To determine the association of race with clinical and laboratory outcomes after initiation of highly active antiretroviral therapy (HAART) in HIV-1-infected women in the United States.
Prospective cohort study.
A total of 961 HIV-1-infected women participating in the Women's Interagency HIV Study initiating HAART between July 1, 1995 and September 30, 2003.
Over a median of 5.1 years of follow-up, in univariate Cox regression analyses, white women were more likely than African American women to attain a virologic response (relative hazard [RH]=1.34, P=0.005), less likely to experience viral rebound (RH=0.76, P=0.051), and less likely to die (RH=0.63, P=0.040). There were no significant differences, however, among racial groups in outcomes after adjustment for pre-HAART CD4, HIV-1 RNA, history of AIDS-defining illness, age, antiretroviral therapy use, baseline HIV-1 exposure category, and post-HAART behavioral and clinical variables associated with poorer response (discontinuation of HAART, lower income, smoking, current drug use, and depression). Continuous HAART use and lack of depression differed by race and were the strongest predictors of favorable outcomes.
No significant differences by race were found in virologic, immunologic, or clinical outcomes after adjustment for continued HAART use and depression. These findings suggest that strategies to enhance HAART continuation, including assessing pharmacogenetic influences that may result in greater toxicity and discontinuation rates, and treating depression can improve individual and population-based effects of treatment and potentially mitigate racial disparities in AIDS-related outcomes.
"And while there were no statistically significant ethnic differences among those with an indication for HAART, there remained a trend towards lower odds of HAART initiation at lower CD4 count thresholds among African American participants when compared with Caucasian participants. A number of previous studies observed disparities in HAART use among certain race/ethnic groups and women although these did not specifically evaluate the elective initiation of HAART at high CD4 counts [8-10,14,21,23-26]. While the etiology of these disparities is largely attributed to differences in healthcare access, other factors have also been shown to contribute and perhaps offer an explanation for the findings in this study. "
[Show abstract][Hide abstract] ABSTRACT: Prior studies have suggested that HAART initiation may vary by race/ethnicity. Utilizing the U.S. military healthcare system, which minimizes confounding from healthcare access, we analyzed whether timing of HAART initiation and the appropriate initiation of primary prophylaxis among those at high risk for pneumocystis pneumonia (PCP) varies by race/ethnicity.
Participants in the U.S. Military HIV Natural History Study from 1998-2009 who had not initiated HAART before 1998 and who, based on DHHS guidelines, had a definite indication for HAART (CD4 <200, AIDS event or severe symptoms; Group A), an indication to consider HAART (including CD4 <350; Group B) or electively started HAART (CD4 >350; Group C) were analyzed for factors associated with HAART initiation. In a secondary analysis, participants were also evaluated for factors associated with starting primary PCP prophylaxis within four months of a CD4 count <200 cells/mm3. Multiple logistic regression was used to compare those who started vs. delayed therapy; comparisons were expressed as odds ratios (OR).
1262 participants were evaluated in the analysis of HAART initiation (A = 208, B = 637, C = 479 [62 participants were evaluated in both Groups A and B]; 94% male, 46% African American, 40% Caucasian). Race/ethnicity was not associated with HAART initiation in Groups A or B. In Group C, African American race/ethnicity was associated with lower odds of initiating HAART (OR 0.49, p = 0.04). Race and ethnicity were also not associated with the initiation of primary PCP prophylaxis among the 408 participants who were at risk.
No disparities in the initiation of HAART or primary PCP prophylaxis according to race/ethnicity were seen among those with an indication for therapy. Among those electively initiating HAART at the highest CD4 cell counts, African American race/ethnicity was associated with decreased odds of starting. This suggests that free healthcare can potentially overcome some of the observed disparities in HIV care, but that unmeasured factors may contribute to differences in elective care decisions.
AIDS Research and Therapy 01/2014; 11(1):10. DOI:10.1186/1742-6405-11-10 · 1.46 Impact Factor
"The estimated prevalence is two to ten times higher than that in the general US population (Bing et al., 2001; Pence, 2009). Depressive symptoms in PLHIV are associated with poor linkage to care (Bhatia, Hartman, Kallen, Graham, & Giordano, 2011), poor medication adherence (Ammassari et al., 2004; Kacanek et al., 2010; Kim et al., 2007), risky behaviors (Bing et al., 2001; Brown et al., 2006; Ryan, Forehand, Solomon, & Miller, 2008), poorer virological response to treatment (Anastos et al., 2005; Hartzell, Spooner, Howard, Wegner, & Wortmann, 2007) and increased risk of mortality (Anastos et al., 2005; Leserman, 2008). In the context of depression, self-evaluation is often negative, critical and self-deprecating (Van Dam, Sheppard, Forsyth, & Earleywine , 2011). "
[Show abstract][Hide abstract] ABSTRACT: The aims of this study were to examine differences in self-schemas between persons living with HIV/AIDS with and without depressive symptoms, and the degree to which these self-schemas predict depressive symptoms in this population. Self-schemas are beliefs about oneself and include self-esteem, HIV symptom management self-efficacy, and self-compassion. Beck's cognitive theory of depression guided the analysis of data from a sample of 1766 PLHIV from the USA and Puerto Rico. Sixty-five percent of the sample reported depressive symptoms. These symptoms were significantly (p ≤ 0.05), negatively correlated with age (r = -0.154), education (r = -0.106), work status (r = -0.132), income adequacy (r = -0.204, self-esteem (r = -0.617), HIV symptom self-efficacy (r = - 0.408), and self-kindness (r = - 0.284); they were significantly, positively correlated with gender (female/transgender) (r = 0.061), white or Hispanic race/ethnicity (r = 0.047) and self-judgment (r = 0.600). Fifty-one percent of the variance (F = 177.530 (df = 1524); p < 0.001) in depressive symptoms was predicted by the combination of age, education, work status, income adequacy, self-esteem, HIV symptom self-efficacy, and self-judgment. The strongest predictor of depressive symptoms was self-judgment. Results lend support to Beck's theory that those with negative self-schemas are more vulnerable to depression and suggest that clinicians should evaluate PLHIV for negative self-schemas. Tailored interventions for the treatment of depressive symptoms in PLHIV should be tested and future studies should evaluate whether alterations in negative self-schemas are the mechanism of action of these interventions and establish causality in the treatment of depressive symptoms in PLHIV.
AIDS Care 10/2013; 26(7). DOI:10.1080/09540121.2013.841842 · 1.60 Impact Factor
"Understaffing of outpatient psychiatric clinics and insurer-based restrictions on mental health coverage can lead to the unavailability of treatment for mentally ill persons in the community. This is of grave concern for mentally ill patients with HIV because, as aforementioned, undertreated mental illness is related to decreased HAART adherence, worse biological outcomes, and increased risk of death [45, 53, 54, 57]. In addition, psychiatric disorders are highly associated with prison recidivism among both HIV-infected and uninfected individuals [21, 51, 58]. "
[Show abstract][Hide abstract] ABSTRACT: The criminal justice system bears a disproportionate burden of the HIV epidemic. Continuity of care is critical for HAART-based prevention of HIV-related morbidity and mortality. This paper describes four major challenges to successful management of HIV in the criminal justice system: relapse to substance use, homelessness, mental illness, and loss of medical and social benefits. Each of these areas constitutes a competing priority upon release that demands immediate attention and diverts time, energy, and valuable resources away from engagement in care and adherence to HAART. Numerous gaps exist in scientific knowledge about these issues and potential solutions. In illuminating these knowledge deficits, we present a contemporary research agenda for the management of HIV in correctional systems. Future empirical research should focus on these critical issues in HIV-infected prisoners and releasees while interventional research should incorporate evidence-based solutions into the criminal justice setting.
AIDS research and treatment 07/2011; 2011(2090-1240):680617. DOI:10.1155/2011/680617
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