Ethnic inequalities in mental health and socioeconomic status among older women living with HIV: results from the PRIME Study

Investigation into the psychological impact of the COVID-19 pandemic for people living with HIV

BACKGROUND

People living with HIV (PLWH) report high levels of anxiety. This study assessed the prevalence of COVID-19-related anxiety in PLWH.

METHODS

Participants were recruited from two UK HIV clinics (01/03/2020 - 30/05/2022) and asked to complete the Coronavirus Anxiety Scale. The proportion with scores ≥9 (cut-off for dysfunctional pandemic-related anxiety) and ≥1 (reporting of any pandemic-related anxiety) were analysed.

RESULTS

115 PLWH were included, predominantly identifying as male (83.5%, n = 96), white (58.3%, n = 67) and reporting post-secondary education (82.6%, n = 95), with a median age of 51 years (range 22-93). Median CAS score was 0, with 4.4% scoring ≥9 (n = 5). More women scored ≥9 than men (16.7% (n = 3) and 2.1% (n = 2) respectively). Black African (13.6%, n = 3) and Other Ethnic Minority PLWH (25%, n = 2) had a greater proportion of scores ≥9 than White/Asian PLWH (both 0%). SARS-CoV-2 exposure was associated with scores greater than 1 but not greater than 9. CAS score was not associated with lower CD4 (<350 cells/mm3), detectable HIV viral load (≥50 copies/ml), or a history of pre-pandemic anxiety.

CONCLUSIONS

Pandemic-related anxiety was low, but we identified a sub-population reporting dysfunctional pandemic related anxiety. Future work should further investigate the psychological impact of the pandemic on this group.

Study protocol: the ILANA study - exploring optimal implementation strategies for long-acting antiretroviral therapy to ensure equity in clinical care and policy for women, racially minoritised people and older people living with HIV in the UK - a qualitative multiphase longitudinal study design

INTRODUCTION

Cabotegravir and rilpivirine (CAB+RPV long-acting (LA)) is recommended as a treatment for HIV-1 allowing people living with HIV to receive 2 monthly injectable treatment, rather than daily pills. Providing injectable therapy in a system designed to provide and manage study participants on oral treatments poses logistical challenges namely how resources are used to accommodate patient preference within constrained health economies with capacity limitations. In this pragmatic multicentre study, we aim to understand the implementation of CAB-RPV-LA administration in two settings via mixed methods to explore perspectives of participants and the clinical team delivering CAB+RPV LA.

METHODS AND ANALYSIS

Women, racially minoritised people and older people are chronically under-represented in HIV clinical trials so the ILANA trial has set recruitment caps to ensure recruitment of 50% women, 50% ethnically diverse people and 30% over 50 years of age to include a more representative study population. Using a mixed-methods approach, the primary objective is to identify and evaluate the critical implementation strategies for CAB+RPV LA in both hospital and community settings. Secondary objectives include evaluating feasibility and acceptability of CAB+RPV LA administration at UK clinics and community settings from the perspective of HIV care providers, nurses and representatives at community sites, evaluating barriers to implementation, the utility of implementation strategies and adherence.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Health Research Authority Research Ethics Committee (REC reference: 22/PR/0318). The dissemination strategy has been formulated with the SHARE Collaborative Community Advisory Board to maximise the impact of this work on clinical care and policy. This strategy draws on and leverages existing resources within the participating organisations, such as their academic infrastructure, professional relationships and community networks. The strategy will leverage the Public Engagement Team and press office to support dissemination of findings.

TRIAL REGISTRATION NUMBER

NCT05294159.

Mental health and adherence to antiretroviral therapy among Mexican people living with HIV during the COVID-19 pandemic

BACKGROUND

The mental health and medical follow-up of people living with HIV (PLWH) have been disrupted by the COVID-19 pandemic. The objectives of this study were to assess anxiety, depression and substance use in Mexican PLWH during the pandemic; to explore the association of these symptoms with adherence to antiretroviral therapy (ART), and to compare patients with and without vulnerability factors (low socioeconomic level, previous psychological and/or psychiatric treatment).

METHODS

We studied 1259 participants in a cross-sectional study, PLWH receiving care at the HIV clinic in Mexico City were contacted by telephone and invited to participate in the study. We included PLWH were receiving ART; answered a structured interview on sociodemographic data and adherence to ART; and completed the psychological instruments to assess depressive and anxiety symptoms and substance use risk. Data collection was performed from June 2020 to October 2021.

RESULTS

84.7% were men, 8% had inadequate ART adherence, 11% had moderate-severe symptoms of depression, and 13% had moderate-severe symptoms of anxiety. Adherence was related to psychological symptoms (p < 0.001). Vulnerable patients were more likely to be women, with low educational level and unemployed (p < 0.001).

CONCLUSIONS

It is important to address mental health of PLWH during the COVID-19 pandemic, with special attention to the most vulnerable individuals. Future studies are needed to understand the relationship between mental health and ART adherence.

Prevalence, severity, and risk factors of disability among adults living with HIV accessing routine outpatient HIV care in London, United Kingdom (UK): A cross-sectional self-report study

BACKGROUND

The study objectives were to measure disability prevalence and severity, and examine disability risk factors, among adults living with HIV in London, United Kingdom (UK).

METHODS

Self-reported questionnaires were administered: World Health Organization Disability Assessment Schedule 2.0 (WHODAS), HIV Disability Questionnaire (HDQ), Equality Act disability definition (EADD), and demographic questionnaire. We calculated proportion (95% Confidence Interval; CI) of "severe" and "moderate" disability measured using EADD and WHODAS scores ≥2 respectively. We measured disability severity with HDQ domain severity scores. We used demographic questionnaire responses to assess risk factors of "severe" and "moderate" disability using logistic regression analysis, and HDQ severity domain scores using linear regression analysis.

RESULTS

Of 201 participants, 176 (87.6%) identified as men, median age 47 years, and 194 (96.5%) virologically suppressed. Severe disability prevalence was 39.5% (n = 79/201), 95% CI [32.5%, 46.4%]. Moderate disability prevalence was 70.5% (n = 141/200), 95% CI [64.2%, 76.8%]. Uncertainty was the most severe HDQ disability domain. Late HIV diagnosis was a risk factor for severe disability [Odds Ratio (OR) 2.71; CI 1.25, 5.87]. Social determinants of health, economic inactivity [OR 2.79; CI 1.08, 7.21] and receiving benefits [OR 2.87; CI 1.05, 7.83], were risk factors for "severe" disability. Economic inactivity [OR 3.14; CI 1.00, 9.98] was a risk factor for "moderate" disability. Economic inactivity, receiving benefits, and having no fixed abode were risk factors (P≤0.05) for higher HDQ severity scores in physical, mental and emotional, difficulty with day-to-day activities, and challenges to social participation domains. Personal factors, identifying as a woman and being aged <50 years, were risk factors (P≤0.05) for higher HDQ severity scores in mental and emotional, uncertainty, and challenges with social participation domains.

CONCLUSIONS

People living with well-controlled HIV in London UK experienced multi-dimensional and episodic disability. Results help to better understand the prevalence, severity, and risk factors of disability experienced by adults living with HIV, identify areas to target interventions, and optimise health and functioning.

From crisis to crisis: impacts of the COVID-19 pandemic on people living with HIV and HIV/AIDS service organizations in Indiana

BACKGROUND

The COVID-19 pandemic thrust people living with HIV (PLWH) and HIV/AIDS service organizations into an environment ripe with uncertainty. This study examined Indiana HIV/AIDS service provider perceptions of how COVID-19 affected the overall health and access to care of their clients, and how the organizations prepared for, adapted, and responded to the needs of PLWH during the pandemic.

METHODS

Guided by the socioecological model, fifteen semi-structured interviews were conducted with ten different HIV/AIDS service organizations across the state of Indiana.

RESULTS

Despite the profound disruptions experienced by HIV programs, HIV/AIDS service organizations responded quickly to the challenges posed by the COVID-19 pandemic through myriad innovative strategies, largely informed by prior experiences with the HIV epidemic.

CONCLUSIONS

The lessons provided by HIV/AIDS service organizations are invaluable to informing future pandemic response for PLWH. Service delivery innovations in response to the COVID-19 crisis may provide insights to improve HIV care continuity strategies for vulnerable populations far beyond the pandemic.

From Crisis To Crisis: Impacts Of The COVID-19 Pandemic On People Living With HIV And AIDS Service Organizations In Indiana

Background: The COVID-19 pandemic thrust people living with HIV (PLWH) and HIV/AIDS service organizations into an environment ripe with uncertainty. This study examined Indiana AIDS services provider perceptions of how COVID-19 affected the overall health and access to care of their clients, and how the organizations prepared for, adapted, and responded to the needs of PLWH during the pandemic. Methods: Guided by the socioecological model, fifteen semi-structured interviews were conducted with ten different HIV/AIDS service organizations across the state of Indiana. Results: Despite the profound disruptions experienced by HIV programs, HIV/AIDS service organizations responded quickly to the challenges posed by the COVID-19 pandemic through myriad innovative strategies, largely informed by prior experiences with the HIV epidemic. Conclusions: The lessons provided by HIV/AIDS service organizations are invaluable to informing future pandemic response for PLWH. Service delivery innovations in response to the COVID-19 crisis may provide insights to improve HIV care continuity strategies for vulnerable populations far beyond the pandemic.

Association between health-related quality of life and menopausal status and symptoms in women living with HIV aged 45-60 years in England: An analysis of the PRIME study

Objectives:

The aim of this study was to compare the health-related quality of life between mid-life women with HIV and the general population and to investigate the association between health-related quality of life and menopausal (1) status and (2) symptoms among women with HIV.

Methods:

Cross-sectional data of women with HIV aged 45–60 years from the Positive Transitions Through the Menopause Study. Health-related quality of life was assessed using the Euroqol questionnaire with utility scores categorizing health as perfect (score = 1.00), sub-optimal (0.75–0.99) or poor (< 0.75). Scores were compared between Positive Transitions Through the Menopause study participants and women (aged 45–59 years) from the Health Survey for England. Associations between health-related quality of life and menopausal status/symptoms in Positive Transitions Through the Menopause participants were assessed using a multivariable two-part regression model, the results of which are combined to produce a single marginal effect.

Results:

In total, 813 women from the Positive Transitions Through the Menopause study were included (median age 49 (interquartile range: 47–53) years); the majority were of Black African ethnicity (72.2%). Overall, 20.9%, 43.7% and 35.3% of women were pre-, peri- and post-menopausal, respectively, and 69.7% experienced mild/moderate/severe menopausal symptoms. Approximately, 40% reported perfect health, 22.1% sub-optimal health and 39.0% poor health, similar to women from the Health Survey for England (perfect health: 36.9%, sub-optimal health: 25.2%, poor health: 37.9%). In multivariable models, we found an association between health-related quality of life and peri-menopausal status (marginal effect: 0.07 (0.02, 0.12)); however, the association with post-menopausal status was attenuated (marginal effect: 0.01 (–0.05, 0.06)). There remained a strong association between lower utility scores and moderate (marginal effect: 0.16 (0.11, 0.20)) and severe (marginal effect: 0.32 (0.27, 0.39)) menopausal symptoms.

Conclusion:

There were no differences in health-related quality of life between women with HIV (Positive Transitions Through the Menopause participants) and women from the Health Survey for England dataset. Among Positive Transitions Through the Menopause participants, health-related quality of life was reduced in peri-menopausal women and those with increasingly severe menopausal symptoms. Our findings highlight the importance of proactive assessment of menopausal status and symptoms to optimize health-related quality of life in women living with HIV as they reach mid-life and beyond.

Ethnic Inequalities in Healthcare Use and Care Quality among People with Multiple Long-Term Health Conditions Living in the United Kingdom: A Systematic Review and Narrative Synthesis

Indicative evidence suggests that the prevalence of multiple long-term conditions (i.e., conditions that cannot be cured but can be managed with medication and other treatments) may be higher in people from minoritised ethnic groups when compared to people from the White majority population. Some studies also suggest that there are ethnic inequalities in healthcare use and care quality among people with multiple long-term conditions (MLTCs). The aims of this review are to (1) identify and describe the literature that reports on ethnicity and healthcare use and care quality among people with MLTCs in the UK and (2) examine how healthcare use and/or care quality for people with MLTCs compares across ethnic groups. We registered the protocol on PROSPERO (CRD42020220702). We searched the following databases up to December 2020: ASSIA, Cochrane Library, EMBASE, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science core collection. Reference lists of key articles were also hand-searched for relevant studies. The outcomes of interest were patterns of healthcare use and care quality among people with MLTCs for at least one minoritised ethnic group, compared to the White majority population in the UK. Two reviewers, L.B. and B.H., screened and extracted data from a random sample of studies (10%). B.H. independently screened and extracted data from the remaining studies. Of the 718 studies identified, 14 were eligible for inclusion. There was evidence indicating ethnic inequalities in disease management and emergency admissions among people with MLTCs in the five studies that counted more than two long-term conditions. Compared to their White counterparts, Black and Asian children and young people had higher rates of emergency admissions. Black and South Asian people were found to have suboptimal disease management compared to other ethnic groups. The findings suggest that for some minoritised ethnic group people with MLTCs there may be inadequate initiatives for managing health conditions and/or a need for enhanced strategies to reduce ethnic inequalities in healthcare. However, the few studies identified focused on a variety of conditions across different domains of healthcare use, and many of these studies used broad ethnic group categories. As such, further research focusing on MLTCs and using expanded ethnic categories in data collection is needed.

Differences in HIV clinical outcomes amongst heterosexuals in the United Kingdom by ethnicity

OBJECTIVE

We investigated differences in clinical outcomes in heterosexual participants, by ethnicity in the UK Collaborative HIV Cohort Study from 2000 to 2017.

DESIGN

Cohort analysis.

METHODS

Logistic/proportional hazard regression assessed ethnic group differences in CD4+ cell count at presentation, engagement-in-care, combination antiretroviral therapy (cART) initiation, viral suppression and rebound.

RESULTS

Of 12 302 participants [median age: 37 (interquartile range: 31-44) years, 52.5% women, total follow-up: 85 846 person-years], 64.4% were black African, 19.1% white, 6.3% black Caribbean, 3.6% black other, 3.3% South Asian/other Asian and 3.4% other/mixed. CD4+ cell count at presentation amongst participants from non-white groups were lower than the white group. Participants were engaged-in-care for 79.6% of follow-up time; however, black and other/mixed groups were less likely to be engaged-in-care than the white group (adjusted odds ratios vs. white: black African: 0.70 (95% confidence interval (CI) 0.63-0.79], black Caribbean: 0.74 (0.63-0.88), other/mixed: 0.78 (0.62-0.98), black other: 0.81 (0.64-1.02)). Of 8867 who started cART, 79.1% achieved viral suppression, with no differences by ethnicity in cART initiation or viral suppression. Viral rebound (22.2%) was more common in the black other [1.95 (1.37-2.77)], black African [1.85 (1.52-2.24)], black Caribbean [1.73 (1.28-2.33)], South Asian/other Asian [1.35 (0.90-2.03)] and other/mixed [1.09 (0.69-1.71)] groups than in white participants.

CONCLUSION

Heterosexual people from black, Asian and minority ethnic (BAME) groups presented with lower CD4+ cell counts, spent less time engaged-in-care and were more likely to experience viral rebound than white people. Work to understand and address these differences is needed.