV / HCV patients, to identify predictive factors associated with sustained viral response (SVR) in these patients. Out of the 956 HIV infected patients, 38 were HCVAb (4%) positive, 14 of which had undetectable HCV RNA, only 6 patients met the inclusion criteria. Screening failure was due to: liver cirrhosis Child Pugh B / C, hepatocellular carcinoma, pulmonary TB, thyroid dysfunction, CD4 <200 cells3, detectable HIV RNA and depressive syndrome. We initiated PegINF and RBV therapy for 48 weeks. SVR was achieved in 16.6% of cases (only one patient) and correlated with HCV RNA level, CD4 count, duration of HIV infection, CDC classification and liver fibrosis. In conclusion, our study group has a low prevalence of HIV / HCV co-infection (2.6%) with a large number of patients HCVAb positive but undetectable HCV RNA. Positive predictive factors for SVR were: low levels of HCV RNA, small duration of HIV infection, high levels of CD4, B1/B2 (CDC classification) and low degree of fibrosis.

Faces of Frailty in Aging with HIV Infection

PURPOSE OF THE REVIEW

The number of adults who are aging successfully and have HIV infection is increasing. More effective antiretroviral therapy (ART) regimens are preventing individuals infected with HIV from reaching end stages of the HIV infection and developing AIDS (acquired immunodeficiency syndrome). However, even at lower viral loads, chronic HIV infection appears to have consequences on aging processes, including the development of frailty.

RECENT FINDINGS

Frailty is a term used to describe vulnerability in aging. Frailty indices such as the Fried Frailty Index (FFI), the Veterans Aging Cohort Study (VACS) Index, and the Center for Epidemiologic Studies Depression scale (CES-D), an index of emotional frailty, associate with or predict clinical outcomes and death. However, even among existing frailty definitions, components require rigorous and consistent standardization. In the Women's Interagency HIV Study (WIHS), we have shown that frailty does not exist in isolation, even in midlife, and we use frailty to predict death. Frailty indices should be systematically used by health professionals to evaluate health and future risks for adverse events. Frailty prevention efforts, especially among those with HIV infection, appear to be essential for "successful aging" or aging without disability or loss of independence and may prevent HIV transmission. Taking care of elderly people is one of the major challenges of this century, and we must expect and be prepared for an increase in the number of aging adults, some of whom are patients with many co-morbidities and HIV infection.

The Global Engagement in Care Convening: Recommended Actions to Improve Health Outcomes for People Living With HIV

The National HIV AIDS Strategy (NHAS) calls for a more coordinated response to the HIV epidemic. The Global Engagement in Care Convening created a forum for domestic and international experts to identify best practices in HIV care. This manuscript summarizes the meeting discussions and recommendations from meeting notes and an audio recording of the meeting. Recommendations include: further standardization of performance goals and performance measures; additional research; a more robust system to support competing needs of clients receiving services; electronic information exchanges for HIV-related data; an expansion of the role of other health professionals to extend the capacity of physicians and other members of the care team; and revisions to current financing systems to increase reimbursement for and access to services that promote linkage to and retention in HIV care. The recommendations provide a unique example of "reverse technical assistance" and will inform U.S. program development, research, and policy.

Associations and Trends in Cause-Specific Rates of Death Among Persons Reported with HIV Infection, 23 U.S. Jurisdictions, Through 2011

Background:

Published death rates for persons with HIV have not distinguished deaths due to HIV from deaths due to other causes. Cause-specific death rates would allow better assessment of care needs.

Methods:

Using data reported to the US national HIV surveillance system, we examined a) associations between selected decedent characteristics and causes of death during 2007-2011, b) trends in rates of death due to underlying causes among persons with AIDS during 1990-2011, and among all persons with diagnosed HIV infection (with or without AIDS) during 2000-2011.

Results:

During 2007-2011, non-HIV-attributable causes of death with the highest rates per 1,000 person-years were heart disease (2.0), non-AIDS cancers other than lung cancer (1.4), and accidents (0.8). During 1990-2011, among persons with AIDS, the annual rate of death due to HIV-attributable causes decreased by 89% (from 122.0 to 13.2), and the rate due to non-HIV-attributable-causes decreased by 57% (from 20.0 to 8.6), while the percentage of deaths caused by non-HIV-attributable causes increased from 11% to 43%. During 2000-2011, among persons with HIV infection, the rate of death due to HIV-attributable causes decreased by 69% (from 26.4 to 8.3), and the rate due to non-HIV-attributable causes decreased by 28% (from 10.5 to 7.6), while the percentage of deaths caused by non-HIV-attributable causes increased from 25% to 48%.

Conclusion:

Among HIV-infected persons, as rates of death due to HIV-attributable causes decreased, rates due to non-HIV-attributable causes also decreased, but the percentages of deaths due to non-HIV-attributable causes, such as heart disease and non-AIDS cancers increased.

Multiple Imputation to Account for Measurement Error in Marginal Structural Models

BACKGROUND

Marginal structural models are an important tool for observational studies. These models typically assume that variables are measured without error. We describe a method to account for differential and nondifferential measurement error in a marginal structural model.

METHODS

We illustrate the method estimating the joint effects of antiretroviral therapy initiation and current smoking on all-cause mortality in a United States cohort of 12,290 patients with HIV followed for up to 5 years between 1998 and 2011. Smoking status was likely measured with error, but a subset of 3,686 patients who reported smoking status on separate questionnaires composed an internal validation subgroup. We compared a standard joint marginal structural model fit using inverse probability weights to a model that also accounted for misclassification of smoking status using multiple imputation.

RESULTS

In the standard analysis, current smoking was not associated with increased risk of mortality. After accounting for misclassification, current smoking without therapy was associated with increased mortality (hazard ratio [HR]: 1.2 [95% confidence interval [CI] = 0.6, 2.3]). The HR for current smoking and therapy [0.4 (95% CI = 0.2, 0.7)] was similar to the HR for no smoking and therapy (0.4; 95% CI = 0.2, 0.6).

CONCLUSIONS

Multiple imputation can be used to account for measurement error in concert with methods for causal inference to strengthen results from observational studies.

Utilization of Alcohol Treatment Among HIV-Positive Women with Hazardous Drinking

Hazardous alcohol consumption has been frequently reported among women with HIV infection and is associated with a variety of negative health consequences. Treatments to reduce alcohol use may bring in health benefits. However, little is known regarding the utilization of alcohol treatment services among HIV+ women with hazardous drinking. Using data from the Women's Interagency HIV Study (WIHS), this study assessed utilization of any alcohol treatment in the past 6 months and performed multivariable logistic regression to determine correlates of receipt of any alcohol treatment. Among 474 HIV+ women reporting recent hazardous drinking, less than one in five (19%) reported recent utilization of any alcohol treatment. Alcoholics Anonymous (AA) was the most commonly reported (12.9%), followed by inpatient detoxification (9.9%) and outpatient alcohol treatment program (7.0%). Half (51%) receiving any alcohol treatment reported utilization of multiple treatments. Multivariable analyses found alcohol treatment was more often utilized by those who had social support (odds ratio [OR]=1.68, 95% confidence interval [CI]=1.00 to 2.83), fewer economic resources (income ≤$12,000 vs. >$12,000, OR=3.10, 95% CI=1.53 to 6.27), higher levels of drinking (16-35 drinks/week vs. 12-15 drinks/week, OR=3.02, 95% CI=1.47 to 6.21; 36+ drinks/week vs. 12-15 drinks/week, OR=4.41, 95% CI=2.03 to 9.59), and those who reported any illicit drug use (OR=2.77, 95% CI=1.44 to 5.34). More efforts are needed to enhance the utilization of alcohol treatment. Our findings highlight the unique profile of those who utilized alcohol treatment. Such information is vital to improve treatment delivery to address unmet need in this particular population.

Use of urine biomarker-derived clusters to predict the risk of chronic kidney disease and all-cause mortality in HIV-infected women

BACKGROUND

Although individual urine biomarkers are associated with chronic kidney disease (CKD) incidence and all-cause mortality in the setting of HIV infection, their combined utility for prediction remains unknown.

METHODS

We measured eight urine biomarkers shown previously to be associated with incident CKD and mortality risk among 902 HIV-infected women in the Women's Interagency HIV Study: N-acetyl-β-d-glucosaminidase (NAG), kidney injury molecule-1 (KIM-1), alpha-1 microglobulin (α1m), interleukin 18, neutrophil gelatinase-associated lipocalin, albumin-to-creatinine ratio, liver fatty acid-binding protein and α-1-acid-glycoprotein. A group-based cluster method classified participants into three distinct clusters using the three most distinguishing biomarkers (NAG, KIM-1 and α1m), independent of the study outcomes. We then evaluated associations of each cluster with incident CKD (estimated glomerular filtration rate <60 mL/min/1.73 m(2) by cystatin C) and all-cause mortality, adjusting for traditional and HIV-related risk factors.

RESULTS

Over 8 years of follow-up, 177 CKD events and 128 deaths occurred. The first set of clusters partitioned women into three groups, containing 301 (Cluster 1), 470 (Cluster 2) and 131 (Cluster 3) participants. The rate of CKD incidence was 13, 21 and 50% across the three clusters; mortality rates were 7.3, 13 and 34%. After multivariable adjustment, Cluster 3 remained associated with a nearly 3-fold increased risk of both CKD and mortality, relative to Cluster 1 (both P < 0.001). The addition of the multi-biomarker cluster to the multivariable model improved discrimination for CKD (c-statistic = 0.72-0.76, P = 0.0029), but only modestly for mortality (c = 0.79-0.80, P = 0.099). Clusters derived with all eight markers were no better for discrimination than the three-biomarker clusters.

CONCLUSIONS

For predicting incident CKD in HIV-infected women, clusters developed from three urine-based kidney disease biomarkers were as effective as an eight-marker panel in improving risk discrimination.

Relationship between Body Mass Index and Mortality in HIV-Infected HAART Users in the Women's Interagency HIV Study

BACKGROUND

Early HIV studies suggested protective associations of overweight against mortality, yet data are lacking for the era of potent highly active antiretroviral therapy (HAART). We evaluated associations of pre-HAART initiation body mass index (BMI) with mortality among HAART-using women.

METHODS

Prospective study of time to death after HAART initiation among continuous HAART users in the Women's Interagency HIV Study. Unadjusted Kaplan-Meier and adjusted proportional hazards survival models assessed time to AIDS and non-AIDS death by last measured pre-HAART BMI.

RESULTS

Of 1428 continuous HAART users 39 (2.7%) were underweight, 521 (36.5%) normal weight, 441 (30.9%) overweight, and 427 (29.9%) obese at time of HAART initiation. A total of 322 deaths occurred during median follow-up of 10.4 years (IQR 5.9-14.6). Censoring at non-AIDS death, the highest rate of AIDS death was observed among underweight women (p = 0.0003 for all 4 categories). In multivariate models, women underweight prior to HAART died from AIDS more than twice as rapidly vs. normal weight women (aHR 2.04, 95% CI 1.03, 4.04); but being overweight or obese (vs. normal weight) was not independently associated with AIDS death. Cumulative incidence of non-AIDS death was similar across all pre-HAART BMI categories.

CONCLUSIONS

Among continuous HAART-using women, being overweight prior to initiation was not associated with lower risk of AIDS or non-AIDS death. Being underweight prior to HAART was associated with over double the rate of AIDS death in adjusted analyses. Although overweight and obesity may be associated with many adverse health conditions, neither was predictive of mortality among the HAART-using women.

Trajectory analyses of virologic outcomes reflecting community-based HIV treatment in Washington DC 1994-2012

BACKGROUND

Effective treatment of HIV since 1996 has reduced morbidity and mortality through virologic suppression. Combination antiretroviral therapy (cART) has been recognized as key to the prevention of drug resistance and the transmission of infection. We used eighteen years of virologic outcomes in a long-standing cohort of women to describe longitudinal viral load trajectories; and examine factors associated with sustained viremia and mortality.

METHODS

We analyzed data from DC WIHS women with > four semiannual visits using a group-based logistic trajectory analysis approach to identify patterns of HIV RNA detection (>80 copies/mL or lower assay limit, and >1000 copies/mL). We verified findings using cumulative viral load suppression-years, explored group characteristics using generalized linear modeling with generalized estimating equations for repeated measures, and examined survival using the Kaplan-Meier and Cox proportional hazard analyses.

RESULTS

329 women contributed 6633 visits between 1994 and 2012 and demonstrated high, moderate, and low probability patterns of HIV RNA detection (>80 copies/mL) in 40.7, 35.6, and 23.7% of participant visits, respectively. Analysis of cumulative years of viral load suppression supported these observations. Kaplan-Meier survival analysis demonstrated high mortality of 31.1% with sustained viremia, but no significant difference in mortality between intermittent viremia and non-viremia patterns, 6.9 and 4.9% respectively. Mortality was associated with higher age, lower CD4+ T lymphocyte count, and sustained viremia by Cox multivariate analysis.

CONCLUSIONS

This ecologic study demonstrates the effectiveness of viral suppression, and conversely the association between viremia and mortality. In community delivery of cART for HIV care, distinct patterns of sustained viremia, intermittent viremia, and non-viremia were identified over nearly 18 years in the DC WIHS, capturing the dynamics and complexity of sustaining long-term HIV care. Persistent viremia was associated with lower CD4s and mortality, but surprisingly mortality was not different between continuous suppression and intermittent viremia. Classification of long-term virologic patterns such as these observed HIV treatment "careers" may provide a suitable framework to identify modifiable factors associated with treatment resilience and failure. Both individual and population interventions are needed to reduce transmission, prevent the emergence of drug resistance, and improve outcomes of community ART programs.

Sex and Racial/Ethnic Differences in Premature Mortality Due to HIV: Florida, 2000-2009

OBJECTIVE

This study aimed to characterize premature mortality among people diagnosed with HIV infection from 2000 to 2009 in Florida, by sex and race/ethnicity, to estimate differences in premature mortality that could be prevented by linkage to HIV care and treatment.

METHODS

Florida surveillance data for HIV diagnoses (excluding concurrent AIDS diagnoses) were linked with vital records data to ascertain deaths through 2011. Years of potential life lost (YPLL) were obtained from the expected number of remaining years of life at a given age from the U.S. sex-specific period life tables.

RESULTS

Among 41,565 people diagnosed with HIV infection during the study period, 5,249 died, and 2,563 (48.8%) deaths were due to HIV/AIDS. Age-standardized YPLL (aYPLL) due to HIV/AIDS per 1,000 person-years was significantly higher for females than males (372.6, 95% confidence interval [CI] 349.8, 396.2 vs. 295.2, 95% CI 278.4, 312.5); for non-Hispanic black (NHB) females than non-Hispanic white (NHW) and Hispanic females (388.2, 95% CI 360.7, 416.9; 294.3, 95% CI 239.8, 354.9; and 295.0, 95% CI 242.9, 352.5, respectively); and for NHB males compared with NHW and Hispanic males (378.7, 95% CI 353.7, 404.7; 210.6, 95% CI 174.3, 250.8; and 240.9, 95% CI 204.8, 280.2, respectively). In multilevel modeling controlling for individual factors, NHB race was associated with YPLL due to HIV/AIDS for women (p=0.04) and men (p<0.001).

CONCLUSION

Among people diagnosed with HIV infection, females and NHB people had a disproportionately high premature mortality from HIV/AIDS, suggesting the need for enhanced efforts to improve linkage to and retention in care and medication adherence for these groups.

Associations of hormonal contraceptive use with measures of HIV disease progression and antiretroviral therapy effectiveness

OBJECTIVE

To examine the associations between hormonal contraceptive use and measures of HIV disease progression and antiretroviral treatment (ART) effectiveness.

STUDY DESIGN

A prospective cohort study of women with prevalent HIV infection in St. Petersburg, Russia, was conducted. After contraceptive counseling, participants chose to use combined oral contraceptives (COCs), depot-medroxyprogesterone acetate (DMPA), a copper intrauterine device (IUD) or male condoms for pregnancy prevention. Among participants not using ART at enrollment, we used multivariate Cox regression to assess the association between current (time-varying) contraceptive use and disease progression, measured by the primary composite outcome of CD4 decline to <350 cells/mm(3), ART initiation or death. Among participants using ART at enrollment, we used linear mixed models to estimate the predicted mean CD4 change at select time points by contraceptive method.

RESULTS

During a total of 5233 months follow-up among participants not using ART with enrollment CD4 ≥350 cells/mm(3) (n=315), 97 experienced disease progression. Neither current use of COCs [adjusted hazard ratio (aHR) 0.91, 95% confidence interval (CI) 0.56-1.48] nor DMPA (aHR 1.28, 95% CI 0.71-2.31) was associated with a statistically significant increased risk for disease progression compared with use of nonhormonal methods (IUD or condoms). Among participants using ART at enrollment (n=77), we found no statistically significant differences in the predicted mean changes in CD4 cell count comparing current use of COCs (p=.1) or DMPA (p=.3) with nonhormonal methods.

CONCLUSION

Hormonal contraceptive use was not significantly associated with measures of HIV disease progression or ART effectiveness among women with prevalent HIV infection.

IMPLICATIONS

Hormonal contraceptive use was not significantly associated with measures of HIV disease progression or ART effectiveness among women with prevalent HIV infection.

Black:White Disparities in HIV Mortality in the United States: 1990-2009

OBJECTIVES

The aim of this study was to assess whether racial disparities in human immunodeficiency virus (HIV) mortality in the USA have changed over time.

METHODS

Using vital records from the National Center for Health Statistics and census data from the US Census Bureau, we calculated the race- and gender-specific HIV mortality rates and corresponding racial rate ratios for non-Hispanic Blacks and non-Hispanic Whites in the USA for four 5-year increments from 1990-2009. Rates were age-adjusted using the 2000 USA standard population. Additionally, we calculated excess Black deaths for 2005-2009.

RESULTS

For the total, male, and female populations, we observed a statistically significant increase in the Black:White HIV mortality disparity between T1 (1990-1994) and T4 (2005-2009). The increasing disparity was due to the fact that the decrease in mortality rates from T1 to T4 was greater among Whites than Blacks. This disparity led to 5603 excess Black deaths in the USA at T4.

CONCLUSIONS

Previous research suggests that as HIV becomes more treatable, racial disparities widen, as observed in this study for both men and women. Existing disparities could be ameliorated if access to care were equal among these groups. Equal access would enable more individuals to achieve viral suppression, the final step of the HIV Care Continuum.

Comparison of Rates of Death Having any Death-Certificate Mention of Heart, Kidney, or Liver Disease Among Persons Diagnosed with HIV Infection with those in the General US Population, 2009-2011

OBJECTIVE

Compare age-adjusted rates of death due to liver, kidney, and heart diseases during 2009-2011 among US residents diagnosed with HIV infection with those in the general population.

METHODS

Numerators were numbers of records of multiple-cause mortality data from the national vital statistics system with an ICD-10 code for the disease of interest (any mention, not necessarily the underlying cause), divided into those 1) with and 2) without an additional code for HIV infection. Denominators were 1) estimates of persons living with diagnosed HIV infection from national HIV surveillance system data and 2) general population estimates from the US Census Bureau. We compared age-adjusted rates overall (unstratified by sex, race/ethnicity, or region of residence) and stratified by demographic group.

RESULTS

Overall, compared with the general population, persons diagnosed with HIV infection had higher age-adjusted rates of death reported with hepatitis B (rate ratio [RR]=42.6; 95% CI: 34.7-50.7), hepatitis C (RR=19.4; 95% CI: 18.1-20.8), liver disease excluding hepatitis B or C (RR=2.1; 95% CI: 1.8-2.3), kidney disease (RR=2.4; 95% CI: 2.2-2.6), and cardiomyopathy (RR=1.9; 95% CI: 1.6-2.3), but lower rates of death reported with ischemic heart disease (RR=0.6; 95% CI: 0.6-0.7) and heart failure (RR=0.8; 95% CI: 0.6-0.9). However, the differences in rates of death reported with the heart diseases were insignificant in some demographic groups.

CONCLUSION

Persons with HIV infection have a higher risk of death with liver and kidney diseases reported as causes than the general population.

Association of markers of hemostasis with death in HIV-infected women

: In HIV negatives, markers of hemostasis, including D-dimer, factor VIII, plasminogen activator inhibitor-1 antigen (PAI-1), and total protein S are associated with all-cause and cardiovascular disease mortality. In HIV positives, studies of D-dimer and factor VIII with death were limited to short follow-up; associations of PAI-1 and total protein S with death have not been examined. In 674 HIV-infected women from the Women's Interagency HIV Study, markers from the first visit after enrollment were exposures of interest in multivariate analyses of death (AIDS and non-AIDS) in separate models at 5 and 16 years. There were 87 AIDS and 44 non-AIDS deaths at 5 years, and 159 AIDS and 113 non-AIDS deaths at 16 years. An inverse association of total protein S quartiles with non-AIDS deaths was observed at 5 (P trend = 0.002) and 16 years (P trend = 0.02); there was no association with AIDS deaths. The third quartile of PAI-1 was associated with AIDS deaths at 5 [hazard ratio (HR) = 4.0; 95% confidence interval (CI): 1.9 to 8.4] and 16 years (HR = 3.4; 95% CI: 1.9 to 5.9); and with non-AIDS deaths at 5 years (HR = 4.8; 95% CI: 1.6 to 13.9). D-dimer and factor VIII were not associated with AIDS or non-AIDS death at 5 or 16 years. Lower total Protein S was a consistent marker of non-AIDS death. We found no association between D-dimer with AIDS or non-AIDS death, in contrast to previous studies showing increased short-term (<5 years) mortality, which may represent sex differences or population heterogeneity. Given longer survival on highly active antiretroviral therapy, further studies of these markers are needed to determine their prognostic value.

Association of urine α1-microglobulin with kidney function decline and mortality in HIV-infected women

BACKGROUND AND OBJECTIVES

Despite advances in therapy, HIV-infected individuals remain at higher risk for kidney dysfunction than uninfected individuals. It was hypothesized that urine levels of α1-microglobulin, a biomarker of proximal tubular dysfunction, would predict kidney function decline and mortality risk in HIV-infected and uninfected women.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In the Women's Interagency HIV Study, urine α1-microglobulin and creatinine concentrations were measured in 903 HIV-infected and 287 uninfected women using stored urine from 1999 to 2000, when prevalence of tenofovir use was <1%. Participants were categorized into three categories by level of α1-microglobulin-to-creatinine ratio, and associations with kidney decline and all-cause mortality over 8 years were evaluated.

RESULTS

Urine α1-microglobulin was detectable in 60% of HIV-infected and 40% of uninfected women (P<0.001). Among HIV-infected women, there were 177 (22%), 61 (7%), and 128 (14%) patients with incident CKD, with 10% annual eGFR decline, and who died, respectively. Compared with HIV-infected women in the lowest α1-microglobulin category, HIV-infected women in the highest α1-microglobulin category had a 2.1-fold risk of incident CKD (95% confidence interval, 1.3 to 3.4), 2.7-fold risk of 10% annual eGFR decline (95% confidence interval, 1.2 to 5.9), and 1.6-fold mortality risk (95% confidence interval, 1.0 to 2.6) in models adjusting for kidney risk factors, baseline eGFR, and albuminuria. Among uninfected women, the highest α1-microglobulin category was associated with 3% (relative risk, 2.2; 95% confidence interval, 1.4 to 3.5) and 5% (relative risk, 2.2; 95% confidence interval, 1.1 to 4.3) annual eGFR decline relative to the lowest α1-microglobulin category.

CONCLUSIONS

Proximal tubular dysfunction, indicated by urine α1-microglobulin, was independently associated with kidney function decline in HIV-infected and uninfected women and mortality risk among HIV-infected women.

Influence of noninjecting and injecting drug use on mortality, retention in the cohort, and antiretroviral therapy, in participants in the Swiss HIV Cohort Study

OBJECTIVES

We studied the influence of noninjecting and injecting drug use on mortality, dropout rate, and the course of antiretroviral therapy (ART), in the Swiss HIV Cohort Study (SHCS).

METHODS

Cohort participants, registered prior to April 2007 and with at least one drug use questionnaire completed until May 2013, were categorized according to their self-reported drug use behaviour. The probabilities of death and dropout were separately analysed using multivariable competing risks proportional hazards regression models with mutual correction for the other endpoint. Furthermore, we describe the influence of drug use on the course of ART.

RESULTS

A total of 6529 participants (including 31% women) were followed during 31 215 person-years; 5.1% participants died; 10.5% were lost to follow-up. Among persons with homosexual or heterosexual HIV transmission, noninjecting drug use was associated with higher all-cause mortality [subhazard rate (SHR) 1.73; 95% confidence interval (CI) 1.07-2.83], compared with no drug use. Also, mortality was increased among former injecting drug users (IDUs) who reported noninjecting drug use (SHR 2.34; 95% CI 1.49-3.69). Noninjecting drug use was associated with higher dropout rates. The mean proportion of time with suppressed viral replication was 82.2% in all participants, irrespective of ART status, and 91.2% in those on ART. Drug use lowered adherence, and increased rates of ART change and ART interruptions. Virological failure on ART was more frequent in participants who reported concomitant drug injections while on opiate substitution, and in current IDUs, but not among noninjecting drug users.

CONCLUSIONS

Noninjecting drug use and injecting drug use are modifiable risks for death, and they lower retention in a cohort and complicate ART.

Critical consciousness, racial and gender discrimination, and HIV disease markers in African American women with HIV

Critical consciousness, the awareness of social oppression, is important to investigate as a buffer against HIV disease progression in HIV-infected African American women in the context of experiences with discrimination. Critical consciousness comprises several dimensions, including social group identification, discontent with distribution of social power, rejection of social system legitimacy, and a collective action orientation. The current study investigated self-reported critical consciousness as a moderator of perceived gender and racial discrimination on HIV viral load and CD4+ cell count in 67 African American HIV-infected women. Higher critical consciousness was found to be related to higher likelihood of having CD4+ counts over 350 and lower likelihood of detectable viral load when perceived racial discrimination was high, as revealed by multiple logistic regressions that controlled for highly active antiretroviral therapy (HAART) adherence. Multiple linear regressions showed that at higher levels of perceived gender and racial discrimination, women endorsing high critical consciousness had a larger positive difference between nadir CD4+ (lowest pre-HAART) and current CD4+ count than women endorsing low critical consciousness. These findings suggest that raising awareness of social oppression to promote joining with others to enact social change may be an important intervention strategy to improve HIV outcomes in African American HIV-infected women who report experiencing high levels of gender and racial discrimination.

Urinary biomarkers of kidney injury are associated with all-cause mortality in the Women's Interagency HIV Study (WIHS)

OBJECTIVES

Chronic kidney disease (CKD) is common in HIV-infected individuals, and is associated with mortality in both the HIV-infected and general populations. Urinary markers of tubular injury have been associated with future kidney disease risk, but associations with mortality are unknown.

METHODS

We evaluated the associations of urinary interleukin-18 (IL-18), liver fatty acid binding protein (L-FABP), kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL) and the albumin-to-creatinine ratio (ACR) with 10-year, all-cause death in 908 HIV-infected women. Serum cystatin C was used to estimate the glomerular filtration rate (eGFRcys).

RESULTS

There were 201 deaths during 9269 person-years of follow-up. After demographic adjustment, compared with the lowest tertile, the highest tertiles of IL-18 [hazard ratio (HR) 2.54; 95% confidence interval (CI) 1.75-3.68], KIM-1 (HR 2.04; 95% CI 1.44-2.89), NGAL (HR 1.50; 95% CI 1.05-2.14) and ACR (HR 1.63; 95% CI 1.13-2.36) were associated with higher mortality. After multivariable adjustment including adjustment for eGFRcys, only the highest tertiles of IL-18 (HR 1.88; 95% CI 1.29-2.74) and ACR (HR 1.46; 95% CI 1.01-2.12) remained independently associated with mortality. Findings for KIM-1 were borderline (HR 1.41; 95% CI 0.99-2.02). We found a J-shaped association between L-FABP and mortality. Compared with persons in the lowest tertile, the HR for the middle tertile of L-FABP was 0.67 (95% CI 0.46-0.98) after adjustment. Associations were stronger when IL-18, ACR and L-FABP were simultaneously included in models.

CONCLUSIONS

Among HIV-infected women, some urinary markers of tubular injury are associated with mortality risk, independently of eGFRcys and ACR. These markers represent potential tools with which to identify early kidney injury in persons with HIV infection.

A functional, genome-wide evaluation of liposensitive yeast identifies the "ARE2 required for viability" (ARV1) gene product as a major component of eukaryotic fatty acid resistance

The toxic subcellular accumulation of lipids predisposes several human metabolic syndromes, including obesity, type 2 diabetes, and some forms of neurodegeneration. To identify pathways that prevent lipid-induced cell death, we performed a genome-wide fatty acid sensitivity screen in Saccharomyces cerevisiae. We identified 167 yeast mutants as sensitive to 0.5 mm palmitoleate, 45% of which define pathways that were conserved in humans. 63 lesions also impacted the status of the lipid droplet; however, this was not correlated to the degree of fatty acid sensitivity. The most liposensitive yeast strain arose due to deletion of the "ARE2 required for viability" (ARV1) gene, encoding an evolutionarily conserved, potential lipid transporter that localizes to the endoplasmic reticulum membrane. Down-regulation of mammalian ARV1 in MIN6 pancreatic β-cells or HEK293 cells resulted in decreased neutral lipid synthesis, increased fatty acid sensitivity, and lipoapoptosis. Conversely, elevated expression of human ARV1 in HEK293 cells or mouse liver significantly increased triglyceride mass and lipid droplet number. The ARV1-induced hepatic triglyceride accumulation was accompanied by up-regulation of DGAT1, a triglyceride synthesis gene, and the fatty acid transporter, CD36. Furthermore, ARV1 was identified as a transcriptional of the protein peroxisome proliferator-activated receptor α (PPARα), a key regulator of lipid homeostasis whose transcriptional targets include DGAT1 and CD36. These results implicate ARV1 as a protective factor in lipotoxic diseases due to modulation of fatty acid metabolism. In conclusion, a lipotoxicity-based genetic screen in a model microorganism has identified 75 human genes that may play key roles in neutral lipid metabolism and disease.

Association of self-reported race with AIDS death in continuous HAART users in a cohort of HIV-infected women in the United States

OBJECTIVE

To assess the association of race with clinical outcomes in HIV-positive women on continuous HAART.

DESIGN

Prospective study that enrolled women from 1994 to 1995 and 2001 to 2002.

SETTING

Women's Interagency HIV Study, a community-based cohort in five US cities.

PARTICIPANTS

One thousand, four hundred and seventy-one HIV-positive continuous HAART users.

MAIN OUTCOME MEASURES

Times to AIDS and non-AIDS death and incident AIDS-defining illness (ADI) after HAART initiation.

RESULTS

In adjusted analyses, black vs. white women had higher rates of AIDS death [adjusted hazard ratio (aHR) 2.14, 95% confidence interval (CI) 1.30, 3.50; P = 0.003] and incident ADI (aHR 1.58, 95% CI 1.08, 2.32; P = 0.02), but not non-AIDS death (aHR 0.91, 95% CI 0.59, 1.39; P = 0.65). Cumulative AIDS death incidence at 10 years was 17.3 and 8.3% for black and white women, respectively. Other significant independent pre-HAART predictors of AIDS death included peak viral load (aHR 1.70 per log₁₀, 95% CI 1.34, 2.16; P < 0.001), nadir CD4⁺ cell count (aHR 0.65 per 100 cells/μl, 95% CI 0.56, 0.76; P < 0.001), depressive symptoms by Center for Epidemiology Studies Depression score at least 16 (aHR 2.10, 95% CI 1.51, 2.92; P < 0.001), hepatitis C virus infection (aHR 1.57, 95% CI 1.02, 2.40; P = 0.04), and HIV acquisition via transfusion (aHR 2.33, 95% CI 1.21, 4.49; P = 0.01). In models with time-updated HAART adherence, association of race with AIDS death remained statistically significant (aHR 3.09, 95% CI 1.38, 6.93; P = 0.006).

CONCLUSION

In continuous HAART-using women, black women more rapidly died from AIDS or experienced incident ADI than their white counterparts after adjusting for confounders. Future studies examining behavioral and biologic factors in these women may further the understanding of HAART prognosis.

Relationship between food insecurity and mortality among HIV-positive injection drug users receiving antiretroviral therapy in British Columbia, Canada

Objectives

Little is known about the potential impact of food insecurity on mortality among people living with HIV/AIDS. We examined the potential relationship between food insecurity and all-cause mortality among HIV-positive injection drug users (IDU) initiating antiretroviral therapy (ART) across British Columbia (BC).

Methods

Cross-sectional measurement of food security status was taken at participant ART initiation. Participants were prospectively followed from June 1998 to September 2011 within the fully subsidized ART program. Cox proportional hazard models were used to ascertain the association between food insecurity and mortality, controlling for potential confounders.

Results

Among 254 IDU, 181 (71.3%) were food insecure and 108 (42.5%) were hungry. After 13.3 years of median follow-up, 105 (41.3%) participants died. In multivariate analyses, food insecurity remained significantly associated with mortality (adjusted hazard ratio [AHR] = 1.95, 95% CI: 1.07–3.53), after adjusting for potential confounders.

Conclusions

HIV-positive IDU reporting food insecurity were almost twice as likely to die, compared to food secure IDU. Further research is required to understand how and why food insecurity is associated with excess mortality in this population. Public health organizations should evaluate the possible role of food supplementation and socio-structural supports for IDU within harm reduction and HIV treatment programs.

Life expectancy living with HIV: recent estimates and future implications

PURPOSE OF REVIEW

The life expectancy of people living with HIV has dramatically increased since effective antiretroviral therapy has been available, and still continues to improve. Here, we review the latest literature on estimates of life expectancy and consider the implications for future research.

RECENT FINDINGS

With timely diagnosis, access to a variety of current drugs and good lifelong adherence, people with recently acquired infections can expect to have a life expectancy which is nearly the same as that of HIV-negative individuals. Modelling studies suggest that life expectancy could improve further if there were increased uptake of HIV testing, better antiretroviral regimens and treatment strategies, and the adoption of healthier lifestyles by those living with HIV. In particular, earlier diagnosis is one of the most important factors associated with better life expectancy. A consequence of improved survival is the increasing number of people with HIV who are aged over 50 years old, and further research into the impact of ageing on HIV-positive people will therefore become crucial. The development of age-specific HIV treatment and management guidelines is now called for.

SUMMARY

Analyses on cohort studies and mathematical modelling studies have been used to estimate life expectancy of those with HIV, providing useful insights of importance to individuals and healthcare planning.