Psychological distress and mental health care utilization among Black survivors of adolescent and young adult cancer

BACKGROUND

Survivors of adolescent and young adult (AYA) cancer experience significant psychological distress and encounter barriers to accessing mental health care. Few studies have investigated racial/ethnic disparities in psychological health outcomes among AYA survivors, and none have compared outcomes within a racially minoritized population.

METHODS

National Health Interview Survey data (2010-2018) were analyzed that identified non-Hispanic Black (hereafter, Black) survivors of AYA cancer and age- and sex-matched Black noncancer controls. Sociodemographic factors, chronic health conditions, modifiable behaviors (smoking and alcohol use), and psychological outcomes were assessed with χ2 tests. Logistic regression models, adjusted for survey weights, were used to evaluate the odds of psychological distress by cancer status after adjusting for covariates. Interactions between variables and cancer status were investigated.

RESULTS

The study included 334 Black survivors of AYA cancer and 3340 Black controls. Compared to controls, survivors were more likely to report moderate/severe distress (odds ratio [OR], 1.64; p < .001), use mental health care (OR, 1.53; p = .027), report an inability to afford mental health care (OR, 3.82; p < .001), and use medication for anxiety and/or depression (OR, 2.16; p = .001). Forty-one percent of survivors reported moderate/severe distress, and only 15% used mental health care. Among survivors, ages 18-39 years (vs. 40-64 years) and current smoking (vs. never smoking) were associated with the presence of moderate/severe distress. Among survivors with distress, high poverty status was associated with reduced utilization of mental health care.

CONCLUSIONS

A cancer diagnosis for a Black AYA is associated with greater psychological distress within an already vulnerable population.

Clinical, demographic factors, and substance use among Hispanic and non-Hispanic young adult childhood cancer survivors

PURPOSE

The purpose of this study is to examine the protective and risk factors of substance use behaviors (tobacco, marijuana, e-cigarette, and alcohol) among young adult childhood cancer survivors. The study focused on clinical (receipt of cancer-related follow-up care, treatment intensity, late effects, depressive symptoms, self-rated health) and demographic (race/ethnicity, neighborhood socioeconomic status) factors and their associations with substance use.

METHODS

Participants were from the Project Forward cohort, a population-based study of young adult survivors of childhood cancers. Participants (N = 1166, Mage = 25.1 years) were recruited through the Los Angeles Cancer Surveillance Program (Cancer Registry covering Los Angeles County, California). Multivariate path analyses were performed with substance use as the outcome variables and clinical and demographic factors as independent variables. Covariates included age and sex.

FINDING

Substance use was positively associated with depressive symptoms, and inversely associated with cancer-related follow-up care, female sex, age, Hispanic ethnicity, treatment intensity, and self-rated health. Neighborhood SES was inversely associated with tobacco use, while being positively associated with binge drinking and e-cigarette use. The results highlight the interrelationship between the clinical and demographic variables and their associations with different substance use.

CONCLUSION

Findings support the need for effective interventions targeting substance use behavior among CCS. This will help improve long-term outcomes and mitigate the risk for early morbidity.

Common antiretroviral combinations are associated with somatic depressive symptoms in women with HIV

OBJECTIVE

While modern antiretroviral therapy (ART) is highly effective and safe, depressive symptoms have been associated with certain ART drugs. We examined the association between common ART regimens and depressive symptoms in women with HIV (WWH) with a focus on somatic vs. nonsomatic symptoms.

DESIGN

Analysis of longitudinal data from the Women's Interagency HIV Study.

METHODS

Participants were classified into three groups based on the frequency of positive depression screening (CES-D ≥16): chronic depression (≥50% of visits since study enrollment), infrequent depression (<50% of visits), and never depressed (no visits). Novel Bayesian machine learning methods building upon a subset-tree kernel approach were developed to estimate the combined effects of ART regimens on depressive symptoms in each group after covariate adjustment.

RESULTS

The analysis included 1538 WWH who participated in 12 924 (mean = 8.4) visits. The mean age was 49.9 years, 72% were Black, and 14% Hispanic. In the chronic depression group, combinations including tenofovir alafenamide and cobicistat-boosted elvitegravir and/or darunavir were associated with greater somatic symptoms of depression, whereas those combinations containing tenofovir disoproxil fumarate and efavirenz or rilpivirine were associated with less somatic depressive symptoms. ART was not associated with somatic symptoms in the infrequent depression or never depressed groups. ART regimens were not associated with nonsomatic symptoms in any group.

CONCLUSIONS

Specific ART combinations are associated with somatic depressive symptoms in WWH with chronic depression. Future studies should consider specific depressive symptoms domains as well as complete drug combinations when assessing the relationship between ART and depression.

Psychological distress and mental health care utilization among Hispanic/Latino survivors of adolescent and young adult cancer

PURPOSE

Survivors of adolescent and young adult (AYA) cancer experience psychological distress and insufficient access to mental health care. Few studies have investigated racial/ethnic disparities in psychological health outcomes in this population. This study compared psychological distress, mental health care use, and inability to afford mental health care between Hispanic/Latino survivors of AYA cancer and Hispanic/Latino controls.

METHODS

The National Health Interview Survey data (2010-2018) were analyzed to identify Hispanic/Latino survivors of AYA cancer and Hispanic/Latino age- and sex-matched non-cancer controls. Sociodemographic, chronic health, modifiable factors, and psychological outcomes were compared using chi-square tests. Logistic regression models with survey weights were used to assess the log-odds of psychological distress in relation to covariates, along with the cancer group. Interactions were evaluated between each variable and cancer group.

RESULTS

The study included 370 Hispanic/Latino survivors of AYA cancer (mean time since diagnosis = 12.34 years) and 3700 Hispanic/Latino controls. Compared to controls, survivors were more likely to report moderate/severe distress (OR = 2.23, p < 0.001), use of mental health care (OR = 2.11, p < 0.001) and inability to afford mental health care (OR = 3.05, p < 0.001). Forty-one percent of survivors reported moderate/severe distress and only 16% utilized mental health care. Among survivors, having more than two chronic health conditions and public insurance (compared to private insurance) were associated with the presence of moderate/severe distress. Among survivors experiencing moderate/severe distress, lack of insurance was associated with decreased utilization of mental health care.

CONCLUSIONS

Having cancer as an AYA may exacerbate disparities in psychological health within the Hispanic/Latino population.

Neuropsychiatric complications and associated management in adolescent and young adult cancer survivors: An All of Us study

BACKGROUND

About 4.5% of new cancer cases affect adolescent and young adult aged between 15 and 39 years in the United States (US). However, the effect of neuropsychiatric conditions on long-term adolescent and young adult cancer (AYAC) survivors has not been formally investigated. Thus, the impact and management of late neuropsychiatric complications in AYAC survivors compared to non-cancer-matched controls (NCMC) in the US were evaluated using the All of Us (AoU) Research Program.

METHODS

Participants in the AoU Controlled Tier Dataset (v6) diagnosed with cancer between ages 15 and 39 were identified from electronic health records and surveys. AYAC survivors were matched with NCMC using the optimal pair-matching algorithm at a 1:4 ratio. Data on past diagnoses, current follow-up care, and treatment patterns of neuropsychiatric complications were collected.

RESULTS

Analysis was performed on 788 AYAC survivors and 3152 NCMC. AYAC survivors, with an average of 8.8 years since their first cancer diagnosis, were more likely than NCMC to receive a diagnosis of neuropathy, memory loss and epilepsy (p  < 0.001). Survivors also had a higher rate of follow-up care and treatment utilization for these neurological conditions compared to NCMC (p  < 0.05). Treatment utilization was highest among survivors receiving care for epilepsy (88%), and lower for neuropathy (70%), memory loss (61%), and chronic fatigue (59%).

CONCLUSIONS

This large study reveals that AYAC survivors, on average 9 years after their cancer diagnosis, require more frequent follow-up care for neurological complications compared to non-cancer individuals. However, the management of neuropathy, memory loss, and chronic fatigue is hindered by a lack of mechanism-based effective therapies.

Unmet Needs, Barriers, and Facilitators for Conducting Adolescent and Young Adult Cancer Survivorship Research in Southern California: A Delphi Survey

Introduction: An adolescent and young adult cancer (AYAC) patient is an individual who has received a cancer diagnosis between 15 and 39 years of age. They require significant survivorship care due to a combination of practical, physical, and mental health problems, but research in these areas is sparse. This study aimed to identify the unmet needs, barriers, and facilitators for conducting AYAC survivorship research in Southern California (SoCal) from the providers' and researchers' perspectives. Methods: A two-round, electronically administered Delphi survey study was conducted, involving a panel of 12 health care professionals and/or researchers with substantial work experience in AYAC. A 10-point Likert scale was used to evaluate 24 areas of unmet needs in AYAC survivors, 39 barriers, and 25 facilitators. Results: The top unmet needs in AYAC survivorship requiring research were in mental health issues, improving school/occupational performance, neurocognitive disorders, subsequent malignant neoplasms, and reproductive health. The top barriers identified were as follows: (1) institutions are too short-staffed to administer survivorship studies; (2) oncologists do not have the time/resources; and (3) lack of available funding. The top facilitators identified were as follows: (1) development of a mechanism/program to fund AYAC survivorship research studies; (2) in-person or virtual investigator engagement between children's hospitals and adult cancer centers to discuss research studies; and (3) developing personalized survivorship goals with AYAC patients and survivors to facilitate enrollment into survivorship studies. Conclusion: Experts identified the lack of time, manpower, funding, and resources as major barriers in AYAC survivorship research. Enhancing communication and collaboration with different stakeholders may facilitate AYAC survivorship research efforts within the SoCal region.

Beyond depression: correlates of well-being in young adult survivors of childhood cancers

PURPOSE

This study investigated the correlates of well-being with psychosocial and clinical factors in young adult childhood cancer survivors (YACCS) above and beyond depressive symptoms.

METHODS

Participants were from the Project Forward Cohort, a population-based study of young adult survivors of childhood cancers. Participants (n = 1166, Mage = 25.1 years) were recruited through the Los Angeles Cancer Surveillance Program (Cancer Registry covering Los Angeles County). A majority received a diagnosis of leukemia (36.1%) or lymphoma (21.7%). Participants completed self-reported questionnaires at one timepoint. Multiple regression analyses were performed with well-being as the outcome variable and psychosocial and clinical variables (social support, sense of adulthood, posttraumatic growth, treatment intensity, and self-rated health) as the independent variables. Covariates included demographics (age, gender, relationship status, race/ethnicity) and depressive symptoms.

RESULTS

In the multivariable model, posttraumatic growth, social support, sense of adulthood, and self-rated health were significantly associated with well-being (all ps < .05), when controlling for depressive symptoms. Treatment intensity and years since diagnosis were not significantly associated with well-being, when controlling for depressive symptoms.

CONCLUSIONS

There are unique correlates of well-being above and beyond depressive symptoms among YACCS. This finding illuminates individual differences that may be associated with well-being and provides targets for intervention.

IMPLICATIONS FOR CANCER SURVIVORS

Psychosocial interventions and survivorship care for YACCS should consider the broad aspects of well-being, independent of depressive symptoms.

Disparities in pediatric cancer survivorship care: A systematic review

BACKGROUND

Childhood cancer survivors (CCS) experience many long-term health problems that can be mitigated with recommended survivorship care. However, many CCS do not have access to survivorship care nor receive recommended survivorship care. We reviewed the empirical evidence of disparities in survivorship care for CCS.

METHODS

This systematic review searched PubMed, CINAHL, and PsycINFO for studies on survivorship care for CCS (PROSPERO: CRD42021227965) and abstracted the reported presence or absence of disparities in care. We screened 7945 citations, and of those, we reviewed 2760 publications at full text.

RESULTS

A total of 22 studies reported in 61 publications met inclusion criteria. Potential disparities by cancer treatment (N = 14), diagnosis (N = 13), sex (N = 13), and current age (N = 13) were frequently studied. There was high quality of evidence (QOE) of survivorship care disparities associated with non-White race, Hispanic ethnicity, and being uninsured. Moderate QOE demonstrated disparities among CCS who were unemployed and older. Lower QOE was found for disparities based on cancer diagnosis, cancer treatment, age at diagnosis, time since diagnosis, sex, insurance type, income, educational attainment, and geographic area.

CONCLUSIONS

We found strong empirical evidence of disparities in survivorship care for CCS associated with race, ethnicity, and insurance status. Multiple other disparate groups, such as those by employment, income, insurance type, education, cancer diagnosis, age at diagnosis, time since diagnosis, cancer treatment, geographic area, sex, and self-identified gender warrant further investigation. Prospective, multilevel research is needed to examine the role of other patient characteristics as potential disparities hindering adequate survivorship care in CCS.

Integrase Inhibitors are Associated with Neuropsychiatric Symptoms in Women with HIV

OBJECTIVE

Women with HIV(WWH) are more likely to discontinue/change antiretroviral therapy(ART) due to side effects including neuropsychiatric symptoms. Efavirenz and integrase strand transfer inhibitors(INSTIs) are particularly concerning. We focused on these ART agents and neuropsychiatric symptoms in previously developed subgroups of WWH that differed on key sociodemographic factors as well as longitudinal behavioral and clinical profiles. WWH from the Women's Interagency HIV Study were included if they had ART data available, completed the Perceived Stress Scale-10 and PTSD Checklist-Civilian. Questionnaires were completed biannually beginning in 2008 through 2016. To examine ART-symptom associations, constrained continuation ratio model via penalized maximum likelihood were fit within 5 subgroups of WWH. Data from 1882 WWH contributed a total of 4598 observations. 353 women were previously defined as primarily having well-controlled HIV with vascular comorbidities, 463 with legacy effects(CD4 nadir < 250cells/mL), 274 aged ≤ 45 with hepatitis, 453 between 35-55 years, and 339 with poorly-controlled HIV/substance users. INSTIs, but not efavirenz, were associated with symptoms among key subgroups of WWH. Among those with HIV legacy effects, dolutegravir and elvitegravir were associated with greater stress/anxiety and avoidance symptoms(P's < 0.01); dolutegravir was also associated with greater re-experiencing symptoms(P = 0.005). Elvitegravir related to greater re-experiencing and hyperarousal among women with well-controlled HIV with vascular comorbidities(P's < 0.022). Raltegravir was associated with less hyperarousal, but only among women aged ≤ 45 years(P = 0.001). The adverse neuropsychiatric effects of INSTIs do not appear to be consistent across all WWH. Key characteristics (e.g., age, hepatitis positivity) may need consideration to fully weight the risk-benefit ratio of dolutegravir and elvitegravir in WWH.

Trauma Across the Life Span and Multisystem Morbidity in Women With HIV

OBJECTIVE

Sexual and physical abuse are highly prevalent among women living with HIV (WLWH) and are risk factors for the development of mental health and substance use disorders (MHDs, SUDs), and cognitive and medical comorbidities. We examined empirically derived patterns of trauma, MHD, and SUD, and associations with later cognitive and health outcomes.

METHODS

A total of 1027 WLWH (average age = 48.6 years) in the Women's Interagency HIV Study completed the World Mental Health Composite International Diagnostic Interview from 2010 to 2013 to identify MHDs, SUDs, and age at onset of sexual and physical abuse. Then, cognitive impairment, cardiovascular/metabolic conditions, and HIV disease outcomes were assessed for up to 8.8 years. Latent class analysis identified patterns of co-occurring trauma, MHDs, and/or SUDs. Generalized estimating equations determined associations between these patterns and midlife cognitive and medical outcomes.

RESULTS

Six distinct profiles emerged: no/negligible sexual/physical trauma, MHD, or SUD (39%); preadolescent/adolescent sexual trauma with anxiety and SUD (22%); SUD only (16%); MHD + SUD only (12%); early childhood sexual/physical trauma only (6%); and early childhood sexual/physical trauma with later MHD + SUD (4%). Profiles including early childhood trauma had the largest number of midlife conditions (i.e., cognitive, cardiovascular, HIV-related). Preadolescent/adolescent sexual trauma with anxiety and SUD predicted both global and domain-specific cognitive declines. Only SUD without trauma predicted lower CD4, whereas childhood trauma with MHD + SUD predicted increased CD8.

CONCLUSIONS

WLWH have complex multisystem profiles of abuse, MHD, and/or SUD that predict midlife cognitive, metabolic/cardiovascular, and HIV outcomes. Understanding the interplay between these factors over time can identify risks and personalize preventative and treatment interventions.

Risk of early death in adolescents and young adults with cancer: a population-based study

BACKGROUND

Advancements in treatment and supportive care have led to improved survival for adolescents and young adults (AYAs) with cancer; however, a subset of those diagnosed remain at risk for early death (within 2 months of diagnosis). Factors that place AYAs at increased risk of early death have not been well studied.

METHODS

The Surveillance, Epidemiology, and End Results registry was used to assess risk of early death in AYAs with hematologic malignancies, central nervous system tumors, and solid tumors. Associations between age at diagnosis, sex, race, ethnicity, socioeconomic status, insurance status, rurality, and early death were assessed.

RESULTS

A total of 268 501 AYAs diagnosed between 2000 and 2016 were included. Early death percentage was highest in patients diagnosed with hematologic malignancies (3.1%, 95% confidence interval [CI] = 2.9% to 3.2%), followed by central nervous system tumors (2.5%, 95% CI = 2.3% to 2.8%), and solid tumors (1.0%, 95% CI = 0.9% to 1.0%). Age at diagnosis, race, ethnicity, lower socioeconomic status, and insurance status were associated with increased risk of early death in each of the cancer types. For AYAs with hematologic malignancies and solid tumors, risk of early death decreased statistically significantly over time.

CONCLUSIONS

A subset of AYAs with cancer remains at risk for early death. In addition to cancer type, sociodemographic factors also affect risk of early death. A better understanding of the interplay of factors related to cancer type, treatment, and health systems that place certain AYA subsets at higher risk for early death is needed to address these disparities and improve outcomes.

Melanoma survival by age group: Population-based disparities for adolescent and young adult patients by stage, tumor thickness, and insurance type

BACKGROUND

Melanoma survival literature predominantly represents patients >65 years of age. Study of younger patients may reveal potential age-group-specific differences in survival outcome.

OBJECTIVE

Identify factors associated with differences in melanoma survival in 2 age groups, adolescents and young adults (AYAs; ages 15-39) and older adults (ages 40-64).

METHODS

This population-based registry study included all cases (n = 81,597) of cutaneous melanoma diagnosed at ages 15 to 64 from 2004 to 2015 in California. Age-group-specific multivariable Cox hazard regressions were used.

RESULTS

In the adjusted, age-group-specific models, AYA patients with stage IV melanoma had worse survival (hazard ratio: 20.39, 95% CI: 13.30-31.20) than was observed among older adults (hazard ratio: 10.79, 95% CI: 9.33-12.48). Thicker tumors and public insurance were also associated with worse survival for AYAs than observed in models for older adults. AYAs experienced better survival when detected at earlier stages.

LIMITATIONS

Registry data do not routinely collect behavioral information or family history of melanoma.

CONCLUSIONS

Survival was much worse for AYAs with stage IV melanoma than observed among older adults. To improve AYA survival, early melanoma detection is critical. Greater awareness, suspicion, and screening for AYA melanoma may disrupt delays in diagnosis and reduce the excess burden of mortality from stage IV melanoma in young patients.

Substance Use Among Young Adult Survivors of Childhood Cancer With Cognitive Impairment: An Analysis of the Project Forward Cohort

PURPOSE

Young adult childhood cancer survivors (YACCSs) are often impacted by cancer-related cognitive impairment (CRCI) and psychological distress. Using the Project Forward Cohort, we evaluated the relationship between CRCI and substance use behaviors.

METHODS

YACCSs were surveyed between 2015 and 2018 (N = 1,106, female = 50.8%, Hispanic = 51.5%, median age = 25.5 years). Associations between CRCI and substance use (tobacco, binge drinking, marijuana, prescription drug misuse, and e-cigarette/vaporizer) were examined in multivariate logistic or log-binomial regressions, adjusting for child at diagnosis (0-14 years), years since diagnosis, sex, race/ethnicity, cancer type, and treatment intensity. Mediation analysis was performed to determine opportunities for interventions.

RESULTS

CRCI was reported by 144 (13.0%) survivors. The highest prevalence was observed in CNS cancers (25.4%) and leukemia (13.3%) survivors. After covariate adjustment, CRCI was associated with 2.26 times the odds of prior 30-day vaping (95% CI, 1.24 to 4.11; P = .007). Mediators with significant indirect effects in the CRCI-vaping relationship include depressive symptoms (Center for Epidemiological Studies Depression Scale) and having two or more cancer-related late effects (P < .05).

CONCLUSION

CRCI among YACCSs was associated with reports of vaping. Oncologists should screen for vaping behavior if CRCI is apparent. Increasing access to long-term follow-up clinics, addressing physical and mental health issues, and monitoring and educating on vaping and other substance use behaviors is recommended to improve the long-term health of YACCSs.

Intersectionality of Socioecological Factors Associated With Cognitive Function Among Older Women With HIV in the United States: A Structural Equation Model Analysis Using Data From the Women's Interagency HIV Study

ABSTRACT

Increased life expectancy of people with HIV has health implications including the intersection of the long-term use of antiretroviral treatment, inflammatory events, and age-related immunosenescence. In a cross-sectional study utilizing using the Socio-Eecological Model, we identified pathways of cognitive function (CF) among 448 women with HIV, 50 years and older. A structural equation model showed the direct effects of mood (β = -0.25, p < .01), comorbidities (β = --0.13, p < .05), race (β = --0.13, p < .05), and abuse (β = 0.27, p < .001) on the latent variable CF. Substance and alcohol use, depressive symptoms, cigarette smoking, and the number of comorbidities are important considerations when designing interventions utilizing using a multi-level and intersectional lens to maximize positive CF outcomes.

Glucocorticoid Receptor Function and Cognitive Performance in Women With HIV

OBJECTIVE

Alterations in glucocorticoid receptor (GCR) function may be a risk factor for cognitive complications among older people with human immunodeficiency virus (HIV). We evaluated whether HIV serostatus and age modify the GCR function-cognition association among women.

METHODS

Eighty women with HIV ( n = 40, <40 years of age [younger]; n = 40, >50 years of age [older]) and 80 HIV-uninfected women ( n = 40 older, n = 40 younger) enrolled in the Women's Interagency HIV Study completed a comprehensive neuropsychological test battery. Peripheral blood mononuclear cells collected concurrent with neuropsychological testing were assessed for GCR function. Multivariable linear regression analyses were conducted to examine whether a) HIV serostatus and age were associated with GCR function, and b) GCR function-cognition associations are moderated by HIV serostatus and age adjusting for relevant covariates.

RESULTS

Among older women, higher baseline FKBP5 expression level was associated with lower attention/working memory performance among women with HIV ( B = 6.4, standard error = 1.7, p = .0003) but not in women without HIV infection ( B = -1.7, standard error = 1.9, p = .37). There were no significant HIV serostatus by age interactions on dexamethasone (DEX)-stimulated expression of the genes regulated by the GCR or lipopolysaccharide-stimulated tumor necrosis factor α levels (with or without DEX stimulation; p values > .13). HIV serostatus was associated with GC target genes PER1 ( p = .006) and DUSP1 ( p = .02), but not TSC22D3 ( p = .32), after DEX stimulation.

CONCLUSIONS

Collectively, these data suggest that HIV serostatus and age may modify the influence of the GCR, such that the receptor is likely engaged to a similar extent, but the downstream influence of the receptor is altered, potentially through epigenetic modification of target genes.

Impacts of Medicaid Expansion on Health Insurance and Coverage Transitions among Women with or at Risk for HIV in the United States

BACKGROUND

As employment, financial status, and residential location change, people can gain, lose, or switch health insurance coverage, which may affect care access and health. Among Women's Interagency HIV Study participants with HIV and participants at risk for HIV attending semiannual visits at 10 U.S. sites, we examined whether the prevalence of coverage types and rates of coverage changes differed by HIV status and Medicaid expansion in their states of residence.

METHODS

Geocoded addresses were merged with dates of Medicaid expansion to indicate, at each visit, whether women lived in Medicaid expansion states. Age-adjusted rate ratios (RRs) and rate differences of self-reported insurance changes were estimated by Poisson regression.

RESULTS

From 2008 to 2018, 3,341 women (67% Black, 71% with HIV) contributed 43,329 visits at aged less than 65 years (27% under Medicaid expansion). Women with and women without HIV differed in their proportions of visits at which no coverage (14% vs. 19%; p < .001) and Medicaid enrollment (61% vs. 51%; p < .001) were reported. Women in Medicaid expansion states reported no coverage and Medicaid enrollment at 4% and 69% of visits, respectively, compared with 20% and 53% of visits for those in nonexpansion states. Women with HIV had a lower rate of losing coverage than those without HIV (RR, 0.81; 95% confidence interval [CI], 0.70 to 0.95). Compared with nonexpansion, Medicaid expansion was associated with lower coverage loss (RR, 0.62; 95% CI, 0.53 to 0.72) and greater coverage gain (RR, 2.32; 95% CI, 2.02 to 2.67), with no differences by HIV status.

CONCLUSIONS

Both women with HIV and women at high risk for HIV in Medicaid expansion states had lower coverage loss and greater coverage gain; therefore, Medicaid expansion throughout the United States should be expected to stabilize insurance for women and improve downstream health outcomes.

Predictors and Consequences of Prescription Opioid Use in Women Living With and Without HIV: 20-Year Follow-Up

Objective: To examine predictors and consequences of prescription opioid use among a cohort of women living with HIV (WLWH) and women without HIV from 2000 to 2019. Materials and Methods: The Women's Interagency HIV Study is a multisite, prospective cohort study. Cumulative proportion of visits with prescription opioid use was categorized as follows: minimal (0%-9%), intermediate (10%-39%), and chronic (>40%). Logistic regression examined independent predictors, and proportional hazards regression estimated unadjusted and adjusted hazards of all-cause mortality, comparing intermediate and chronic prescription opioid use with minimal use. Results: Annual prevalence of prescription opioid use significantly increased from 12.6% to 19.3% from 2000 to 2019 (p < 0.0001). Prescription opioid use was minimal in 75%, intermediate in 16%, and chronic in 9% of women. WLWH had 56% higher odds of chronic prescription opioid use compared with women without HIV. Even after adjusting for quality-of-life scores including ratings of pain, women with intermediate and chronic prescription opioid use had greater odds of being sexual minorities (lesbian or bisexual), unemployed, and were more likely to report benzodiazepine and nonprescription substance use compared with those with minimal use. Intermediate and chronic prescription opioid use were each associated with an almost 1.5-fold increased risk of all-cause mortality. Conclusions: Despite federally mandated opioid prescribing guidelines, prescription opioid use and related mortality significantly increased in women experiencing physical and psychosocial vulnerabilities. The higher mortality rate found among prescription opioid users may reflect the many underlying chronic medical and psychosocial conditions for which these opioids were prescribed, as well as complications of opioids themselves. Findings underscore the need for non-opioid and nonpharmacological interventions for chronic pain, particularly in sexual minorities and WLWH. Avoiding concurrent use of opioids with benzodiazepines and nonprescription drugs might reduce mortality. Clinical Trial Registration Number: NCT00000797.

Clinical Trial Participation: A Qualitative Study of Adolescents and Younger Adults Recently Diagnosed with Cancer

Purpose: Although participation of adolescents and young adults (AYAs) in cancer clinical trials (CCTs, i.e., cancer-directed treatment studies) is low, their decision-making perspectives are not well understood, especially following recent diagnosis. Methods: Semistructured interviews with younger AYAs (15-21 years old) eligible for a CCT were to be held within 60 days of beginning treatment at Children's Hospital Los Angeles, an academic pediatric hospital. Using grounded theory methods, key themes regarding CCT participation, barriers, and facilitators were identified from interview transcripts. Thematic saturation was confirmed. Results: Of nine participants, three were <18 years old, four Hispanic, six male, six diagnosed with leukemia, eight enrolled in a CCT, and eight also enrolled in ancillary studies. Four overarching themes emerged: (1) Initial Consent encompassed the first discussion of CCT with patients reflecting positive and negative effects of timing, decisional role, and the emotional impact following cancer diagnosis; (2) Informing Participation involved decision-making processes, specific knowledge, comprehension, and external influences; (3) Participant Relationships emphasized the importance of communication and relationships with providers and parents; and (4) Patient Determinants centered on motives from different perspectives, pre-conceived attitudes, and understanding of CCTs. Conclusion: Recommendations for improving CCT participation among younger AYAs include separating the diagnosis/treatment and CCT discussions, assigning AYAs a meaningful decisional role, having ongoing provider conversations, designing trials to minimize burden, and developing age-appropriate decision aids.

Self-Reported Sexually Transmitted Infections After Incarceration in Women with or at Risk for HIV in the United States, 2007-2017

Background: U.S. women who have been incarcerated report high rates of sexual risk behavior and sexually transmitted infections (STIs). Materials and Methods: We estimated the effect of incarceration on the time to first incident STI in a multicenter cohort of U.S. women with or at risk for HIV. We used marginal structural models to compare time to first self-reported gonorrhea, chlamydia, or trichomonas infection for nonincarcerated women and incarcerated women. Covariates included demographic factors, HIV status, sex exchange, drug/alcohol use, and prior incarceration. Results: Three thousand hundred twenty-four women contributed a median of 4 at-risk years and experienced 213 first incident STI events. The crude incidence of STIs was 3.7 per 100 person-years for incarcerated women and 1.9 per 100 person-years for nonincarcerated women. The weighted hazard ratio for incident STIs was 4.05 (95% confidence interval: 1.61-10.19). Conclusion: Women with or at risk for HIV in the United States who have recently experienced incarceration may be at increased STI risk.

Patient care satisfaction and emergency room utilization among young adult colorectal cancer survivors during the SARS-CoV-2 pandemic

34

Background: Survivors of colorectal cancer (CRC) are at risk for late effects of therapy and recurrence of cancer. With recurrence rates ranging between 30-40% (Siegal et al., 2020), consistent, survivor-focused follow-up care is needed for early detection of late effects and recurrence (Jeffery et al., 2019). CRC-related care delivery has been significantly disrupted by the SARS-CoV-2 pandemic, with decreases of 40% in CRC services in the United States between April 2020 and 2019 (Jammu, 2020). Consequentially, survivors may be left with fewer options for care, potentially causing increases in emergency room (ER) utilization. Methods: This cross-sectional study examined the patterns of ER utilization during the SARS-CoV-2 pandemic among young adult CRC survivors and assessed the relationship between self-reported care satisfaction and ER use. Eligible participants were diagnosed with colon or rectal cancer between 18-39 years, between 6-36 months from diagnosis/relapse, English speaking, and based in the United States. Questions on care satisfaction were Consumer Assessment of Healthcare Providers and Systems (CAHPS) questions. A multivariable logistic regression was conducted to assess the association between patient satisfaction and ER utilization, adjusting for factors related to the pandemic. Covariates for this analysis were chosen based on a significance of p < 0.1 at the univariate level, as well as general clinical significance. Results: The overall sample was N = 196, mean age (SD) was 32.1 years (4.5), and 116 survivors (59%) were male. Tumor location was colon or rectal in 42% and 57%, respectively, and the majority (56%) were diagnosed with stage 2 disease; 42.6% reported relapsed disease, and 20% had an ostomy. The majority of survivors (72.5%) had between 1-4 visits to an emergency room in the last 12 months and were categorized as normal users. Approximately 24.7% of the sample had greater than 4 visits to the ER in the last 12 months and were categorized as super-utilizers (Johnson et al., 2015). Colorectal cancer survivors that reported a delay in their follow-up cancer care as a result of the pandemic were two times (OR: 2.05, 95% CI 0.99, 4.24) more likely to be super-utilizers of the ER. Higher self-reported satisfaction with overall care was associated with a 13.7% (OR: 0.86, 95%CI: -0.68, 1.09) lower likelihood of being a super-utilizer. Conclusions: This study found strong associations between delays in care, self-reported care satisfaction, and being a super-utilizer of the ER during the pandemic among young adult CRC survivors off treatment. Increasing patient satisfaction and minimizing care interruptions amongst this vulnerable population may aid in mitigating over-utilization in the ER during an ongoing pandemic.

Prevalence of information needs among emerging and young adult colorectal cancer survivors

71

Background: The information needs of young adult (YA) cancer survivors have been described, however, the specific needs of YA colorectal cancer (CRC) survivors are not well-documented. Characterizing the distinct unmet needs of YA CRC survivors is important given their unique cancer experience which may include an ostomy, chronic bowel symptoms, and functional deficits. The purpose of this study was to examine CRC survivors’ unmet needs across general, clinical, and psychosocial domains. Methods: An online, cross-sectional survey was administered via Facebook in collaboration with a national YA CRC patient advocacy organization. Respondents (diagnosed 18-39) endorsed areas in which they required more information on aspects of their lives that may have been affected by their cancer experience. Needs were stratified by life stage (emerging [18-29 years] and young [30-39] adulthood). Results: Respondents (n=189) were colon (40.2%) and rectal (59.8%) cancer survivors with a mean current age of 32.2 years (SD=4.6) and a mean age of 30.2 years (SD=4.3) at diagnosis. Most endorsed items per domain included: nutrition and diet (52.1%), complementary and alternative treatments (45.4%), and talking about your cancer experience with family, friends, and co-workers (36.1%). Survivors in emerging adulthood (n=80), compared with those in young adulthood (n=109), endorsed notably greater needs in: staying physically fit (57.5% versus 38.5%), complementary and alternative treatments (57.5% versus 36.7%), and advice/help about dating and intimate relationships (18.8% versus 6.4%). Conclusions: Overall, half of respondents endorsed a desire for information on nutrition and diet, staying physically fit, and complementary and alternative treatments. Differing endorsement rates by age group indicate the importance of tailored approaches. Optimal counseling, resources, and referrals specific to life stage can mitigate the unmet needs of YA CRC survivors to improve health outcomes and quality of life.[Table: see text]

Intensity of Social Support Matters: A Latent Class Analysis to Identify Levels of Social Support Associated with Optimal Health Outcomes Among Women Living with HIV

Social support is associated with improved HIV care and quality of life. We utilized latent class analysis to identify three classes of baseline emotional and tangible perceived social support, termed "Strong", "Wavering" and "Weak". "Weak" vs. "Strong" perceived social support was associated over time with an 8% decreased risk of optimal antiretroviral therapy (ART) adherence for emotional and 6% decreased risk for tangible perceived social support. Importantly, "Wavering" vs "Strong" social support also showed a decreased risk of ART adherence of 6% for emotional and 3% for tangible support. "Strong" vs. "Weak" perceived support had a similar association with undetectable viral load, but the association for "Strong" vs. "Wavering" support was not statistically significant. Intensity of social support is associated with HIV care outcomes, and strong social support may be needed for some individuals. It is important to quantify the level or intensity of social support that is needed to optimize HIV outcomes.

Factors Associated with Interest in Complementary and Alternative Medicine Among Young Adult Survivors of Childhood Cancer

Background: Use of complementary and alternative medicine (CAM) by those undergoing cancer treatment is common. While some childhood cancer survivors (CCS) may use CAM to treat late effects, others may lack information about available alternative therapies. We sought to determine characteristics associated with seeking more information about CAM among an ethnically diverse sample of young adult CCS. Methods: Young adult CCS were selected from the population-based Los Angeles SEER cancer registry and surveyed at ages 18 to 39 as part of the Project Forward Cohort. Associations between demographic, clinical, and other factors with seeking information on CAM were examined with t-tests, Chi Square analyses, and logistic regression. Results: Among 1106 participants surveyed, 182 (18%) reported interest in obtaining more information on CAM. Interest in CAM was highest among males, older (vs. younger) participants, those born outside the U.S., those with a history of relapsed/recurrent or second cancers, those with greater depressive symptoms, and those with poorer self-rated health. Among Hispanic/Latino/Latinx respondents, depressive symptoms, birth outside the U.S., and higher Latino culture orientation was positively associated with CAM interest. Discussion: Depressive symptoms and unresolved health problems are associated with a need for information about alternative forms of therapy, particularly in those with born outside the U.S. Healthcare providers caring for CCS can incorporate appropriate CAM information to help address unmet physical and mental health needs.

Adverse lifestyle behaviors among childhood cancer survivors with cognitive impairment: The Project Forward Cohort

138

Background: Childhood cancer survivors (CCS) are often impacted by cancer-related cognitive impairment (CRCI), requiring long-term follow-up care. It is unknown whether survivors reporting CRCI are at higher likelihood to suffer from adverse lifestyle behaviors such as smoking and vaping. Using the Project Forward cohort, we analyzed the prevalence of CRCI and its association with substance abuse. Methods: The Project Forward study surveyed adolescent and young adult CCS between 2015 to 2018 to evaluate the quality of cancer follow-up care. Associations between self-reported CRCI and adverse lifestyle behaviors were examined in multivariable logistic regressions, adjusting for covariates: cancer type, treatment intensity, race/ethnicity, gender, and age at diagnosis. Stratified analysis by recency of latest cancer follow-up care was performed to examine its impact on the risk of substance abuse among CRCI patients. Results: The cohort comprised 1,106 CCS, with median ages of 25.5 years (IQR: 22, 29) at survey completion and 13 years (IQR: 7, 16) at diagnosis, with over half (n = 570, 51.5%) were being Hispanic. A total of 144 (13%) patients self-reported CRCI, with the highest prevalence observed among brain cancer (25.4%) and leukemia (13.3%) survivors. Cancer-related follow-ups were more frequently observed among survivors reporting CRCI, comparing to non-CRCI survivors (66.7% vs 56.9%, p = 0.030). After adjusting for confounders, survivors reporting CRCI were at higher odds to vape with e-cigarettes than those without CRCI (OR = 2.24, 95% CI = 1.24–4.09, p = 0.008). Among those who did not engage any recent cancer follow-up care (n = 455), CRCI was associated with 2.9 times the odds of vaping with e-cigarettes (OR = 2.9, 95% CI = 1.07–7.88, p = 0.037). No association was observed between CRCI and the use of cigarettes, alcohol, or marijuana. Conclusions: Vaping is more prevalent among CCS reporting CRCI, especially those who are less likely to attend follow-up care. Our data suggests the importance of encouraging long-term follow-ups to monitor adverse lifestyle behaviors in CCS experiencing cognitive symptoms and provide timely interventions.

Project Forward: A Population-Based Cohort Among Young Adult Survivors of Childhood Cancers

Background

Childhood cancer survivors (CCS) face increased risk of morbidity and are recommended to receive lifelong cancer-related follow-up care. Identifying factors associated with follow-up care can inform efforts to support the long-term health of CCS.

Methods

Eligible CCS (diagnosed between 1996 and 2010) identified through the Los Angeles County Cancer Surveillance Program responded to a self-report survey that assessed demographic, clinical, health-care engagement, and psychosocial risk and protective factors of recent (prior 2 years) cancer-related follow-up care. Weighted multivariable logistic regression was conducted to identify correlates of care. All statistical tests were 2-sided.

Results

The overall response rate was 44.9%, with an analytical sample of n = 1106 (54.2% Hispanic; mean [SD] ages at survey, diagnosis, and years since diagnosis were 26.2 [4.9], 11.6 [5.4], and 14.5 [4.4] years, respectively). Fifty-seven percent reported a recent cancer-related visit, with lower rates reported among older survivors. Having insurance, more late effects, receipt of a written treatment summary, discussing long-term care needs with treating physician, knowledge of the need for long-term care, having a regular source of care, and higher health-care self-efficacy were statistically significantly associated with greater odds of recent follow-up care, whereas older age, Hispanic or Other ethnicity (vs non-Hispanic White), and years since diagnosis were associated with lower odds of recent care (all Ps < .05).

Conclusions

Age and ethnic disparities are observed in receipt of follow-up care among young adult CCS. Potential intervention targets include comprehensive, ongoing patient education; provision of written treatment summaries; and culturally tailored support to ensure equitable access to and the utilization of care.

A cross-sectional examination of caregiver mental health and childhood cancer survivors' tobacco, alcohol, and marijuana use

PURPOSE

As childhood cancer survivors (CCS) age, they face numerous long-term consequences, or late effects, from their cancer treatments. Late effects may be mitigated by health-promoting behaviors, including the avoidance of substance use. CCS with greater depression symptomology have reported greater substance use, but whether their habits are associated with the mental health of their caregivers is unknown. The aim of this study was to examine caregiver psychosocial correlates of CCS substance use.

METHODS

This study utilizes data from the Project Forward pilot study, which collected data from 129 CCS-caregiver dyads (CCS mean age = 19.43, SD = 2.78; years since diagnosis = 7.62, SD = 2.06) from two large hospitals in Los Angeles County. CCS provided self-reported information on substance use, while caregivers self-reported on posttraumatic stress symptomatology (PTSS) associated with their child's cancer and current depressive symptoms.

RESULTS

Among CCS, prior 30-day tobacco, marijuana, binge drinking, and polysubstance use were 12.50%, 14.17%, 13.18%, and 12.40%. In multivariable logistic regression models, caregiver PTSS was independently positively associated with CCS tobacco use. No other significant relationships between caregiver mental health (PTSS or depressive symptoms) and CCS substance use were observed.

CONCLUSION

These findings suggest that caregiver PTSS is partially associated with CCS behavioral health. Survivorship care may improve tobacco use prevention efforts by incorporating family or caregiver mental health needs. Future research should examine the potential mediating effect of CCS mental health, including depressive symptoms, on this relationship.

Weight and Body Mass Index Change After Switching to Integrase Inhibitors or Tenofovir Alafenamide Among Women Living with HIV

Weight and body mass index (BMI) change was assessed among women after switch to integrase inhibitors (INSTIs) and/or tenofovir alafenamide (TAF). From 2006 to 2019, 1,458 women living with HIV enrolled in the Women's Interagency HIV Study and on antiretroviral therapy (ART) with ≥1 study visit before and after switching to INSTIs and/or TAF were included. Weight and BMI were compared pre- and postswitch to INSTI (by class and type) and/or TAF using multivariable linear mixed effects models; all models were also stratified by preswitch presence or absence of obesity (BMI ≥30 vs. <30 kg/m2). Mean age preswitch was 47 ± 6 years, 64% were black, mean CD4 = 475 ± 201 cells/mm3, 56% had HIV RNA <200 copies/mL, 36% switched to TAF but not INSTI, 60% to INSTI but not TAF, and 3.5% to TAF+INSTI. Time from pre- to postswitch was 12.8 ± 11.8 months. The INSTI-only group but not TAF groups had small but significant increases in weight and BMI: mean 79.2-80.6 kg and 30.2-30.7 kg/m2, p's < .001, respectively, with congruent findings by INSTI type (p's ≤ .01). In stratified (preswitch BMI) analyses, only nonobese subgroups experienced increases in weight and BMI across all ART treatment groups (p's < .05). Significant, although small-to-medium, increases in weight and BMI occurred among nonobese women who switched to INSTIs and/or TAF over short follow-up. Given long-term health consequences of obesity particularly as a low-grade inflammatory condition, identifying women at highest risk of ART-associated weight gain is imperative.

Prevalence of fertility discussions between young adult colorectal cancer survivors and their providers

3518

Background: Clinical guidelines indicate that oncologists should discuss potential treatment-induced infertility with patients with reproductive potential. Due to tumor location and use of multimodal therapies, young adults with colorectal cancer (CRC) are at heightened risk for treatment-related infertility. Methods: An online, cross-sectional survey was administered in collaboration with a national patient advocacy organization for young adult CRC survivors (currently under age 50). Survivors were asked to indicate if a doctor had ever talked to them about potential problems with their ability to have children after treatment and if they banked eggs/embryos (females) or sperm (males) prior to their cancer therapy. Those who reported that they did not preserve fertility were asked to indicate why ( not sure; I chose not to; I did not know this was an option; I wanted to, but could not afford it; and I wanted to, but my treatment would not allow it). Results: A total of 234 colon (N=86) or rectal (N=148) cancer survivors were included in the study (male [61.9%] and White [77.9%; table]). Most respondents were diagnosed with stage 2 cancer (55.8% colon, 61.6% rectal). Over half of male and female survivors reported that their doctor did not talk to them about problems with their ability to have children after treatment, and 75% did not bank eggs/embryos or sperm prior to their cancer therapy. Of those, over 20% endorsed ‘I wanted to, but could not afford it’ and over 20% endorsed ‘I did not know this was an option’. Conclusions: Most CRC survivors in this study reported never having a fertility discussion with their provider, suggesting that survivors are not receiving, or cannot recall, comprehensive and guideline-concordant cancer care. In addition, one-fifth were not aware of preservation options, suggesting potential healthcare and/or provider-level barriers to appropriate fertility counseling. Fertility preservation cost is another barrier to the appropriate delivery of care. Providers must ensure that patients receive timely fertility discussions covering options to preserve fertility to mitigate this late effect of cancer treatment to ensure optimal quality of life for CRC patients with reproductive potential.[Table: see text]

Incidence and Prevalence of Incarceration in a Longitudinal Cohort of Women at Risk for Human Immunodeficiency Virus in the United States, 2007-2017

Background: To estimate the incidence, prevalence, frequency, and duration of incarceration and to identify risk factors for incarceration among women at risk for human immunodeficiency virus (HIV) in the United States. Methods: During semiannual study visits in a multicenter cohort study, 970 HIV sero-negative participants at risk for HIV were asked about their own incarceration (10/2007-09/2017) and incarceration of sexual partners (10/2013-09/2017). We used descriptive statistics and multivariable log-binomial regression to identify baseline predictors of incident incarceration. Results: Median follow-up time across the 970 participants was 5.5 years (IQR 3.5-9.5). Nearly half (n = 453, 46.7%) of participants were incarcerated during or before the study, and the incarceration rate was 5.5 per 100 person-years. In multivariable models, incident incarceration was associated with prior incarceration (RR 5.20, 95% CI: 3.23-8.41) and noninjection drug use (RR 1.57, 95% CI: 1.10-2.25). Conclusions: Incarceration is common for women at risk for HIV. Prevention interventions that address the complex interplay of drug use, sex exchange, and housing instability for women who have experienced incarceration have the potential to reach an important group of U.S. women at risk of HIV infection.

Integrase Strand Transfer Inhibitor Start or Switch Impacts Learning in Women With HIV

BACKGROUND

Integrase strand transfer inhibitors (INSTIs) are first-line regimens for HIV treatment. We aimed to examine their impact on cognitive performance and depressive symptoms in women with HIV (WWH).

SETTING

Women's Interagency HIV Study, a multisite, prospective, cohort study.

METHODS

WWH who started or switched to INSTI-based antiretroviral therapy (ART) and completed neuropsychological testing and the Center for Epidemiological Studies-Depression (CES-D) scale before and after INSTI start/switch were included in the analyses. Primary outcomes were demographically corrected cognitive domain T-scores. Linear mixed-effects models adjusted for relevant covariates were used to examine effects of start/switch of any INSTI and individual INSTI drugs on cognition and CES-D scores.

RESULTS

Six hundred thirty-nine WWH, median age 49 (interquartile range 12) years, 66% Black non-Hispanic, had neuropsychological and CES-D scale data before and after INSTI start/switch. Although 14% started INSTI-based ART, the remainder switched to INSTI-based ART from another regimen. Overall, any INSTI use was associated with poorer learning post-INSTI. Specifically, use of dolutegravir and elvitegravir, but not raltegravir, was associated with poorer learning. In analyses restricted to INSTI switch, any INSTI use, and dolutegravir use, was associated with poorer learning. Among those switching from a PI-based regimen, INSTIs overall and dolutegravir remained associated with poorer learning; switching from a nonnucleoside reverse transcriptase inhibitor to dolutegravir was also associated with poorer learning. INSTI start/switch was not related to depressive symptom changes.

CONCLUSIONS

INSTI use was associated with poorer learning among WWH. These changes were mainly observed in elvitegravir and dolutegravir users, indicating that the impact of INSTI on cognition in WWH may not be a class effect.

Associations between Antiretrovirals and Cognitive Function in Women with HIV

Cognitive complications persist in antiretroviral therapy(ART)-treated people with HIV. However, the pattern and severity of domain-specific cognitive performance is variable and may be exacerbated by ART-mediated neurotoxicity. 929 women with HIV(WWH) from the Women's Interagency HIV Study who were classified into subgroups based on sociodemographic and longitudinal behavioral and clinical data using semi-parametric latent class trajectory modelling. Five subgroups were comprised of: 1) well-controlled HIV with vascular comorbidities(n = 116); 2) profound HIV legacy effects(CD4 nadir <250 cells/μL; n = 275); 3) primarily <45 year olds with hepatitis C(n = 165); 4) primarily 35-55 year olds(n = 244), and 5) poorly-controlled HIV/substance use(n = 129). Within each subgroup, we fitted a constrained continuation ratio model via penalized maximum likelihood to examine adjusted associations between recent ART agents and cognition. Most drugs were not associated with cognition. However, among the few drugs, non-nucleoside reverse transcriptase inhibitor (NNRTIs) and protease inhibitors(PIs) were most commonly associated with cognition, followed by nucleoside reverse transcriptase inhibitors(NRTIs) and integrase inhibitors(IIs). Directionality of ART-cognition associations varied by subgroup. Better psychomotor speed and fluency were associated with ART for women with well-controlled HIV with vascular comorbidities. This pattern contrasts women with profound HIV legacy effects for whom poorer executive function and fluency were associated with ART. Motor function was associated with ART for younger WWH and primarily 35-55 year olds. Memory was associated with ART only for women with poorly-controlled HIV/substance abuse. Findings demonstrate interindividual variability in ART-cognition associations among WWH and highlight the importance of considering sociodemographic, clinical, and behavioral factors as an underlying contributors to cognition. Are antiretroviral agents a risk factor for cognitive complications in women with HIV? We examind associations between ART-agents and cognitive function among similar subgroups of women with HIV from the Women's Interagency HIV study. The patterns of associations depended on sociodemographic, clinical, and behavioral characteristics of women.

Associations between Antiretroviral Drugs on Depressive Symptomatology in Homogenous Subgroups of Women with HIV

Antiretroviral therapy (ART) is inconsistently associated with depression. These associations may depend on factors such as biological sex, age, and health status. Identifying such factors may help optimize treatment of HIV and depression. We implemented a novel approach to examine interindividual variability in the association between ART agents and depressive symptoms. 3434 women living with HIV (WLWH) from the Women's Interagency HIV Study (WIHS) were computationally divided into subgroups based on sociodemographic (e.g., age) and longitudinal (from 1995 to 2016) behavioral and clinical profiles (e.g., substance use, HIV RNA, CD4 counts). Five subgroups (n's ranged from 482 to 802) were identified and characterized as those with: controlled HIV/vascular comorbidities; profound HIV legacy effects; younger women [<45 years of age] with hepatitis C; primarily 35-55 year olds; and poorly controlled HIV/substance use. Within each subgroup, we examined associations between ART agents used over the past 6 months and item-level depressive symptoms on the Center for Epidemiologic Studies Depression Scale. Tenofovir (4 of 5 subgroups) followed by efavirenz, emtricitabine, stavudine, lopinavir, etravirine, nelfinavir, ritonavir, and maraviroc were the most common agents associated with depressive symptoms, although the pattern and directionality varied by subgroup. For example, lopinavir was associated with fewer symptoms among the subgroup with a legacy HIV effect but more symptoms among the subgroup with well-controlled HIV/vascular comorbidities. Unexpectedly, dolutegravir and raltegravir were not associated with depressive symptoms among any subgroup. Findings underscore marked interindividual variability in ART agents on depression in WLWH. Sociodemographic, clinical, and behavioral factors are important determinants of the relationship between ART agents and depressive symptoms in WLWH. Graphical Abstract Are antiretroviral agents a risk factor for depressive symptoms in women with HIV? We examined associations between ART-agents and depressive symptoms among similar subgroups of women with HIV from the Women's Interagency HIV Study. The patterns of associations depended on sociodemographic, clinical, and behavioral characteristics of women.

Patterns and Predictors of Cognitive Function Among Virally Suppressed Women With HIV

Cognitive impairment remains frequent and heterogeneous in presentation and severity among virally suppressed (VS) women with HIV (WWH). We identified cognitive profiles among 929 VS-WWH and 717 HIV-uninfected women from 11 Women's Interagency HIV Study sites at their first neuropsychological (NP) test battery completion comprised of: Hopkins Verbal Learning Test-Revised, Trail Making, Symbol Digit Modalities, Grooved Pegboard, Stroop, Letter/Animal Fluency, and Letter-Number Sequencing. Using 17 NP performance metrics (T-scores), we used Kohonen self-organizing maps to identify patterns of high-dimensional data by mapping participants to similar nodes based on T-scores and clustering those nodes. Among VS-WWH, nine clusters were identified (entropy = 0.990) with four having average T-scores ≥45 for all metrics and thus combined into an "unimpaired" profile (n = 311). Impaired profiles consisted of weaknesses in: (1) sequencing (Profile-1; n = 129), (2) speed (Profile-2; n = 144), (3) learning + recognition (Profile-3; n = 137), (4) learning + memory (Profile-4; n = 86), and (5) learning + processing speed + attention + executive function (Profile-5; n = 122). Sociodemographic, behavioral, and clinical variables differentiated profile membership using Random Forest models. The top 10 variables distinguishing the combined impaired vs. unimpaired profiles were: clinic site, age, education, race, illicit substance use, current and nadir CD4 count, duration of effective antiretrovirals, and protease inhibitor use. Additional variables differentiating each impaired from unimpaired profile included: depression, stress-symptoms, income (Profile-1); depression, employment (Profile 2); depression, integrase inhibitor (INSTI) use (Profile-3); employment, INSTI use, income, atazanavir use, non-ART medications with anticholinergic properties (Profile-4); and marijuana use (Profile-5). Findings highlight consideration of NP profile heterogeneity and potential modifiable factors contributing to impaired profiles.

Health-related quality of life and time from diagnosis among young adult colorectal cancer survivors

34

Background: Incidence of colorectal cancer (CRC) in patients under 50 years of age is rising. Quality of life in survivorship is not well-described in this population. We compared health-related quality of life (HRQoL) in CRC survivors ≤ 50 years old who were 6-18 months or 19-36 months from initial diagnosis or relapse. Methods: A cross-sectional online survey was administered in collaboration with a national organization for young CRC survivors. The Functional Assessment of Cancer Therapy (FACT-C) was used to measure HRQoL, which assesses HRQoL globally, including a CRC specific scale, and emotional, physical, social, and functional well-being domains. T-tests were conducted to compare HRQoL between survivors who were 6-18 months versus 19-36 months from diagnosis/relapse. Results: This sample (n=308) had a mean age of 33.76 SD±6.68; 201 (65.3%) were male; tumor location was colon or rectal in 41.7% and 58.3%, respectively. The majority (55.23%) were diagnosed with stage 2 disease; 98.0% were non-metastatic. 42.2% experienced relapse; 25% had an ostomy. Most survivors were 6-18 months (N=189; 61.4%) from diagnosis/relapse, and key demographics and disease characteristics did not significantly differ between those who were shorter versus longer time from diagnosis/relapse. The mean global HRQoL score was 67.3 out of a possible score of 136. Across domains, scores were low, with social well-being the highest (15.15/28) and emotional well-being the lowest (11.44/24). Social well-being was significantly higher among survivors who were 6-18 months from diagnosis/relapse compared to those 19-36 months (15.98 for 6-18 months vs. 13.83 for 19-36; p<0.01), as was functional well-being (13.20 for 6-18 months vs. 11.12 for 19-36; p<0.01). Emotional well-being and physical well-being did not significantly differ between groups. Conclusions: Overall HRQoL scores were low among younger CRC survivors, and social and functional well-being were significantly worse for those longer from diagnosis. Appropriate counseling and other targeted interventions are necessary to maintain HRQoL over time in this at-risk population. [Table: see text]

Starting or Switching to an Integrase Inhibitor-Based Regimen Affects PTSD Symptoms in Women with HIV

As the use of Integrase inhibitor (INSTI)-class antiretroviral medications becomes more common to maintain long-term viral suppression, early reports suggest the potential for CNS side-effects when starting or switching to an INSTI-based regimen. In a population already at higher risk for developing mood and anxiety disorders, these drugs may have significant effects on PTSD scale symptom scores, particularly in women with HIV (WWH). A total of 551 participants were included after completing ≥ 1 WIHS study visits before and after starting/switching to an INSTI-based ART regimen. Of these, 14% were ART naïve, the remainder switched from primarily a protease inhibitor (PI) or non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen. Using multivariable linear mixed effects models, we compared PTSD Civilian Checklist subscale scores before and after a "start/switch" to dolutegravir (DTG), raltegravir (RAL), or elvitegravir (EVG). Start/switch to EVG improved re-experiencing subscale symptoms (P's < 0.05). Switching to EVG improved symptoms of avoidance (P = 0.01). Starting RAL improved arousal subscale symptoms (P = 0.03); however, switching to RAL worsened re-experiencing subscale symptoms (P < 0.005). Starting DTG worsened avoidance subscale symptoms (P = 0.03), whereas switching to DTG did not change subscale or overall PTSD symptoms (P's > 0.08). In WWH, an EVG-based ART regimen is associated with improved PTSD symptoms, in both treatment naïve patients and those switching from other ART. While a RAL-based regimen was associated with better PTSD symptoms than in treatment naïve patients, switching onto a RAL-based regimen was associated with worse PTSD symptoms. DTG-based regimens either did not affect, or worsened symptoms, in both naïve and switch patients. Further studies are needed to determine mechanisms underlying differential effects of EVG, RAL and DTG on stress symptoms in WWH.

Resilience Factors That Modify Genetic Risk for ADHD Matter for Later Life Emotional and Cognitive Health Outcomes

Having features of Attention Deficit Hyperactivity Disorder (ADHD) is associated with challenges with emotional regulation and cognitive function. Heritability for ADHD in adults is estimated to be 30%. The degree to which genetic risk for ADHD can be modified by protective factors, such as strong personal relationships and pursuing more education, to result in better emotional and cognitive outcomes at later ages is not well understood. We evaluated these relationships in a population-representative sample of older adults in the U.S. Health and Retirement Study, with 9,003 European Americans (EA; 57% women, age M=68.6, SD=10.4), and 1,622 African Americans (AA; 63% women, age M=64.4, SD=9.5). Outcomes included validated scales for psychological resilience, life satisfaction, depressive symptoms (DepSx), cognitive functioning, and impairment, assessed between 2008-2012. A genetic risk score for ADHD (GRS-ADHD) was calculated from a genomewide-scan, using a mixed ancestry sample. We used multivariable linear and logistic regression models, adjusted for age, gender, and genetic ancestry. We found a protective effect such that stronger personal relationships in adulthood reduced the inverse relationship between the GRS-ADHD and resilience and life satisfaction in later age (interaction p’s&lt;.004 in EAs), but not with DepSx. In contrast, strong parental relationships in childhood attenuated the association between the GRS-ADHD and later life DepSx (interaction p’s&lt;.007 in EAs and AAs) only. Education did not modify, but mediated the main effect of the GRS-ADHD on cognitive abilities and impairment in EAs and AAs. Findings have implications for later age health for those at greater genetic risk for ADHD.

Greater Levels of Self-Reported Adherence to Pre-Exposure Prophylaxis (PrEP) are Associated with Increased Condomless Sex Among Men Who Have Sex with Men

The effectiveness of pre-exposure prophylaxis (PrEP) against HIV acquisition depends on treatment adherence; however, within-person associations between levels of PrEP adherence and engagement in condomless sex have not been well studied. In the context of a demonstration project, 372 men who have sex with men received once-daily PrEP and completed six study visits over 48 weeks. Two-part growth mixture modeling was used to examine the longitudinal trajectory of condomless anal intercourse (CAI) and self-reports of PrEP adherence, controlling for relevant covariates. Over time, greater PrEP adherence was contemporaneously associated with both a higher likelihood of engaging in any CAI and with a greater number of CAI acts. Substance use was also associated with a higher likelihood of engaging in CAI. Contemporaneous associations between self-reported PrEP adherence and CAI suggest that adherence behaviors may be motivated by the desire to mitigate risk of HIV infection; however, exact directionality is unknown.

Abstract IA15: Mobile virtual human health care guides for young adult childhood cancer survivors

Since the mid-1990s, a significant scientific literature has evolved regarding the mental/physical health outcomes from the use of what we now refer to as Clinical Virtual Reality (VR). While the preponderance of clinical work with VR has focused on building immersive virtual worlds for treating anxiety disorders with exposure therapy, providing distracting immersive experiences for acute pain management, and supporting physical rehabilitation with game-based interactive content, there are other emerging areas that have extended the impact of VR in healthcare. One such area involves the recent technological advances that have led to the evolution of intelligent virtual human (VH) agents. VH representations can now be designed to perceive and act in a 3D virtual world, engage in face-to-face spoken dialogues with real users, and in some cases, can exhibit human-like emotional reactions. We have reported positive outcomes from studies using VHs in the role of virtual patients for training novice clinicians, as job interview/social skill trainers for persons on the autism spectrum, and as online health care support agents with university students and military veterans. The computational capacity now exists to deliver similar VH interactions by way of mobile device technology. This capability can support the “anywhere/anytime” availability of VH characters as agents for engaging users with clinical care information and could provide opportunities for improving access to care and emotional support for childhood cancer survivors (CCS). With a survivorship rate of over 83%, CCS are living longer, with estimates indicating that there will be over 500,000 CCS in the United States by 2020. However, CCS are at high risk for late effects of treatment, including recurring or secondary cancers, unhealthy lifestyle, disengagement from care, and the lack of the social support that has been shown to be vital for health and well-being. The majority of CCS will have at least one chronic condition by age 40. Moreover, existing initiatives to serve the needs of CCS have had limited success as these populations can be hard to reach and difficult to engage. We conducted two preliminary studies to inform development and evaluate the usefulness of a mobile app that included VH interaction and guidance to help CCS navigate survivorship and maintain health. In Study 1, two rounds of focus group interviews were conducted with 15 CCS aged 13-30 years. In Study 2, a pilot VH-driven app was developed using the information collected in Study 1. The app was downloaded, tested, and evaluated for one week by 60 CCS between the ages of 13-29 years. The results indicated that dynamic, accessible, engaging and survivor-focused VH approaches could address the needs of young, “digitally native” CCS. We will present a brief introduction to the clinical use of VHs within the VR context (Rizzo), followed by a discussion of a new mobile-enabled VH project designed to promote access to health care information and emotional support in young adult CCS (Spruijt-Metz).

Citation Format: Skip Rizzo, Donna Spruijt-Metz, Arno Hartholt, Bill Swartout, Kayla de la Haye, Joel Milam, David Freyer, Kimberly Miller, Anamara Ritt-Olson, Stacy Schepens-Niemiec, Shinyi Wu, Maryalice Jordan-Marsh, Amie Hwang, Anya Samek, Dennis Wixon, George Tolomiczenko, Kenneth Hayashida, Marientina Gotsis, Stefan Schneider, Swaroop Samek, Yaniv Bar-Cohen. Mobile virtual human health care guides for young adult childhood cancer survivors [abstract]. In: Proceedings of the AACR Special Conference on Modernizing Population Sciences in the Digital Age; 2019 Feb 19-22; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(9 Suppl):Abstract nr IA15.

Examining adherence barriers among women with HIV to tailor outreach for long-acting injectable antiretroviral therapy

Background

Long-acting (LA) injectable antiretroviral therapy (ART) has been found non-inferior to daily oral ART in Phase 3 trials. LA ART may address key barriers to oral ART adherence and be preferable to daily pills for some people living with HIV. To date, women have been less represented than men in LA ART research. Using longitudinal data from the Women’s Interagency HIV Study (WIHS) cohort of women living with HIV in the United States, we examined barriers and facilitators of daily oral ART adherence that may be related to or addressed by LA ART.

Methods

We conducted a secondary analysis of WIHS cohort data from 1998 to 2017 among participants seen for at least 4 visits since 1998 who reported using ART at least once (n = 2601). Two dichotomous outcomes, patient-reported daily oral ART adherence and viral suppression were fit using generalized linear models, examining the role of socio-demographic and structural factors.

Results

At study enrollment, the median age was 40.5 years, 63% of participants were African American and 22% were Latina. The majority (82%) reported taking ART more than 75% of the time and 53% were virally suppressed. In multivariate analysis, several sub-groups of women had lower odds of reported adherence and viral suppression: 1) younger women (adherence aOR: 0.71; viral suppression aOR: 0.63); 2) women who inject drugs (adherence aOR: 0.38; viral suppression aOR: 0.50) and those with moderate (adherence aOR: 0.59; viral suppression aOR: 0.74) and heavy alcohol consumption (adherence aOR: 0.51; viral suppression aOR: 0.69); 3) those with depressive symptoms (adherence aOR: 0.61; viral suppression aOR: 0.76); and 4) those with a history of going on and off ART (adherence aOR: 0.62, viral suppression aOR: 0.38) or changing regimens (adherence aOR: 0.83, viral suppression aOR: 0.56).

Conclusions

Current injectable contraceptive users (vs. non-users) had greater odds of oral ART adherence (aOR: 1.87) and viral suppression (aOR: 1.28). Findings identify profiles of women who may benefit from and be interested in LA ART. Further research is warranted focused on the uptake and utility of LA ART for such key subpopulations of women at high need for innovative approaches to achieve sustained viral suppression.

Utilizing SEER Cancer Registries for Population-Based Cancer Survivor Epidemiologic Studies: A Feasibility Study

BACKGROUND

While the primary role of central cancer registries in the United States is to provide vital information needed for cancer surveillance and control, these registries can also be leveraged for population-based epidemiologic studies of cancer survivors. This study was undertaken to assess the feasibility of using the NCI's Surveillance, Epidemiology, and End Results (SEER) Program registries to rapidly identify, recruit, and enroll individuals for survivor research studies and to assess their willingness to engage in a variety of research activities.

METHODS

In 2016 and 2017, six SEER registries recruited both recently diagnosed and longer-term survivors with early age-onset multiple myeloma or colorectal, breast, prostate, or ovarian cancer. Potential participants were asked to complete a survey, providing data on demographics, health, and their willingness to participate in various aspects of research studies.

RESULTS

Response rates across the registries ranged from 24.9% to 46.9%, with sample sizes of 115 to 239 enrolled by each registry over a 12- to 18-month period. Among the 992 total respondents, 90% answered that they would be willing to fill out a survey for a future research study, 91% reported that they would donate a biospecimen of some type, and approximately 82% reported that they would consent to have their medical records accessed for research.

CONCLUSIONS

This study demonstrated the feasibility of leveraging SEER registries to recruit a geographically and racially diverse group of cancer survivors.

IMPACT

Central cancer registries are a source of high-quality data that can be utilized to conduct population-based cancer survivor studies.

Depression and Psychosocial Stress Are Associated With Subclinical Carotid Atherosclerosis Among Women Living With HIV

Background To identify reasons for increased atherosclerotic risk among women living with HIV (WLWH), we evaluated the associations between psychosocial risk factors (depressive symptoms, perceived stress, and posttraumatic stress disorder symptoms) and subclinical atherosclerosis among WLWH and HIV-negative women. Methods and Results Carotid artery focal plaque (localized intima-media thickness >1.5 mm) was measured using B-mode ultrasound imaging in 2004-2005 and 2010-2012 in the Women's Interagency HIV Study. We created psychosocial risk groups using latent class analysis and defined prevalent plaque at the final measurement. We also examined repeated semiannual depression measures with respect to focal plaque formation throughout follow-up. The associations between latent class and prevalent plaque, and between depressive symptom persistence and plaque formation, were assessed separately by HIV status using multivariable logistic regression. Among 700 women (median age 47 years), 2 latent classes were identified: high (n=163) and low (n=537) psychosocial risk, with corresponding prevalence of depression (65%/13%), high stress (96%/12%), and probable posttraumatic stress disorder (46%/2%). Among WLWH, plaque prevalence was 23% and 11% in high versus low psychosocial risk classes (adjusted odds ratio [aOR], 2.12; 95% CI, 1.11-4.05) compared with 9% and 9% among HIV-negative women (aOR, 1.07; 95% CI, 0.24-4.84), respectively. New plaque formation occurred among 17% and 9% of WLWH who reported high depressive symptoms at ≥45% versus <45% of visits (aOR, 1.96; 95% CI, 1.06-3.64), compared with 9% and 7% among HIV-negative women (aOR, 0.82; 95% CI, 0.16-4.16), respectively. Conclusions Psychosocial factors were independent atherosclerotic risk factors among WLWH. Research is needed to determine whether interventions for depression and psychosocial stress can mitigate the increased risk of atherosclerosis for WLWH.

Abstract A013: Parental health communication and satisfaction with medical providers of childhood cancer survivors: Differences by race/ethnicity and language

Purpose: Among childhood cancer survivors (CCS), parents inherently take on the role of informal caregivers. Effective communication between patient and provider or caregiver contributes to better treatment decision making and patient health outcomes. However, few studies have examined the frequency and scope of communication among childhood cancer survivors, caregivers, and medical providers. The purpose of this study was to examine the association between Hispanic ethnicity and language spoken with communication and satisfaction with their CCS health care provider. We hypothesized that Spanish-speaking Hispanic parents would have more barriers with provider communication and would be less satisfied with medical providers than English-speaking Hispanics and non-Hispanic parents. We also hypothesized that Spanish-speaking Hispanic parents would have greater communication with their child about their diagnosis.

Methods: We analyzed data from parents of CCS, who were selected from the Los Angeles Cancer Surveillance Program and had been diagnosed between 2000 and 2007 at Children's Hospital Los Angeles (CHLA) or Miller Children's Hospital, Long Beach. We used ANOVA and chi-square statistics to test for differences in demographic characteristics.

Results: A total of 173 parents participated in this study, including 50 Spanish-speaking Hispanics, 49 English-speaking Hispanics, and 74 English-speaking non-Hispanics. Spanish-speaking Hispanics were younger, had less than high school education, were lower income, and were less likely to have health care coverage compared to English-speaking Hispanics and non-Hispanic parents. Spanish-speaking Hispanic parents were more likely to report talking to their child about his/her needs for cancer-related follow-up care (p&lt;.001) and health insurance issues (p=.01). Regardless of language spoken, Hispanic parents were more likely to receive health information about their child's cancer from hospital sources. Spanish-speaking Hispanic parents were more likely than English-speaking Hispanics and non-Hispanic parents to report difficulties with written information (p=.02) and understanding doctors due to language barriers (p=.003). However, there was no statistically significant difference by ethnicity/language in parent satisfaction with their child's health care provider or in receiving a survivorship care plan.

Conclusion: Despite reporting similar rates of satisfaction with CCS medical providers, Spanish-speaking parents were more likely to report communication barriers with providers. Nevertheless, in order to build sustainable relationships with providers, language barriers need to be addressed to improve communication effectiveness. In future studies, we will explore the role of parent-child and parent-provider communication on their health outcomes.

Citation Format: Carol Y. Ochoa, Lourdes Baezconde-Garbanati, Joel Milam. Parental health communication and satisfaction with medical providers of childhood cancer survivors: Differences by race/ethnicity and language [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A013.

Incarceration and Number of Sexual Partners After Incarceration Among Vulnerable US Women, 2007-2017

Objectives. To examine whether women's incarceration increases numbers of total and new sexual partners.Methods. US women with or at risk for HIV in a multicenter cohort study answered incarceration and sexual partner questions semiannually between 2007 and 2017. We used marginal structural models to compare total and new partners at visits not following incarceration with all visits following incarceration and visits immediately following incarceration. Covariates included demographics, HIV status, sex exchange, drug or alcohol use, and housing instability.Results. Of the 3180 participants, 155 were incarcerated. Women reported 2 partners, 3 or more partners, and new partners at 5.2%, 5.2%, and 9.3% of visits, respectively. Relative to visits not occurring after incarceration, odds ratios were 2.41 (95% confidence interval [CI] = 1.20, 4.85) for 2 partners, 2.03 (95% CI = 0.97, 4.26) for 3 or more partners, and 3.24 (95% CI = 1.69, 6.22) for new partners at visits immediately after incarceration. Odds ratios were similar for all visits following incarceration.Conclusions. Women had more total partners and new partners immediately and at all visits following incarceration after confounders and loss to follow-up had been taken into account.

Seeking refuge in the present moment: A qualitatively refined model of dispositional mindfulness, minority stress, and psychosocial health among Latino/a sexual minorities and their families

Racial/ethnic and sexual minorities may experience excess stress from social prejudice and structural disadvantage, which is associated with family relationship problems and poorer psychosocial health. There is increasing evidence that certain positive psychological processes can attenuate these negative outcomes at the individual and interpersonal levels; however, the mechanisms of these effects remain poorly understood. Based on previous research and two extant conceptual frameworks, we constructed a preliminary model of how dispositional mindfulness operated in the context of minority stress among Latino/a sexual minority young adults and their families. We then conducted semi-structured interviews in a life history format with 21 Latino/a sexual minority young adults and 15 family members to test our preliminary model and refine it. We mixed content analysis and grounded theory techniques, whereby we initially used deductive coding with pre-established codes based on our preliminary model, and subsequently used inductive coding to account for novel categories in the interview data that could not be explained by the preliminary model. The refined model revealed pathways by which five constructs of dispositional mindfulness (act with awareness, observe, describe, non-judge, non-react) buffered negative effects of minority stress on psychosocial health in young adults, and were qualitatively associated with compassion, acceptance of sexual minorities, and closeness among family members. Young adults reporting deficiencies in mindfulness reported greater suffering and negative coping related to minority stress. Our model provides a framework to explore modes of resilience and adaptation to minority stress, and offers a basis for further refinement in other affected populations.

Randomized Controlled Trial of Daily Text Messages to Support Adherence to Preexposure Prophylaxis in Individuals at Risk for Human Immunodeficiency Virus: The TAPIR Study

Background

Adherence is critical for efficacy of tenofovir disoproxil fumarate/emtricitabine (FTC) as preexposure prophylaxis (PrEP).

Methods

Between February 2013 and February 2016, 398 men who have sex with men and transgender women were randomized 1:1 to receive individualized texting for adherence building (iTAB) or standard care (SoC) for 48 weeks. The primary endpoint was dried blood spot (DBS) tenofovir diphosphate (TFV-DP) concentrations at both week 12 and the last on-drug visit of >719 fmol/punch (ie, adequate adherence). Secondary outcomes included DBS TFV-DP concentrations of >1246 fmol/punch (ie, near-perfect adherence) and plasma FTC >350 ng/mL (consistent with dosing within the past 24 hours).

Results

Concentrations >719 fmol/punch of TFV-DP were found in 88.6% of participants at week 12 and 82.5% at week 48. For the primary endpoint, the study arms did not differ (72.0% in iTAB and 69.2% in SoC; P > .05). For the secondary composite endpoint of >1246 fmol/punch the iTAB arm was superior to SoC (33.5% vs 24.8%; P = .06), reaching statistical significance when adjusting for age (odds ratio, 1.56 [95% confidence interval, 1.00-2.42]; P < .05). At week 48, iTAB was superior to SoC for near-perfect adherence (51.0% vs 37.4%; P = .02). At week 12, iTAB was superior to SoC for dosing in past 24 hours by plasma FTC (47.5% vs 33.3%; P = .007), but not at weeks 24, 36, and 48 (all P > .05).

Conclusions

Automated text messaging is a low-burden tool that improves durability of near-perfect PrEP adherence.

Clinical Trials Registration

NCT01761643.

Worry about quality of life for younger versus older adult thyroid cancer survivors

157

Background: Thyroid cancer is one of the most common cancers in young adults, age 18-39 years. Since this population has distinct medical and developmental needs, it is important to understand age differences in worry about quality of life. Methods: Thyroid cancer patients diagnosed between 2014-15 were accrued from the Surveillance, Epidemiology and End Results Program (SEER) registries of Georgia and Los Angeles County and surveyed between 2017-18. The primary outcome was patient reported worry about quality of life. Covariates for this analysis included age (categorized 18-25, 26-39, 40-64, and 65-79), involvement in surgical decision making (low, just right, high) and amount of information received on treatment side effects (low, just right, high). Race/ethnicity, sex, and tumor characteristics were also evaluated. Multivariable analyses were used to assess associations between worry about quality of life and independent variables. Results: In the cohort of 2,632 patients, 39.8% were somewhat to very much worried about quality of life not being the same as before thyroid cancer diagnosis, 15.1% reported low involvement in surgical decision making, and 32.6% reported low amount of information regarding side effects. Younger age was associated with high worry about quality of life (p < 0.001), low involvement in decision making (p < 0.001) and low amount of information on treatment side effects (p < 0.001). In multivariable analyses, high worry was significantly associated with female sex (Odds ratio [OR]: 1.29 95% confidence Interval [CI]:1.04-1.59), non-white, non-Hispanic race/ethnicity (OR: 1.64 CI: 1.38-1.95), positive lymph nodes (OR: 1.41 CI: 1.14-1.75) and younger age (ages 18-25 years OR: 2.34 CI: 1.45-3.76; ages 26-39 years OR: 2.26 CI: 1.68-3.05; and ages 40-64 years OR:1.94 CI 1.50-2.51). Age differences remained significant after adding either involvement in decision-making or information received. Conclusions: Young adults report higher worry about quality of life. Controlling for decision-making involvement or information received about side effects did not eliminate age differences in worry. Ongoing psychosocial support addressing quality of life worries among younger survivors is needed.

Association between Use of Methadone, Other Central Nervous System Depressants, and QTc Interval-Prolonging Medications and Risk of Mortality in a Large Cohort of Women Living with or at Risk for Human Immunodeficiency Virus Infection

STUDY OBJECTIVE

To evaluate the association between use of methadone, other central nervous system (CNS) depressants, and QTc interval-prolonging medications and risk of mortality among human immunodeficiency virus (HIV)-infected and at-risk HIV-uninfected women.

DESIGN

Multicenter, prospective, observational cohort study (Women's Interagency HIV Study [WIHS]).

PARTICIPANTS

A total of 4150 women enrolled in the WIHS study between 1994 and 2014 who were infected (3119 women) or not infected (1031 women) with HIV.

MEASUREMENTS AND MAIN RESULTS

Data on medication utilization were collected from all study participants via interviewer-administered surveys at 6-month intervals (1994-2014). Mortality was confirmed by National Death Index data. With age defining the time scale for the analysis, Cox proportional hazards models were used to estimate hazard ratios (HRs) for all-cause mortality in HIV-infected and -uninfected women and non-acquired immunodeficiency syndrome (AIDS) deaths in HIV-infected women. A total of 1046 deaths were identified, of which 429 were considered non-AIDS deaths. Use of benzodiazepines, CNS depressants (excluding methadone), and number of medications with conditional QTc interval-prolonging effects were each associated with all-cause mortality in multivariate models of HIV-infected women: hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.01-1.60, p=0.037; HR 1.61, 95% CI 1.35-1.92, p<0.0001; and HR 1.15 per drug, 95% CI 1.00-1.33, p=0.047, respectively. Other explanatory variables for all-cause mortality in this model included HIV viral load, CD4+  cell count, renal function, hemoglobin and albumin levels, HIV treatment era, employment status, existence of depressive symptoms, ever use of injection drugs, and tobacco smoking. Of interest, use of CNS depressants (excluding methadone) was also associated with non-AIDS deaths (HR 1.49, 95% CI 1.49-2.2, p<0.0001). Although use of benzodiazepines and conditional QT interval-prolonging medications were associated with increased risk of non-AIDS mortality (HR 1.32 and 1.25, respectively), the effect was not statistically significant (p>0.05).

CONCLUSION

In this cohort of HIV-infected and at-risk HIV-uninfected women, use of benzodiazepines, CNS depressants, and conditional QTc interval-prolonging medications were associated with a higher risk of mortality independent of methadone and other well-recognized mortality risk factors. Care must be taken to assess risk when prescribing these medications in this underserved and at-risk patient population.