Alcohol and drug use severity are independently associated with antiretroviral adherence in the current treatment era

Substance use in people with HIV (PWH) negatively impacts antiretroviral therapy (ART) adherence. However, less is known about this in the current treatment era and the impact of specific substances or severity of substance use. We examined the associations of alcohol, marijuana, and illicit drug use (methamphetamine/crystal, cocaine/crack, illicit opioids/heroin) and their severity of use with adherence using multivariable linear regression in adult PWH in care between 2016 and 2020 at 8 sites across the US. PWH completed assessments of alcohol use severity (AUDIT-C), drug use severity (modified ASSIST), and ART adherence (visual analogue scale). Among 9400 PWH, 16% reported current hazardous alcohol use, 31% current marijuana use, and 15% current use of ≥1 illicit drugs. In multivariable analysis, current methamphetamine/crystal use, particularly common among men who had sex with men, was associated with 10.1% lower mean ART adherence (p < 0.001) and 2.6% lower adherence per 5-point higher severity of use (ASSIST score) (p < 0.001). Current and more severe use of alcohol, marijuana, and other illicit drugs were also associated with lower adherence in a dose-dependent manner. In the current HIV treatment era, individualized substance use treatment, especially for methamphetamine/crystal, and ART adherence should be prioritized.

Racial and ethnic disparities in COVID-19 disease incidence independent of comorbidities, among people with HIV in the US

OBJECTIVES

To define the incidence of clinically-detected COVID-19 in people with HIV (PWH) in the US and evaluate how racial and ethnic disparities, comorbidities, and HIV-related factors contribute to risk of COVID-19.

DESIGN

Observational study within the CFAR Network of Integrated Clinical Systems cohort in 7 cities during 2020.

METHODS

We calculated cumulative incidence rates of COVID-19 diagnosis among PWH in routine care by key characteristics including race/ethnicity, current and lowest CD4 count, and geographic area. We evaluated risk factors for COVID-19 among PWH using relative risk regression models adjusted with disease risk scores.

RESULTS

Among 16,056 PWH in care, of whom 44.5% were Black, 12.5% were Hispanic, with a median age of 52 years (IQR 40-59), 18% had a current CD4 count < 350, including 7% < 200; 95.5% were on antiretroviral therapy, and 85.6% were virologically suppressed. Overall in 2020, 649 PWH were diagnosed with COVID-19 for a rate of 4.94 cases per 100 person-years. The cumulative incidence of COVID-19 was 2.4-fold and 1.7-fold higher in Hispanic and Black PWH respectively, than non-Hispanic White PWH. In adjusted analyses, factors associated with COVID-19 included female sex, Hispanic or Black identity, lowest historical CD4 count <350 (proxy for CD4 nadir), current low CD4/CD8 ratio, diabetes, and obesity.

CONCLUSIONS

Our results suggest that the presence of structural racial inequities above and beyond medical comorbidities increased the risk of COVID-19 among PWHPWH with immune exhaustion as evidenced by lowest historical CD4 or current low CD4:CD8 ratio had greater risk of COVID-19.

Potential Health Effects of Loneliness in the Pandemic Era

Background

COVID-19 has posed a public health problem leading to considerably higher healthcare costs in the U.S. population. Additionally, social connectedness has been demonstrated to be directly correlated with improved disease management and outcome of treatment. The purpose of the current study was to explore 10-year mortality outcomes of loneliness.

Methods

We assessed data from the 1999-2008 National Health and Nutrition Examination Survey, with mortality data obtained through 2015. All individuals from this nationally representative study were 20 years and older. Hazard ratios with 95% confidence intervals (CIs) for all-cause and cardiovascular disease (CVD) mortality were estimated using Cox Regression models.

Results

Out of 994 participants (54% females vs. 46% males) with loneliness, 324 deaths were reported (including 71 CVD deaths) during an average of 10-year follow-up. The hazard ratio for mortality among those experiencing social isolation was 1.28 (95% CI = 1.17-1.39). The adjusted HR for all-cause mortality [1.24 (CI 1.12-1.38, p < 0.05)] and CVD mortality [1.31 (CI 1.09-2.56, p < 0.05)] were significant, after additional adjustment for demographic and health risk factors. There was also an increase in COVID-19 related loneliness search behavior.

Conclusions

Individuals who experience loneliness have a significantly higher likelihood of overall and CVD-mortality than those who are socially connected. Consequently, addressing loneliness in the face of social distancing and isolation may contribute to lower premature death risk and improve CVD-mortality in this vulnerable population.

Key messages

Loneliness may longitudinally lead to increased mortality from cardiovascular disease.

Future public health interventions should incorporate active efforts to address loneliness.

Stroke as an Antecedent Risk Factor for Depression among Post-Menopausal Women

Background

As many as one out of every three individuals develop depression after stroke. Numerous studies have also shown a link between depression and increased rates of mortality after stroke. Additionally, the risk factors and characteristics of stroke are different between men and women. However, the association between stroke and depression has not been investigated in postmenopausal women in a nationally representative sample.

Methods

The association between currently active depression [score ≥ 10 on a Patient Health Questionnaire (PHQ)-9 scale] and self-reported history of stroke were assessed among participants from the 2005-2010 National Health and Nutrition Examination Survey (NHANES). All post-menopausal women from the nationally representative NHANES study were included in the analysis. Multivariable complex samples logistic regression was used to calculate multivariate-adjusted odds ratios (ORs) of depression.

Results

Out of the 3,636 (representative sample=44,110,822) postmenopausal women, the mean age was 62.6 ± 0.33. The ethnic distribution was 77.3% non-Hispanic Whites, 10.9% non-Hispanic Blacks, 7.5% Hispanics, and 4.3% other nationalities. In age-adjusted analysis, individuals with a history of stroke had 2.5-fold higher odds of active depression than those without a history of stroke (OR 2.57, 95% CI 1.57-4.19, p < .001). Controlling for vascular risk factors (diabetes, hypertension, C-reactive protein, and BMI) of depression and socio-demographic risk factors (age, ethnicity, and income level) attenuated the effect (OR 2.16, 95% CI 1.17-3.99, p < .05).

Conclusions

A significant association between previous stroke and current depression was found in this population, independent of vascular disease risk measures among post-menopausal women. These findings highlight the possible importance of screening for and treating depression among stroke survivors. Longitudinal studies need to be conducted assessing the mental health impact of stroke.

Key messages

Occurrence of stroke may lead to an increased likelihood of depression, especially among post-menopausal women.

Due to the global COVID-19 pandemic, surveillance efforts should include mental health complication including those related to stroke.

Anemia risk factors among people living with HIV across the United States in the current treatment era: a clinical cohort study

Background

Anemia is common among people living with HIV infection (PLWH) and is associated with adverse health outcomes. Information on risk factors for anemia incidence in the current antiretroviral therapy (ART) era is lacking.

Methods

Within a prospective clinical cohort of adult PLWH receiving care at eight sites across the United States between 1/2010–3/2018, Cox proportional hazards regression analyses were conducted among a) PLWH free of anemia at baseline and b) PLWH free of severe anemia at baseline to determine associations between time-updated patient characteristics and development of anemia (hemoglobin < 10 g/dL), or severe anemia (hemoglobin < 7.5 g/dL). Linear mixed effects models were used to examine relationships between patient characteristics and hemoglobin levels during follow-up. Hemoglobin levels were ascertained using laboratory data from routine clinical care. Potential risk factors included: age, sex, race/ethnicity, body mass index, smoking status, hazardous alcohol use, illicit drug use, hepatitis C virus (HCV) coinfection, estimated glomerular filtration rate (eGFR), CD4 cell count, viral load, ART use and time in care at CNICS site.

Results

This retrospective cohort study included 15,126 PLWH. During a median follow-up of 6.6 (interquartile range [IQR] 4.3–7.6) years, 1086 participants developed anemia and 465 participants developed severe anemia. Factors that were associated with incident anemia included: older age, female sex, black race, HCV coinfection, lower CD4 cell counts, VL ≥400 copies/ml and lower eGFR.

Conclusion

Because anemia is a treatable condition associated with increased morbidity and mortality among PLWH, hemoglobin levels should be monitored routinely, especially among PLWH who have one or more risk factors for anemia.

Lessons learned from the design and implementation of myocardial infarction adjudication tailored for HIV clinical cohorts

We developed, implemented, and evaluated a myocardial infarction (MI) adjudication protocol for cohort research of human immunodeficiency virus. Potential events were identified through the centralized Centers for AIDS Research Network of Integrated Clinical Systems data repository using MI diagnoses and/or cardiac enzyme laboratory results (1995-2012). Sites assembled de-identified packets, including physician notes and results from electrocardiograms, procedures, and laboratory tests. Information pertaining to the specific antiretroviral medications used was redacted for blinded review. Two experts reviewed each packet, and a third review was conducted if discrepancies occurred. Reviewers categorized probable/definite MIs as primary or secondary and identified secondary causes of MIs. The positive predictive value and sensitivity for each identification/ascertainment method were calculated. Of the 1,119 potential events that were adjudicated, 294 (26%) were definite/probable MIs. Almost as many secondary (48%) as primary (52%) MIs occurred, often as the result of sepsis or cocaine use. Of the patients with adjudicated definite/probable MIs, 78% had elevated troponin concentrations (positive predictive value = 57%, 95% confidence interval: 52, 62); however, only 44% had clinical diagnoses of MI (positive predictive value = 45%, 95% confidence interval: 39, 51). We found that central adjudication is crucial and that clinical diagnoses alone are insufficient for ascertainment of MI. Over half of the events ultimately determined to be MIs were not identified by clinical diagnoses. Adjudication protocols used in traditional cardiovascular disease cohorts facilitate cross-cohort comparisons but do not address issues such as identifying secondary MIs that may be common in persons with human immunodeficiency virus.