Use of highly active antiretroviral therapy in a cohort of HIV-seropositive women

Vitamin D deficiency and periodontal clinical attachment loss in HIV-seropositive women: A secondary analysis conducted in the Women's Interagency HIV Study (WIHS)

OBJECTIVE

The aim of this study was to test a hypothesized positive association between low vitamin D (VitD) serum levels and the severity of periodontal disease in women with HIV infection.

STUDY DESIGN

This was a cross-sectional secondary analysis of data from an oral substudy conducted within the Chicago site of the Women's Interagency HIV Study. Serum VitD levels and clinical attachment loss (CAL) measurements were available for 74 women with HIV infection. VitD levels were treated as both continuous and categorical variables in bivariate and multivariate analyses. Mean clinical attachment loss (mCAL) was determined for each subject by obtaining the averages of measurements taken at 4 sites in each measured tooth.

RESULTS

Average age of study participants (n = 74) was 39.6 years (standard deviation 7.2), and the majority were African Americans (70.3%) with VitD deficiency (58.1%). VitD deficiency was positively associated with higher mCAL (P = .012). After adjustment for race, age, smoking, and HIV viral load, an association was found between VitD deficiency and mCAL (Beta 0.438; P = .036).

CONCLUSIONS

We identified a previously unreported association between VitD deficiency and mCAL in women with HIV infection. Larger and more inclusive, multisite, longitudinal studies are warranted to investigate whether these findings can be generalized to all individuals with HIV infection in the current treatment era and to determine causality.

ASSESSING THE RELATIONSHIP BETWEEN PHYSICIAN AVAILABILITY AND VIRAL LOAD SUPPRESSION IN BRITISH COLUMBIA

OBJECTIVES

In 2014, the Joint United Nations Programme HIV/AIDS (UNAIDS) set the target of dramatically reducing the burden of HIV through expansion of access to timely HIV treatment. In order to achieve this target it is necessary to expand access to care along the HIV cascade of care. This study examines the relationship between viral suppression and the availability of physicians providing HIV treatment in British Columbia, Canada.

METHODS

Data from the Drug Treatment Program of the British Columbia (BC) Centre for Excellence in HIV/AIDS was used for this analysis. The floating catchment method was used to assess physician availability. Multivariable Logistic Regression was used to implement a confounder selection technique to independently assess the relationship between physician availability and viral load suppression.

RESULTS

Individuals with more than 25 physicians within a one-hour catchment were more likely to reside in urban areas and almost twice as likely to have a suppressed viral load (adjusted odd ratio: 1.97; 95% CI 1.50 - 2.58).

CONCLUSIONS

This study highlights the impact of physicians' availability on viral load levels. Mapping technology was used to identify the locations in which patients were most impacted by the lack of physicians.

Incidence of Oral Lesions in HIV-1-infected Women: Reduction with HAART

Few studies assess the effectiveness of HAART on reducing the incidence and recurrence of oral lesions. We investigated such changes among 503 HIV+ women over six years in the Women’s Interagency HIV Study. The incidence of erythematous candidiasis (EC), pseudomembranous candidiasis (PC), hairy leukoplakia (HL), and warts was computed over follow-up visits after HAART initiation compared with before HAART initiation. Analysis of our data demonstrates a strong decrease in candidiasis after HAART initiation. The incidence of EC fell to 2.99% from 5.48% (RR 0.545); PC fell to 2.85% from 6.70% (RR 0.425); and EC or PC fell to 3.43% from 7.35% (RR 0.466). No changes were seen in HL or warts. Higher HIV-RNA was associated with greater incidence of candidiasis and HL, but not warts. Analysis of these data indicates that recurrence and incidence of candidiasis are reduced by HAART, and that recurrence is reduced independently of CD4 and HIV-RNA.

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

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

Physical activity and health outcomes among HIV-infected men who have sex with men: a longitudinal mediational analysis

BACKGROUND

Low physical activity is associated with depression, which may, in turn, negatively impact antiretroviral therapy (ART) adherence among HIV-infected individuals; however, prior studies have not investigated the relationships between physical inactivity and ART non-adherence.

PURPOSE

The purpose of this study was to examine the association of physical inactivity, depression, ART non-adherence, and viral load in HIV-infected men who have sex with men.

METHODS

The sample (N = 860) was from a large, multicenter cohort of HIV-infected patients engaged in clinical care.

RESULTS

Across time, depression mediated the relationship between physical inactivity and ART non-adherence (γ = 0.075) and the relationship between physical inactivity and viral load (γ = 0.05). ART non-adherence mediated the relationship between depression and viral load (γ = 0.002) and the relationship between physical inactivity and viral load (γ = 0.009).

CONCLUSIONS

Low levels of physical activity predicted increased depression and poor ART adherence over time, which subsequently predicted higher viral load.

Linking HIV-positive adolescents to care in 15 different clinics across the United States: creating solutions to address structural barriers for linkage to care

Linkage to care is a critical corollary to expanded HIV testing, but many adolescents are not successfully linked to care, in part due to fragmented care systems. Through a collaboration of the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC) and the Adolescent Trials Network (ATN), a linkage to care outreach worker was provided to ATN clinics. Factors related to linkage were explored to better understand how to improve retention rates and health outcomes for HIV-positive adolescents. We conducted 124 interviews with staff at 15 Adolescent Trials Network clinics to better understand linkage to care processes, barriers, and facilitators. Content analysis was conducted focusing on structural barriers to care and potential solutions, specifically at the macro-, meso-, and micro-levels. Macro-level barriers included navigating health insurance policies, transportation to appointments, and ease of collecting and sharing client-level contact information between testing agencies, local health departments and clinics; meso-level barriers included lack of youth friendliness within clinic space and staff, and duplication of linkage services; micro-level barriers included adolescents' readiness for care and adolescent developmental capacity. Staff initiated solutions included providing transportation for appointments and funding clinic visits and tests with a range of grants and clinic funds while waiting for insurance approval. However, such solutions were often ad hoc and partial, using micro-level solutions to address macro-level barriers. Comprehensive initiatives to improve linkage to care are needed to address barriers to HIV-care for adolescents, whose unique developmental needs make accessing care particularly challenging. Matching the level of structural solution to the level of structural barriers (i.e., macro-level with macro-level), such as creating policy to address needed youth healthcare entitlements versus covering uninsured patients with clinic funds is imperative to achieving the goal of increasing linkage to care rates for newly diagnosed adolescents.

Community poverty and trends in racial/ethnic survival disparities among people diagnosed with AIDS in Florida, 1993-2004

OBJECTIVES

We described the racial/ethnic disparities in survival among people diagnosed with AIDS in Florida from 1993 to 2004, as the availability of highly active antiretroviral therapy (HAART) became widespread. We determined whether these disparities decreased after controlling for measures of community-level socioeconomic status.

METHODS

We compared survival from all causes between non-Hispanic Blacks and non-Hispanic Whites vis-a-vis survival curves and Cox proportional hazards models controlling for demographic, clinical, and area-level poverty factors.

RESULTS

Racial/ethnic disparities in survival peaked for those diagnosed during the early implementation of HAART (1996-1998) with a Black-to-White hazard ratio (HR) of 1.72 (95% confidence interval [CI] = 1.62, 1.83) for males and 1.40 (95% CI = 1.24, 1.59) for females. These HRs declined significantly to 1.48 (95% CI = 1.35, 1.64) for males and nonsignificantly to 1.25 (95% CI = 1.05, 1.48) for females in the 2002 to 2004 diagnosis cohort. Disparities decreased significantly for males but not females when controlling for baseline demographic factors and CD4 count and percentage, and became nonsignificant in the 2002 to 2004 cohort after controlling for area poverty.

CONCLUSIONS

Area poverty appears to play a role in racial/ethnic disparities even after controlling for demographic factors and CD4 count and percentage.

Association between smoking and size of anal warts in HIV-infected women

While the association between smoking and human papillomavirus infection, cervical cancer, and anal cancer has been well studied, evidence on the association between cigarette smoking and anal warts is limited. The purpose of this study was to investigate if cigarette smoking status influences the size of anal warts over time in HIV-infected women in a sample of 976 HIV-infected women from the Women's Interagency HIV Study (WIHS). A linear mixed model was used to determine the effect of smoking on anal wart size. Even though women who were currently smokers had larger anal warts at baseline and slower growth rate of anal wart size after each visit than women who were not current smokers, there was no association between size of anal wart and current smoking status over time. Further studies on the role of smoking and interaction between smoking and other risk factors, however, should be explored.

Use of and Adherence to Antiretroviral Therapy in a Large U.S. Sample of HIV-infected Adults in Care, 2007-2008

Background:

Antiretroviral therapy (ART) is the cornerstone of HIV clinical care and is increasingly recognized as a key component of HIV prevention. However, the benefits of ART can be realized only if HIV-infected persons maintain high levels of adherence.

Methods:

We present interview data (collected from June 2007 through September 2008) from a national HIV surveillance system in the United States—the Medical Monitoring Project (MMP)—to describe persons taking ART. We used multivariate logistic regression to assess behavioral, sociodemographic, and medication regimen factors associated with three measures that capture different dimensions of nonadherence to ART: dose, schedule, and instruction.

Results:

The use of ART among HIV-infected adults in care was high (85%), but adherence to ART was suboptimal and varied across the three measures of nonadherence. Of MMP participants currently taking ART, the following reported nonadherence during the past 48 hours: 13% to dose, 27% to schedule, and 30% to instruction. The determinants of the three measures also varied, although younger age and binge drinking were associated with all aspects of nonadherence.

Conclusion:

Our results support the measurement of multiple dimensions of medication-taking behavior in order to avoid overestimating adherence to ART.

CD4+ cell count and HIV load as predictors of size of anal warts over time in HIV-infected women

BACKGROUND

Little is known about the associations between CD4(+) cell counts, human immunodeficiency virus (HIV) load, and human papillomavirus "low-risk" types in noncancerous clinical outcomes. This study examined whether CD4(+) count and HIV load predict the size of the largest anal warts in 976 HIV-infected women in an ongoing cohort.

METHODS

A linear mixed model was used to determine the association between size of anal wart and CD4(+) count and HIV load.

RESULTS

The incidence of anal warts was 4.15 cases per 100 person-years (95% confidence interval [CI], 3.83-4.77) and 1.30 cases per 100 person-years (95% CI, 1.00-1.58) in HIV-infected and HIV-uninfected women, respectively. There appeared to be an inverse association between size of the largest anal warts and CD4(+) count at baseline; however, this was not statistically significant. There was no association between size of the largest anal warts and CD4(+) count or HIV load over time.

CONCLUSIONS

There was no evidence for an association between size of the largest anal warts and CD4(+) count or HIV load over time. Further exploration on the role of immune response on the development of anal warts is warranted in a larger study.

Human leukocyte antigen genotype and risk of HIV disease progression before and after initiation of antiretroviral therapy

While the human leukocyte antigen (HLA) genotype has been associated with the rate of HIV disease progression in untreated patients, little is known regarding these relationships in patients using highly active antiretroviral therapy (HAART). The limited data reported to date identified few HLA-HIV disease associations in patients using HAART and even occasional associations that were opposite of those found in untreated patients. We conducted high-resolution HLA class I and II genotyping in a random sample (n = 860) of HIV-seropositive women enrolled in a long-term cohort initiated in 1994. HLA-HIV disease associations before and after initiation of HAART were examined using multivariate analyses. In untreated HIV-seropositive patients, we observed many of the predicted associations, consistent with prior studies. For example, HLA-B*57 (β = -0.7; 95% confidence interval [CI] = -0.9 to -0.5; P = 5 × 10⁻¹¹) and Bw4 (β = -0.2; 95% CI = -0.4 to -0.1; P = 0.009) were inversely associated with baseline HIV viral load, and B*57 was associated with a low risk of rapid CD4+ decline (odds ratio [OR] = 0.2; 95% CI = 0.1 to 0.6; P = 0.002). Conversely, in treated patients, the odds of a virological response to HAART were lower for B*57:01 (OR = 0.2; 95% CI = 0.0 to 0.9; P = 0.03), and Bw4 (OR = 0.4; 95% CI = 0.1 to 1.0; P = 0.04) was associated with low odds of an immunological response. The associations of HLA genotype with HIV disease are different and sometimes even opposite in treated and untreated patients.

Challenges and successes in linking HIV-infected women to care in the United States

Women currently account for 27% of new human immunodeficiency virus (HIV) infections in the United States, the majority of which are acquired through heterosexual transmission. In the United States, black and Latino persons are disproportionately affected by the HIV epidemic, a disparity that is most dramatically present among HIV-infected women. Many of these women face significant discrimination as a result of race or ethnicity and sex, and they suffer disproportionately from poverty, low health literacy, and lack of access to high-quality HIV care. As a consequence, despite the availability of highly active antiretroviral therapy (HAART), women with HIV often have delayed entry into care and experience poor outcomes. This article reviews risk factors for HIV infection in women, barriers to engagement in care, and strategies to improve linkage to HIV-related medical and social care.

Female gender predicts lower access and adherence to antiretroviral therapy in a setting of free healthcare

Background

Barriers to HIV treatment among injection drug users (IDU) are a major public health concern. However, there remain few long-term studies investigating key demographic and behavioral factors - and gender differences in particular - that may pose barriers to antiretroviral therapy (ART), especially in settings with universal healthcare. We evaluated access and adherence to ART in a long-term cohort of HIV-positive IDU in a setting where medical care and antiretroviral therapy are provided free of charge through a universal healthcare system.

Methods

We evaluated baseline antiretroviral use and subsequent adherence to ART among a Canadian cohort of HIV-positive IDU. We used generalized estimating equation logistic regression to evaluate factors associated with 95% adherence to antiretroviral therapy estimated based on prescription refill compliance.

Results

Between May 1996 and April 2008, 545 IDU participants were followed for a median of 23.8 months (Inter-quartile range: 8.5 - 91.6), among whom 341 (63%) were male and 204 (37%) were female. Within the six-month period prior to the baseline interview, 133 (39%) men and 62 (30%) women were on ART (p = 0.042). After adjusting for clinical characteristics as well as drug use patterns measured longitudinally throughout follow-up, female gender was independently associated with a lower likelihood of being 95% adherent to ART (Odds Ratio [OR] = 0.70; 95% Confidence Interval: 0.53-0.93).

Conclusions

Despite universal access to free HIV treatment and medical care, female IDU were less likely to access and adhere to antiretroviral therapy, a finding that was independent of drug use and clinical characteristics. These data suggest that interventions to improve access to HIV treatment among IDU must be tailored to address unique barriers to antiretroviral therapy faced by female IDU.

The impact of the AIDS Drug Assistance Program (ADAP) on use of highly active antiretroviral and antihypertensive therapy among HIV-infected women

OBJECTIVES

To evaluate the association between enrollment into an AIDS Drug Assistance Program (ADAP) and use of highly active antiretroviral therapy (HAART) and antihypertensive therapy.

METHODS

Cross-sectional analyses of data were performed on HAART-eligible women enrolled in the California (n = 439), Illinois (n = 168), and New York (n = 487) Women's Interagency HIV Study sites. A subset of HIV-infected women with hypertension (n = 395) was also analyzed. Unadjusted and adjusted backward stepwise elimination logistic regression measured the association between demographic, behavioral, and health service factors and nonuse of HAART or antihypertensive medication.

RESULTS

In adjusted analysis of HAART nonuse, women without ADAP were significantly more likely not to use HAART (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.5-3.7) than women with ADAP. In adjusted analysis of antihypertensive medication nonuse, women without ADAP had an increased but not significant odds of antihypertensive medication nonuse (OR, 2.4; 95% CI, 0.93-6.0) than women with ADAP.

CONCLUSIONS

Government-funded programs for prescription drug coverage such as ADAP may play an important role in how HIV-positive women access and use essential medications for chronic diseases.

Adherence in people living with HIV/AIDS, mental illness, and chemical dependency: a review of the literature

Adherence to antiretroviral medications is central to reducing morbidity and mortality among people living with HIV/AIDS. Relatively few studies published to date address HIV adherence among special populations. The purpose of this article is to review the existing literature on HIV antiretroviral adherence, with an emphasis on studies among the triply diagnosed population of people living with HIV/AIDS, mental illness, and chemical dependency. In order to reflect the most current information available, data from conference proceedings, federally funded studies in progress, and the academic literature are presented for consideration.

Access to antiretroviral therapy among HIV/AIDS patients in khon kaen province, Thailand

This study attempted to identify the factors associated with the access to antiretroviral therapy (ARV) among HIV/AIDS patients in Khon Kaen Province, Thailand. We collected medical and sociodemographic data from the medical charts of adult patients living in the province who received medical services at two public hospitals in the province. The study period was from December 1, 2001 to February 28, 2002. Total 593 outpatients were included in the analysis. One hundred and forty-six patients (24.6%) received ARV. A logistic regression analysis was conducted to identify the factors associated with the use of ARV. Patients who were covered by the Civil Servant Medical Benefit Scheme were significantly more likely to receive ARV than those who were covered by the Universal Coverage Scheme (UC), a publicly-funded medical insurance (OR = 12.43; 95% CI = 6.03-25.62). The results of this study indicated that there were inequalities in access to and use of ARV among HIV/AIDS patients by health insurance status. The current government announced that they would include ARV in the benefits package of UC. It would be important to monitor how this policy will improve the access to ARV among HIV/AIDS patients.

Multi-dimensional risk factor patterns associated with non-use of highly active antiretroviral therapy among human immunodeficiency virus-infected women

OBJECTIVES

Relationships between non-use of highly active antiretroviral therapy (HAART), race/ethnicity, violence, drug use, and other risk factors are investigated using qualitative profiles of five risk factors (unprotected sex, multiple male partners, heavy drinking, crack, cocaine or heroin use, and exposure to physical violence) and association of the profiles and race/ethnicity with non-use of HAART over time.

METHODS

A hidden Markov model was used to summarize risk factor profiles and changes in profiles over time in a longitudinal sample of HIV-infected women enrolled in the Women's Interagency HIV Study with follow-up from 2002 to 2005 (n = 802).

RESULTS

Four risk factor profiles corresponding to four distinct latent states were identified from the five risk factors. Trajectory analysis indicated that states characterized by high probabilities of all risk factors or by low probabilities of all risk factors were both relatively stable over time. Being in the highest risk state did not significantly elevate the odds of HAART non-use (odds ratio [OR], 1.05; 95% confidence interval [CI], 0.6-1.8). However, being in a latent state characterized by elevated probabilities of heavy drinking and exposure to physical violence, along with slight elevations in three other risk factors, significantly increased odds of HAART non-use (OR, 1.4; 95% CI, 1.1-1.9).

CONCLUSION

The research suggests that HAART use might be improved by interventions aimed at women who are heavy drinkers with recent exposure to physical violence and evidence of other risk factors. More research about the relationship between clustering and patterns of risk factors and use of HAART is needed.

Characteristics and outcome of HIV infection in gypsies in the Spanish VACH Cohort

OBJECTIVE

To study the characteristics of HIV infection in the gypsy (Roma) population in Spain, as compared with those of the Caucasian, non-gypsy majority.

DESIGN

Cross-sectional, historical cohort study from the Spanish VACH Cohort.

METHODS

Patients attending VACH clinics between 1 June 2004 and 30 November 2004 were classified according to their racial and ethnic origin as "gypsies", Caucasian non-gypsy Spanish natives (CNGN), and "other" (the last being excluded from this study). Their sociodemographic and clinico-epidemiological characteristics were compared, as well as the Kaplan-Meier curves of time to AIDS, or death, or disease progression (either of the 2 outcomes).

RESULTS

4819 (48%) of 10,032 cases included in the VACH database were eligible: 210 (4.2%) were gypsies and 4252 (84.8%) were CNGN. Differences were observed in age, household, academic, inmate, marital, and employment history. Injecting drug use had been the most frequent mechanism of transmission in both groups, but to a greater extent among gypsies (72% versus 50%; P<0.000). Sex distribution, CD4 cell counts, and viral loads at the first visit were similar in the 2 groups, as was the percentage of patients with previous AIDS, percentage receiving antiretrovirals, and percentage subsequently starting antiretroviral therapy. Up to 1 April 2005, 416 new AIDS cases and 85 deaths were recorded. The percentage of these outcomes did not differ between groups, but log-rank test showed a shorter time to AIDS and disease progression among gypsies.

CONCLUSIONS

The sociodemographic characteristics of gypsies, the largest minority in the VACH Cohort, show differences relative to those of CNGN. HIV-related outcomes suggest that gypsies have a poorer prognosis.

Association of race, substance abuse, and health insurance coverage with use of highly active antiretroviral therapy among HIV-infected women, 2005

OBJECTIVES

We examined racial/ethnic disparities in highly active antiretroviral therapy (HAART) use and whether differences are moderated by substance use or insurance status, using data from the Women's Interagency HIV Study (WIHS).

METHODS

Logistic regression examined HAART use in a longitudinal cohort of women for whom HAART was clinically indicated in 2005 (N = 1354).

RESULTS

Approximately 3 of every 10 eligible women reported not taking HAART. African American and Hispanic women were less likely than were White women to use HAART. After we adjusted for potential confounders, the higher likelihood of not using HAART persisted for African American but not for Hispanic women. Uninsured and privately insured women, regardless of race/ethnicity, were less likely than were Medicaid enrollees to use HAART. Although alcohol use was related to HAART nonuse, illicit drug use was not.

CONCLUSIONS

These findings suggest that expanding and improving insurance coverage should increase access to antiretroviral therapy across racial/ethnic groups, but it is not likely to eliminate the disparity in use of HAART between African American and White women with HIV/AIDS.

CYP1A1 genotype modifies the impact of smoking on effectiveness of HAART among women

We have recently shown that cigarette smoking is associated with lesser responses to potent antiretroviral therapies. Certain Cytochrome P-450 enzymes activate compounds derived from tobacco smoke into toxic forms that may promote HIV-1 gene expression through promotion of DNA-adduct formation by the oxidation of chemical constituents of cigarette smoke, such as polyaromatic hydrocarbons and dioxins. To explore the association between environmental and genetic factors to viral replication in women who smoke and receive highly active anti-retroviral therapy (HAART), we assessed the impact of polymorphisms in a panel of four Cytochrome P-450 genes (CYP1A1, CYP2A6, CYP2D6, and CYP2E1) and two Glutathione S-transferase genes (GSTM1 and GSST1) in 924 participants of the Women's Interagency HIV Study (WIHS). Our findings showed that GSTM1 and GSST1 deletions were not associated with HAART effectiveness. By contrast, homozygosity for the CYP1A1-m1 polymorphism, was associated with impaired viral response to treatment among smokers (relative hazard (RH) = 0.54; 95% confidence interval = 0.31-0.94) after adjustment for pretreament viral load, CD4 count, age, hepatitis C infection, prior HAART therapy and race, although it had no effect among nonsmokers. We conclude that the association of the CPY1A1-m1 variant with a reduced response to HAART therapy in HIV infected smokers is consistent with this enzyme's role in the metabolic conversion of environmental toxins to DNA adducts, which may directly promote HIV-1 gene expression.

Association of child care burden and household composition with adherence to highly active antiretroviral therapy in the Women's Interagency HIV Study

Our objective was to describe the association that childcare burden, household composition, and health care utilization have with adherence to highly active antiretroviral therapy (HAART) among women in the United States. The primary outcome was 95% or more adherence to HAART evaluated at 10,916 semiannual visits between October 1998 and March 2006 among 1419 HIV-infected participants enrolled in the Women's Interagency HIV Study. HAART adherence levels of 95% or more were reported at 76% of the semiannual visits. At only 4% of the person-visits did women report either quite a bit or extreme difficulty in caring for child; at 52% of the person-visits women reported at least one child 18 years of age or older living in the household. We found a one-unit increase in the difficulty in caring for children (childcare burden was assessed on a 5-point scale: not difficult [1] to extremely difficult [5]) was associated with a 6% decreased odds of 95% or more HAART adherence (adjusted odds ratio [OR] = 0.94; p = 0.07). Each additional child 18 years of age or less living in the household was associated with an 8% decreased odds of 95% or more adherence (adjusted OR = 0.92, p = 0.03). Both the number and type of adult living in the household, as well as health care utilization were not associated with HAART adherence. Greater child care burden and number of children 18 years old or younger living in household were both inversely associated with HAART adherence. Assessing patients' difficulties in caring for children and household composition are important factors to consider when addressing adherence to HAART.

A review of barriers and facilitators of HIV treatment among injection drug users

Globally, injection drug use continues to account for a substantial proportion of HIV infections. There have not, however, been any evidence-based reviews of the barriers and facilitators of HIV treatment among injection drug users. For this review, published studies were extracted from nine academic databases, with no language or date specified in the search criteria. Existing evidence demonstrates that, although injection drug users often have worse outcomes from HIV treatment than non-injection drug users, major antiretroviral-associated survival gains still have been observed among this population. Inferior outcomes are explained by a range of barriers to antiretroviral access and adherence, which often stem from the negative influences of illicit drug policies, as well as issues within medical systems, including lack of physician education about substance abuse. Evidence demonstrates that several under-utilized interventions and novel antiretroviral delivery modalities have helped to greatly address these barriers in several settings, and there is sufficient evidence to support immediate scale-up of these programmes. These interventions include coupling antiretroviral therapy with opioid substitution therapies as well as directly administered antiretroviral therapy programmes. Of particular interest for future evaluation is the coupling of HIV treatment programmes within comprehensive services, which also provide low-threshold (harm reduction) HIV prevention programmes. Scale-up of evidence-based HIV treatment and prevention to injection drug users, however, will require increasing political will among both national policy-makers and international public health agencies.

Association between living with children and adherence to highly active antiretroviral therapy in the Women's Interagency HIV Study

OBJECTIVE

The purpose of this work was to evaluate whether living with children adversely affects adherence to highly active antiretroviral therapy in HIV-infected women.

PARTICIPANTS AND METHODS

We conducted a prospective cohort study between October 1998 and September 2005. The study outcome was > or = 95% adherence to highly active antiretroviral therapy evaluated at 5832 semiannual visits among 1366 HIV-infected women in the Women's Interagency HIV Study. The primary exposure defined at the visit immediately before outcome ascertainment was the number of children < or = 18 years of age reported living in the household.

RESULTS

The percentage of women who reported > or = 2 children in the household who also reported > or = 95% adherence ranged from 68% to 75% compared with adherence when either 1 child or no children were reported. Each additional child reported living in the household was associated with a 6% decrease in the odds of > or = 95% adherence.

CONCLUSION

The impact of living with a child on the ability to take medications by HIV-infected women has not been examined thoroughly. Our data suggest that adherence to highly active antiretroviral therapy is inversely associated with the number of children living in the household.

Illicit drug use, depression and their association with highly active antiretroviral therapy in HIV-positive women

BACKGROUND

We examined the interaction of illicit drug use and depressive symptoms, and how they affect the subsequent likelihood of highly active antiretroviral therapy (HAART) use among women with HIV/AIDS.

METHODS

Subjects included 1710 HIV-positive women recruited from six sites in the U.S. including Brooklyn, Bronx, Chicago, Los Angeles, San Francisco/Bay Area, and Washington, DC. Cases of probable depression were identified using depressive symptom scores on the Center for Epidemiologic Studies Depression Scale. Crack, cocaine, heroin, and amphetamine use were self-reported at 6-month time intervals. We conducted multivariate random logistic regression analysis of data collected during 16 waves of semiannual interviews conducted from April 1996 through March 2004.

RESULTS

We found an interaction effect between illicit drug use and depression that acted to suppress subsequent HAART use, controlling for virologic and immunologic indicators, socio-demographic variables, time, and study site.

CONCLUSIONS

This is the first study to document the interactive effects of drug use and depressive symptoms on reduced likelihood of HAART use in a national cohort of women. Since evidence-based behavioral health and antiretroviral therapies for each of these three conditions are now available, comprehensive HIV treatment is an achievable public health goal.

Association of serum lipid levels with HIV serostatus, specific antiretroviral agents, and treatment regimens

BACKGROUND

The effects of HIV infection, highly active antiretroviral therapy (HAART), and specific antiretroviral agents on lipoproteins in women are not well described.

METHODS

In a cross-sectional substudy of the Women's Interagency HIV Study with 623 HIV-negative and 1556 HIV-positive women (636 untreated, 419 on non-protease inhibitor [PI] HAART, and 501 on PI-containing HAART), we performed multivariate analyses of associations among fasting lipoprotein levels, HIV infection, and HAART.

RESULTS

Untreated HIV-positive women had lower high-density lipoprotein cholesterol (HDL-C) and higher triglycerides (TGs) but not lower low-density lipoprotein cholesterol (LDL-C) than HIV-negative women and were the most likely to have unfavorable HDL-C by National Cholesterol Education Program (NCEP) guidelines. PI HAART users had higher LDL-C than untreated HIV-infected women (107 vs. 100 mg/dL, P = 0.0006) and were the most likely to have unfavorable LDL-C and TGs by NCEP guidelines. HIV-negative women and non-PI HAART users had similar HDL-C levels (55 and 53 mg/dL, respectively), which were higher than those in untreated HIV-infected women and PI HAART users (42 and 49 mg/dL, respectively; P < 0.001 for all). Lamivudine, didanosine, nevirapine, and efavirenz were independently associated with higher HDL-C (P < 0.001 for all). Ritonavir, indinavir/ritonavir, and nelfinavir were associated with higher LDL-C (P < 0.01 for all). Stavudine, abacavir, and all ritonavir-containing regimens were associated with higher TGs (P < 0.05 for all), and tenofovir was associated with lower TGs (P = 0.009).

CONCLUSIONS

A dyslipidemic pattern was associated with HIV infection itself, was more severe in users of PI-containing HAART, but was not present in women taking non-PI HAART.

Appropriateness of antiretroviral therapy in clients of an HIV/AIDS case management organization

We sought to assess appropriateness of antiretroviral therapy (ART) reported by clients of an HIV/AIDS case management organization and identify variables associated with appropriate ART receipt. A total of 295 such clients were mailed a survey asking them to identify antiretroviral medications they were taking. Of them 220 (75%) returned surveys; 201 (93%) were taking antiretrovirals. Of these, 159 were on appropriate and 36 on inappropriate ART, as determined by guidelines created by the CDC, the International AIDS Society (USA Panel), and the Panel on Clinical Practices for Treatment of HIV Infection. In unadjusted analyses, age, sex, race, sexual orientation, history of injection drug use, history of sexual risk, and HIV knowledge were associated (p< or =0.10) with appropriate ART and entered into one of two logistic regression models. The first model indicated that women (p=0.003) and heterosexuals (p=0.001) were less likely to receive appropriate ART than men and gay/bisexuals (and variables interacted, p=0.001). HIV knowledge--a proxy indicator determined by self-report of a CD4 cell count and viral load--was added to variables retained in first model to create a second model. Only sexual orientation was retained in this second model (p=0.02, in the same direction as in the first model), and those with less versus more HIV knowledge (p=0.04) were found to be less likely to receive appropriate ART (and variables interacted, p=0.04). Findings suggest that heterosexual men are less likely than women who, in turn, are less likely than gay/bisexual men to receive appropriate ART. HIV-related knowledge appears to increase likelihood of receiving appropriate ART and it attenuates the effect of sex.

Optimizing resource allocation in United States AIDS drug assistance programs

BACKGROUND

US acquired immunodeficiency syndrome (AIDS) Drug Assistance programs (ADAPs) provide medications to low-income patients with human immunodeficiency virus (HIV) infection/AIDS. Nationally, ADAPs are in a fiscal crisis. Many states have instituted waiting lists, often serving clients on a first-come, first-served basis. We hypothesized that CD4 cell count-based ADAP eligibility would improve ADAP outcomes, allowing them to serve more-diverse patient populations and to prioritize persons who are at greatest risk of HIV-related mortality.

METHODS

We used Massachusetts ADAP administrative data to create a retrospective cohort of Massachusetts ADAP clients from fiscal year 2003. We then used a model-based analysis to apply potential eligibility criteria for a limited program and to compare characteristics of patients included under CD4 cell count-based and first-come, first-served eligibility criteria.

RESULTS

In fiscal year 2003, Massachusetts ADAPs served 3560 clients at a direct cost of 10.3 million dollars. With use of CD4 cell count-based eligibility (with an eligibility criterion of a current or nadir CD4 cell count < or = 350 cells/microL), it would have served 2253 clients (37% fewer than in fiscal year 2003) and appreciated savings of 2.7 million dollars. Given the same budget constraint and using first-come, first-served eligibility, Massachusetts ADAPs would have served 2406 clients (32% fewer than in fiscal year 2003). The first-come, first-served approach would have excluded patients with median CD4 cell count of 257 cells/microL (interquartile range, 124-377 cells/microL) in favor of serving patients with median CD4 cell count of 659 cells/microL (interquartile range, 511-841 cells/microL). In addition, a CD4 cell count-based scheme would have served a greater proportion of nonwhite individuals (65% vs. 55%; P<.0001), non-English speakers (24% vs. 19%; P=.03), and unemployed people (69% vs. 61%; P=.0009), compared with the population that would have been served by a first-come, first-served policy.

CONCLUSIONS

With limited resources, ADAPs will serve more-diverse populations and patients with significantly more advanced HIV disease by using CD4 cell count-based enrollment criteria rather than a first-come, first-served approach.

HIV-AIDS in Minorities

HIV-AIDS has disproportionately affected minority populations in the United States. Significant disparities in case rates and mortality have been noted. This article reviews the magnitude of the problem and the many factors involved in the development and perpetuation of these disparities. Possible measures to help correct the problem are also reviewed.

Effects of treated and untreated depressive symptoms on highly active antiretroviral therapy use in a US multi-site cohort of HIV-positive women

This study examines the effects of treated and untreated depressive symptoms on the likelihood of utilization of highly active antiretroviral therapy (HAART) among a multi-site cohort of HIV-infected women who screened positive for probable depression. Data were collected biannually from 1996 through 2001 in a prospective cohort study. Random-effects regression analysis was used to estimate the longitudinal effects of mental health treatment on the probability of HAART utilization, controlling for clinical indicators (CD4 count, viral load), demographic features (race/ethnicity, income), and behavioural factors (recent crack, cocaine, or heroin use). Use of antidepressants plus mental health therapy, or use of mental health therapy alone significantly increased the probability of HAART utilization, compared to receiving no depression treatment. Use of antidepressants alone did not differ significantly from receiving no depression treatment. African American women and those who used crack, cocaine, or heroin also were less likely to use HAART. These findings suggest that efforts to enhance depressed women's access to psychopharmacologic treatment and therapy may increase their use of the most effective HIV therapies.

Association of cigarette smoking with HIV prognosis among women in the HAART era: a report from the women's interagency HIV study

OBJECTIVE

We assessed the association of cigarette smoking with the effectiveness of highly active antiretroviral therapy (HAART) among low-income women.

METHODS

Data were analyzed from the Women's Interagency HIV Study, a multisite longitudinal study up to 7.9 years for 924 women representing 72% of all women who initiated HAART between July 1, 1995, and September 30, 2003.

RESULTS

When Cox's regression was used after control for age, race, hepatitis C infection, illicit drug use, previous antiretroviral therapy, and previous AIDS, smokers on HAART had poorer viral responses (hazard ratio [HR]=0.79; 95% confidence interval [CI]=0.67, 0.93) and poorer immunologic response (HR=0.85; 95% CI=0.73, 0.99). A greater risk of virologic rebound (HR=1.39; 95% CI=1.06, 1.69) and more frequent immunologic failure (HR=1.52; 95% CI=1.18, 1.96) were also observed among smokers. There was a higher risk of death (HR=1.53; 95% CI=1.08, 2.19) and a higher risk of developing AIDS (HR=1.36; 95% CI=1.07, 1.72) but no significant difference between smokers and nonsmokers in the risk of death due to AIDS.

CONCLUSIONS

Some of the benefits provided by HAART are negated in cigarette smokers.

Longitudinal relationships between use of highly active antiretroviral therapy and satisfaction with care among women living with HIV/AIDS

OBJECTIVES

We used longitudinal data to examine the roles of 4 dimensions of patient satisfaction as both predictors and outcomes of use of highly active antiretroviral therapy (HAART) among women in the United States with HIV/AIDS.

METHODS

Generalized estimating equations were used to analyze time-lagged satisfaction-HAART relationships over 8 years in the Women's Interagency HIV Study.

RESULTS

Multivariate models showed that, over time, HAART use was associated with higher patient satisfaction with care in general, with providers, and with access/convenience of care; however, patient satisfaction was not associated with subsequent HAART use. Symptoms of depression and poor health-related quality of life were associated with less satisfaction with care on all 4 dimensions assessed, whereas African American race/ethnicity, illegal drug use, and fewer primary care visits were associated with less HAART use.

CONCLUSIONS

Our findings suggest that dissatisfaction with care is not a reason for underuse of HAART among women with HIV and that providers should not be discouraged from recommending HAART to dissatisfied patients. Rather, increasing women's access to primary care could result in both increased HAART use and greater patient satisfaction.

Religious beliefs, practices and treatment adherence among individuals with HIV in the southern United States

Nonadherence with medical treatment is a critical threat to the health of those living with HIV disease. Unfortunately the search for explanatory factors for nonadherence is still not fully developed, particularly in the area of religion and spirituality. Extant literature suggests that church attendance, religious practices and spiritual beliefs may improve health and generally benefit patients. However, religious beliefs may also play a negative role in treatment adherence due to the stigma attached to HIV disease, particularly in geographical areas and in population subgroups where religious practices are strong. In this exploratory study, HIV-positive individuals (n = 306) in a southern state were surveyed as to their attitudes and beliefs surrounding HIV disease and adherence with medical treatment for the disease. The results indicate that multiple factors influence adherence with treatment and that certain religious practices are positively associated with adherence, but certain religious beliefs are negatively related to adherence. The findings of this study reinforce the importance of remembering and addressing a patient's religious beliefs as a part of medical care.

Changes in service delivery following HIV/AIDS education of medical and mental health service providers: results of a one-year follow-up

This study examined changes in service delivery patterns of health and mental health service providers one year after a training on the fundamentals of HIV/AIDS and mental health. Paired t-tests for 424 training recipients showed significant increases in delivery of HIV-related services, and these remained significant while controlling for additional training, job changes, region (urban, rural, suburban), and provider discipline. Multiple logistic regression analysis revealed a significantly greater likelihood of providing direct services to HIV+ individuals among male providers, those with more years of HIV experience, those in counseling disciplines, and those working in a new job since the training.

The social realities of adherence to protease inhibitor regimens: substance use, health care and psychological states

Adherence to HIV antiretroviral treatments is impacted by a variety of factors nested within the realities of people's lives. To understand this phenomenon, we undertook an investigation to assess HIV medication adherence in a community-based sample of 300 HIV seropositive men-who-have-sex-with-men (MSM). Using multiple measurement strategies (self-report, electronic monitoring, calendar-based assessments) we assessed factors related to medication adherence. Our findings indicate that adherence to protease inhibitor regimens are highly variable and are related to contextual, intrapersonal and behavioral factors, including access to health care, the use of specific recreational substances, self-efficacy toward adherence and avoidant coping strategies. These results suggest that a complex interaction between intrapsychic and socio-cultural realities may help to explain adherence to HIV treatment medications.

The impact of race/ethnicity on mother-to-child HIV transmission in the United States in Pediatric AIDS Clinical Trials Group Protocol 316

The present analysis was designed to determine whether race/ethnicity was independently associated with mother-to-child HIV-1 transmission risk in subjects enrolled in a trial of 2-dose intra-partum nevirapine in combination with standard antiretroviral therapy and to determine what factors, including race/ethnicity, predicted maternal viral suppression at the time of delivery. Women enrolled in Pediatric AIDS Clinical Trials Group (PACTG) 316 from sites in the United States and Puerto Rico were included. Distribution of selected maternal disease and treatment characteristics was assessed by race/ethnicity category. Logistic regression models were fit to evaluate possible association of factors with HIV transmission and with viral load at delivery. Variables associated with the outcome at P < 0.05 level were retained in the final models. Of 1052 women randomized at PACTG sites, 891 were included in the present analysis: 572 (64%) were black; 206 (23%) were Hispanic; and 113 (13%) were white. All women who had infected infants were black or Hispanic (11/572 and 3/206, respectively), whereas none of the women identified as white had an infected infant (0/113). This difference was not statistically significant (P = 0.54). White women had higher entry CD4 cell counts and lower HIV-1 RNA at delivery than women of other races/ethnicities. Black and Hispanic women were more likely than white women to start therapy during their current pregnancy but did not initiate prenatal care later. In bivariate models that included antiretroviral type and variables that had values of P < or = 0.25 in univariate analysis, time of antiretroviral initiation, time of prenatal care initiation, and race/ethnicity each retained significance in predicting viral suppression at delivery. Race/ethnicity remained predictive of viral suppression at delivery in a multivariate model incorporating all of these variables (P = 0.01). Higher HIV-1 RNA and lower CD4 cell counts in women identified as black or Hispanic have significant implications for the health of these women and their newborns. Race/ethnicity is significant in predicting viral suppression at the time of delivery.

Changes in attitudes toward antiviral medication: a comparison of women living with HIV/AIDS in the pre-HAART and HAART Eras

To examine potential changes in attitudes toward antiviral medication since the advent of highly active antiretroviral therapy (HAART), focused interviews were conducted with two samples of women living with HIV/AIDS; one in the pre-HAART era (1994-1996) and a second matched sample in the HAART era (2000-2003). Women in the pre-HAART era held highly negative attitudes toward antiviral medications, perceived them as ineffective with few benefits and viewed side effects as intolerable. In contrast, women in the HAART era were less likely to report negative attitudes, which were balanced by more frequent reports of perceived benefits and more likely to view side effects as temporary and manageable. African American women in both eras were more likely to hold negative attitudes and less likely to perceive benefits than White and Puerto Rican women. These findings suggest that views of antiviral medication have improved since the advent of HAART, but that negative attitudes and side-effect concerns remain which should be addressed in interventions to promote treatment acceptance and adherence.

Health and health care among male-to-female transgender persons who are HIV positive

Recent studies have reported high rates of HIV infection among male-to-female transgender persons, but little research has examined how male-to-female transgender persons manage living with HIV. We compared demographic and health characteristics of 59 male-to-female transgender persons who were HIV positive with 300 nontransgender control subjects who were HIV positive. We found several demographic differences between the groups but no significant differences in HIV-related health status. Male-to-female transgender persons were less likely than the control group to take highly active antiretroviral therapy.

The relationship between non-injection drug use behaviors on progression to AIDS and death in a cohort of HIV seropositive women in the era of highly active antiretroviral therapy use

AIMS

To evaluate the effects of longitudinal patterns and types of non-injection drug use (NIDU) on HIV progression in the highly active antiretroviral therapy (HAART) era.

DESIGN

Women's Interagency HIV Study (WIHS), a prospective cohort study conducted at six US sites.

METHODS

Data were collected semi-annually from 1994 to 2002 on 1046 HIV(+) women. Multivariate Cox proportional hazards modeling was used to estimate relative hazards for developing AIDS and for death by pattern and type of NIDU.

FINDINGS

During follow-up, 285 AIDS events and 287 deaths, of which 177 were AIDS-related, were reported. At baseline, consistent and former NIDU was associated with CD4(+) counts of < 200 cells/microl (43% and 46%, respectively) and viral load > 40,000 copies/ml (53% and 55%, respectively). Consistent NIDU reported less HAART use (53%) compared with other NIDU patterns. Stimulant use was associated with CD4(+) cell counts of < 200 cells/microl (53%) and lower HAART initiation (63%) compared with other NIDU types. In multivariate analyses, progression to AIDS was significantly higher among consistent (RH = 2.52), inconsistent (RH = 1.63) and former (RH = 1.56) users compared with never users; and for stimulant (RH = 2.04) and polydrug (RH = 1.65) users compared with non-users. Progression to all-cause death was higher only among former users (RH = 1.48) compared with never users in multivariate analysis. NIDU behaviors were not associated with progression to AIDS-related death.

CONCLUSIONS

In this study, pattern and type of NIDU were associated with HIV progression to AIDS and all-cause mortality. These differences were associated with lower HAART utilization among consistent NIDU and use of stimulants, and poor baseline immunological and virological status among former users.

Effective HIV treatment and the employment of HIV(+) adults

OBJECTIVE

To examine whether highly active antiretroviral therapy (HAART) helps HIV-infected patients return to work, remain employed, and maintain hours of work.

DATA SOURCE

Longitudinal data from a national probability sample of HIV+ patients older than 18 years old who made at least one visit in the contiguous United States in early 1996.

STUDY DESIGN

We consider the effect of HAART on three employment outcomes: (1) returning to work within six months of treatment, conditional on not working pretreatment; (2) remaining employed within six months of treatment, conditional on working pretreatment; (3) hours of work conditional on working at the second follow-up survey. We use a bivariate probit model to jointly model employment and treatment with HAART for the first two outcomes and the two-stage least squares method for hours of work. State policies regarding prescription drug coverage are used as instrumental variables for HAART to account for a key source of potential bias-the more severely ill tend to have the most difficulty working, but are also the most likely to be on HAART.

PRINCIPAL FINDINGS

Our results indicate that HAART increases the probability of remaining employed by HIV patients and hours of work for those working within six months of treatment. In the case of remaining employed, the employment effect (an increase from 58 percent to 94 percent in the probability of remaining employed) is statistically significant and the related incremental income is sizable compared to the incremental costs of HAART. Sensitivity analyses demonstrate that the results are robust to different specifications for insurance coverage.

CONCLUSIONS

Patients who are working are more likely to remain employed because of treatment with HAART. HAART prescribed to patients in less advanced stages of the infection may lead to the greatest gain in employment.

Initiation of regular marijuana use among a cohort of women infected with or at risk for HIV in the Women's Interagency HIV Study (WIHS)

Our study sought to determine the incidence of weekly marijuana use among HIV-infected and uninfected women, to identify correlates of weekly marijuana use, and to test its association with stage of HIV disease and type of HIV treatment received. A total of 2059 HIV-positive and 569 HIV-negative women from 6 sites were recruited between 1994 and 1995 and followed through 2000. After excluding women who reported weekly marijuana use at baseline, 2050 women were included in the analysis. The incidence rate for initiating marijuana was calculated and survival analysis was performed to determine the correlates of initiating weekly marijuana use. Three hundred and three women initiated weekly marijuana use within 5.5 years of the baseline visit, yielding a cumulative incidence (CI) of 14.8%. There was no significant difference in weekly marijuana use initiation between HIV-infected (CI = 14.5%) and HIV-uninfected women (CI = 16.0%). Younger age and having more sex partners was associated with incident weekly marijuana use among both infected and uninfected women. While undetectable viral load was associated with lower incidence rate (p < 0.001, RH = 0.44) and wasting syndrome with higher incidence (p < 0.01, relative hazard [RH] = 3.1), CD4 count was not. Compared to receiving no AIDS treatment at all, women who received basic combination antiretroviral therapy had significantly higher incidence of weekly marijuana use (p < 0.001, RH = 1.93), while highly active antiretroviral therapy (HAART) receivers had significantly lower incidence (p < 0.001, RH = 0.24). In summary, among HIV-infected women, the incidence of weekly marijuana use was associated with only one marker of HIV disease stage and HAART was associated with lower initiation rate of weekly marijuana use.

Provider barriers to prescribing HAART to medically-eligible HIV-infected drug users

We aimed to identify factors associated with a medical provider's resistance to prescribing HAART to medically-eligible HIV-infected illicit drug users. In four US cities, a mailed, self-administered survey queried 420 HIV care providers about patients' characteristics and barriers to care. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were estimated using logistic regression. Providers identified as resistant to prescribing HAART to medically-eligible HIV-infected illicit drug users were more likely to be non-physicians (AOR=1.89, 95% CI: 1.04-3.46), to work in populations with a high prevalence of both mental illness (AOR=2.42; 95% CI: 1.11-5.26) and injection drug use (AOR=1.82 95% CI: 1.02-3.25) and were deterred from prescribing HAART by patients' limited ability to keep appointments, (AOR=3.19; 95% CI: 1.39-7.37), alcoholism (AOR=1.92; 95% CI: 1.04-3.55) and homelessness (AOR=1.81; 95% CI: 1.07-3.06). Providers working in populations with a high injection drug use prevalence commonly reported higher prevalence of non-injection drug use, alcohol problems and mental illness, and higher antiretroviral therapy refusal rates within their patient populations. Our findings underscore the challenges to providers who treat HIV-infected drug users and suggest that their care and treatment would benefit from on-site drug treatment, mental health and social services.

Changes in sexual behavior among HIV-infected women after initiation of HAART

OBJECTIVES

We assessed the association between initiation of highly active antiretroviral treatment (HAART) regimens and sexual risk behaviors among HIVinfected women.

METHODS

We analyzed data from 724 women who initiated HAART between January 1996 and January 2001 and who had pre-HAART viral loads at or above 400 copies per milliliter.

RESULTS

Sexually active women were less likely (odds ratio [OR] = 0.79) to report 2 or more partners during a 6-month period after HAART initiation than before HAART initiation. However, the risk for unprotected sex was higher after HAART initiation than before HAART initiation among all sexually active women (both those who reported 2 or more partners [OR = 1.84] and those who reported 1 partner [OR = 1.22]).

CONCLUSIONS

Sexual risk behaviors are associated with receipt of therapy but not with therapeutic response, indicating a risk for transmission among female HAART recipients.

Depressive symptoms and AIDS-related mortality among a multisite cohort of HIV-positive women

OBJECTIVES

We examined associations between depressive symptoms and AIDS-related mortality after controlling for antiretroviral therapy use, mental health treatment, medication adherence, substance abuse, clinical indicators, and demographic factors.

METHODS

One thousand seven hundred sixteen HIV-seropositive women completed semiannual visits from 1994 through 2001 to clinics at 6 sites. Multivariate Cox and logistic regression analyses estimated time to AIDS-related death and depressive symptom severity.

RESULTS

After we controlled for all other factors, AIDS-related deaths were more likely among women with chronic depressive symptoms, and symptoms were more severe among women in the terminal phase of their illness. Mental health service use was associated with reduced mortality.

CONCLUSIONS

Treatment for depression is a critically important component of comprehensive care for HIV-seropositive women, especially those with end-stage disease.

Prevalence of clinical symptoms associated with highly active antiretroviral therapy in the Women's Interagency HIV Study

BACKGROUND

The extended use of antiretroviral drugs among human immunodeficiency virus (HIV)-seropositive individuals underscores the need for a comprehensive evaluation of therapy-associated clinical symptoms.

METHODS

Beginning in April 2000, 364 HIV-seronegative and 1256 HIV-seropositive women enrolled in a multicenter cohort study reported clinical symptoms that included abdominal pain, diarrhea, anorexia, nausea and/or vomiting, myalgias, fatigue, fever, body fat redistribution, dizziness, headaches, paresthesias, xerostomia, nephrolithiasis, and rash. We examined the prevalence of symptoms with respect to HIV infection and the use of highly active antiretroviral therapy (HAART), using data-correlation models.

RESULTS

In the 6 months before a study visit, 49% of HIV-seronegative women, 67% of HIV-seropositive women not receiving therapy, and 69% of HIV-seropositive women receiving HAART reported any clinical symptom. The odds ratios (ORs) for reporting any symptom were 1.4 (95% confidence interval [CI], 1.1-1.8) for women who changed HAART regimens and 0.9 (95% CI, 0.7-1.1) for women reporting stable HAART use, compared with those reporting no therapy use. Significant findings (P<.05) for particular symptoms were an increased odds of diarrhea, nausea and/or vomiting, body fat redistribution, myalgias, and paresthesias, when data for women who changed HAART regimens were compared with those for women not receiving therapy. The OR for reporting any symptom was 1.5 (95% CI, 1.2-1.9) for women who switched HAART regimens and 1.6 (95% CI, 1.3-1.9) for women who discontinued HAART, compared with those reporting stable HAART use.

CONCLUSIONS

Our findings confirm the high prevalence of clinical symptoms among HIV-seropositive women who changed HAART regimens. The high prevalence of symptoms among HIV-seronegative women and HIV-seropositive women not receiving therapy demonstrates that caution should be used when attributing the occurrence of symptoms entirely to HAART.

Medically eligible women who do not use HAART: the importance of abuse, drug use, and race

OBJECTIVES

We investigated the prevalence and characteristics of HIV-positive women who do not report highly active antiretroviral therapy (HAART) use.

METHODS

We analyzed HAART use among 1165 HIV-positive participants in the Women's Interagency HIV Study.

RESULTS

Between October 1, 2000, and March 31, 2001, 254 women with clinical indications for HAART reported not using it, 635 reported HAART use, and 276 had no clinical indications. In multivariate analysis, using crack/cocaine/heroin and a history of abuse decreased the likelihood of using HAART, whereas being White increased it.

CONCLUSIONS

One of 4 women for whom HAART was indicated reported not using HAART. Childhood sexual abuse prevention, more intensive abuse treatment, and continuing drug treatment may enhance HIV disease treatment of women.

Healthcare use by varied highly active antiretroviral therapy (HAART) strata: HAART use, discontinuation, and naivety

OBJECTIVES

Prior reports have found a temporal association between the introduction of highly active antiretroviral therapy (HAART) and population rates of health service use among persons living with HIV. Our objective was to explore further the effect of HAART by comparing healthcare use among persons who use HAART and persons who discontinue HAART to that among HAART-naive and HIV-negative persons.

METHODS

Longitudinal analyses of 1485 women with and at-risk for HIV who contributed data to the Women's Interagency HIV Study between April 1997 and March 2000.

RESULTS

Compared with HAART-naive women, those using HAART had a higher probability of more than three primary care visits per 6 months [odds ratio (OR), 1.38; 95% confidence interval (CI), 1.16-1.65), a lower probability of more than one emergency room visit per 6 months (OR, 0.75; CI, 0.59-0.95), and a lower probability of more than one hospitalization per 6 months (OR, 0.67; CI, 0.51-0.88). Compared with HAART-naive women, women who had discontinued HAART had a higher frequency of primary care visits (OR, 1.57; CI, 1.26-1.97) but did not demonstrate a significant change in emergency room or hospital use. Modeling of a standardized population HIV-positive women without AIDS indicated hospitalization and emergency room use among HAART users was equivalent to that among HIV-negative women.

CONCLUSIONS

HIV-positive HAART users (without AIDS) exhibited emergency room and hospitalization use patterns equivalent to those of HIV-negative women. Furthermore, the discontinuation of HAART was associated with a loss of the reduction in hospital use that was achieved with HAART.