Publications by authors named "Ighovwerha Ofotokun"

75 Publications

Psychosocial Mechanisms of Self-rated Successful Aging with HIV: A Structural Equation Model.

AIDS Behav 2021 Jun 11. Epub 2021 Jun 11.

Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, GA, USA.

This study tested a conceptual psychosocial model of self-rated successful aging (SRSA) with HIV. Our sample (n = 356) included older women living with HIV (OWLH): average age 56.5 years, 73% Black. SRSA was assessed using a research-based 10-point scale (higher scores = better outcomes). We conducted adjusted structural equation modeling. The global model included two latent variables-protective attributes (composite of positive psychosocial factors: resilience, personal mastery, optimism, spirituality) and psychological distress (composite of negative psychosocial factors: anxiety, depression, loneliness, internalized HIV-related stigma). The model showed good fit (χ(58) = 76, p = 0.06; RMSEA = 0.03; CFI = 0.99). Increased protective attributes were associated with improved SRSA both directly and mediated by improved coping with stress. While psychological distress did not have a direct effect on SRSA, it was indirectly associated with worsened SRSA via diminished protective attributes and via decreased coping with stress. Findings suggest the need for interventions enhancing positive and mitigating negative psychosocial factors in OWLH.
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http://dx.doi.org/10.1007/s10461-021-03340-7DOI Listing
June 2021

Intersections of food insecurity, violence, poor mental health and substance use among US women living with and at risk for HIV: Evidence of a syndemic in need of attention.

PLoS One 2021 26;16(5):e0252338. Epub 2021 May 26.

Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, United States of America.

Background: Food insecurity and intimate partner violence (IPV) are associated with suboptimal HIV prevention and treatment outcomes, yet limited research has explored how food insecurity and IPV intersect to influence HIV-related behaviors. To fill this gap, we conducted a qualitative study with women living with or at risk for HIV in the United States.

Methods: We conducted 24 in-depth interviews with women enrolled in the San Francisco and Atlanta sites of the Women's Interagency HIV study (WIHS). Participants were purposively sampled so half were living with HIV and all reported food insecurity and IPV in the past year. Semi-structured interviews explored experiences with food insecurity and IPV, how these experiences might be related and influence HIV risk and treatment behaviors. Analysis was guided by an inductive-deductive approach.

Results: A predominant theme centered on how food insecurity and IPV co-occur with poor mental health and substance use to influence HIV-related behaviors. Women described how intersecting experiences of food insecurity and IPV negatively affected their mental health, with many indicating using substances to "feel no pain". Substance use, in turn, was described to perpetuate food insecurity, IPV, and poor mental health in a vicious cycle, ultimately facilitating HIV risk behaviors and preventing HIV treatment adherence.

Conclusions: Food insecurity, IPV, poor mental health and substance use intersect and negatively influence HIV prevention and treatment behaviors. Findings offer preliminary evidence of a syndemic that goes beyond the more widely studied "SAVA" (substance use, AIDS, and violence) syndemic, drawing attention to additional constructs of mental health and food insecurity. Quantitative research must further characterize the extent and size of this syndemic. Policies that address the social and structural drivers of this syndemic, including multi-level and trauma-informed approaches, should be implemented and evaluated to assess their impact on this syndemic and its negative health effects.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0252338PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8153505PMC
May 2021

Perceived Neighborhood-Level Drivers of Food Insecurity Among Aging Women in the United States: A Qualitative Study.

J Acad Nutr Diet 2021 May 3;121(5):844-853. Epub 2021 Feb 3.

Background: Aging populations in the United States exhibit high rates of food insecurity and chronic illness. Few studies have explored the neighborhood-level drivers of food insecurity among such populations, and how they intersect with experiences of aging.

Objective: The aim of this study was to explore how aging women experience food insecurity in the United States, and the neighborhood-level factors that influence these experiences.

Design: Semistructured qualitative interviews were conducted to elicit participants' perceptions of how their neighborhood influenced their experiences with food security and aging.

Participants/setting: Thirty-eight food-insecure women aged 50 years and older were purposively sampled from the Northern California, Georgia, and North Carolina sites of the Women's Interagency Human Immunodeficiency Virus Study. Interviews were conducted between November 2017 and July 2018 at the three Women's Interagency Human Immunodeficiency Virus Study sites.

Statistical Analysis: Three researchers thematically analyzed the data using an inductive-deductive approach.

Results: Participants described neighborhood-level drivers of food insecurity that centered around three themes: accessibility of food from traditional food stores, the role of food aid institutions, and the intersection of aging with the food environment. Participants explained that food insecurity was related to limited access to food stores largely due to long distances and poor public transportation in Georgia and North Carolina, and high food prices in Northern California. Most participants described being dependent on food aid programs, but found this difficult due to poor quality food and long wait times. Aging-related issues emerged as a cross-cutting theme, with fatigue, poor strength, and chronic illness amplifying barriers to accessing food.

Conclusions: Findings from this study reveal the structural barriers that aging women face in accessing healthy food within their neighborhoods, and how experiences with aging and chronic illnesses exacerbate these barriers. Although future programs should address common neighborhood-level barriers such as the accessibility and affordability of healthy foods, they should also be tailored to aging women and the local context.
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http://dx.doi.org/10.1016/j.jand.2020.12.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084897PMC
May 2021

Incident Non-AIDS Comorbidity Burden among Women with or at-risk for HIV in the U.S.

Clin Infect Dis 2021 Jan 3. Epub 2021 Jan 3.

Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA.

Background: HIV infection may accelerate development of aging-related non-AIDS comorbidities (NACM). The incidence of NACM is poorly characterized among women living with HIV (WLWH).

Methods: WLWH and HIV-seronegative participants followed in the Women's Interagency HIV Study (WIHS) through ≥2009 (when >80% of WLWH used antiretroviral therapy) were included, with outcomes measured through 3/31/2018. Sociodemographics, clinical covariates and prevalent NACM were determined at enrollment. We used Poisson regression models to determine incident NACM burden (number of NACM accrued through most recent WIHS visit out of ten total NACM assessed) by HIV serostatus and age.

Results: There were 3,129 participants (2239 WLWH, 890 HIV-seronegative) with 36,589 person-years of follow-up. At enrollment, median age was 37 years, 65% were black, 47% currently smoked. In fully-adjusted analyses, WLWH had a higher incident NACM rate compared with HIV-seronegative women (IRR 1.36, 95% CI 1.02-1.81). Incident NACM burden was higher among WLWH versus HIV-seronegative women in most age strata (HIV*age interaction p=0.0438) and women <25 years old had the greatest incidence rate ratio by HIV serostatus at 1.48 (95% CI 1.19-1.84) compared with those in older age groups. Incident NACM burden was associated with traditional comorbidity risk factors, but not HIV-specific indices.

Conclusions: Incident NACM burden was higher among WLWH than HIV-seronegative women. This difference was most dramatic among women aged <25 years, a group for whom routine comorbidity screening is not prioritized. Established non-HIV comorbidity risk factors were significantly associated with incident NACM burden. More data are needed to inform best practices for NACM screening, prevention and management among WLWH, particularly young women.
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http://dx.doi.org/10.1093/cid/ciaa1928DOI Listing
January 2021

Exploring the role of social capital in managing food insecurity among older women in the United States.

Soc Sci Med 2020 11 2;265:113492. Epub 2020 Nov 2.

Division of HIV, ID and Global Medicine, Department of Medicine, UCSF, 995 Potrero Ave, Building 80, Ward 84, San Francisco, CA, 94110, USA.

Food insecurity, which affects 37 million individuals in the United States (U.S.) and disproportionately burdens women, minorities and older adults, is a well-established determinant of poor health. Previous studies suggest social capital, defined as the material and social benefits arising from relationships among individuals within and between groups, may be protective against food insecurity. Drawing on this evidence, calls have been made for interventions and policies to promote social capital to address food insecurity. However, limited research has explored in-depth how social capital shapes the lived experience of food insecurity in the U.S. We explored how older women from three settings in the U.S. used forms of social capital to navigate their food environments. Between November 2017-July 2018, we conducted 38 semi-structured interviews with food-insecure women aged 50 years or older enrolled in the Northern California, Georgia, and North Carolina sites of the Women's Interagency HIV study, an ongoing cohort study of women living with and at risk of HIV. Interviews were analyzed using an inductive-deductive approach. Women from the three sites explained how they drew upon different forms of capital to access food. Women in Georgia and North Carolina depended on support from members within their social group (bonding social capital) to address food insecurity but described limited opportunities to build relationships with members from other social groups (bridging social capital) or representatives of institutions (linking social capital). In contrast, women from Northern California frequently used bridging and linking social capital to access food but described limited bonding social capital. Findings show how the role of social capital in protecting against food insecurity is diverse, complex, and structurally determined. Intervention implications are discussed.
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http://dx.doi.org/10.1016/j.socscimed.2020.113492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757784PMC
November 2020

Metabolic Changes Associated With the Use of Integrase Strand Transfer Inhibitors Among Virally Controlled Women.

J Acquir Immune Defic Syndr 2020 11;85(3):355-362

Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA.

Background: Integrase strand transfer inhibitors (INSTIs) have been associated with weight gain among women living with HIV. We aimed to investigate the association between INSTIs and change in cardiometabolic risk indicators.

Setting: Retrospective cohort.

Methods: Data from 2006 to 2017 were analyzed from women living with HIV enrolled in the longitudinal Women's Interagency HIV Study who were virally controlled on antiretroviral therapy (ART) for ≥5 consecutive semiannual visits. Women who switched/added an INSTI to ART (INSTI group) were compared with women who remained on non-INSTI ART (non-INSTI group). Outcomes included changes in fasting lipids and glucose, hemoglobin A1c (HbA1c), blood pressure (BP), and incident diabetes, hypertension, and insulin resistance. Outcomes were measured 6-12 months before and 6-18 months after INSTI switch/add in the INSTI group with comparable visits in the non-INSTI group. Longitudinal linear regression models compared change over time in each outcome by the study group.

Results: One thousand one hundred eighteen participants (234 INSTI, 884 non-INSTI) were followed for a median 2.0 (Q1 1.9, Q3 2.0) years. Participants were median age 49 years, 61% Black, and 73% overweight or obese (body mass index ≥25 kg/m). Compared with non-INSTI, the INSTI group experienced greater increases in HbA1c (+0.05 vs. -0.06 mg/dL, P = 0.0318), systolic BP (+3.84 vs. +0.84 mm Hg, P = 0.0191), and diastolic BP (+1.62 vs. -0.14 mm Hg, P = 0.0121), with greatest change in HbA1c among women on INSTIs with ≥5% weight gain.

Conclusions: INSTI use was associated with unfavorable changes in HbA1c and systolic and diastolic BP during short-term follow-up. Further research is needed to understand long-term cardiometabolic effects of INSTI use.
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http://dx.doi.org/10.1097/QAI.0000000000002447DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577246PMC
November 2020

Mechanisms from Food Insecurity to Worse HIV Treatment Outcomes in US Women Living with HIV.

AIDS Patient Care STDS 2020 10 17;34(10):425-435. Epub 2020 Sep 17.

Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, USA.

Food insecurity (FI) contributes to HIV-related morbidity and mortality, but the mechanisms whereby FI negatively impacts HIV health are untested. We tested the hypothesis that FI leads to poor HIV clinical outcomes through nutritional, mental health, and behavioral paths. We analyzed data from Women's Interagency HIV Study (WIHS) among 1803 women living with HIV (WLWH) (8225 person-visits) collected from 2013 to 2015 biannually from nine sites across the United States participating in the WIHS. FI was measured with the US Household Food Security Survey Module. Outcomes included HIV viral nonsuppression, CD4 cell counts, and physical health status (PHS). We used longitudinal logistic and linear regression models with random effects to examine associations adjusting for covariates and path analysis to test nutritional, mental health, and behavioral paths. Increasing severity of FI was associated with unsuppressed viral load, lower CD4 counts, and worse PHS (all  < 0.05). Report of FI 6 months earlier was independently associated with most outcomes after adjusting for concurrent FI. For viral nonsuppression, the nutritional and behavioral paths accounted for 2.09% and 30.66% of the total effect, with the mental health path operating via serial mediation through the behavioral path. For CD4 count, the mental health and behavioral paths accounted for 15.21% and 17.0% of the total effect, respectively. For PHS, depressive symptoms accounted for 60.2% of the total effect. In conclusion, FI is associated with poor health among WLWH through different paths depending on the outcome. Interventions should target FI and its behavioral and mental health mechanisms to improve HIV outcomes.
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http://dx.doi.org/10.1089/apc.2020.0009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585614PMC
October 2020

Cultural Competence and Humility in Infectious Diseases Clinical Practice and Research.

J Infect Dis 2020 09;222(Suppl 6):S535-S542

Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.

Infectious diseases as a specialty is tilted toward social justice, and practitioners are frequently on the front lines of the battle against health inequity in practices that are diverse and sometimes cross international borders. Whether caring for patients living with the human immunodeficiency virus, tuberculosis, or Ebola, infectious diseases practitioners often interact with those at the margins of societies (eg, racial/ethnic/sexual/gender minorities), who disproportionately bear the brunt of these conditions. Therefore, cultural barriers between providers and patients are often salient in the infectious diseases context. In this article, we discuss cultural competence broadly, to include not only the knowledge and the skills needed at both the organizational and the individual levels to provide culturally appropriate care, but also to include "cultural humility"-a lifelong process of learning, self-reflection, and self-critique. To enhance the quality and the impact of our practices, we must prioritize cultural competence and humility and be mindful of the role of culture in the patient-provider-system interactions, in our larger healthcare systems, and in our research agendas and workforce development.
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http://dx.doi.org/10.1093/infdis/jiaa227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489471PMC
September 2020

Clinical characteristics, comorbidities and outcomes among persons with HIV hospitalized with coronavirus disease 2019 in Atlanta, Georgia.

AIDS 2020 10;34(12):1789-1794

Division of Infectious Diseases, Emory University School of Medicine.

Background: There are limited data describing the presenting characteristics and outcomes among US persons with HIV (PWH) requiring hospitalization for coronavirus disease 2019 (COVID-19).

Methods: We performed a case series of all PWH sequentially admitted with COVID-19 from 8 March 2020 to 23 April 2020 at three hospitals in Atlanta, Georgia. Sociodemographic, clinical and HIV-associated characteristics were collected.

Results: Of 530 confirmed COVID-19 cases hospitalized during this period, 20 occurred among PWH (3.8%). The median age was 57 (Q1-Q3, 48-62) years, 65% were men, and 85% were non-Hispanic Black. Presenting median symptom duration was 5 (Q1-Q3, 3-7) days; cough (90%), fever (65%), malaise (60%) and dyspnea (60%) were most common. On admission, 40% of patients required oxygenation support and 65% had an abnormal chest radiograph. Median length of hospitalization was 5 (Q1-Q3, 4-12) days, 30% required intensive care, 15% required intubation, and 15% died. Median CD4 cell count prior to admission was 425 (Q1-Q3, 262-815) cells/μl and 90% of patients had HIV-1 RNA less than 200 copies/ml. Half of the patients had at least five comorbidities; hypertension (70%), dyslipidemia (60%) and diabetes (45%) were most prevalent. All three patients who died had CD4 cell count more than 200, HIV suppression and each had a total of five comorbidities.

Conclusion: The multisite series in the Southern United States provides characteristics and early outcomes of hospitalized PWH with COVID-19. Nearly all patients had controlled HIV and a high comorbidity burden. Additional study of COVID-19 among PWH is needed to determine the role of age, comorbidities and HIV control in mediating COVID-19 presentation and its sequelae.
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http://dx.doi.org/10.1097/QAD.0000000000002632DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7484356PMC
October 2020

Immature/transitional B-cell expansion is associated with bone loss in HIV-infected individuals with severe CD4+ T-cell lymphopenia.

AIDS 2020 08;34(10):1475-1483

Division of Endocrinology, Metabolism and Lipids.

Background: Antiretroviral therapy (ART) has led to a significant decline in HIV-related morbidity and mortality in people living with HIV (PLWH). PLWH however experience non-AIDS ageing-associated comorbidities, including decreased bone mass and osteoporosis, earlier and more severely, than uninfected people. We previously reported that total B-cell production of the key osteoclastogenic cytokine receptor activator of NF-κB ligand (RANKL) was elevated in PLWH, concurrent with a decrease in total B-cell production of RANKL's physiological moderator Osteoprotegerin (OPG). The resulting increased total B-cell RANKL/OPG ratio was significantly associated with bone loss in the appendicular (long bones), but not axial (spine) skeletons of PLWH. A role for immature/transitional B cells (BImm) in HIV-induced bone loss has not been reported.

Methods: BImm frequency was determined by flow cytometry; plasma IL-7 was quantified by ELISA and bone mineral density (BMD) measured by dual X-ray absorptiometry (DXA) in a cross-sectional study of 62 ART-naive HIV-infected and 58 HIV-negative individuals.

Results: BImm expansion correlated with the total B-cell RANKL/OPG ratio in HIV-infected individuals and inversely with BMD at the total hip, femoral neck and the lumbar spine, and with IL-7.

Conclusion: These data suggest that BImm contribute to the increased B-cell RANKL/OPG ratio in PLWH, and reveal a previously unrecognized link between BImm expansion and HIV-induced bone loss in the axial and appendicular skeletons of severely immunocompromised HIV-infected individuals. BImm expansion may be a novel biomarker for screening patients at risk of osteoporosis.
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http://dx.doi.org/10.1097/QAD.0000000000002563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371241PMC
August 2020

Intracellular Tenofovir and Emtricitabine Concentrations in Younger and Older Women with HIV Receiving Tenofovir Disoproxil Fumarate/Emtricitabine.

Antimicrob Agents Chemother 2020 08 20;64(9). Epub 2020 Aug 20.

UNC School of Medicine, Chapel Hill, North Carolina, USA.

The altered immune states of aging and HIV infection may affect intracellular metabolism of tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC); increased cellular senescence decreases FTC-triphosphate (FTCtp) concentrations. The effects of age and inflammation on the ratio of intracellular metabolites (IMs; tenofovir diphosphate [TFVdp] and FTCtp) to their endogenous nucleotides (ENs; dATP and dCTP), a potential treatment efficacy marker, were assessed among participants of the Women's Interagency HIV Study (WIHS), who ranged from 25 to 75 years. Samples from women receiving TDF-FTC with viral loads of <200 copies/ml were dichotomized by age at collection into two groups (≤45 years and ≥60 years). IM/EN concentrations were measured in peripheral blood mononuclear cell (PBMC) pellets; interleukin-6 (IL-6) and sCD163 were measured in plasma; senescent CD8 T cells were measured in viable PBMCs. The TFVdp:dATP and FTCtp:dCTP ratios had statistically significantly different distributions in older and younger women (log-rank test,  = 0.0023 and  = 0.032, respectively); in general, IM and EN concentrations were higher in the older women. After adjusting for potential confounders, these findings were not significant. In women aged ≤45 years, TFVdp was negatively associated with IL-6 and sCD163, while FTCtp was positively associated with sCD163 and IL-6 in women aged ≥60 years. Body mass index (BMI) was positively associated with IL-6 in both age groups and negatively associated with TFVdp in women aged ≤45 years. After adjustment, age remained significant for sCD163, while black race, BMI, and renal function remained significant for several IMs and ENs, suggesting that factors associated with aging, but not age itself, govern intracellular TDF-FTC pharmacology.
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http://dx.doi.org/10.1128/AAC.00177-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7449168PMC
August 2020

The Prevalence and Burden of Non-AIDS Comorbidities Among Women Living With or at Risk for Human Immunodeficiency Virus Infection in the United States.

Clin Infect Dis 2021 04;72(8):1301-1311

Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA.

Background: The prevalence and burden of age-related non-AIDS comorbidities (NACMs) are poorly characterized among women living with HIV (WLWH).

Methods: Virologically suppressed WLWH and HIV-seronegative participants followed in the Women's Interagency HIV Study (WIHS) through at least 2009 (when >80% of WLWH used antiretroviral therapy) were included, with outcomes measured through 31 March 2018. Covariates, NACM number, and prevalence were summarized at most recent WIHS visit. We used linear regression models to determine NACM burden by HIV serostatus and age.

Results: Among 3232 women (2309 WLWH, 923 HIV-seronegative) with median observation of 15.3 years, median age and body mass index (BMI) were 50 years and 30 kg/m2, respectively; 65% were black; 70% ever used cigarettes. WLWH had a higher mean NACM number than HIV-seronegative women (3.6 vs 3.0, P < .0001) and higher prevalence of psychiatric illness, dyslipidemia, non-AIDS cancer, kidney, liver, and bone disease (all P < .01). Prevalent hypertension, diabetes, and cardiovascular and lung disease did not differ by HIV serostatus. Estimated NACM burden was higher among WLWH versus HIV-seronegative women in those aged 40-49 (P < .0001) and ≥60 years (P = .0009) (HIV × age interaction, P = .0978). In adjusted analyses, NACM burden was associated with HIV, age, race, income, BMI, alcohol abstinence, cigarette, and crack/cocaine use; in WLWH, additional HIV-specific indices were not associated, aside from recent abacavir use.

Conclusions: Overall, NACM burden was high in the cohort, but higher in WLWH and in certain age groups. Non-HIV traditional risk factors were significantly associated with NACM burden in WLWH and should be prioritized in clinical guidelines for screening and intervention to mitigate comorbidity burden in this high-risk population.
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http://dx.doi.org/10.1093/cid/ciaa204DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8075036PMC
April 2021

Factors associated with condom use among HIV-positive women living in Atlanta, Georgia.

PLoS One 2019 13;14(12):e0225406. Epub 2019 Dec 13.

Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia, United States of America.

Objectives: Consistent condom use is essential to reducing heterosexual transmission of HIV. African Americans are disproportionately affected by HIV in the United States despite comprising a small percentage of the population. Our objectives were to evaluate factors associated with self-reported condom use in a cohort of predominantly African American women receiving HIV care in Atlanta, Georgia.

Methods: A cross-sectional study of reproductive knowledge, attitudes, and practices among adult, sexually-active, HIV-positive women attending the Grady Infectious Disease Clinic in Atlanta, Georgia was conducted from July, 2013 to November, 2014 to evaluate factors associated with self-reported condom use. Primary outcomes included: condom use at last vaginal intercourse and consistent condom use with vaginal intercourse over the last six months. Descriptive, bivariable, and multivariable logistic regression analyses were performed.

Results: Of 187 women enrolled, 170 reported having vaginal intercourse in the last six months. Seventy-four percent used condoms at last vaginal intercourse, whereas 53% reported consistent condom use over the last six months. In adjusted analyses, factors associated with condom use at last intercourse included decreased frequency of sex, no history of drug use, and confidence to discuss condom use with sexual partners (p<0.05). Factors associated with consistent condom use in the past six months were older age, being single/dating, and confidence to discuss condom use with sexual partners. History of drug use, having HIV-positive partners, and unprotected anal intercourse were associated with inconsistent use (p<0.05).

Conclusions: Improved strategies are needed to educate women on the importance of safe sexual practices and condom negotiation. Healthcare providers should strive to have an open dialogue with patients about condom use, whether they engage in anal sex, and its risks.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0225406PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6910822PMC
March 2020

Precarity and health: Theorizing the intersection of multiple material-need insecurities, stigma, and illness among women in the United States.

Soc Sci Med 2020 01 16;245:112683. Epub 2019 Nov 16.

Division of HIV, ID and Global Medicine, Department of Medicine, UCSF, San Francisco, CA, USA.

Material-need insecurities (including insecurities in basic resources such as income, food, housing, and healthcare) are widespread in the United States (US) and may be important predictors of poor health outcomes. How material-need insecurities besides food insecurity are experienced, however, remains under-researched, including how multiple material-need insecurities might intersect and converge on the individual. Here we used qualitative methods to investigate experiences with multiple material-need insecurities among 38 food-insecure women aged over 50 years living with or at risk for HIV in the US. Our aims were: (1) to understand the co-experience of material-need insecurities beyond food insecurity; (2) to elucidate how multiple material-need insecurities might intersect; and (3) to discover how this intersection might be detrimental to health. During November 2017-July 2018, we conducted semi-structured interviews at three sites across the US (Northern California, Georgia, North Carolina) and analyzed the data using an inductive-deductive approach. We identified a common and complex picture of multiple material-need insecurities, stigma, and illness among participants across all three sites. There were five primary themes: (1) insecure income arising from a combination of precarious wage labor and federal disability benefits; (2) resultant experiences of uncertainty, compromised quality, insufficiency, and having to use socially unacceptable coping strategies across finances, food, housing, and healthcare; (3) participants' disempowerment arising from their engagement with social safety net institutions; (4) closely related experiences of intersectional stigma and discrimination; and (5) negative implications for health across a wide range of illnesses. By employing the sociological concept of precarity-a term denoting the contemporary convergence of insecure wage labor and retraction of the welfare state-we combine these themes into a unifying framework of precarity and health. This framework may prove useful for testing how the widespread intersection of multiple material-need insecurities interacts with stigma and discrimination to negatively impact physical and mental health.
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http://dx.doi.org/10.1016/j.socscimed.2019.112683DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7111434PMC
January 2020

Prevalence and Correlates of Self-Rated Successful Aging Among Older Women Living With HIV.

J Acquir Immune Defic Syndr 2019 12;82 Suppl 2:S162-S169

Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, GA.

Background: Despite marked gains in longevity attributable to antiretroviral therapy (ART), older women living with HIV (OWLH) experience substantial health challenges, and few studies addressed whether they can achieve successful aging (SA). This is among the first studies examining prevalence and psychosocial correlates of self-rated SA (SRSA) among OWLH and women at risk of HIV.

Methods: The sample included 386 OWLH and 137 HIV-seronegative women enrolled in the Women's Interagency HIV Study (WIHS) who were aged 50 years and older and participated in the "From Surviving to Thriving" (FROST) substudy. The FROST survey included measures of SRSA and positive psychosocial constructs.

Results: Participants were on average 57 years (SD = 5.3), 74% African American and 30% unemployed. Among OWLH, 94% were on ART and 73% were virally suppressed. Compared with OWLH, a higher proportion of HIV-seronegative women had an annual income ≤ $6000, no health insurance, and reported lower optimism and health-related quality of life. We found no differences in SRSA prevalence by HIV status: 84% of OWLH and 83% of HIV-seronegative women reported SRSA ≥7 (range = 2-10, higher scores signify better SRSA). Having SRSA ≥7 was associated with higher levels of positive psychosocial characteristics (eg, resilience and optimism) among both OWLH and HIV-seronegative women.

Conclusions: SRSA is achievable among older women with and at risk of HIV despite health complications. Among disadvantaged women, factors other than HIV may be primary drivers of SRSA. Future research is needed to examine determinants of SRSA and to design public health interventions enhancing SA within this population.
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http://dx.doi.org/10.1097/QAI.0000000000002175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6830959PMC
December 2019

Clinical and procedural characteristics of persons living with HIV presenting with acute coronary syndrome.

AIDS 2020 01;34(1):81-90

Division of Infectious Diseases, Department of Medicine Division of Cardiology, Department of Medicine, Emory University School of Medicine Department of Medicine, Grady Healthcare System, Atlanta, Georgia, USA.

Objectives: Persons living with HIV (PLWH) are at greater risk for acute coronary syndrome (ACS). Practice patterns of ACS management by HIV serostatus are unknown. We examined the presentation and management of ACS in PLWH.

Design: Retrospective case-control study.

Methods: We included 86 PLWH and 263 sex-matched and race-matched HIV-negative controls hospitalized with ACS between 2004 and 2013. We performed multivariable conditional logistic regression to determine the associations between HIV serostatus and ACS type and management.

Results: Both groups were predominantly of black race and male sex. PLWH were significantly younger (53 vs. 60 years) and more likely to smoke (48 vs. 31%). Among PLWH, 30% had CD4 cell count less than 200 cells/μl and 58% had undetectable HIV RNA. PLWH had more single-vessel disease and a higher median Gensini score among those with single-vessel disease (32 vs. 4.25) than controls. HIV serostatus was positively associated with ST-elevation myocardial infarction (STEMI) [adjusted odds ratio (aOR) (95% confidence interval (CI)):5.05 (1.82-14.02)], and any revascularization procedure after ACS [aOR (95% CI): 2.90 (1.01-8.39)] and negatively associated with non-STEMI [aOR (95% CI): 0.33 (0.14-0.79)] presentation. PLWH who underwent stent placement had a higher likelihood of bare metal stent placement compared with controls [70 vs. 15%, aOR (95% CI): 5.94 (1.33-26.55)]. Among PLWH, ACS characteristics were not significantly associated with CD4 cell count, HIV RNA, or antiretroviral therapy.

Conclusion: PLWH hospitalized with ACS were more likely to have severe single-vessel disease, present with STEMI rather than non-STEMI, and undergo revascularization, and less likely to have a drug-eluting stent placed than matched HIV-negative controls, suggesting that coronary plaque morphology and/or distribution is different with HIV infection and warrants further investigation.
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http://dx.doi.org/10.1097/QAD.0000000000002393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7002021PMC
January 2020

Antiretroviral Therapy-Induced Bone Loss Is Durably Suppressed by a Single Dose of Zoledronic Acid in Treatment-Naive Persons with Human Immunodeficiency Virus Infection: A Phase IIB Trial.

Clin Infect Dis 2020 10;71(7):1655-1663

Division of Endocrinology and Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.

Background: Human immunodeficiency virus (HIV) infection and antiretroviral therapy (ART) are associated with bone loss leading to increased fracture rate among persons with HIV (PWH). We previously showed long-acting antiresorptive zoledronic acid (ZOL) prevented ART-induced bone loss through 48 weeks of therapy and here investigate whether protection persisted.

Methods: We randomized 63 nonosteoporotic, treatment-naive adult PWH initiating ART to ZOL (5 mg) versus placebo in a double-blinded, placebo-controlled, phase IIb trial. Here we analyzed the long-term outcome data (144 weeks). Plasma bone turnover markers and bone mineral density (BMD) were quantified at weeks 0, 12, 24, 48, 96, and 144. Primary outcome was change in bone resorption marker C-terminal telopeptide of collagen (CTx). Repeated-measures analyses using mixed linear models were used to estimate and compare study endpoints.

Results: At 96 weeks, mean CTx was 62% lower with ZOL relative to placebo (n = 46; CTx = 0.123 vs 0.324 ng/mL; P < .001); at 144 weeks a 25% difference between arms was not statistically significant. At 48 weeks, lumbar spine BMD with ZOL was 11% higher than placebo (n = 60; P < .001) and remained 9-11% higher at 96 (n = 46) and 144 (n = 41; P < .001) weeks. 144 weeks after ZOL infusion, BMD did not change at the lumbar spine (P = .22) but declined at the hip (P = .04) and femoral neck (P = .02).

Conclusions: A single dose of ZOL administered at ART initiation blunts bone resorption and BMD loss at key fracture-prone anatomical sites in treatment-naive PWH for 3 years. A multicenter randomized phase III clinical trial validating these results in a larger population is needed.

Clinical Trials Registration: NCT01228318.
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http://dx.doi.org/10.1093/cid/ciz1027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755092PMC
October 2020

Food Insecurity Is Associated With Lower Levels of Antiretroviral Drug Concentrations in Hair Among a Cohort of Women Living With Human Immunodeficiency Virus in the United States.

Clin Infect Dis 2020 09;71(6):1517-1523

Division of Prevention Science, Department of Medicine, University of California-San Francisco, San Francisco, California, USA.

Background: Food insecurity is a well-established determinant of suboptimal, self-reported antiretroviral therapy (ART) adherence, but few studies have investigated this association using objective adherence measures. We examined the association of food insecurity with levels of ART concentrations in hair among women living with human immunodeficiency virus (WLHIV) in the United States.

Methods: We analyzed longitudinal data collected semiannually from 2013 through 2015 from the Women's Interagency HIV Study, a multisite, prospective, cohort study of WLHIV and controls not living with HIV. Our sample comprised 1944 person-visits from 677 WLHIV. Food insecurity was measured using the US Household Food Security Survey Module. ART concentrations in hair, an objective and validated measure of drug adherence and exposure, were measured using high-performance liquid chromatography with mass spectrometry detection for regimens that included darunavir, atazanavir, raltegravir, or dolutegravir. We conducted multiple 3-level linear regressions that accounted for repeated measures and the ART medication(s) taken at each visit, adjusting for sociodemographic and clinical characteristics.

Results: At baseline, 67% of participants were virally suppressed and 35% reported food insecurity. In the base multivariable model, each 3-point increase in food insecurity was associated with 0.94-fold lower ART concentration in hair (95% confidence interval, 0.89 to 0.99). This effect remained unchanged after adjusting for self-reported adherence.

Conclusions: Food insecurity was associated with lower ART concentrations in hair, suggesting that food insecurity may be associated with suboptimal ART adherence and/or drug absorption. Interventions seeking to improve ART adherence among WLHIV should consider and address the role of food insecurity.
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http://dx.doi.org/10.1093/cid/ciz1007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7486839PMC
September 2020

Weight Gain Associated With Integrase Stand Transfer Inhibitor Use in Women.

Clin Infect Dis 2020 07;71(3):593-600

Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA.

Background: Integrase strand-transfer inhibitor (INSTI)-based antiretroviral therapy (ART) is recommended for human immunodeficiency virus (HIV) management. Although studies have suggested associations between INSTIs and weight gain, women living with HIV (WLHIV) have been underrepresented in research. We evaluated the effect of switching or adding INSTIs among WLHIV.

Methods: Women enrolled in the Women's Interagency HIV Study (WIHS) from 2006-2017 who switched to or added an INSTI to ART (SWAD group) were compared to women on non-INSTI ART (STAY group). Body weight, body mass index (BMI), percentage body fat (PBF), and waist, hip, arm, and thigh circumferences were measured 6-12 months before and 6-18 months after the INSTI switch/add in SWAD participants, with comparable measurement time points in STAY participants. Linear regression models compared changes over time by SWAD/STAY group, adjusted for age, race, WIHS site, education, income, smoking status, and baseline ART regimen.

Results: We followed 1118 women (234 SWAD and 884 STAY) for a mean of 2.0 years (+/- 0.1 standard deviation [SD]; mean age 48.8 years, SD +/- 8.8); 61% were Black. On average, compared to the STAY group, the SWAD group experienced mean greater increases of 2.1 kg in body weight, 0.8 kg/m2 in BMI, 1.4% in PBF, and 2.0, 1.9, 0.6, and 1.0 cm in waist, hip, arm, and thigh circumference, respectively (all P values < .05). No differences in magnitudes of these changes were observed by INSTI type.

Conclusions: In WLHIV, a switch to INSTI was associated with significant increases in body weight, body circumferences, and fat percentages, compared to non-INSTI ART. The metabolic and other health effects of these changes deserve further investigation.
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http://dx.doi.org/10.1093/cid/ciz853DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384314PMC
July 2020

Food insecurity is associated with anxiety, stress, and symptoms of posttraumatic stress disorder in a cohort of women with or at risk of HIV in the United States.

J Nutr 2019 08;149(8):1393-1403

Division of HIV, ID and Global Medicine.

Background: Food insecurity, which disproportionately affects marginalized women in the United States, is associated with depressive symptoms. Few studies have examined relations of food insecurity with other mental health outcomes.

Objective: The aim of this study was to investigate the associations of food insecurity with symptoms of generalized anxiety disorder (GAD), stress, and posttraumatic stress disorder (PTSD) in the Women's Interagency HIV Study (WIHS), a prospective cohort study of women with or at risk of HIV in the United States.

Methods: Participants were 2553 women with or at risk of HIV, predominantly African American/black (71.6%). Structured questionnaires were conducted during April 2013-March 2016 every 6 mo. Food security (FS) was the primary predictor, measured using the Household Food Security Survey Module. We measured longitudinal outcomes for GAD (GAD-7 score and a binary GAD-7 screener for moderate-to-severe GAD). Only cross-sectional data were available for outcomes measuring perceived stress (PSS-10 score) and PTSD (PCL-C score and a binary PCL-C screener for PTSD). We examined associations of FS with the outcomes through use of multivariable linear and logistic regression, including lagged associations with GAD outcomes.

Results: After adjusting for sociodemographic and health-related factors including HIV serostatus, current marginal, low, and very low FS were associated with increasingly higher GAD-7 scores, and with 1.41 (95% CI: 1.10, 1.80; P < 0.01), 2.03 (95% CI: 1.59, 2.61; P < 0.001), and 3.23 (95% CI: 2.43, 4.29; P < 0.001) times higher odds of screening positive for moderate-to-severe GAD, respectively. Low and very low FS at the previous visit (6 mo earlier) were independently associated with GAD outcomes at current visit. Associations of FS with PSS-10 and PCL-C scores exhibited similar dose-response relations. Very low FS was associated with 1.93 (95% CI: 1.15, 3.24; P < 0.05) times higher odds of screening positive for PTSD.

Conclusions: Food insecurity may be associated with a range of poor mental health outcomes among women in the United States with or at risk of HIV.
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http://dx.doi.org/10.1093/jn/nxz093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6675617PMC
August 2019

Pilot Study of Markers for High-grade Anal Dysplasia in a Southern Cohort From the Women's Interagency Human Immunodeficiency Virus Study.

Clin Infect Dis 2020 03;70(6):1121-1128

Atlanta Women's Interagency HIV Study, Rollins School of Public Health, Emory University, Georgia.

Background: Anal cancer rates have increased, particularly in human immunodeficiency virus (HIV)-infected (HIV+) women. We assessed factors associated with anal precancer in HIV+ and at-risk HIV-negative women from the Atlanta Women's Interagency HIV Study cohort.

Methods: All participants underwent high-resolution anoscopy and anal cytology and had anal and cervical samples collected. Specimens were tested for 37 human papillomavirus (HPV) types and for FAM19A4 and microRNA124-2 promoter methylation. Binary logistic regression and multivariate analysis were conducted with histologic anal high-grade squamous intraepithelial lesion (A-HSIL) as the dependent variable.

Results: Seventy-five women were enrolled: 52 (69%) were HIV+ with three-fourths having undetectable viral load; 64 (86%) were black; mean age was 49 ± 8 years. Forty-nine (65%) anal cytology samples were abnormal, and 38 (51%) of anal samples were positive for at least 1 of 13 high-risk HPV (hrHPV) types. Thirteen (18%) anal biopsies identified A-HSIL. Hypermethylation of FAM19A4 and/or microRNA124-2 was found in 69 (95%) anal samples and 19 (26%) cervical samples. In multivariate analyses, the odds of having A-HSIL were >6 times higher in women with anal hrHPV (adjusted odds ratio [aOR], 6.08 [95% confidence interval {CI}, 1.27-29.18], P = .02) and with positive cervical methylation (aOR, 6.49 [95% CI, 1.66-25.35], P = .007), but not significantly higher in women with positive anal methylation.

Conclusions: Anal hrHPV and promoter hypermethylation in the cervix show promise as biomarkers for anal cancer screening in HIV+ and at-risk HIV-negative women. Greater understanding of gene silencing by promoter hypermethylation in anal carcinogenesis is needed.
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http://dx.doi.org/10.1093/cid/ciz336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7319055PMC
March 2020

Food insecurity and violence in a prospective cohort of women at risk for or living with HIV in the U.S.

PLoS One 2019 6;14(3):e0213365. Epub 2019 Mar 6.

Center for AIDS Prevention Studies, University of California, San Francisco (UCSF), CA, United States of America.

Background: Food insecurity and violence are two major public health issues facing U.S. women. The link between food insecurity and violence has received little attention, particularly regarding the temporal ordering of events. The present study used data from the Women's Interagency Human Immunodeficiency Virus Study to investigate the longitudinal association of food insecurity and violence in a cohort of women at risk for or living with HIV.

Methods: Study participants completed six assessments from 2013-16 on food insecurity (operationalized as marginal, low, and very low food security) and violence (sexual or physical, and psychological). We used multi-level logistic regression, controlling for visits (level 1) nested within individuals (level 2), to estimate the association of experiencing violence.

Results: Among 2,343 women (8,528 visits), we found that victims of sexual or physical violence (odds ratio = 3.10; 95% confidence interval: 1.88, 5.19) and psychological violence (odds ratio = 3.00; 95% confidence interval: 1.67, 5.50) were more likely to report very low food security. The odds of experiencing violence were higher for women with very low food security at both the current and previous visit as compared to only the current visit. HIV status did not modify these associations.

Conclusions: Food insecurity was strongly associated with violence, and women exposed to persistent food insecurity were even more likely to experience violence. Food programs and policy must consider persistent exposure to food insecurity, and interpersonal harms faced by food insecure women, such as violence.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0213365PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6402690PMC
December 2019

Persistent Food Insecurity Is Associated with Adverse Mental Health among Women Living with or at Risk of HIV in the United States.

J Nutr 2019 02;149(2):240-248

Division of HIV, Infectious Disease, and Global Medicine, San Francisco, San Francisco, CA.

Background: Food insecurity and mental health negatively affect the lives of women in the United States. Participants in the Women's Interagency HIV Study (WIHS) provided the opportunity to understand the association of food insecurity with depression and mental well-being over time.

Objective: We investigated the association between current and persistent food insecurity and depression among women at risk of or living with HIV in the United States.

Methods: We used longitudinal data from the WIHS, a prospective cohort study in women at risk of or living with HIV from multiple sites in the United States. Participants completed 6 semiannual assessments from 2013 to 2016 on food security (FS; high, marginal, low, and very low) and mental health (i.e., depressive symptoms and mental well-being). We used multiple regression analysis to estimate the association between these variables.

Results: Among 2551 participants, 44% were food insecure and 35% reported depressive symptoms indicative of probable depression. Current marginal, low, and very low FS were associated with 2.1-, 3.5-, and 5.5-point (all P < 0.001) higher depression scores, respectively. In models adjusting for both current and previous FS, previous marginal, low, and very low FS were associated with 0.2-, 0.93-, and 1.52-point higher scores, respectively (all P < 0.001). Women with very low FS at both time points (persistent food insecurity) had a 6.86-point higher depression score (P < 0.001). In the mental health models, there was a dose-response relation between current FS and worse mental health even when controlling for previous FS (all P < 0.001). Previous low FS was associated with worse mental health. These associations did not differ by HIV status.

Conclusions: Food insecurity placed women at risk of depression and poor mental well-being, but the risk was substantially higher for women experiencing persistent food insecurity. Future interventions to improve women's mental health call for multilevel components that include addressing food insecurity.
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http://dx.doi.org/10.1093/jn/nxy203DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6698636PMC
February 2019

Changes in Waist Circumference in HIV-Infected Individuals Initiating a Raltegravir or Protease Inhibitor Regimen: Effects of Sex and Race.

Open Forum Infect Dis 2018 Nov 16;5(11):ofy201. Epub 2018 Nov 16.

University of California, Los Angeles, Los Angeles, California.

Background: This study investigates the association of clinical and demographic predictors with abdominal fat gain, measured using waist circumference (WC) and self-reported abdominal size.

Methods: We analyzed data from ACTG A5257, a clinical trial that randomized treatment-naïve HIV-infected participants to 1 of 3 antiretroviral regimens: raltegravir (RAL) or the protease inhibitors (PIs) atazanavir/ritonavir (ATV/r) or darunavir/ritonavir (DRV/r), each in combination with tenofovir disoproxil fumarate/emtricitabine. Associations of treatment and baseline/demographic characteristics with 96-week WC change were assessed using repeated-measures models. Ordinal logistic regression was used to examine the associations of predictors with week 96 self-reported abdominal changes.

Results: The study population (n = 1809) was 76.0% male and predominantly black non-Hispanic (41.9%) and white non-Hispanic (34.1%). Mean baseline WC was 90.6 cm, with an average 96-week increase of 3.4 cm. WC increases were higher in the RAL arm compared with DRV/r ( = .0130). Females experienced greater increases in WC on RAL vs ATV/r than males ( = .0065). Similarly, a larger difference in WC change was found for RAL vs DRV/r for black vs nonblack individuals ( = .0043). A separate multivariable model found that in addition to the treatment regimen, higher baseline viral load and lower CD4+ were also associated with WC increases.

Conclusions: With antiretroviral therapy initiation, higher WC increases in the RAL arm compared with PIs were more pronounced in female and black participants, and a more advanced baseline HIV disease state was a strong predictor of larger abdominal increases. Understanding factors predisposing individuals to abdominal fat gain could inform health management after therapy initiation.
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http://dx.doi.org/10.1093/ofid/ofy201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6239079PMC
November 2018

Predicting diabetes risk among HIV-positive and HIV-negative women.

AIDS 2018 11;32(18):2767-2775

Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia.

Objective: To assess the performance of an adapted American Diabetes Association (ADA) risk score and the concise Finnish Diabetes Risk Score (FINRISC) for predicting type 2 diabetes development in women with and at risk of HIV infection.

Design: Longitudinal analysis of the Women's Interagency HIV Study.

Methods: The women's Interagency HIV Study is an ongoing prospective cohort study of women with and at risk for HIV infection. Women without prevalent diabetes and 3-year data on fasting blood glucose, hemoglobin A1c, self-reported diabetes medication use, and self-reported diabetes were included. ADA and FINRISC scores were computed at baseline and their ability to predict diabetes development within 3 years was assessed [sensitivity, specificity and area under the receiver operating characteristics (AUROC) curve].

Results: A total of 1111 HIV-positive (median age 41, 60% African American) and 454 HIV-negative women (median age 38, 63% African-American) were included. ADA sensitivity did not differ between HIV-positive (77%) and HIV-negative women (81%), while specificity was better in HIV-negative women (42 vs. 49%, P = 0.006). Overall ADA discrimination was suboptimal in both HIV-positive [AUROC = 0.64 (95% CI: 0.58, 0.70)] and HIV-negative women [AUROC = 0.67 (95% CI: 0.57, 0.77)]. FINRISC sensitivity and specificity did not differ between HIV-positive (72 and 49%, respectively) and HIV-negative women (86 and 52%, respectively). Overall FINRISC discrimination was suboptimal in HIV-positive [AUROC = 0.68 (95% CI: 0.62, 0.75)] and HIV-negative women [AUROC = 0.78 (95% CI: 0.66, 0.90)].

Conclusion: Model performance was suboptimal in women with and at risk of HIV, while greater misclassification was generally observed among HIV-positive women. HIV-specific risk factors known to contribute to diabetes risk should be explored in these models.
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http://dx.doi.org/10.1097/QAD.0000000000002017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6673643PMC
November 2018

Longitudinal associations between food insecurity and substance use in a cohort of women with or at risk for HIV in the United States.

Addiction 2019 01 25;114(1):127-136. Epub 2018 Sep 25.

Division of HIV, ID and Global Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA.

Background And Aims: Few longitudinal studies have examined the relationship between food insecurity and substance use. We aimed to investigate this relationship using longitudinal data among women with or at risk for HIV in the United States.

Design: Women's Interagency HIV Study (WIHS), a prospective cohort study.

Setting: Nine sites across the United States.

Participants: A total of 2553 women with or at risk for HIV.

Measurements: Semi-annual structured interviews were conducted during April 2013-March 2016. Food security (FS) was the primary predictor, measured using the Household Food Security Survey Module. Outcomes were: any illicit substance use except cannabis; licit or illicit cannabis use; stimulant use (crack, cocaine, or methamphetamine); opioid use (heroin or methadone in a non-prescribed way); and prescription drug misuse (prescription narcotics, amphetamines, or tranquilizers in a non-prescribed way) since the last visit. We used multivariable logistic regression with random effects to examine longitudinal associations of current and previous FS with the outcomes simultaneously, adjusting for socio-demographic factors, HIV serostatus, physical health and health insurance.

Findings: Average number of visits was 4.6. At baseline, 71% of participants were HIV-seropositive, 44% reported marginal, low, or very low FS, and 13% were using illicit substances. In adjusted analyses, current low and very low FS were significantly associated with 1.59 [95% confidence interval (CI) = 1.02, 2.46; P = 0.039] and 2.48 (95% CI = 1.52, 4.04; P < 0.001) higher odds of any illicit substance use, compared to high FS, and also with higher odds of cannabis, stimulant and opioid use, exhibiting a consistent dose-response relationship. Marginal, low, and very low FS at the previous visit were associated with 1.66 (95% CI = 1.08, 2.54; P = 0.020), 1.77 (95% CI = 1.14, 2.74; P = 0.011), and 2.28 (95% CI = 1.43, 3.64; P < 0.001) higher odds of current illicit substance use.

Conclusions: Food insecurity appears to be longitudinally associated with substance use among US women with or at risk for HIV.
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http://dx.doi.org/10.1111/add.14418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6516859PMC
January 2019

HIV RNA persists in rectal tissue despite rapid plasma virologic suppression with dolutegravir-based therapy.

AIDS 2018 09;32(15):2151-2159

Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases.

Objectives: Despite plasma virologic suppression with antiretroviral therapy (ART), HIV persists in gut tissue. The objectives of this study were to compare plasma and rectal tissue HIV RNA dynamics and to assess relationships with dolutegravir (DTG) plasma and tissue concentrations.

Design: A longitudinal cohort study of HIV-infected treatment-naïve individuals initiating DTG-based ART was conducted over 12 weeks with plasma and rectal tissue sampling (Clinicaltrials.gov:NCT02924389).

Methods: HIV RNA and DTG concentrations were quantified in plasma and rectal tissue samples collected pre-ART (baseline) and post-ART at weeks 2, 6, and 12 using Abbott Real-Time HIV-1 assays and high-performance liquid chromatography tandem mass spectroscopy, respectively. Relationships between rectal tissue RNA and DTG concentrations were modeled using binary logistic regression, controlling for repeated measures.

Results: Twelve participants were enrolled: six (50.0%) women, nine (75.0%) black, median age 42.0 years (Q1 31.2, Q3 52.0). All attained plasma virologic suppression by week 6. 11 of 12 (91.7%) had detectable rectal tissue HIV RNA at baseline, and only three of 11 (27.3%) achieved rectal tissue virologic suppression at any time-point. Compared with rectal tissue nonsuppressors, three of three (100.0%) of rectal tissue suppressors were women, had higher BMI, 35.9 kg/m (range 24.9-38.5) versus 20.6 (17.7-29.9), P = 0.05, and lower baseline log plasma HIV RNA: 3.7 copies/ml (range 3.6-4.4) versus 4.7 (3.8-5.4), P = 0.02. No significant relationships between rectal tissue RNA suppression and DTG concentrations were seen.

Conclusion: Rectal tissue HIV RNA persisted in most participants and was not predicted by DTG concentrations. Impact of host factors, particularly sex, on tissue HIV viral dynamics warrants further exploration.
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http://dx.doi.org/10.1097/QAD.0000000000001945DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200454PMC
September 2018

Food Insecurity, Internalized Stigma, and Depressive Symptoms Among Women Living with HIV in the United States.

AIDS Behav 2018 Dec;22(12):3869-3878

Division of HIV, Infectious Disease and Global Medicine, Department of Medicine, San Francisco General Hospital, University of California, San Francisco (UCSF), 995 Potrero Avenue, Bldg 80, Ward 84, Campus Box 0874, San Francisco, CA, 94110, USA.

Food insecurity, internalized HIV stigma, and depressive symptoms are independently associated with poor HIV outcomes. Food insecurity, stigma, and depression may be interrelated among women living with HIV (WLHIV). We hypothesized that food insecurity would be independently associated with internalized stigma and depressive symptoms among WLHIV in the United States (US), and would partially account for associations between stigma and depressive symptoms. We tested hypotheses using regression models and partial correlation analysis with cross-sectional data among 1317 WLHIV from the Women's Interagency HIV Study. In adjusted models, greater food insecurity was associated with internalized HIV stigma and depressive symptoms (all p < 0.05), exhibiting dose-response relationships. Food insecurity accounted for 23.2% of the total shared variance between depressive symptoms and internalized stigma. Food insecurity is associated with depressive symptoms and internalized HIV stigma among US WLHIV, and may play a role in the negative cycle of depression and internalized stigma.
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http://dx.doi.org/10.1007/s10461-018-2164-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6209540PMC
December 2018

Room for Improvement: The HIV-Diabetes Care Continuum Over 15 Years in the Women's Interagency HIV Study.

Open Forum Infect Dis 2018 Jun 22;5(6):ofy121. Epub 2018 May 22.

Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia.

Background: Gains in life expectancy through optimal control of HIV infection with antiretroviral therapy (ART) may be threatened if other comorbidities, such as diabetes, are not optimally managed.

Methods: We analyzed cross-sectional data of the Women's Interagency HIV Study (WIHS) from 2001, 2006, and 2015. We estimated the proportions of HIV-positive and HIV-negative women with diabetes who were engaged in care and achieved treatment goals (hemoglobin A1c [A1c] <7.0%, blood pressure [BP] <140/90 mmHg, low-density lipoprotein [LDL] cholesterol <100 mg/dL, not smoking) and viral suppression. Repeated-measures models were used to estimate the adjusted prevalence of achieving each diabetes treatment goal at each time point, by HIV status.

Results: We included 486 HIV-positive and 258 HIV-negative women with diabetes. In 2001, 91.8% visited a health care provider, 60.7% achieved the A1c target, 70.5% achieved the BP target, 38.5% achieved the LDL cholesterol target, 49.2% were nonsmokers, 23.3% achieved combined ABC targets (A1c, BP, and cholesterol), and 10.9% met combined ABC targets and did not smoke. There were no differences by HIV status, and patterns were similar in 2006 and 2015. Among HIV-positive women, viral suppression increased from 41% in 2001 to 87% in 2015 compared with 8% and 13% achieving the ABC goals and not smoking. Viral suppression was not associated with achievement of diabetes care goals.

Conclusions: Successful management of HIV is outpacing that of diabetes. Future studies are needed to identify factors associated with gaps in the HIV-diabetes care continuum and design interventions to better integrate effective diabetes management into HIV care.
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http://dx.doi.org/10.1093/ofid/ofy121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6007350PMC
June 2018

HIV and symptoms of depression are independently associated with impaired glucocorticoid signaling.

Psychoneuroendocrinology 2018 10 18;96:118-125. Epub 2018 Jun 18.

Emory University, State University of New York - Downstate Medical Center, Brooklyn NY, United states; Virginia Commonwealth University, State University of New York - Downstate Medical Center, Brooklyn NY, United states. Electronic address:

Chronic inflammation caused by HIV infection may lead to deficient glucocorticoid (GC) signaling predisposing people living with HIV to depression and other psychiatric disorders linked to GC resistance. We hypothesized that comorbid HIV and depressive symptoms in women would synergistically associate with deficits in GC signaling. This cross-sectional study used samples obtained from the Women's Interagency HIV Study (WIHS). The Centers for Epidemiological Studies (CES-D) was used to define depression in four groups of women from the Women's Interagency HIV Study (WIHS): 1) HIV-negative, non-depressed (n = 37); 2) HIV-negative, depressed (n = 34); 3) HIV-positive, non-depressed (n = 38); and 4) HIV-positive, depressed (n = 38). To assess changes in GC signaling from peripheral blood mononuclear cells (PBMCs), we examined baseline and dexamethasone (Dex)-stimulated changes in the expression of the GC receptor (GR, gene: Nr3c1) and its negative regulator Fkbp5 via quantitative RT-PCR. GR sensitivity was evaluated in vitro by assessing the Dex inhibition of lipopolysaccharide (LPS)-stimulated IL-6 and TNF-α levels. Depressive symptoms and HIV serostatus were independently associated with elevated baseline expression of Fkbp5 and Nr3c1. Depressive symptoms, but not HIV status, was independently associated with reduced LPS-induced release of IL-6. Counter to predictions, there was no interactive association of depressive symptoms and HIV on any outcome. Comorbid depressive symptoms with HIV infection were associated with a gene expression and cytokine profile similar to that of healthy control women, a finding that may indicate further disruptions in disease adaptation.
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http://dx.doi.org/10.1016/j.psyneuen.2018.06.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6131054PMC
October 2018
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