THE AUTHORS REPLY Lesko, Catherine R; Fox, Matthew P; Edwards, Jessie K
American journal of epidemiology,
04/2023, Letnik:
192, Številka:
4
Journal Article
THE AUTHORS REPLY Lesko, Catherine R; Fox, Matthew P; Edwards, Jessie K
American journal of epidemiology,
04/2023, Letnik:
192, Številka:
4
Journal Article
THE AUTHORS REPLY Lesko, Catherine R; Fox, Matthew P; Edwards, Jessie K
American journal of epidemiology,
04/2023, Letnik:
192, Številka:
4
Journal Article
Ancillary service needs likely influence time to diagnosis and presentation for HIV care. The effect of both met and unmet needs on late presentation to HIV care is not well understood. We used ...baseline data from 348 people with HIV (PWH) with no prior HIV care who enrolled in iENGAGE (a randomized controlled trial (RCT) of an intervention to support retention in care) at one of four HIV clinics in the US. A standardized baseline questionnaire collected information on ancillary service needs, and whether each need was presently unmet. We examined covariates known to be associated with disease stage at presentation to care and their association with needs. We subsequently assessed the relationship of needs with CD4 accounting for those other covariates by estimating prevalence ratios (PR) using inverse probability weights. Most patients enrolling in the RCT were male (79%) and the majority were Black (62%); median age was 34 years. Prevalence of any reported individual need was 69%. One-third of the sample had a baseline CD4 cell count <200, 42% between 200 and 499 and 27% ≥500. There was no statistically significant association between need or unmet need and baseline CD4. In general, psychiatric health and SU issues (depression, anxiety, and drug use) were consistently associated with higher prevalence of need (met and unmet). Additionally, the Black race was associated with higher basic resource needs (housing: PR 1.67, 95%CI 1.08-2.59; transportation: PR 1.65, 95% CI 1.12-2.45). Ancillary service needs (met and unmet) were common among patients new to HIV care and impacted vulnerable subgroups. However, we found no evidence that reporting a specific individual need, whether met or unmet, was associated with a timely presentation to HIV care. The impact of needs on subsequent steps of the HIV care continuum will be examined with longitudinal data.
Alcohol misuse is associated with increased human immunodeficiency virus sexual risk behaviors by women. Drug use, intimate partner violence (IPV), and depressive symptoms frequently co-occur, are ...well-recognized alcohol misuse comorbidities, and may interact to increase risk behaviors. Using a syndemic framework we examined associations between drug use, IPV, and depressive symptoms and sexual risk behaviors by 400 women with alcohol misuse attending an urban sexually transmitted infections clinic.
Participants completed computer-assisted interviews querying drug use, IPV, and depressive symptoms and sexual risk behavior outcomes—unprotected sex under the influence of alcohol, sex for drugs/money, and number of lifetime sexual partners. We used multivariable analysis to estimate prevalence ratios (PR) for independent and joint associations between drug use, IPV, and depressive symptoms and our outcomes. To investigate synergy between risk factors we calculated the relative excess prevalence owing to interaction for all variable combinations.
In multivariable analysis, drug use, IPV, and depressive symptoms alone and in combination were associated with higher prevalence/count of risk behaviors compared with women with alcohol misuse alone. The greatest prevalence/count occurred when all three were present (unprotected sex under the influence of alcohol PR, 2.6; 95% confidence interval, 1.3–4.9), sex for money or drugs PR, 2.6; 95% confidence interval, 1.7–4.2, and number of lifetime partners PR, 3.2; 95% confidence interval, 1.9–5.2). Drug use, IPV, and depressive symptoms did not interact synergistically to increase sexual risk behavior prevalence.
A higher prevalence of sexual risk behaviors by women with alcohol misuse combined with drug use, IPV, and depressive symptoms supports the need for alcohol interventions addressing these additional comorbidities.
Black and Latina transgender women (TW) experience a disparate burden of HIV and related comorbidities, including poor mental health and cardiovascular disease (CVD) risks. Pervasive multilevel ...stigma and discrimination operate as psychosocial stressors for TW living with HIV and shape health disparities for this population. Gender-affirming hormone therapy (GAHT) is commonly used by TW to facilitate alignment of the body with gender identity; in the context of stigma, GAHT may both improve mental health and increase CVD risks.
This study aims to quantify the longitudinal relationship between stigma and chronic stress among black and Latina TW living with HIV. Secondary objectives include identifying pathways linking chronic stress to HIV comorbidities and exploring chronic stress as a mediator in the pathway linking stigma and GAHT to CVD comorbidities.
This US-based mixed methods longitudinal study will enroll a prospective cohort of 200 black and Latina TW living with HIV, collecting quantitative survey data, qualitative interviews, and biomarkers of chronic stress. Interviewer-administered surveys will include validated psychosocial measures of self-reported stigma and discrimination, perceived stress, CVD risk factors, mental health, access to gender-affirming care, coping, and social support. Medical record abstraction will collect data on GAHT use, CD4 count, HIV viral load, antiretroviral therapy, treatment, and comorbid conditions. Clinical measures will include physiological biomarkers as well as salivary and blood-based biomarkers of chronic stress. Survey data will be collected every 6 months (baseline, and 6, 12, 18, and 24 months), and biospecimens will be collected at baseline and at 12 and 24 months. A purposive subsample (stratified by use of GAHT and presence of depressive symptoms) of 20 to 30 TW living with HIV will be invited to participate in in-depth interviews at 6 and 18 months to explore experiences of intersectional stigma, chronic stress, and the role of GAHT in their lives.
This study was funded by the National Institute on Minority Health and Health Disparities in December 2018. The study community advisory board and scientific advisors provided critical input on study design. Recruitment began in October 2019 (n=29 participants as of submission) and data collection will continue through 2022, with publication of baseline results anticipated summer 2021.
This study will focus on black and Latina TW living with HIV, an understudied health disparities population, advance both stigma and intersectionality research, and move chronic stress physiology research toward a more nuanced understanding of sex and gender. The comprehensive methodology will support the exploration of the role of exogenous estrogen in the pathways between stress and HIV comorbidities, elucidating the role of GAHT in the stress-health relationship. Finally, this study will provide longitudinal evidence of the impact of stigma-related chronic stress on the lives of black and Latina TW living with HIV integrating qualitative and quantitative data with psychosocial, clinical, and biological measures.
DERR1-10.2196/17076.
PURPOSE.The impact of pharmacist-assisted management (PAM) of pharmacotherapy for patients with human immunodeficiency virus (HIV) infection was investigated.
METHODS.A retrospective cohort analysis ...was conducted to evaluate antiretroviral therapy (ART) outcomes in treatment-naive patients initiated on ART at an HIV clinic. Eligible patients enrolled in the clinic during the period 1999–2013 were classified into two groupsthose referred to a clinic-based HIV pharmacist for initiation of ART (the PAM group) and those managed by a primary care provider (the control group). The primary study objective was the median time to viral suppression; secondary objectives included the durability of response to the first ART regimen. Relative hazards for the events of interest were estimated using a marginal structural Cox proportional hazards model and Kaplan–Meier curves, with inverse probability weights used to control for selection and confounding bias.
RESULTS.Patients referred for PAM services (n = 819) typically had higher baseline viral loads and lower CD4+ cell counts than those in the control group (n = 436). The likelihood of viral suppression during the first two years after ART initiation was significantly higher in the PAM group versus the control group (hazard ratio, 1.37; 95% confidence interval, 1.18–1.59; p < 0.0001). The median durability of the first ART regimen was 100 months in the PAM group versus 44 months in the control group (p > 0.05).
CONCLUSION.In treatment-naive patients, suppression of HIV viral load occurred earlier when pharmacists assisted with initiating ART than when ART was initiated without that assistance.
BACKGROUND:Marginal structural models are an important tool for observational studies. These models typically assume that variables are measured without error. We describe a method to account for ...differential and nondifferential measurement error in a marginal structural model.
METHODS:We illustrate the method estimating the joint effects of antiretroviral therapy initiation and current smoking on all-cause mortality in a United States cohort of 12,290 patients with HIV followed for up to 5 years between 1998 and 2011. Smoking status was likely measured with error, but a subset of 3,686 patients who reported smoking status on separate questionnaires composed an internal validation subgroup. We compared a standard joint marginal structural model fit using inverse probability weights to a model that also accounted for misclassification of smoking status using multiple imputation.
RESULTS:In the standard analysis, current smoking was not associated with increased risk of mortality. After accounting for misclassification, current smoking without therapy was associated with increased mortality (hazard ratio HR1.2 95% confidence interval CI = 0.6, 2.3). The HR for current smoking and therapy 0.4 (95% CI = 0.2, 0.7) was similar to the HR for no smoking and therapy (0.4; 95% CI = 0.2, 0.6).
CONCLUSIONS:Multiple imputation can be used to account for measurement error in concert with methods for causal inference to strengthen results from observational studies.
Among HIV-infected persons, antiretroviral therapy (ART) and depression are strongly associated with mortality. We estimated reductions in 5-year mortality in Women's Interagency HIV Study ...participants under plausible hypothetical increases in ART initiation and reductions in depression (CES-D score≥16).
We followed 885 ART-naïve Women's Interagency HIV Study participants for 5 years from their first study visit after April 1998 to death or censoring. We used the parametric extended g-formula to estimate cumulative mortality under the natural course (NC) and alternative exposure distributions.
Baseline prevalence of depression was 52% and 62% initiated ART by 5 years. Compared with mortality under NC (13.2%), immediate ART and elimination of 36% or 67% of depressive episodes were associated with risk differences (RDs) of −5.2% (95% CI: −7.7%, −2.6%) and −5.7 (95% CI: −8.7, −2.7). Compared with immediate ART and NC for depression, additionally eliminating 67% of the depressive episodes was associated with RD = −1.6 (95% CI: −3.9, 0.8). Compared with 5-year mortality under NC for ART and elimination of 67% of depression, also initiating ART immediately was associated with RD = -2.6 (95% CI: -5.0, -0.3).
Increasing ART initiation and reducing depression were associated with moderate reductions in 5-year mortality among HIV-infected women.
Despite their dynamic, socially constructed, and imprecise nature, both race and gender are included in common risk calculators used for clinical decision-making about statin therapy for ...atherosclerotic cardiovascular disease (ASCVD) prevention.
We assessed the effect of manipulating six different race-gender categories on ASCVD risk scores among 90 Black transgender women.
Risk scores varied by operationalization of race and gender and affected the proportion for whom statins were recommended.
Race and gender are social constructs underpinning racialized and gendered health inequities. Their rote use in ASCVD risk calculators may reinforce and perpetuate existing inequities.
PDF
