Prevalence, incidence, and persistence of psychiatric and substance use disorders among mothers living with HIV

Health Outcomes around Pregnancy and Exposure to HIV/Antiretrovirals (HOPE) study protocol: a prospective observational cohort study of reproductive-aged women living with HIV

INTRODUCTION

Over 265 000 women are living with HIV in the USA, but limited research has investigated the physical, mental and behavioural health outcomes among women living with HIV of reproductive age. Health status during the reproductive years before, during and after pregnancy affects pregnancy outcomes and long-term health. Understanding health outcomes among women living with HIV of reproductive age is of substantial public health importance, regardless of whether they experience pregnancy. The Health Outcomes around Pregnancy and Exposure to HIV/Antiretrovirals (HOPE) study is a prospective observational cohort study designed to investigate physical and mental health outcomes of young women living with HIV as they age, including HIV disease course, engagement in care, reproductive health and choices and cardiometabolic health. We describe the HOPE study design, and characteristics of the first 437 participants enrolled as of 1 January 2024.

METHODS AND ANALYSIS

The HOPE study seeks to enrol and follow 1630 women living with HIV of reproductive age, including those with perinatally-acquired HIV, at 12 clinical sites across 9 US states and Puerto Rico. HOPE studies multilevel dynamic determinants influencing physical, mental and social well-being and behaviours of women living with HIV across the reproductive life course (preconception, pregnancy, post partum, not or never-pregnant), informed by the socioecological model. Key research areas include the clinical course of HIV, relationship of HIV and antiretroviral medications to reproductive health, pregnancy outcomes and comorbidities and the influence of racism and social determinants of health. HOPE began enrolling in April 2022.

ETHICS AND DISSEMINATION

The HOPE study received approval from the Harvard Longwood Campus Institutional Review Board, the single institutional review board of record for all HOPE sites. Results will be disseminated through conference presentations, peer-reviewed journals and lay summaries.

Self-medication of pain and discomfort with alcohol and other substances by people with HIV infection and substance use disorder: preliminary findings from a secondary analysis

There is a limited literature regarding factors associated with self-medication of pain and discomfort using alcohol, non-prescription substances or overuse of prescription medications among people living with Human Immunodeficiency Virus (HIV). This cross-sectional analysis used data from the Boston ARCH Cohort among participants with HIV infection and a history of alcohol or other substance use. Among 248 participants, 37% were female, 50% Black, 25% Latinx; 36% reported fair to poor health and 89% had CD4 cell counts >200/mm3. Half reported self-medication and of those, 8.8% reported doing so only with alcohol, 48.8% only with other substances and 42.4% with both alcohol and other substances. Those reporting self-medication were significantly (p < .05) younger (mean 47 vs 50 years), less employed (11% vs 21%), and less likely to have HIV viral suppression (60% vs. 80%). Depression, anxiety, and HIV symptoms were associated with significantly greater odds of self-medicating, as were substance dependence, recent injection substance use, heavy alcohol use, cocaine use, opioid use, sedative use, and cannabis use. Self-medication, highly prevalent and associated with worse mental health symptoms, greater substance use, and lesser HIV disease control, should be explored by HIV clinicians caring for people who use substances.

Prevalence and Correlates of Intimate Partner Violence Victimization Among Urban Adolescents and Young Adults Living With Perinatally-Acquired HIV Infection or Perinatal HIV Exposure

INTRODUCTION

Because of privacy and ethical concerns, the data cannot be made available because of the sensitivity of the HIV data and the relatively small sample and ease of identifying people if a few demographics are known.Few studies have examined intimate partner violence (IPV) victimization among adolescents and young adults (AYAs) with perinatally acquired HIV-infection (PHIV) or perinatal HIV exposure without infection (PHEU) in the United States. The purpose of this study was to (1) estimate lifetime and past-year prevalence of IPV victimization and (2) examine correlates of IPV victimization by subtype (physical, psychological, and sexual) and severity (low, moderate, and severe).

METHODS

Data came from the sixth interview of an ongoing New York City-based longitudinal study of primarily Black and Latinx AYAPHIV and AYAPHEU. We examined 232 participants (142 PHIV; 90 PHEU) who had reported having been in at least 1 romantic relationship. We used logistic regression models to explore the association between IPV victimization outcomes and select sociodemographic, psychiatric, and environmental factors. Models were adjusted for age, gender, race, ethnicity, and HIV status.

RESULTS

IPV victimization prevalence was 84% for lifetime and 65% for the past year. There were no differences in IPV victimization prevalence by PHIV status. Having a recent substance use disorder, reporting higher levels of neighborhood stress, and being male were all positively associated with at least 1 IPV outcome; stronger familial relationships exhibited a protective effect.

CONCLUSIONS

The present study suggests that the prevalence of IPV victimization among AYAPHIV and AYAPHEU is exceedingly high that warrants targeted IPV screening and programming for this population.

Mental health, substance use, and risky sexual behaviors among women living with HIV

INTRODUCTION

Risky sexual behavior has been explored in women living with HIV (WLHIV) internationally but is not well studied in WLHIV in the United States (U.S.). This merits further investigation due to the negative reproductive and HIV health outcomes associated with risky sexual behavior, such as the increased risk for HIV transmission and infertility from sexually transmitted infections (STIs). The aims of this study are to (1) describe sexual behaviors in a cohort of WLHIV in Florida, (2) determine whether demographic characteristics, substance use, and mental health symptoms are associated with risky sexual behavior in a cohort of WLHIV in Florida, and (3) explore whether the relationship between substance use and mental health symptoms and risky sexual behavior differs in reproductive-age (age 18-49), compared to non-reproductive-age WLHIV (age 50+).

DESIGN

This was a cross-sectional analysis of data from a multisite cohort study done in Florida.

METHODS

Data were collected from a sample of 304 participants who were recruited into the Florida Cohort Study from 9 clinical and community sites in Florida between 2014 to 2017. The predictor variables of interest were mental health symptoms, substance use, and demographic variables. The outcome variable of interest was risky sexual behavior which was defined as reporting ≥1 of the following: (1) at least one STI diagnosis in the past 12 months, (2) two or more sexual partners in the past 12 months, or (3) any inconsistent condom use in the past 12 months. Descriptive statistics, bivariate analysis, and logistic regression (p < 0.1) were conducted on the variables of interest.

RESULTS

The mean age of the sample was 47.8 years, and approximately half (51.6%) of the sample was of reproductive-age. Reporting ≥1 risky sexual behavior was reported in over half (51.6%) of the reproductive-age WLHIV in the sample and 32% of the non-reproductive-age WLHIV in the sample. Binge drinking, alcohol-related problems, marijuana use, and age were all significantly associated with self-reporting ≥1 risky sexual behaviors in all WLHIV. Self-reporting binge drinking, marijuana use, and a high alcohol-related problems score respectively were associated with increased odds of self-reporting ≥1 risky sexual behavior in all WLHIV. Neither mental health symptoms nor race/ethnicity or education were significantly associated with self-reporting ≥1 risky sexual behavior in all WLHIV. Self-reporting severe anxiety symptoms and high alcohol-related problems scores respectively were associated with increased odds of self-reporting ≥1 risky sexual behavior only in reproductive-age WLHIV from the sample.

CONCLUSION

Marijuana use, binge drinking, and alcohol-related problems appear to have a relationship with risky sexual behavior in WLHIV regardless of age. Reproductive-age also appears to influence risky sexual behavior in WLHIV, and specific reporting severe anxiety symptoms and high alcohol-related problems in reproductive-age WLHIV increases the odds of engaging in risky sexual behavior.

CLINICAL SIGNIFICANCE

This study holds clinical significance for nurses and other clinicians working in reproductive health settings and clinics with WLHIV. Results indicate that it could be beneficial to do more screening for mental health symptoms (particularly anxiety) and alcohol use in younger reproductive-age WLHIV.

Stress, coping and the acceptability of mindfulness skills among pregnant and parenting women living with HIV in the United States: A focus group study

Pregnant and parenting women living with HIV (WLWH) face high levels of psychological stress and mental illness but lack tailored and acceptable psychosocial treatments. The research team sought to inform the adaptation of a mindfulness intervention for pregnant and parenting WLWH through focus groups exploring psychosocial treatment needs and mindfulness intervention preferences. The research team conducted focus groups with pregnant and parenting WLWH (n = 16) and case managers (n = 6) recruited from a community-based enhanced case management program. The research team utilised an iterative inductive approach to coding of the transcripts from these focus groups. Five themes emerged: stressors, signs of stress, coping, lack of access and acceptability of care, and motivation and trust in care engagement. These focus groups revealed a desire for a group intervention that could decrease isolation while protecting against involuntary disclosure of HIV status. Participants expressed openness to mindfulness skills for coping with stress. The focus group participants' preference for a non-stigmatising group intervention supports the potential of a mindfulness-based group intervention to reduce stress and improve the mental health of pregnant and parenting women living with HIV.

"Even if I'm undetectable, I just feel like I would die": a qualitative study to understand the psychological and socioeconomic impacts of the COVID-19 pandemic on women living with HIV (WLWH) in Chicago, IL

Background

The COVID-19 pandemic has affected the health and well-being of people worldwide, yet few studies have qualitatively examined its cumulative effects on ciswomen living with HIV (WLWH). We aimed to explore how the pandemic has impacted WLWH, including challenges related to HIV care, employment, finances, and childcare. We also investigated how HIV status and different psychosocial stressors affected their mental health.

Methods

We performed 25 semi-structured qualitative interviews with WLWH regarding the ways in which COVID-19 impacted their social determinants of health and physical well-being during the pandemic. 19 WLWH who received care at the University of Chicago Medicine (UCM) and 6 women who received care at Howard Brown Health, a federally qualified health center (FQHC) in Chicago, were interviewed remotely from June 2020 to April 2021. All interviews were audio recorded and transcribed. Interviews were thematically analyzed for commonalities regarding HIV-specific and general experiences of WLWH during the pandemic.

Results

The majority of participants reported COVID-19 impacted their HIV care, such as appointment cancellations and difficulties adhering to antiretroviral therapy. In addition to HIV care obstacles, almost all participants described perceived heightened vulnerability to or fear of COVID-19. The pandemic also affected the socioeconomic well-being of participants, with reported financial strains and employment disruptions. Some mothers took on additional childcare responsibilities, such as homeschooling. Increased mental health concerns and negative psychological effects from the social isolation associated with the pandemic were also experienced by most participants.

Conclusions

We gained invaluable insight into how WLWH were challenged by and adapted to the COVID-19 pandemic, including its destabilizing effects on their HIV care and mental health. Women described how they undertook additional childcare responsibilities during the pandemic and how their HIV status compounded their concerns (e.g., perceived heightened vulnerability to COVID-19). Strategies to better support WLWH in maintaining their overall health throughout the pandemic include childcare assistance, access to affordable mental health services, support groups, and education from HIV care providers. These findings have significant implications for examining future health crises through the perspective of potential gender inequalities.

Psychosocial health in pregnancy and postpartum among women living with - and without HIV and non-pregnant women living with HIV living in the Nordic countries - Results from a longitudinal survey study

BACKGROUND

The success of antiretroviral therapy has normalized pregnancy among women living with HIV (WWH) with a very low risk of perinatal transmission of HIV. Despite these advances, WWH still face complex medical and psychosocial issues during pregnancy and postpartum. The aim of this study was to assess differences in psychosocial health outcomes between pregnant WWH, non-pregnant WWH, and pregnant women without HIV, and further identify factors associated with probable depression in the third trimester and postpartum.

METHODS

In a longitudinal survey study, participants were included from sites in Denmark, Finland, and Sweden during 2019-2020. Data was collected in the 3rd trimester, 3 and 6 months postpartum using standardized questionnaires assessing depression, perceived stress, loneliness, and social support. Mixed regression models were used to assess changes over time within and between groups. Logistic regression models were used to identify factors associated with depression in pregnancy and postpartum.

RESULTS

A total of 47 pregnant WWH, 75 non-pregnant WWH, and 147 pregnant women without HIV were included. The prevalence of depression was high among both pregnant and non-pregnant WWH. There was no significant difference between pregnant and non-pregnant WWH in depression scores, perceived stress scores, or social support scores at any time point. Compared to pregnant women without HIV, pregnant WWH reported worse outcomes on all psychosocial scales. Social support and loneliness were associated with an increased odds of depressive symptoms in the adjusted analysis.

CONCLUSIONS

A high burden of adverse psychosocial outcomes was observed in both pregnant and non-pregnant women living with HIV compared to pregnant women without HIV. Loneliness and inadequate social support were associated with increased odds of depression in pregnancy and should be a focus in future support interventions.

Marijuana, Opioid, and Alcohol Use Among Pregnant and Postpartum Individuals Living With HIV in the US

Importance

Amid the opioid epidemic and evolving legal and social changes with marijuana, little is known about substance use among pregnant and postpartum people living with HIV.

Objectives

To evaluate trends in marijuana, alcohol, and opioid use during pregnancy and the first year postpartum among US people living with HIV and the differences in substance use based on marijuana legalization status.

Design, Setting, and Participants

Data from the Surveillance Monitoring for Antiretroviral Toxicities (SMARTT) study of the Pediatric HIV/AIDS Cohort Study were analyzed. SMARTT-enrolled, pregnant people living with HIV at 22 US sites from January 1, 2007, to July 1, 2019, with self-reported substance use data available in pregnancy, 1 year postpartum, or both were assessed.

Exposures

Calendar year and state marijuana legalization status.

Main Outcomes and Measures

The prevalence of any use of each of the following substances was calculated by calendar year, separately for pregnancy and postpartum: marijuana, alcohol, opioid, and concomitant alcohol and marijuana. Log binomial models were fit using general estimating equations to evaluate the mean annual change, accounting for repeat pregnancies. The study also evaluated differences in substance use by state recreational or medical marijuana legalization status.

Results

Substance use data were available for 2926 pregnancies from 2310 people living with HIV (mean [SD] age, 28.8 [6.1] years; 822 [28.1%] Hispanic, 1859 [63.5%] non-Hispanic Black, 185 [6.3%] White, 24 [0.8%] of more than 1 race, 24 [0.8%] of other race or ethnicity [individuals who identified as American Indian, Asian, or Native Hawaiian or other Pacific Islander], and 12 [0.4%] with unknown or unreported race or ethnicity). Between 2007 and 2019, marijuana use during pregnancy increased from 7.1% to 11.7%, whereas alcohol and opioid use in pregnancy were unchanged. Postpartum alcohol (44.4%), marijuana (13.6%), and concomitant alcohol and marijuana (10.0%) use were common; marijuana use increased from 10.2% to 23.7% from 2007 to 2019, whereas postpartum alcohol use was unchanged. The adjusted mean risk of marijuana use increased by 7% (95% CI, 3%-10%) per year during pregnancy and 11% (95% CI, 7%-16%) per year postpartum. Postpartum concomitant alcohol and marijuana use increased by 10% (95% CI, 5%-15%) per year. Differences in substance use were not associated with recreational legalization, but increased marijuana use was associated with medical marijuana legalization.

Conclusions and Relevance

In this cohort study, opioid use among pregnant people living with HIV remained stable, whereas marijuana use during pregnancy and postpartum increased over time and in states with legalized medical marijuana. These patterns of increasing marijuana use among pregnant and postpartum people living with HIV suggest that enhanced clinical attention is warranted, given the potential maternal and child health implications of substance use.

A multidimensional examination of psychological distress among Latina mothers with and without HIV

The Latino population is disproportionally affected by HIV in the United States. Latina women, in particular, have significantly higher rates of HIV diagnosis than their White counterparts. Latinas with HIV who are primary family caregivers face multidimensional challenges from caregiving demands to stressors related to chronic illness, acculturation, family functioning, and socioeconomic disparities, which may contribute to higher psychological distress than Latina mothers without HIV. However, to date, scant research has focused on the mental health needs of Latina mothers living with HIV (MLHs) and how these needs are similar or different to Latina mothers without HIV. Thus, using a multidimensional approach we: (a) examined the associations between HIV status, acculturation, family functioning, socioeconomic status, and psychological distress among Latina mothers and (b) identified how these associations differed between Latina mothers with and without HIV. Cross-sectional, self-reported data were obtained via face-to-face interviews from 221 Latina MLHs and 116 Latina neighborhood control mothers (NCMs) living without HIV in Los Angeles, California. Results from multivariate ordinary least square regressions showed that higher acculturation was associated with psychological distress among MLHs, whereas higher levels of family conflict and education were associated with psychological distress among NCMs. Findings highlight the differential mental health needs of Latina mothers based on HIV status. Our study findings provide social work implications for culturally responsive interventions that can address multidimensional stressors experienced by marginalized Latinas MLHs.

Mental Health in Women Living With HIV: The Unique and Unmet Needs

Women living with HIV (WLWH) experience depression, anxiety, and posttraumatic stress symptoms at higher rates than their male counterparts and more often than HIV-unaffected women. These mental health issues affect not only the well-being and quality of life of WLWH, but have implications for HIV management and transmission prevention. Despite these ramifications, WLWH are under-treated for mental health concerns and they are underrepresented in the mental health treatment literature. In this review, we illustrate the unique mental health issues faced by WLWH such as a high prevalence of physical and sexual abuse histories, caregiving stress, and elevated internalized stigma as well as myriad barriers to care. We examine the feasibility and outcomes of mental health interventions that have been tested in WLWH including cognitive behavioral therapy, mindfulness-based interventions, and supportive counseling. Future research is required to address individual and systemic barriers to mental health care for WLWH.

Neurodevelopment of HIV-Exposed Uninfected Infants Born to Women With Perinatally Acquired HIV in the United States

BACKGROUND

Lifelong HIV and antiretroviral therapy may confer neurodevelopmental risk on the children of women with perinatally acquired HIV infection (PHIV).

SETTING

We analyzed data from HIV-exposed uninfected (HEU) infants born to women with PHIV vs. non-perinatally acquired HIV (NPHIV) enrolled in the Surveillance Monitoring for Antiretroviral Therapy Toxicities (SMARTT) study.

METHODS

Using the Bayley Scales of Infant and Toddler Development, third Ed. (Bayley-III), we compared neurodevelopmental outcomes at the age of 1 year in HEU infants born to women with PHIV vs. NPHIV. Those with valid Bayley-III data at the age of 1 year and a mother born after 1982 were included. Cognitive, language, and motor domains were assessed as continuous composite scores. Linear mixed effects models were fit to estimate the mean difference in Bayley-III scores between groups, adjusting for confounders.

RESULTS

Five hundred fifty women with HIV gave birth to 678 HEU children (125 and 553 born to women with PHIV and NPHIV, respectively). Mean scores for each of the Bayley-III domains were not significantly different between infants born to women with PHIV vs. NPHIV in unadjusted models. After adjustment, infants of women with PHIV had lower language (91.9 vs. 94.8, P = 0.05) and motor (93.7 vs. 96.8, P = 0.03) composite scores, but no differences in cognitive composite scores.

CONCLUSIONS

Cognitive domain outcomes of infants born to women with PHIV vs. NPHIV are reassuring. Differences in early language and motor functioning, while of modest clinical significance, highlight the importance of long-term monitoring of neurodevelopment in children of women with PHIV.

All-cause mortality among males living with and without HIV initiating long-term opioid therapy, and its association with opioid dose, opioid interruption and other factors

BACKGROUND

While the relationship between long-term opioid therapy (LTOT) dose and overdose is well-established, LTOT's association with all-cause mortality is less understood, especially among people living with HIV (PLWH). There is also limited information regarding the association of LTOT cessation or interruption with mortality.

METHODS

Among PLWH and matched uninfected male veterans in care, we identified those who initiated LTOT. Using time-updated cox regression, we examined the association between all-cause mortality, unnatural death, and overdose, and opioid use categorized as 1-20 (reference group), 21-50, 51-90, and ≥ 91 mg morphine equivalent daily dose (MEDD).

RESULTS

There were 22,996 patients on LTOT, 6,578 (29 %) PLWH and 16,418 (71 %) uninfected. Among 5,222 (23 %) deaths, 12 % were unnatural deaths and 6 % overdoses. MEDD was associated with risk of all 3 outcomes; compared to patients on 1-20 mg MEDD, adjusted risk for all-cause mortality monotonically increased (Hazard Ratios (HR) [95 % CI] for 21-50 mg MEDD = 1.36 [1.21, 1.52], 51-90 mg MEDD = 2.06 [1.82, 2.35], and ≥ 91 mg MEDD = 3.03 [2.71, 3.39]). Similar results were seen in models stratified by HIV. LTOT interruption was also associated with all-cause, unnatural, and overdose mortality (HR [95 % CI] 2.30 [2.09, 2.53], 1.47 [1.13, 1.91] and 1.52 [1.04, 2.23], respectively).

CONCLUSIONS

Among PLWH and uninfected patients on LTOT we observed a strong dose-response relationship with all 3 mortality outcomes. Opioid risk mitigation approaches should be expanded to address the potential effects of higher dose on all-cause mortality in addition to unnatural and overdose fatalities.

Psychiatric trajectories across adolescence in perinatally HIV-exposed youth: the role of HIV infection and associations with viral load

OBJECTIVE

Identify factors associated with trajectories of psychiatric disorder among 340 adolescents and young adults (AYA) living with perinatal HIV infection (PHIV) and perinatal HIV-exposure but not infection (PHEU).

DESIGN

Longitudinal cohort study of AYA in New York City, 9-16 years at enrollment.

METHODS

We used multivariate longitudinal latent class analysis to identify trajectories of psychiatric disorder, and logistic regression to examine predictors of trajectories (e.g. PHIV status) and associations between trajectories and viremia in young adulthood (AYA with PHIV only).

RESULTS

Among all AYA, we identified three psychiatric trajectories: relatively 'low disorder' (63%), 'consistent anxiety' (26%), and 'escalating comorbidity' (11%). Compared with AYA with 'low disorder', AYA with 'escalating comorbidity' were significantly older, reported more neighborhood stress, and lived with a caregiver with alcohol use disorder, whereas AYA with 'consistent anxiety' were more likely female individuals. Although we found no statistically significant HIV status differences, among AYA with PHIV, nearly half (48%) were viremic in young adulthood, with higher odds of viremia among AYA with 'escalating comorbidity' (OR: 3.88, 95% CI: 0.93-16.26) and 'consistent anxiety' (OR: 2.41, 95% CI: 1.011-5.75) compared with 'low disorder'.

CONCLUSION

Despite significant adversity, AYA with PHIV and PHEU had relatively low prevalence of psychiatric disorder over time, although one-third had consistent or escalating psychiatric disorders. Among AYA with PHIV, psychiatric trajectories were associated with viremia in young adulthood. Given the growing population of AYA living with PHIV and PHEU worldwide, addressing the substantial and evolving mental health needs of both groups as they reach young adulthood is critical.

Global estimate of the prevalence of post-traumatic stress disorder among adults living with HIV: a systematic review and meta-analysis

OBJECTIVES

Although people living with HIV (PLWH) have been disproportionately affected by post-traumatic stress disorder (PTSD), the global prevalence of PTSD among PLWH is unknown. This study aimed to systematically review the prevalence of PTSD among PLWH worldwide and explore variation in prevalence across sociodemographic and methodological factors.

DESIGN

A meta-analysis using a random-effects model was conducted to pool the prevalence estimated from individual studies, and subgroup analyses were used to analyse heterogeneities.

SETTING, PARTICIPANTS AND MEASURES

Observational studies providing PTSD prevalence data in an adult HIV population were searched from January 2000 to November 2019. Measurements were not restricted, although the definition of PTSD had to align with the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases diagnostic criteria.

RESULTS

A total of 38 articles were included among 2406 records identified initially. The estimated global prevalence of PTSD in PLWH was 28% (95% CI 24% to 33%). Significant heterogeneity was detected in the proportion of PLWH who reported PTSD across studies, which was partially explained by geographic area, population group, measurement and sampling method (p<0.05).

CONCLUSION

PTSD among PLWH is common worldwide. This review highlights that PTSD should be routinely screened for and that more effective prevention strategies and treatment packages targeting PTSD are needed in PLWH.

Modelling the impact of maternal HIV on uninfected children: correcting current estimates

A mathematical model, populated primarily with data from South Africa, was developed to model the numbers of children affected by maternal HIV, and the number who will experience long-term negative developmental consequences. A micro-simulation model generated two scenarios. The first simulated a cohort of women whose HIV status mimicked that of a target population, and mother-child dyads by way of age- and disease-specific fertility rates. Factors defining risk were used to characterize the simulated environment. The second scenario simulated mother-child dyads without maternal HIV. In the first scenario an estimated 26% of children are orphaned, compared to 10% in the absence of HIV. And a further 19% of children whose mother is alive when they turn 18 are affected by maternal HIV. School drop-out among all children increased by 4 percentage points because of maternal HIV, similarly population level estimates of abuse and negative mental health outcomes are elevated. Relative to HIV unaffected children, HIV affected have elevated risk of poor outcomes, however not all will suffer long-term negative consequences. Interventions to protect children should target the proportion of children at risk, while interventions to mitigate harm should target the smaller proportion of children who experience long-term negative outcomes..

Study protocol: becoming and being a mother living with HIV - a multicentre longitudinal mixed methods study among pregnant women living with HIV, non-pregnant women living with HIV and pregnant women not living with HIV in a high-income setting (the 2B MOM study)

INTRODUCTION

The success of combination antiretroviral therapy has decreased the risk of perinatal HIV transmission and normalised pregnancy in women living with HIV (WLWH). Despite these advances, WLWH still face complex medical and psychosocial issues during pregnancy and postpartum, and there is a gap of knowledge on the experiences of becoming and being a mother living with HIV in today's context. The overall aim of this study is to investigate psychosocial outcomes and experiences of WLWH in Scandinavia during pregnancy and early motherhood.

METHODS AND ANALYSIS

This is a multicentre longitudinal convergent mixed methods study consisting of a quantitative survey study, a qualitative interview study and a mixed methods analysis. The survey study aims to examine psychosocial outcomes of WLWH across the pregnancy - postpartum trajectory. Participants are pregnant WLWH living in Scandinavia. Two control groups of HIV-negative pregnant women and non-pregnant WLWH are also included. Data is collected in the third trimester, 3 and 6 months postpartum using standardised questionnaires. Statistical analysis will assess changes over time and identify predictors of adverse outcomes. The interview study seeks to understand experiences of pregnancy and becoming a mother while living with HIV. Pregnant WLWH who are enrolled in the survey study will be asked to participate in individual interviews in the third trimester and 6 months postpartum. Data will be analysed using narrative analysis. The survey and interview results will be merged in a mixed methods analysis to assess confirmation, expansion or discordance between the data sets.

ETHICS AND DISSEMINATION

Approval from the Danish Data Protection Agency (VD-2018-253), and the Finnish and Swedish Ethics Committees have been obtained (HUS/1330/2019 and Dnr: 2019-04451, respectively). Study results will be disseminated to patient organisations, through publications in peer-reviewed journals and at scientific conferences.

No. 354-Canadian HIV Pregnancy Planning Guidelines

OBJECTIVE

The objective of the Canadian HIV Pregnancy Planning Guidelines is to provide clinical information and recommendations for health care providers to assist Canadians affected by HIV with their fertility, preconception, and pregnancy planning decisions. These guidelines are evidence- and community-based and flexible and take into account diverse and intersecting local/population needs based on the social determinants of health.

INTENDED OUTCOMES

EVIDENCE: Literature searches were conducted by a librarian using the Medline, Cochrane Central Register of Controlled Trials (CENTRAL), and Embase databases for published articles in English and French related to HIV and pregnancy and HIV and pregnancy planning for each section of the guidelines. The full search strategy is available upon request.

VALUES

The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the SOGC under the leadership of the principal authors, and recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care and through use of the Appraisal of Guidelines Research and Evaluation instrument for the development of clinical guidelines.

BENEFITS, HARMS, AND COSTS

Guideline implementation should assist the practitioner in developing an evidence-based approach for the prevention of unplanned pregnancy, preconception, fertility, and pregnancy planning counselling in the context of HIV infection.

VALIDATION

These guidelines have been reviewed and approved by the Infectious Disease Committee and the Executive and Council of the SOGC.

SPONSOR

Canadian Institutes of Health Research Grant Planning and Dissemination grant (Funding Reference # 137186), which funded a Development Team meeting in 2016.

RECOMMENDATIONS

The protective roles of ethnic identity and community cohesion on substance use among Black women experiencing adversity

This study employs a strengths-based approach to explore associations of ethnic identity and community cohesion with substance use among Black women experiencing adversity. Black women (N = 107; M_age = 34.2, SD = 7.7) completed interviews about their sociodemographics, HIV status, intimate partner violence exposure, ethnic identity, community connectedness, and substance use. Hierarchical linear regression analysis was used to examine associations of ethnic identity and community cohesion with substance use, accounting for age and socioeconomic status. The overall model was significant, with greater ethnic identity (β = -.25, p < .01) and more community cohesion (β = -.29, p < .01) associated with lower substance use. Findings highlight the value of contextual factors in substance use prevention among Black women.

Characteristics, Prevention, and Management of Cardiovascular Disease in People Living With HIV: A Scientific Statement From the American Heart Association

As early and effective antiretroviral therapy has become more widespread, HIV has transitioned from a progressive, fatal disease to a chronic, manageable disease marked by elevated risk of chronic comorbid diseases, including cardiovascular diseases (CVDs). Rates of myocardial infarction, heart failure, stroke, and other CVD manifestations, including pulmonary hypertension and sudden cardiac death, are significantly higher for people living with HIV than for uninfected control subjects, even in the setting of HIV viral suppression with effective antiretroviral therapy. These elevated risks generally persist after demographic and clinical risk factors are accounted for and may be partly attributed to chronic inflammation and immune dysregulation. Data on long-term CVD outcomes in HIV are limited by the relatively recent epidemiological transition of HIV to a chronic disease. Therefore, our understanding of CVD pathogenesis, prevention, and treatment in HIV relies on large observational studies, randomized controlled trials of HIV therapies that are underpowered to detect CVD end points, and small interventional studies examining surrogate CVD end points. The purpose of this document is to provide a thorough review of the existing evidence on HIV-associated CVD, in particular atherosclerotic CVD (including myocardial infarction and stroke) and heart failure, as well as pragmatic recommendations on how to approach CVD prevention and treatment in HIV in the absence of large-scale randomized controlled trial data. This statement is intended for clinicians caring for people with HIV, individuals living with HIV, and clinical and translational researchers interested in HIV-associated CVD.

Treatment adherence among mothers living with HIV in the US: a scoping review

The purpose of this review was to understand research about treatment adherence among mothers in the US who are living with HIV. Treatment adherence included Antiretroviral Therapy and attending medical care appointments. A scoping review was conducted, and five peer-reviewed databases were searched with predetermined search terms for the period of 2006-2016. Thirty-five articles were identified for the review, including (n = 17) quantitative studies, (n = 6) qualitative studies, (n = 4) reviews and (n = 8) conceptual/theoretical articles. The most frequently identified theme among the articles was prevention of mother-to-child transmission of HIV. Authors disagreed about whether parenting children was a burden or a source of strength for the affected women. Implications identified for practice included a more longitudinal approach to care for mothers, rather than focusing narrowly on prevention of transmission to infants.

Alcohol use, mental health, and parenting practices among HIV-positive mothers

Mothers living with HIV (MLH) must balance childcare, their illness, and oftentimes other mental health problems/stressors. It is important to understand how a maladaptive coping strategy, (alcohol use) is linked to poorer parenting practices. We assessed the relationship between mental health/coping (anxiety, depression, alcohol use, social support) and parenting/family dimensions (communication, parenting style/stress, family routines/cohesion) among 152 MLH. Mothers reporting more psychiatric symptoms and less social support also reported poorer parenting practices and interactions. Further, MLH who used more alcohol reported less parenting involvement and fewer family interactions. Alcohol use, even at subclinical levels, can negatively impact the parent-child relationship.

Mental Health Diagnoses, Symptoms, and Service Utilization in US Youth with Perinatal HIV Infection or HIV Exposure

Youth perinatally HIV infected (PHIV) or HIV exposed, but uninfected (PHEU), are aging into adolescence and adulthood with multiple complex risk factors for mental health (MH) problems and poor MH treatment utilization. Our aims were to estimate prevalence of MH diagnoses, clinically significant symptoms, and MH treatment utilization among youth with PHIV and among PHEU youth, 10-22 years old. We also aimed to identify correlates of diagnoses and treatment utilization. Analyses of data from standardized interviews, behavioral assessments, and chart review of 551 youth revealed that 36% had a previous or current MH diagnosis, with no significant HIV status group differences. Prevalence of clinically significant symptoms was 15% for both groups, of whom a third had no diagnosis, and half were not receiving treatment. Among youth with a current MH diagnosis, those with PHIV had greater utilization of services than PHEU youth (67% vs. 51%; p = 0.04). Factors associated with MH diagnoses and/or treatment utilization included caregiver characteristics, age and sex of child, HIV status, and stressful life events. Prevalence of MH diagnoses was higher than in the general population, but lower than in similar perinatally HIV-exposed cohorts, with some unmet service needs, particularly in PHEU youth. Family characteristics warrant careful consideration in early diagnosis and treatment of MH problems among youth affected by HIV.

High-risk behaviours, and their associations with mental health, adherence to antiretroviral therapy and HIV parameters, in HIV-positive men who have sex with men

Objectives

To investigate the patterns and frequency of multiple risk behaviours (alcohol, drugs, smoking, higher risk sexual activity) among men who have sex with men (MSM) living with HIV.

Methods

Cross sectional study.

Results

147 out of 819 HIV‐positive MSM exhibited a high‐risk phenotype (defined as >3 of smoking, excess alcohol, sexually transmitted infection and recent recreational drug use). This phenotype was associated with younger age, depressive symptoms and <90% adherence in multivariable logistic regression.

Conclusion

In a cohort of MSM, a small, but significant proportion exhibited multiple concurrent risk behaviours.

Prevalence, Comorbidity, and Correlates of Psychiatric and Substance Use Disorders and Associations with HIV Risk Behaviors in a Multisite Cohort of Women Living with HIV

We used the World Health Organization’s Composite International Diagnostic Interview to determine the prevalence, comorbidity, and correlates of lifetime and 12-month behavioral health disorders in a multisite cohort of 1027 women living with HIV in the United States. Most (82.6%) had one or more lifetime disorders including 34.2% with mood disorders, 61.6% with anxiety disorders, and 58.3% with substance use disorders. Over half (53.9%) had at least one 12-month disorder, including 22.1% with mood disorders, 45.4% with anxiety disorders, and 11.1% with substance use disorders. Behavioral health disorder onset preceded HIV diagnosis by an average of 19 years. In multivariable models, likelihood of disorders was associated with women’s race/ethnicity, employment status, and income. Women with 12-month behavioral health disorders were significantly more likely than their counterparts to engage in subsequent sexual and substance use HIV risk behaviors. We discuss the complex physical and behavioral health needs of women living with HIV.

Incidence and Persistence of Depression Among Women Living with and Without HIV in South Africa: A Longitudinal Study

Depression and trauma are common among women living with HIV. This is the first study to track the longitudinal course of depression and examine the relationship between depression and trauma over time among women in South Africa. HIV-infected and uninfected women (N = 148) were assessed at baseline and one year later. Results of a path analysis show the multi-directional and entwined influence of early life stress, other life-threatening traumas across the lifespan, depression and PTSD over the course of HIV. We also observed higher rates of depressive symptomatology and more persistent cases among infected women compared to uninfected women, as well as a more consistent and enduring relationship between childhood trauma and depression among women living with HIV. The present study is unique in documenting the course of untreated depression and PTSD in women with and without HIV infection with a high prevalence of early childhood trauma.

Prevalence and Predictors of Substance Use Disorders Among HIV Care Enrollees in the United States

Prior efforts to estimate U.S. prevalence of substance use disorders (SUDs) in HIV care have been undermined by caveats common to single-site trials. The current work reports on a cohort of 10,652 HIV-positive adults linked to care at seven sites, with available patient data including geography, demography, and risk factor indices, and with substance-specific SUDs identified via self-report instruments with validated diagnostic thresholds. Generalized estimating equations also tested patient indices as SUD predictors. Findings were: (1) a 48 % SUD prevalence rate (between-site range of 21-71 %), with 20 % of the sample evidencing polysubstance use disorder; (2) substance-specific SUD rates of 31 % for marijuana, 19 % alcohol, 13 % methamphetamine, 11 % cocaine, and 4 % opiate; and (3) emergence of younger age and male gender as robust SUD predictors. Findings suggest high rates at which SUDs occur among patients at these urban HIV care sites, detail substance-specific SUD rates, and identify at-risk patient subgroups.

Prevalence, Recurrence, and Incidence of Current Depressive Symptoms among People Living with HIV in Ontario, Canada: Results from the Ontario HIV Treatment Network Cohort Study

Introduction

Current studies of depression among people living with HIV focus on describing its point prevalence. Given the fluctuating nature of depression and its profound impacts on clinical and quality-of-life outcomes, this study aimed to examine the prevalence, recurrence and incidence of current depressive symptoms and its underlying catalysts longitudinally and systematically among these individuals.

Methods

We conducted a prospective cohort study between October 1, 2007 and December 31, 2012 using longitudinal linked data sources. Current depressive symptoms was identified using the Centre for Epidemiologic Studies Depression Scale or the Kessler Psychological Distress Scale, first at baseline and again during follow-up interviews. Multivariable regressions were used to characterize the three outcomes.

Results

Of the 3,816 HIV-positive participants, the point prevalence of depressive symptoms was estimated at 28%. Of the 957 participants who were identified with depressive symptoms at baseline and who had at least two years of follow-up, 43% had a recurrent episode. The cumulative incidence among 1,745 previously depressive symptoms free participants (at or prior to baseline) was 14%. During the five-year follow-up, our multivariable models showed that participants with greater risk of recurrent cases were more likely to feel worried about their housing situation. Participants at risk of developing incident cases were also likely to be younger, gay or bisexual, and unable to afford housing-related expenses.

Conclusions

Depressive symptoms are prevalent and likely to recur among people living with HIV. Our results support the direction of Ontario’s HIV/AIDS Strategy to 2026, which addresses medical concerns associated with HIV (such as depression) and the social drivers of health in order to enhance the overall well-being of people living with or at risk of HIV. Our findings reinforce the importance of providing effective mental health care and demonstrate the need for long-term support and routine management of depression, particularly for individuals at high risk.

The Association Between Post-traumatic Stress Disorder and Markers of Inflammation and Immune Activation in HIV-Infected Individuals With Controlled Viremia

BACKGROUND

Post-traumatic stress disorder (PTSD) may be associated with chronic immune dysregulation and a proinflammatory state. Among HIV-infected individuals, PTSD is associated with greater morbidity and mortality, but the association with immune dysfunction has not been evaluated. This study explores the association between PTSD and selected markers of inflammation and immune activation in a cohort of HIV-infected, virally-suppressed individuals.

METHODS

HIV-infected adults who were virologically controlled on antiretroviral medications were recruited through a screening protocol for studies of HIV-related neurocognitive disorders. Each participant underwent blood draws, urine toxicology screen, and completed the Client Diagnostic Questionnaire, a semistructured psychiatric interview.

RESULTS

Of 114 eligible volunteers, 72 (63%) were male, 77 (68%) African American, and 34 (30%) participants met criteria for PTSD. Participants with PTSD were more likely to be current smokers (79%) than those without (60%) (p = 0.05). The PTSD cohort had significantly higher total white blood cell counts (5318 and 6404 cells/uL, p = 0.03), absolute neutrophil count (2767 and 3577 cells/uL, p = 0.02), CD8% (43 and 48, p = 0.05), and memory CD8% (70 and 78%, p = 0.04); lower naïve CD8% (30 and 22%, p = 0.04) and higher rate of high-sensitivity C-reactive protein >3mg/L (29 and 20, p = 0.03).

DISCUSSION

A high prevalence of PTSD was identified in this cohort of HIV-infected adults who were virally suppressed. These results suggest that PTSD may be associated with immune dysregulation even among antiretroviral therapy-adherent HIV-infected individuals.

Exposure to Violence and Virologic and Immunological Outcomes Among Youth With Perinatal HIV in the Pediatric HIV/AIDS Cohort Study

PURPOSE

Exposure to violence in childhood has been linked to adverse health outcomes. Little is known about the prevalence and relationship of youth and caregiver violence exposure to clinical outcomes among youth with perinatal human immunodeficiency virus (HIV) infection (PHIV). We evaluated associations of youth and caregiver violence exposure with unsuppressed viral load (VL) (HIV RNA > 400 copies/mL) and CD4% <25% among 8- to 15-year-old participants with PHIV in the Pediatric HIV/AIDS Cohort Study Adolescent Master Protocol.

METHODS

Annual clinical examination, record abstraction, and interview data were collected, including youth report of recent exposure to violence and caregivers' self-report of being assaulted/abused in adulthood. Multivariable logistic regression methods were used to calculate adjusted odds ratios for unsuppressed VL and CD4% <25%, controlling for sociodemographic characteristics.

RESULTS

Among 268 youth with PHIV (53% girls, mean age 12.8 years, 21% white, 42% with household income <$20,000/year), 34% reported past year violence exposure; 30% had a caregiver who reported being assaulted in adulthood. One quarter of youth (24%) had unsuppressed VL and 22% had CD4% <25%. Youth who were exposed to violence in the past year versus those who were not had elevated odds of unsuppressed VL. Youth with indirect exposure to violence in the past year versus those without had elevated odds of unsuppressed VL and CD4% <25% in adjusted models.

CONCLUSIONS

Youth with PHIV report a high prevalence of recent violence exposure, which was associated with poor virologic and immunologic outcomes. Reducing violence and providing support to youth with violence exposure and PHIV may improve health outcomes.