The influence of race and comorbidity on the timely initiation of antiretroviral therapy among older persons living with HIV/AIDS

Virologic failure and all-cause mortality among older people living with HIV/AIDS in South China

This retrospective cohort study investigated older people living with HIV/AIDS (PLWHA) characteristics, HIV care, and treatment outcomes among all cases between 1996 and 2019 in Guangxi, China. Secondary data were extracted from two national surveillance databases. Older (≥50 years old) and younger (18-49 years old) PLWHA were compared regarding demographic and behavioral characteristics, HIV care, virologic failure, and all-cause mortality. Older PLWHA accounted for 41.6% of all HIV cases (N = 144,952) between 1996 and 2019. The proportion of older cases increased from 10.4% to 64.8% for men and from 2.4% to 66.7% for women between 2002 and 2019. Heterosexual contact accounted for 96.0% of older adults. Moreover, older PLWHA had a lower median CD4 count at the HIV diagnosis (193 vs. 212 cells/μL, p < 0.0001) and were less likely to receive antiretroviral therapy (ART) than younger adults (72.1% vs. 86.1%, p < 0.001). The all-cause mortality risk of older PLWHA was 2.87 times of younger adults [adjusted hazard ratio (AHR) 2.87; 95% confidence interval (CI) 2.76-2.98]. In addition, older PLWHA reported an 18% increase in odds for virologic failure than younger adults (AOR 1.18; 95% CI 1.08-1.30). Therefore, enhanced HIV prevention and care are urgently needed in older people.

Symptoms and Comorbidities Differ Based on Race and Weight Status in Persons with HIV in the Northern United States: a Cross-Sectional Study

BACKGROUND

Persons with HIV (PWHIV) on highly active antiretroviral treatments (HAART) may require specialized care based on health and demographic indicators. This study investigated the association of comorbidities, race, weight status, and gastrointestinal (GI) and cardiovascular (CV) symptoms among PWHIV.

METHODS

The Symptom Checklist, Co-Morbidity Questionnaire, and Sociodemographic Questionnaire were used to assess weight status and GI and CV symptoms among 283 PWHIV. Data were analyzed using latent class analysis on John's Macintosh Project 13 Platform.

RESULTS

Participants were majority Black (50%), 69% male, and 35% AIDS diagnosed. Ages were 25 to 66. Clusters included least symptomatic status, weight gain, and weight loss by Black and non-Black participants. The non-Black weight gain cluster reported a higher incidence of AIDS (70.6% vs 38.2%), nausea (70.6% vs 17.6%), diarrhea (70.6% vs 26.5%), and shortness of breath (58.8% vs 20.6%) compared to the Black weight gain cluster. The Black weight loss cluster reported a higher incidence of CV symptoms such as chest palpitations (42.2% vs 2.7%), chest pain (44.4% vs 8.1%), and shortness of breath (73.3% vs 35.1%). Moreover, the Black weight loss cluster reported a higher incidence of all GI symptoms with the most prominent being diarrhea (71.1% vs 48.6%) compared to the non-Black weight loss cluster.

CONCLUSIONS

The existing racial disparities in health-related quality of life for PWHIV may be improved through precision health and nutrition modifications. Continued research is needed investigating differential health outcomes among PWHIV on HAART.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00222716. Registered 22 September 2005. Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT00222716?term=NCT00222716&draw=2&rank=1.

A Qualitative Study on the Social Determinants of HIV Treatment Engagement Among Black Older Women Living With HIV in the Southeastern United States

ABSTRACT

Black older women living with HIV (BOWLH) in the United States are disproportionately affected by HIV infection and poor treatment engagement rates, often caused by multiple social determinants of health. In this descriptive qualitative study, we interviewed 17 BOWLH to investigate the facilitators and barriers to HIV treatment engagement. Data were analyzed using the socioecological framework. Findings demonstrate the positive influences of supportive social networks, perceived benefits, HIV-related knowledge, raising HIV awareness in communities, and impact of HIV state laws. The highlighted barriers were mainly low income, substance use, HIV-related stigma, influence of stereotypes and assumptions about older women living with HIV, and health insurance. Religion, managing comorbidities, attitude toward, HIV disclosure, and caregiving roles had both positive and negative influences on engagement. These findings illuminate factors of HIV treatment engagement that might be culturally founded; disseminating these factors to health care professionals is a critical intervention to support this population.

A systematic review of engagement in care and health care utilization among older adults living with HIV and non-communicable diseases

It is critical to understand health care engagement and utilization among older persons living with HIV (OPWH) who may have greater burden for non-communicable diseases. Following the PRISMA guidelines, a systematic review using 5 electronic databases was conducted to appraise and synthesize the current literature on the relationship of non-communicable diseases on engagement in care and health care utilization among OPWH. Original studies published in English between 2009 and 2019 were included, yielding 16 relevant articles. Overall, having co-morbid non-communicable diseases was associated with a decreased likelihood of initiating and adhering to ART. Being on ART and viral suppression were associated with better engagement in non-communicable disease care. Findings also suggest that an increasing number of co-morbidities is associated with higher health care utilization and financial burden. This review underscores the need for preventing and managing co-morbidities to enhance engagement in HIV care and that health care practitioners need to ensure that OPWH are engaged in care for both HIV and their co-morbid conditions by providing coordinated and integrated care.

Older African Americans and the HIV Care Continuum: A Systematic Review of the Literature, 2003-2018

Evidence suggests that racial disparities in the HIV care continuum persist in older age groups, particularly among African Americans. The objective of this systematic review was to identify factors that facilitate or hinder older African Americans' engagement in the HIV care continuum. For studies published between 2003 and 2018, we: (1) searched databases using keywords, (2) excluded non-peer-reviewed studies, (3) limited findings to older African Americans and the HIV care continuum, and (4) retrieved and summarized data focused on barriers and facilitators of the HIV care continuum. Among the 1023 studies extracted, 13 were included: diagnosis/testing (n = 1), engagement in care (n = 7), and antiretroviral adherence (n = 5). Barriers included lack of HIV risk awareness, routine testing, and healthcare access, stigma, and multimorbidities. Social support, health/medication literacy, and increased self-efficacy facilitated engagement. A targeted focus on older African Americans is needed to achieve national goals of improving HIV care and treatment outcomes.

SENSITIVITY ANALYSIS FOR UNMEASURED CONFOUNDING IN COARSE STRUCTURAL NESTED MEAN MODELS

Coarse Structural Nested Mean Models (SNMMs, Robins (2000)) and G-estimation can be used to estimate the causal effect of a time-varying treatment from longitudinal observational studies. However, they rely on an untestable assumption of no unmeasured confounding. In the presence of unmeasured confounders, the unobserved potential outcomes are not missing at random, and standard G-estimation leads to biased effect estimates. To remedy this, we investigate the sensitivity of G-estimators of coarse SNMMs to unmeasured confounding, assuming a nonidentifiable bias function which quantifies the impact of unmeasured confounding on the average potential outcome. We present adjusted G-estimators of coarse SNMM parameters and prove their consistency, under the bias modeling for unmeasured confounding. We apply this to a sensitivity analysis for the effect of the ART initiation time on the mean CD4 count at year 2 after infection in HIV-positive patients, based on the prospective Acute and Early Disease Research Program.

Redefining Aging in HIV Infection Using Phenotypes

Purpose of review

This article critically reviews the utility of “phenotypes” as behavioral descriptors in aging/HIV research that inform biological underpinnings and treatment development. We adopt a phenotypic redefinition of aging conceptualized within a broader context of HIV infection and of aging. Phenotypes are defined as dimensions of behavior, closely related to fundamental mechanisms, and, thus, may be more informative than chronological age. Primary emphasis in this review is given to comorbid aging and cognitive aging, though other phenotypes (i.e., disability, frailty, accelerated aging, successful aging) are also discussed in relation to comorbid aging and cognitive aging.

Recent findings

The main findings that emerged from this review are as follows: (1) the phenotypes, comorbid aging and cognitive aging, are distinct from each other, yet overlapping; (2) associative relationships are the rule in HIV for comorbid and cognitive aging phenotypes; and (3) HIV behavioral interventions for both comorbid aging and cognitive aging have been limited.

Summary

Three paths for research progress are identified for phenotype-defined aging/HIV research (i.e., clinical and behavioral specification, biological mechanisms, intervention targets), and some important research questions are suggested within each of these research paths.

Risk factors for delayed antiretroviral therapy initiation among HIV-seropositive patients

Prompt initiation of combination antiretroviral therapy (ART) is important to reduce comorbidity and mortality among people living with HIV, especially for those with a low CD4 cell count. However there is evidence that not everyone receives prompt initiation of ART after enrolling into HIV care. The current study investigated factors associated with failure to initiate ART within two years of entering into care among those with a CD4 count at or below 350 cells/mm³. The sample included 4,907 ART-naive patients with a CD4 count at or below 350 cells/mm³ enrolled between January 1, 2003 and December 31, 2012 at any of eight clinical sites in the Center for AIDS Research Network of Integrated Clinical Systems (CNICS). The two-year risk of delayed ART initiation was estimated using a log-binomial regression model with stabilized inverse probability of censoring weights for those lost to follow-up. Adjusting for other factors, an earlier enrollment date was the sole demographic characteristic associated with an increased risk of delayed ART initiation. Higher CD4 count, lower viral load, and a prevalent AIDS diagnosis were clinical characteristics associated with delayed ART initiation. Gender, age, race/ethnicity and HIV risk factors such as reported male-to-male sexual contact and injection drug use were not associated with delayed ART initiation. This study identified characteristics of patients for whom treatment was strongly to moderately recommended but who did not initiate ART within two years of entering care. Despite the known benefits of early antiretroviral therapy initiation, a lower viral load measurement may continue to be an important clinical characteristic in the more recent era with current ART initiation guidelines. These findings provide a target for closer monitoring and intervention to reduce disparities in HIV care.

Healthy Aging in Older Women Living with HIV Infection: a Systematic Review of Psychosocial Factors

Due to life-enhancing effects of antiretroviral therapy, HIV-positive persons have the potential for long life comparable to their uninfected peers. Older women (age 50+) living with HIV (OWLH) are often an under-recognized aging group. We conducted a systematic review to examine psychosocial factors that impact how OWLH live, cope, and age with HIV. Initial key word search yielded 1527 records, and 21 studies met our inclusion criteria of original quantitative or qualitative research published between 2013 and 2016 with results specific to OWLH. These focused on health care and self-management, sexual health and risk, stigma, loneliness, mental health (depression, substance use), and protective factors (coping, social support, well-being). Due to the scarcity of studies on each topic and inconclusive findings, no clear patterns of results emerged. As the number of OWLH continues to grow, more research, including longitudinal studies, is needed to fully characterize the psychosocial factors that impact aging with HIV.

Identifying social and economic barriers to regular care and treatment for Black men who have sex with men and women (BMSMW) and who are living with HIV: a qualitative study from the Bruthas cohort

Background

There is little research regarding the ability of Black men who have sex with men and women (BMSMW) to access and maintain HIV-related health care and treatment adherence. This population, who often insist on secrecy about their same-sex desire, may experience unique barriers to seeking regular care and treatment.

Methods

From March 2011-April 2014, we recruited 396 BMSMW in the San Francisco Bay Area to be enrolled in our randomized controlled trial. At baseline we administered a behavioral survey assessing: demographics, homelessness, employment, history of incarceration, HIV status and disclosure practices, care and treatment adherence. 64 men reported living with HIV at intake. To learn more about their experiences, we recruited N = 25 to participate in qualitative interviews, which were conducted April-December 2014. Topics included: current living situation, diagnosis story, disclosure practices, experiences of accessing and maintaining care and treatment, and HIV-related stigma. Recordings were transcribed and coded for major themes.

Results

Despite being located in an area where treatment is plentiful, men faced social and economic barriers to maintaining regular care and treatment adherence. Several findings emerged to shed light on this quandary: (1) Competing needs particularly around attaining stable housing, food security, and money created barriers to treatment and care; (2) Side effects of HIV medications discouraged men from adhering to treatment; (3) Provider and Institutional level characteristics influenced care engagement; (4) Disclosure and social support made a difference in care and treatment behaviors; and (5) Participants expressed a desire for group-based intervention activities to support treatment and care among HIV+ BMSMW. Inadequate engagement in the continuum of care for HIV was born out in the quantitative data where 28% of participants did not know their Viral Load.

Conclusions

A holistic approach to HIV health for BMSMW would appear to translate to better outcomes for men living with HIV, where a goal of viral suppression must also include attending to their basic social and economic support needs.

Adherence to combination antiretroviral treatment and clinical outcomes in a Medicaid sample of older HIV-infected adults

The adherence threshold for combination antiretroviral therapy (cART) has historically been set at 95% or greater. We examined whether different levels of cART adherence (≥95% [optimal adherence], 90-94%, 80-89%, and <80%) were associated with different clinical outcomes (emergency department visits [ED visits] and duration of hospital admission) in a sample of older (50-64 years) persons living with HIV (PLWH). Medicaid data from 29 US states (n = 5177) were used for this study. cART adherence was measured and data regarding relevant covariates, such as race, sex, age, urbanicity, and comorbidity were obtained. Descriptive statistics were conducted to characterize study participants. We conducted univariate and multivariable regression analyses to evaluate the association between cART adherence and ED visits and duration of hospital admission while adjusting for covariates (race, sex, age, urbanicity, and comorbidity). Approximately 32% of all participants (n = 5177) reported optimal cART adherence (≥95%). After adjusting for covariates, only participants who reported <80% adherence were more likely to have an ED visit (adjusted odds ratio = 1.34, 95% CI = 1.08-1.48, p < .0001) and a longer duration of hospital admission (regression coefficient = 1.24, 95% CI = 0.53-1.96, p = .0007) when compared to participants who reported ≥95% adherence. There were no significant differences in likelihood of having an ED visit and longer duration of hospital admission between participants who reported ≥95% adherence and participants who reported 90-94% adherence and 80-89% adherence. Significant differences by covariates were observed. Adverse clinical outcomes were associated with low cART adherence (<80%) among older PLWH, though they did not differ between optimal and moderate cART adherence (90-94% and 80-89%). Although optimal cART adherence is an important goal, clinical outcomes in older PLWH may not differ between moderate and optimal cART adherence.

Correlates of Combination Antiretroviral Adherence Among Recently Diagnosed Older HIV-Infected Adults Between 50 and 64 years

Optimal adherence to combination antiretroviral therapy is essential to the health of older people living with HIV (PLWH), however, the literature on adherence and aging is limited. Using Medicaid data from 29 states (N = 5177), we explored correlates of optimal adherence among older PLWH. The prevalence of optimal adherence was low (32 %) in this study. Males were more adherent than females (APR = 1.11, 95 % CI 1.02-1.21, P = 0.0127); persons with three or more co-morbidities (APR = 0.67, 95 % CI 0.60-0.74, P < 0.001), two co-morbidities (APR = 0.86, 95 % CI 0.75-0.98, P = 0.0319) and one co-morbidity (APR = 0.82, 95 % CI 0.73-0.92, P = 0.0008) were less adherent than those without any co-morbidity; and residents of rural areas (APR = 0.90, 95 % CI 0.63-0.98, P = 0.0385) and small metropolitan areas (APR = 0.82, 95 % CI 0.72-0.94, P = 0.0032) were less adherent than residents of large metropolitan areas. There were no racial differences in optimal adherence. Targeted interventions that provide adherence support, case management, and peer navigation services may be of benefit in achieving optimal adherence in this population.

HIV Screening Rates among Medicaid Enrollees Diagnosed with Other Sexually Transmitted Infections

Introduction

Approximately 20 million new sexually transmitted infections (STIs) are diagnosed yearly in the United States costing the healthcare system an estimated $16 billion in direct medical expenses. The presence of other STIs increases the risk of HIV transmission. The Centers for Disease Control and Prevention (CDC) has long recommended routine HIV screening for individuals with a diagnosed STI. Unfortunately, HIV screening prevalence among STI diagnosed patients are still sub-optimal in many healthcare settings.

Objective

To determine the proportion of STI-diagnosed persons in the Medicaid population who are screened for HIV, examine correlates of HIV screening, and to suggest critical intervention points to increase HIV screening in this population.

Methods

A retrospective database analysis was conducted to examine the prevalence and correlates of HIV screening among participants. Participant eligibility was restricted to Medicaid enrollees in 29 states with a primary STI diagnosis (chlamydia, gonorrhea, and syphilis) or pelvic inflammatory disease claim in 2009. HIV-positive persons were excluded from the study. Frequencies and descriptive statistics were conducted to characterize the sample in general and by STI diagnosis. Univariate and multivariate logistic regression were performed to estimate unadjusted odds ratios and adjusted odds ratio respectively and the 95% confidence intervals. Multivariate logistic regression models that included the independent variables (race, STI diagnosis, and healthcare setting) and covariates (gender, residential status, age, and state) were analyzed to examine independent associations with HIV screening.

Results

About 43% of all STI-diagnosed study participants were screened for HIV. STI-diagnosed persons that were between 20–24 years, female, residing in a large metropolitan area and with a syphilis diagnosis were more likely to be screened for HIV. Participants who received their STI diagnosis in the emergency department were less likely to be screened for HIV than those diagnosed in a physician’s office.

Conclusion

This study showed that HIV screening prevalence among persons diagnosed with an STI are lower than expected based on the CDC’s recommendations. These suboptimal HIV screening prevalence present “missed opportunities” for HIV screening in at-risk populations. Measures and incentives to increase HIV screening among all STI-diagnosed persons are vital to the timely identification of HIV infection, linkage to HIV care, and mitigating further HIV transmission.

Prevalence and Factors Associated With Statin Use Among a Nationally Representative Sample of US Adults: National Health and Nutrition Examination Survey, 2011-2012

The 2013 American College of Cardiology/American Heart Association guidelines recommend statins for adults age ≤75 years who have clinical atherosclerotic cardiovascular disease (IA) and adults age 40 to 75 years with diabetes mellitus and LDL-C 70-189 mg/dl (IA). Our aim was to estimate the prevalence and likelihood of statin use among selected statin benefit groups. Using data from the National Health and Nutrition Examination Survey (NHANES) 2011-2012, we examined 5319 adults age ≥20 years. We estimated weighted frequencies and prevalence of statin use for adults with diabetes mellitus and dyslipidemia (or low-density lipoprotein cholesterol ≥70 mg/dL), defined as statin benefit group 1 (SBG1); and for adults with atherosclerotic cardiovascular disease, defined as statin benefit group 2 (SBG2). We constructed a logistic regression model to estimate odds of statin use in SBG1. Overall, an estimated 38.6 million Americans are on a statin. In adjusted models, uninsured and Hispanic adults were less likely to be on a statin compared with white adults; 59.5% (95% confidence interval [CI]: 53.0-66.1) of all adults in SBG1, 58.8% (95% CI: 51.5-66.1) of adults age 40 to 75 in SBG1, and 63.5% (95% CI: 55.6-71.4) of all adults in SBG2 were on a statin. Although the prevalence of statin use has increased over time, Hispanic ethnicity and lack of insurance remain barriers to statin use. Black-white racial disparities were not significant. Our study provides a baseline estimate of statin use in the noninstitutionalized population just prior to introduction of the new guidelines and provides a reference for evaluating the impact of the new guidelines on statin utilization.