How Do Outcomes Compare between Women & Men Living with HIV in Australia?

Background: 

Gender differences vary across geographical settings and are poorly reported in the literature. The aim of this study was to evaluate demographics and clinical characteristics of participants from the Australian HIV Observational Database (AHOD), and to explore any differences between females and males in the rate of new clinical outcomes, as well as initial immunological and virological response to antiretroviral therapy.

Methods: 

Time to a new clinical end-point, all-cause mortality and/or AIDS illness was analysed using standard survival methods. Univariate and covariate adjusted Cox proportional hazard models were used to evaluate the time to plasma viral load suppression in all patients that initiated antiretroviral therapy (ART) and time to switching from a first-line ART to a second-line ART regimen. 

Results: 

There was no significant difference between females and males for the hazard of all-cause mortality [adjusted hazard ratio: 0.98 (0.51, 1.55), P = 0.67], new AIDS illness [adjusted hazard ratio: 0.75 (0.38, 1.48), P = 0.41] or a composite end-point [adjusted hazard ratio: 0.74 (0.45, 1.21), P = 0.23]. Incident rates of all-cause mortality were similar between females and males; 1.14 (0.61, 1.95) vs 1.28 (1.12, 1.45) per 100 person years. Virological response to ART was similar for females and males when measured as time to viral suppression and/or time to virological failure. 

Conclusion: 

This study supports current Australian HIV clinical care as providing equivalent standards of care for male and female HIV-positive patients. Future studies should compare ART-associated toxicity differences between ART-associated toxicity differences between men and women living with HIV in Australia.

Purchase full article at:   http://goo.gl/uo3P3Z

By:  Michelle L. Giles A B I, Marin C. Zapata C, Stephen T. Wright D E, Kathy PetoumenosD, Miriam Grotowski F, Jennifer Broom G, Matthew G. Law D and Catherine C. O’Connor C D H 

A Department of Infectious Diseases, Monash University, Clayton, Vic. 3168, Australia. B Monash Infectious Diseases, Monash Health, Clayton, Vic. 3168, Australia. C RPA Sexual Health, Sydney Local Health District, Sydney, NSW 2050, Australia. D The Kirby Institute, UNSW Australia, Sydney, NSW 2052, Australia. E School of Mathematical and Physical Sciences, University of Technology, Sydney, NSW 2007, Australia. F Tamworth Sexual Health Service, Tamworth, NSW 2340, Australia. G Department of Medicine, Nambour Hospital, Nambour, Qld 4560, Australia. H Central Clinical School, University of Sydney, Sydney, NSW 2052, Australia. I Corresponding author. Email: m.giles@alfred.org.au 

Sex Health. 2016 Feb 1. doi: 10.1071/SH15124. 

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State Variation in HIV/AIDS Health Outcomes: The Effect of Spending on Social Services and Public Health

OBJECTIVE:

Despite considerable advances in the prevention and treatment of HIV/AIDS, the burden of new infections of HIV and AIDS varies substantially across the country. Previous studies have demonstrated associations between increased healthcare spending and better HIV/AIDS outcomes; however, less is known about the association between spending on social services and public health spending and HIV/AIDS outcomes. We sought to examine the association between state-level spending on social services and public health and HIV/AIDS case rates and AIDS deaths across the United States.

DESIGN:

We conducted a retrospective, longitudinal study of the 50 U.S. states over 2000-2009 using a dataset of HIV/AIDS case rates and AIDS deaths per 100 000 people matched with a unique dataset of state-level spending on social services and public health per person in poverty.

METHODS:

We estimated multivariable regression models for each HIV/AIDS outcome as a function of the social service and public health spending 1 and 5 years earlier in the state, adjusted for the log of state GDP per capita, regional and time fixed effects, Medicaid spending as % of GDP, and socio-demographic, economic, and health resource factors.

RESULTS:

States with higher spending on social services and public health per person in poverty had significantly lower HIV and AIDS case rates and fewer AIDS deaths, both 1 and 5 years post expenditure (P ≤ 0.05).

CONCLUSION:

Our findings suggest that spending on social services and public health may provide a leverage point for state policymakers to reduce HIV/AIDS case rates and AIDS deaths in their state.

Purchase full article at:   http://goo.gl/6gYf0q

By:  Talbert-Slagle KM1, Canavan ME, Rogan EM, Curry LA, Bradley EH.

• 1Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA. 
• AIDS. 2016 Feb 20;30(4):657-63. doi: 10.1097/QAD.0000000000000978.

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 More about map:  http://goo.gl/Zrvl62

Trauma History in African-American Women Living with HIV: Effects on Psychiatric Symptom Severity and Religious Coping

Women living with HIV (WLHIV) have rates of post-traumatic stress disorder (PTSD) up to 5 times higher than the general population. Individuals living with HIV and a concurrent diagnosis of PTSD have poorer HIV-related outcomes; however, the prevalence and impact of PTSD on African-American WLHIV seeking mental health treatment is unknown. 

The aim of this study is to examine the associations between PTSD symptoms with psychiatric symptom severity and psychological/religious coping strategies in African-American WLHIV who are seeking mental health treatment. This is a cross-sectional study of 235 African-American WLHIV attending an urban community mental health clinic. Bivariate analyses were conducted to evaluate associations between a PTSD symptoms scale (PSS≥21 versus PSS<21) and (1) psychiatric severity, (2) coping strategies, and (3) religious coping strategies. 

Thirty-six percent reported symptoms consistent with PTSD (PSS≥21). These women were significantly more likely to have worse mental health symptoms and were more likely to employ negative psychological and religious coping strategies. On the contrary, women with a PSS<21 reported relatively low levels of mental health symptoms and were more likely to rely on positive psychological and religious coping strategies. 

Over one-third of African-American WLHIV attending an outpatient mental health clinic had symptoms associated with PTSD. These symptoms were associated with worse mental health symptoms and utilization of dysfunctional religious and nonreligious coping strategies. 

Untreated PTSD in WLHIV predicts poorer HIV-related health outcomes and may negatively impact comorbid mental health outcomes. Screening for PTSD in WLHIV could identify a subset that would benefit from evidence-based PTSD-specific therapies in addition to mental health interventions already in place. PTSD-specific interventions for WLHIV with PTSD may improve outcomes, improve coping strategies, and allow for more effective treatment of comorbid mental health disorders.

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By:   Brownley JR1, Fallot RD, Wolfson Berley R, Himelhoch SS.

• 1 Department of Psychiatry , University of Maryland School of Medicine, Baltimore , MD , USA. 

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Antiretroviral Treatment Efficacy and Safety in Older HIV-Infected Adults

Highly active antiretroviral therapy (ART) and its widespread availability have revolutionized the landscape of HIV care and patient outcomes, transforming infection with HIV into a manageable chronic condition rather than a life-limiting disease. 

This transformation has created an older patient demographic. The effect that older age has on the outcomes of ART is not completely understood. Limited data are available in older individuals due to underrepresentation in clinical trials. 

To better understand this relationship, we conducted a literature search to assess the impact of older age on the outcomes of ART in the older HIV-infected population, including immunologic and virologic outcomes, mortality, disease progression, toxicity of ART, and pharmacokinetic considerations. In addition, package inserts of antiretroviral (ARV) medications were reviewed for efficacy, safety, and pharmacokinetic information pertaining to the older population. 

Most studies in older adults (50 yrs or older) demonstrated slower and blunted CD4 immune recovery but better virologic suppression in response to ART. Higher rates of mortality and faster disease progression have been observed in adults 50 years and older, particularly during the first year after ART initiation. HIV-infected patients aged 50 years and older appear to be at greater risk for certain ART-associated toxicities including nephrotoxicity, decline in bone mineral density and bone fracture, symptomatic peripheral neuropathy, and cardiovascular disease including myocardial infarction. 

The available literature suggests that clinicians should consider avoiding agents such as tenofovir disoproxil fumarate (TDF) in older patients with risk factors for renal impairment and/or osteoporosis. If TDF is used in patients aged 50 years or older, more frequent monitoring should be considered. Older age was a significant predictor for higher atazanavir exposure and higher lopinavir trough concentration at 24 weeks. 

The clinical implications of these findings are unknown. It is imperative that future development of novel ARV drug therapies includes a greater proportion of older subjects in clinical trials.

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By:   Jourjy J¹, Dahl K¹, Huesgen E¹.

¹Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida.

Pharmacotherapy. 2015 Dec;35(12):1140-51. doi: 10.1002/phar.1670. 

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Ryan White HIV/AIDS Program Assistance and HIV Treatment Outcomes

The Ryan White HIV/AIDS Program (RWHAP) provides persons infected with human immunodeficiency virus (HIV) with services not covered by other healthcare payer types. Limited data exist to inform policy decisions about the most appropriate role for RWHAP under the Patient Protection and Affordable Care Act (ACA).

METHODS:

We assessed associations between RWHAP assistance and antiretroviral therapy (ART) prescription and viral suppression. We used data from the Medical Monitoring Project, a surveillance system assessing characteristics of HIV-infected adults receiving medical care in the United States. Interview and medical record data were collected in 2009-2013 from 18 095 patients.

RESULTS:

Nearly 41% of patients had RWHAP assistance; 15% relied solely on RWHAP assistance for HIV care. Overall, 91% were prescribed ART, and 75% were virally suppressed. Uninsured patients receiving RWHAP assistance were significantly more likely to be prescribed ART (52% vs 94%; P < .01) and virally suppressed (39% vs 77%; P < .01) than uninsured patients without RWHAP assistance. Patients with private insurance and Medicaid were 6% and 7% less likely, respectively, to be prescribed ART than those with RWHAP only (P < .01). Those with private insurance and Medicaid were 5% and 12% less likely, respectively, to be virally suppressed (P ≤ .02) than those with RWHAP only. Patients whose private or Medicaid coverage was supplemented by RWHAP were more likely to be prescribed ART and virally suppressed than those without RWHAP supplementation (P ≤ .01).

CONCLUSIONS:

Uninsured and underinsured HIV-infected persons receiving RWHAP assistance were more likely to be prescribed ART and virally suppressed than those with other types of healthcare coverage.

Purchase full article at:   http://goo.gl/QW0z7z

By:   Bradley H1, Viall AH1, Wortley PM1, Dempsey A2, Hauck H2, Skarbinski J1.

• 1Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.
• 2HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, Maryland. 

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Virological Outcome among HIV-1 Infected Patients on First-Line Antiretroviral Treatment in Semi-Rural HIV Clinics in Togo

Background

Access to antiretroviral treatment (ART) in resource-limited countries has increased significantly but scaling-up ART into semi-rural and rural areas is more recent. Information on treatment outcome in such areas is still very limited notably due to additional difficulties to manage ART in these areas.

Results

387 HIV-1 infected adults (≥18 years) were consecutively enrolled when attending healthcare services for their routine medical visit at 12 or 24 months on first-line ART in five HIV care centers (four semi-rural and one rural). Among them, 102 patients were on first-line ART for 12 ± 2 months (M12) and 285 for 24 ± 2 months (M24). Virological failure was observed in 70 (18.1 %) patients ranging from 13.9 to 31.6 % at M12 and from 8.1 to 22.4 % at M24 across the different sites. For 67/70 patients, sequencing was successful and drug resistance mutations were observed in 65 (97 %). The global prevalence of drug resistance in the study population was thus at least 16.8 % (65/387). Moreover, 32 (8.3 %) and 27 (6.9 %) patients were either on a completely ineffective ART regime or with only a single drug active. Several patients accumulated high numbers of mutations and developed also cross-resistance to abacavir, didanosine or the new NNRTI drugs like etravirine and rilpivirine.

Conclusion

The observations on ART treatment outcome from ART clinics in semi-rural areas are close to previous observations in Lomé, the capital city suggesting that national ART-programme management plays a role in treatment outcome.

Below:  Togo map indicating locations of the healthcare centers where patients were enrolled. The sites where samples were collected for this study are indicated with grey full circles, and the name of the corresponding city at the right. Lomé, the capital city, is indicated with a black full circle

Full article at:   http://goo.gl/Zjtucp

By:

Abla A. Konou, 

Mounerou Salou, 

Nicole Vidal, 

Pascal Kodah, 

Damobé Kombate, 

Pyabalo Kpanla, 

Tchabia Nabroulaba, 

Djifa Nyametso,

Assétina Singo-Tokofaï, 

Palokinam Pitche, 

Eric Delaporte, 

Mireille Prince-David, 

Martine Peeters and 

Anoumou Y. Dagnra

Affiliated with

• Laboratoire de Biologie Moléculaire et d’Immunologie (BIOLIM/FSS/UL), Université de Lomé
• Département des sciences fondamentales et biologiques, Faculté des Sciences de la Santé, Université de Lomé

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Sex-Related Disparities in Criminal Justice and HIV Treatment Outcomes: A Retrospective Cohort Study of HIV-Infected Inmates

We evaluated sex-related differences in HIV and criminal justice (CJ) outcomes.

We quantified sex-related differences in criminal offenses, incarcerations, and HIV outcomes among all HIV-infected inmates on antiretroviral therapy (ART) in Connecticut (2005-2012). Computed criminogenic risk scores estimated future CJ involvement. Stacked logistic regression models with random effects identified significant correlates of HIV viral suppression on CJ entry, reflecting preceding community-based treatment.

Compared with 866 HIV-infected men on ART (1619 incarcerations), 223 women (461 incarcerations) were more likely to be younger, White, and medically insured, with shorter incarceration periods (mean = 196.8 vs 368.1 days), mostly for public disorder offenses. One third of both women and men had viral suppression on CJ entry, correlating positively with older age and having treated comorbidities. Entry viral suppression inversely correlated with incarceration duration for women and with criminogenic risk score for men.

In the largest contemporary cohort of HIV-infected inmates on ART, women's higher prevalence of nonviolent offenses and treatable comorbidities supports alternatives to incarceration strategies. Sex-specific interventions for CJ populations with HIV effectively align public health and safety goals.

Table 1

Descriptive Characteristics of HIV-infected Individuals (N=1089) and Incarceration Periods (N=2080), Stratified by Sex

Individuals	Total Sample N=1089	Men N=866	Women N=223	p-value1
Mean age, years (SD)	42.6 (8.4)	43.3 (8.5)	40.2 (7.1)	<0.001
Race/ethnicity, n (%)				<0.001
White, non-Hispanic	218 (20.0)	149 (17.1)	69 (31.0)
Black, non-Hispanic	515 (47.3)	411 (47.5)	104 (46.6)
Hispanic	351 (32.2)	303 (35.0)	48 (21.5)
Other	5 (0.5)	3 (0.4)	2 (0.9)
Married, n (%)	179 (16.4)	149 (17.2)	30 (13.5)	0.18
Dependent children, n (%)				0.21
None	400 (36.7)	310 (35.8)	90 (40.4)
At least one	689 (63.3)	556 (64.2)	133 (59.6)
Education, n (%)				0.28
High school or less	502 (46.1)	392 (45.3)	110 (49.3)
At least high school	587 (53.9)	474 (54.7)	113 (50.7)
Ever had medical insurance on entry, n (%)	194 (17.8)	79 (9.1)	115 (51.6)	<0.001

Incarceration Periods	Total N=2080	Men N=1619	Women N=461	p-value
Mean number incarceration periods per person (SD)	1.9 (1.4)	1.9 (1.4)	2.1 (1.4)	0.06
Duration incarceration, days				<0.001
Mean (SD)	330.1 (473.4)	368.1 (510.6)	196.8 (269.7)
Median (IQR)	166.5 (304)	182 (383)	96 (222)
Number of inter-facility transfers (%)				0.05
Zero	1954 (93.9)	1512 (93.4)	442 (95.9)
≥ One	126 (6.1)	107 (6.6)	19 (4.1)
Time spent in community between incarceration periods, days2
Mean (SD)	325.9 (357.7)	323.1 (353.3)	334.6 (317.9)	0.30
Median (Min, Max)	194.5 (1,2069)	190.5 (1,2069)	208 (5,2064)	0.68
Intake Year, n (%)				<0.001
2005-2007	1025 (49.3)	759 (46.9)	266 (57.7)
2008-2010	803 (38.6)	655 (40.5)	148 (32.1)
2011-2012	252 (12.1)	205 (12.7)	47 (10.2)
Discharge status, n (%)				0.22
Probation/parole	679 (32.6)	533 (32.9)	146 (31.7)
Release	1384 (66.6)	1070 (66.1)	314 (68.1)
Death	17 (0.8)	16 (1.0)	1 (0.2)
Re-incarceration rate3				0.006
Mean (SD)	0.63	0.67 (1.0)	0.47 (0.38)
Median (IQR)	0.41 (0.22-0.72)	0.42 (0.23-0.75)	0.38 (0.20-0.60)

1Using Student's t-test for continuous variables and Chi-squared test for categorical variables unless otherwise noted

2For individuals with more than one incarceration during the observation period

3By Wilcoxon rank sum

Full article at:   http://goo.gl/4zeF2K

By:  Meyer JP1, Cepeda J1, Taxman FS1, Altice FL1.

• 1Jaimie P. Meyer and Frederick L. Altice are with the AIDS Program, Yale School of Medicine, New Haven, CT. Jaimie P. Meyer is also with the Chronic Disease Epidemiology Department, Yale School of Public Health, New Haven. Javier Cepeda and Frederick L. Altice are with the Department of Epidemiology of Microbial Diseases, Yale School of Public Health. Faye S. Taxman is with the Criminology, Law, and Society Department, George Mason University, Fairfax, VA. 

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