Publications by authors named "Kathryn Anastos"

367 Publications

Mental health and initiation of antiretroviral treatment at enrolment into HIV care in Cameroon under a national "treat all" policy: a cross-sectional analysis.

J Int AIDS Soc 2021 11;24(11):e25842

City University of New York, Institute of Implementation Science in Population Health, Graduate School of Public Health and Health Policy, New York, New York, USA.

Introduction: Rapid antiretroviral treatment (ART) initiation reduces time from HIV infection to viral suppression, decreasing HIV transmission risk. Mental health symptoms may influence timing of ART initiation. This study estimated the prevalence of ART initiation at enrolment into HIV care and the relationship between mental health and ART initiation at enrolment into HIV care.

Methods: We conducted interviews with 426 individuals initiating HIV care in Cameroon between June 2019 and March 2020 to estimate the association between mental health and timing of ART initiation. Depression (Patient Health Questionnaire-9; cut-point 10), anxiety (Generalized Anxiety Disorder-7; cut-point 10), post-traumatic stress disorder (PTSD) (PTSD Checklist for DSM-5; cut-point 31) and harmful alcohol use (Alcohol Use Disorders Identification Test; cut-point 16) were dichotomized to represent those with and without each exposure at first HIV care appointment. Date of ART initiation (date ART prescribed) was ascertained from medical records. Separate multivariable log-binomial regression models were used to estimate the association between mental health exposures and ART initiation at enrolment into care.

Results And Discussion: Overall, 87% initiated ART at enrolment into HIV care. Approximately 20% reported depressive symptoms, 15% reported PTSD symptoms, 12% reported anxiety symptoms and 13% reported harmful alcohol use. In multivariable analyses, individuals with moderate to severe depressive symptoms had 1.7 (95% confidence interval [CI] 1.1, 2.7) times the prevalence of not initiating ART at enrolment into HIV care compared to those with no or mild depressive symptoms. Those with symptoms of PTSD, compared to those without, had 1.9 (95% CI 1.2, 2.9) times the prevalence of not initiating ART at enrolment into HIV care. Symptoms of anxiety or harmful drinking were not associated with ART initiation at enrolment into HIV care in multivariable models.

Conclusions: Symptoms of depression and PTSD were associated with lower prevalence of ART initiation at enrolment into HIV care among this sample of individuals initiating HIV care in Cameroon under a "treat all" policy. Research should examine barriers to timely ART initiation, whether incorporating mental health services into HIV care improves timely ART initiation, and whether untreated symptoms of depression and PTSD drive suboptimal HIV care outcomes.
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http://dx.doi.org/10.1002/jia2.25842DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8609224PMC
November 2021

Prevalence and correlates of restless legs syndrome in men living with HIV.

PLoS One 2021 1;16(10):e0258139. Epub 2021 Oct 1.

Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, United States of America.

Background: Data on the prevalence and correlates of restless legs syndrome (RLS) in people with HIV are limited. This study sought to determine the prevalence of RLS, associated clinical correlates, and characterize sleep-related differences in men with and without HIV.

Methods: Sleep-related data were collected in men who have sex with men participating in the Multicenter AIDS Cohort Study (MACS). Demographic, health behaviors, HIV status, comorbidities, and serological data were obtained from the MACS visit coinciding with sleep assessments. Participants completed questionnaires, home polysomnography, and wrist actigraphy. RLS status was determined with the Cambridge-Hopkins RLS questionnaire. RLS prevalence was compared in men with and without HIV. Multinomial logistic regression was used to examine correlates of RLS among all participants and men with HIV alone. Sleep-related differences were examined in men with and without HIV by RLS status.

Results: The sample consisted of 942 men (56% HIV+; mean age 57 years; 69% white). The prevalence of definite RLS was comparable in men with and without HIV (9.1% vs 8.7%). In multinomial regression, HIV status was not associated with RLS prevalence. However, white race, anemia, depression, and antidepressant use were each independently associated with RLS. HIV disease duration was also associated with RLS. Men with HIV and RLS reported poorer sleep quality, greater sleepiness, and had worse objective sleep efficiency/fragmentation than men without HIV/RLS.

Conclusions: The prevalence of RLS in men with and without HIV was similar. Screening for RLS may be considered among people with HIV with insomnia and with long-standing disease.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0258139PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8486089PMC
November 2021

A new smoking cessation "cascade" among women with or at risk for HIV infection.

AIDS 2021 Sep 29. Epub 2021 Sep 29.

School of Medicine, University of North Carolina, Chapel Hill Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill School of Medicine, Emory University, Atlanta, GA Department of Medicine/Infectious Diseases, Georgetown University, Washington DC Department of Medicine, Johns Hopkins University, Baltimore, MD Department of Medicine, School of Nursing, University of Mississippi, Jackson, MS Department of Psychiatry and Behavioral Sciences, University of Miami, Miami, FL Department of Epidemiology, Johns Hopkins University, Baltimore, MD Department of Medicine, Stroger Hospital of Cook County Health, Chicago, IL Department of Medicine, University of California San Francisco, and Department of Veterans Affairs, San Francisco, CA Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY Department of Medicine, Albert Einstein College of Medicine, Bronx, NY.

Objectives: To define a smoking cessation "cascade" among US women with and without HIV and examine differences by sociodemographic characteristics.

Design: Observational cohort study using data from smokers participating in the Women's Interagency HIV Study between 2014 and 2019.

Methods: We followed 1165 women smokers with and without HIV from their first study visit in 2014 or 2015 until 1) an attempt to quit smoking within approximately three years of follow-up, 2) initial cessation (i.e., no restarting smoking within approximately six months of a quit attempt), and 3) sustained cessation (i.e., no restarting smoking within approximately 12 months of a quit attempt). Using the Aalen-Johansen estimator, we estimated the cumulative probability of achieving each step, accounting for the competing risk of death.

Results: Forty-five percent of smokers attempted to quit, 27% achieved initial cessation, and 14% achieved sustained cessation with no differences by HIV status. Women with some post-high school education were more likely to achieve each step than those with less education. Outcomes did not differ by race. Thirty-six percent (95% CI: 31, 42) of uninsured women attempted to quit compared to 47% (95% CI: 44, 50) with Medicaid and 49% (95% CI: 41, 59) with private insurance.

Conclusions: To decrease smoking among US women with and without HIV, targeted, multi-stage interventions and increased insurance coverage are needed to address shortfalls along this cascade.
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http://dx.doi.org/10.1097/QAD.0000000000003089DOI Listing
September 2021

Heavy episodic drinking and HIV disclosure by HIV treatment status among People with HIV in IeDEA Cameroon.

Int J Drug Policy 2021 Sep 14;98:103431. Epub 2021 Sep 14.

University of North Carolina at Chapel Hill, United States.

Background: Heavy alcohol use is common among people with HIV (PWH), leading to sub-optimal HIV care outcomes. Yet, heavy episodic drinking (HED) is not routinely addressed within most HIV clinics in sub-Saharan Africa. HIV disclosure may provide social support, potentially reducing HED to cope with HIV. We examined the prevalence of HED and HIV disclosure by antiretroviral treatment (ART) status among PWH receiving HIV care in Cameroon.

Methods: We analyzed routine HIV clinical data augmented with systematic alcohol use data among adult PWH receiving HIV care in three regional hospitals from January 2016 to March 2020. Recent HED prevalence was examined across PWH by ART status: those not on ART, recent ART initiators (ART initiation ≤30 days prior), and ART users (ART initiation >30 days prior); and by gender. We used log-binomial regression to estimate prevalence differences (PD) between HIV disclosure and recent HED by ART status.

Results: Among 12,517 PWH in care, 16.4% (95%CI: 15.7, 17.0) reported recent HED. HED was reported among 21.2% (95%CI: 16.0, 26.3) of those not on ART, 24.5% (95%CI: 23.1, 26.0) of recent ART initiators, and 12.9% (95%CI: 12.2, 13.6) of ART users. Regardless of ART status, men were more likely than women to report HED. Those who disclosed HIV status had a lower HED prevalence than those who had not disclosed (aPD: -0.07; 95%CI: -0.10, -0.05) and not modified by gender.

Conclusion: The prevalence of recent HED was high among PWH in care. HED prevalence was highest among men and recent ART initiators. Longitudinal analyses should explore how HIV disclosure may support PWH in reducing or abstaining from HED through social support. Systematic HED screening and referral to care should be included in routine HIV clinical care, particularly for men, to improve engagement in the HIV care continuum in Cameroon.
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http://dx.doi.org/10.1016/j.drugpo.2021.103431DOI Listing
September 2021

Restriction of HIV-1 infection in sickle cell trait.

Blood Adv 2021 Dec;5(23):4922-4934

Center for Sickle Cell Disease.

Patients with sickle cell disease (SCD) have a lower risk for HIV-1 infection. We reported restriction of ex vivo HIV-1 infection in SCD peripheral blood mononuclear cells (PBMCs) that was due, in part, to the upregulation of antiviral, inflammatory, and hemolytic factors, including heme oxygenase-1 (HO-1). Here, we investigated whether individuals with sickle cell trait (SCT), who develop mild hemolysis, also restrict HIV-1 infection. Ex vivo infection of SCT PBMCs exhibited an approximately twofold reduction of HIV-1 replication and lower levels of HIV-1 reverse transcription products, 2-long terminal repeat circle, HIV-1 integration, and gag RNA expression. SCT PBMCs had higher HO-1 messenger RNA (mRNA) and protein levels and reduced ribonucleotide reductase 2 (RNR2) protein levels. HO-1 inhibition by tin porphyrin eliminated ex vivo HIV-1 restriction. Among Howard University clinic recruits, higher levels of HO-1 and RNR2 mRNA and lower HIV-1 env mRNA levels were found in SCT individuals living with HIV-1. To determine the population-level effect of SCT on HIV-1 prevalence, we assessed SCT among women living with HIV (WLH) in the WIHS (Women Interagency HIV-1 Study). Among WIHS African-American participants, the prevalence of SCT was lower among women with HIV compared with uninfected women (8.7% vs 14.2%; odds ratio, 0.57; 95% confidence interval, 0.36-0.92; P = .020). WIHS WLH with SCT had higher levels of CD4+/CD8+ ratios over 20 years of follow-up (P = .003) than matched WLH without SCT. Together, our findings suggest that HIV-1 restriction factors, including HO-1 and RNR2, might restrict HIV-1 infection among individuals with SCT and limit the pathogenicity of HIV.
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http://dx.doi.org/10.1182/bloodadvances.2021004247DOI Listing
December 2021

Depressive Symptoms, Gender, Disclosure, and HIV Care Stage Among People Living with HIV in Cameroon.

AIDS Behav 2021 Aug 17. Epub 2021 Aug 17.

Department of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA.

Depression is associated with suboptimal HIV care outcomes. Little is known about the extent to which the prevalence of depressive symptoms varies across the HIV care continuum. Also, the relationship among gender, HIV disclosure, HIV care stage, and depressive symptoms in PLWH remains poorly understood. We analyzed cross-sectional data from 12,507 PLWH at enrollment in International epidemiology Databases to Evaluate AIDS (IeDEA) Cameroon between 2016 and 2020. Recent depressive symptoms were assessed using the Patient Health Questionnaire-2 (PHQ-2). A score of three or greater on the PHQ-2 was considered indicative of likely major depressive disorder. We estimated the prevalence of depressive symptoms across three stages of HIV care: those not yet on antiretroviral therapy (ART), recent ART initiators (ART initiation ≤ 30 days prior), and ART users (ART initiation > 30 days prior). Adjusted prevalence differences (aPD) of depressive symptoms were estimated comparing recent ART initiators and ART users. Disclosure and gender were examined as effect measure modifiers of the relationship between HIV care stage and depressive symptoms. The prevalence of depressive symptoms was 11.9%, 22.0%, and 8.7% among PLWH not yet on ART, recent ART initiators, and ART users, respectively. ART users had significantly lower prevalence of depressive symptoms compared to recent ART initiators (aPD - 0.09 [95% CI - 0.11, - 0.08]). Neither gender nor HIV disclosure modified the effect measure of the relationship between HIV care stage and depressive symptoms. Depressive symptoms were commonly reported among this group of PLWH and were associated with recent ART initiation. Integration of screening and treatment of depression into HIV care should be prioritized and may be particularly relevant for PLWH initiating ART.
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http://dx.doi.org/10.1007/s10461-021-03425-3DOI Listing
August 2021

Hypertension among people living with HIV/AIDS in Cameroon: A cross-sectional analysis from Central Africa International Epidemiology Databases to Evaluate AIDS.

PLoS One 2021 22;16(7):e0253742. Epub 2021 Jul 22.

Department of Public Health, New York Medical College, Valhalla, New York, United States of America.

Background: Antiretroviral therapy (ART) success has led people to live longer with HIV/AIDS (PLWH) and thus be exposed to increasing risk of cardiovascular diseases (CVD). Hypertension (HTN), the biggest contributor to CVD burden, is a growing concern among PLWH. The current report describes the prevalence and predictors of HTN among PLWH in care in Cameroon.

Methods: This cross-sectional study included all PLWH aged 20 years and above who received care between 2016 and 2019 at one of the three Central Africa International Epidemiology Databases to Evaluate AIDS (CA-IeDEA) sites in Cameroon (Bamenda, Limbe, and Yaoundé). HTN was defined as blood pressure (BP) ≥140/90 mm Hg or self-reported use of antihypertensive medication. Logistic regressions models examined the relationship between HTN and clinical characteristics, and HIV-related factors.

Results: Among 9,839 eligible PLWH, 66.2% were women and 25.0% had prevalent HTN [age-standardized prevalence 23.9% (95% CI: 22.2-25.6)], among whom 28 (1.1%) were on BP lowering treatment, and 6 of those (21.4%) were at target BP levels. Median age (47.4 vs. 40.5 years), self-reported duration of HIV infection (5.1 vs 2.8 years years), duration of ART exposure (4.7 vs 2.3 years), and CD4 count (408 vs 359 cell/mm3) were higher in hypertensives than non-hypertensives (all p<0.001). Age and body mass index (BMI) were independently associated with higher prevalent HTN risk. PLWH starting ART had a 30% lower risk of prevalent HTN, but this advantage disappeared after a cumulative 2-year exposure to ART. There was no significant association between other HIV predictive characteristics and HTN.

Conclusion: About a quarter of these Cameroonian PLWH had HTN, driven among others by age and adiposity. Appropriate integration of HIV and NCDs services is needed to improve early detection, treatment and control of common comorbid NCD risk factors like hypertension and safeguard cardiovascular health in PLWH.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0253742PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8297808PMC
November 2021

Brief Report: Acute Kidney Injury in People Living With HIV Hospitalized With Coronavirus Disease 2019: Clinical Characteristics and Outcomes.

J Acquir Immune Defic Syndr 2021 08;87(5):1167-1172

Division of Nephrology, Albert Einstein College of Medicine, Montefiore Health System Bronx, NY.

Background: Data on clinical characteristics and outcomes of people living with HIV (PLWH) hospitalized with coronavirus disease 2019 (COVID-19) who develop acute kidney injury (AKI) are limited.

Setting: Large tertiary health care system in the Bronx, NY.

Methods: We performed a retrospective cohort study of 83 PLWH and 4151 patients without HIV hospitalized with COVID-19 from March 10, 2020, to May 11, 2020. We compared the clinical characteristics and outcomes associated with AKI by HIV serostatus and evaluated HIV-related factors for AKI among PLWH. AKI was defined and staged using Kidney Disease Improving Global Outcomes criteria.

Results: The incidence of AKI in hospitalized patients with COVID-19 did not differ significantly by HIV serostatus (54.2% in PLWH vs 49.5% in patients without HIV, P = 0.6). Despite a higher incidence of stage 3 AKI (28.9% vs 17.1% P = 0.05) in PLWH compared with those without HIV, there was no significant difference in the need for renal replacement therapy (22.2% vs 13.4% P = 0.12), renal recovery (76.9% vs 82.5% P = 0.61), or dependence on renal replacement therapy (7.7% vs 3.8% P = 0.27). CD4 T-cell count, HIV-1 RNA viral suppression, and antiretroviral therapy use were not associated with AKI. AKI was associated with increased need for invasive ventilation and in-hospital death, but HIV was not an independent risk factor of in-hospital death after AKI [adjusted hazard ratio 1.01 (95% CI: 0.59 to 1.72), P = 0.98].

Conclusions: HIV-related factors were not associated with increased risk of AKI in PLWH hospitalized with COVID-19. PLWH hospitalized with COVID-19 had more stage 3 AKI, but outcomes after AKI were similar to those without HIV.
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http://dx.doi.org/10.1097/QAI.0000000000002698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8629144PMC
August 2021

Evaluation of the Abbott ARCHITECT HIV Ag/Ab combo assay for determining recent HIV-1 infection.

PLoS One 2021 1;16(7):e0242641. Epub 2021 Jul 1.

Division of HIV/ AIDS Prevention, National Center for HIV/AIDS, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.

Background: Given the challenges and costs associated with implementing HIV-1 incidence assay testing, there is great interest in evaluating the use of commercial HIV diagnostic tests for determining recent HIV infection. A diagnostic test with the capability of providing reliable data for the determination of recent HIV infection without substantial modifications to the test protocol would have a significant impact on HIV surveillance. The Abbott ARCHITECT HIV Ag/Ab Combo Assay is an antigen/antibody immunoassay, which meets the criteria as the first screening test in the recommended HIV laboratory diagnostic algorithm for the United States.

Methods: In this study, we evaluated the performance characteristics of the ARCHITECT HIV Ag/Ab Combo signal-to-cutoff ratio (S/Co) for determining recent infection, including estimation of the mean duration of recent infection (MDRI) and false recent rate (FRR), and selection of recency cutoffs.

Results: The MDRI estimates for the S/Co recency cutoff of 400 is within the 4 to 12 months range recommended for HIV incidence assays, and the FRR rate for this cutoff was 1.5%. Additionally, ARCHITECT Combo S/Co values were compared relative to diagnostic test results from two prior prospective HIV-1 diagnostic studies in order to validate the use of the S/Co for both diagnostic and recency determination.

Conclusion: Dual-use of the ARCHITECT Combo assay data for diagnostic and incidence purposes would reduce the need for separate HIV incidence testing and allow for monitoring of recent infection for incidence estimation and other public health applications.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0242641PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8248699PMC
November 2021

Trends in demographic and clinical characteristics and initiation of antiretroviral therapy among adult patients enrolling in HIV care in the Central Africa International epidemiology Database to Evaluate AIDS (CA-IeDEA) 2004 to 2018.

J Int AIDS Soc 2021 06;24(6):e25672

Department of Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA.

Introduction: The Central Africa International epidemiology Database to Evaluate AIDS (CA-IeDEA) is an open observational cohort study investigating impact, progression and long-term outcomes of HIV/AIDS among people living with HIV (PLWH) in Burundi, Cameroon, Democratic Republic of Congo (DRC), Republic of Congo (ROC) and Rwanda. We describe trends in demographic, clinical and immunological characteristics as well as antiretroviral therapy (ART) use of patients aged > 15 years entering into HIV care in the participating CA-IeDEA site.

Methods: Information on sociodemographic characteristics, height, weight, body mass index (BMI), CD4 cell count, WHO staging and ART status at entry into care from 2004 through 2018 were extracted from clinic records of patients aged > 15 years enrolling in HIV care at participating clinics in Burundi, Cameroon, DRC, ROC and Rwanda. We assessed trends in patient characteristics at enrolment in HIV care including ART initiation within the first 30 days after enrolment in care and calculated proportions, means and medians (interquartile ranges) for the main variables of interest.

Results: Among 69,176 patients in the CA-IeDEA cohort, 39% were from Rwanda, 24% from ROC, 18% from Cameroon, 14% from Burundi and 5% from DRC. More women (66%) than men enrolled in care and subsequently initiated ART. Women were also younger than men (32 vs. 38 years, P < 0.001) at enrolment and at ART initiation. Trends over time show increases in median CD4 cell count at enrolment from 190 cells/µL in 2004 to 334 cells/µL in 2018 at enrolment. Among those with complete data on CD4 counts (60%), women had a higher median CD4 cell count at care entry than men (229 vs. 249 cells/µL, P < 0.001). Trends in the proportion of patients using ART within 30 days of enrolment at the participating site show an increase from 16% in 2004 to 75% in 2018.

Conclusions: Trends from 2004 to 2018 in the characteristics of patients participating in the CA-IeDEA cohort highlight improvements at entry into care and subsequent ART initiation including after the implementation of Treat All guidelines in the participating sites.
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http://dx.doi.org/10.1002/jia2.25672DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216247PMC
June 2021

Trends in demographic and clinical characteristics and initiation of antiretroviral therapy among adult patients enrolling in HIV care in the Central Africa International epidemiology Database to Evaluate AIDS (CA-IeDEA) 2004 to 2018.

J Int AIDS Soc 2021 06;24(6):e25672

Department of Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA.

Introduction: The Central Africa International epidemiology Database to Evaluate AIDS (CA-IeDEA) is an open observational cohort study investigating impact, progression and long-term outcomes of HIV/AIDS among people living with HIV (PLWH) in Burundi, Cameroon, Democratic Republic of Congo (DRC), Republic of Congo (ROC) and Rwanda. We describe trends in demographic, clinical and immunological characteristics as well as antiretroviral therapy (ART) use of patients aged > 15 years entering into HIV care in the participating CA-IeDEA site.

Methods: Information on sociodemographic characteristics, height, weight, body mass index (BMI), CD4 cell count, WHO staging and ART status at entry into care from 2004 through 2018 were extracted from clinic records of patients aged > 15 years enrolling in HIV care at participating clinics in Burundi, Cameroon, DRC, ROC and Rwanda. We assessed trends in patient characteristics at enrolment in HIV care including ART initiation within the first 30 days after enrolment in care and calculated proportions, means and medians (interquartile ranges) for the main variables of interest.

Results: Among 69,176 patients in the CA-IeDEA cohort, 39% were from Rwanda, 24% from ROC, 18% from Cameroon, 14% from Burundi and 5% from DRC. More women (66%) than men enrolled in care and subsequently initiated ART. Women were also younger than men (32 vs. 38 years, P < 0.001) at enrolment and at ART initiation. Trends over time show increases in median CD4 cell count at enrolment from 190 cells/µL in 2004 to 334 cells/µL in 2018 at enrolment. Among those with complete data on CD4 counts (60%), women had a higher median CD4 cell count at care entry than men (229 vs. 249 cells/µL, P < 0.001). Trends in the proportion of patients using ART within 30 days of enrolment at the participating site show an increase from 16% in 2004 to 75% in 2018.

Conclusions: Trends from 2004 to 2018 in the characteristics of patients participating in the CA-IeDEA cohort highlight improvements at entry into care and subsequent ART initiation including after the implementation of Treat All guidelines in the participating sites.
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http://dx.doi.org/10.1002/jia2.25672DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216247PMC
June 2021

Gender, Mental Health, and Entry Into Care with Advanced HIV Among People Living with HIV in Cameroon Under a National 'Treat All' Policy.

AIDS Behav 2021 Dec 5;25(12):4018-4028. Epub 2021 Jun 5.

Institute of Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA.

Delays in diagnosis and linkage to HIV care persist among people living with HIV (PLWH), even after expanded access to ART worldwide. Mental health may influence timely linkage to HIV care. Greater understanding of the relationship among gender, mental health, and delayed linkage to HIV care can inform strategies to improve the health of PLWH. We interviewed 426 PLWH initiating HIV care in Cameroon between June 2019 and March 2020 to estimate the prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) and the association between mental health and entry into care with advanced HIV. Separate multivariable log binomial regression models were used to estimate the association between mental health exposure and entry into HIV care with advanced HIV. Stratified analyses were used to assess effect modification by gender. Approximately 20, 15, and 12% of participants reported symptoms of depression, PTSD, and anxiety, respectively. The prevalence of mental health symptoms did not vary significantly by gender. Overall, 53% of participants enrolled in HIV care with advanced HIV: 51% of men and 54% of women. Screening positive for one of the mental health disorders assessed was associated with greater prevalence of enrollment with advanced HIV among men, but not among women. Future research should examine gender-specific pathways between mental health symptoms and entry into care with advanced HIV, particularly for men in Cameroon. The extent to which untreated mental health symptoms drive gender disparities throughout the HIV care continuum should be explored further.
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http://dx.doi.org/10.1007/s10461-021-03328-3DOI Listing
December 2021

Correlates of self-reported history of mental health help-seeking: a cross-sectional study among individuals with symptoms of a mental or substance use disorder initiating care for HIV in Cameroon.

BMC Psychiatry 2021 06 5;21(1):293. Epub 2021 Jun 5.

Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: Mental health and substance use disorders (MSDs) increase the risk of poor human immunodeficiency virus (HIV) care outcomes among people living with HIV (PLWH). Receipt of mental health care may improve these adverse outcomes. We aimed to identify correlates of prior mental health help-seeking among PLWH with symptoms of an MSD in Cameroon.

Methods: We characterize prior mental health help-seeking from formal (mental health specialist/general medical provider) and informal (traditional healer/religious leader) sources among 161 people with symptoms of depression (Patient Health Questionnaire-9 scores> 9), anxiety (General Anxiety Disorder-7 scores> 9), probable post-traumatic stress disorder (PTSD Checklist for DSM-5 scores> 30), or possible alcohol use disorder (Alcohol Use Disorders Identification Test scores≥16) who were newly entering HIV care at three healthcare facilities in Cameroon between June 2019 and March 2020. Help-seeking was defined as ever speaking to a formal or informal source about emotional problems, sadness, or the way they were feeling or behaving. We estimated the association between sociodemographic and psychosocial measures and lifetime mental health help-seeking from each type of source using log-binomial regression.

Results: Overall, 55.3% of 161 PLWH with MSD symptoms reported prior mental health help-seeking, with 24.2% and 46.0% seeking help from formal and informal sources, respectively. Religious leaders were the most common source of help (40.4%), followed by general medical professionals (22.4%), traditional healers (16.8%), and mental health specialists (7.4%). Individuals with higher depressive, anxiety, and trauma symptom severity scores were more likely to have sought help than those with lower scores. Individuals with possible alcohol use disorder were the least likely to have sought help. Prior help-seeking was more common among those reporting a higher number of lifetime traumatic events (prevalence ratio [PR]: 1.06; 95% confidence interval [CI]: 1.01, 1.11) and those with a history of emotional intimate partner violence (PR: 1.34; 95% CI: 1.01, 1.80).

Conclusions: Prior mental health help-seeking was associated with psychosocial stressors. Help-seeking from informal networks was more common than formal help-seeking. Training in the provision of evidence-based mental health support for informal networks could improve access to mental health care for PLWH with MSDs in Cameroon.
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http://dx.doi.org/10.1186/s12888-021-03306-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8180128PMC
June 2021

How early is too early? Challenges in ART initiation and engaging in HIV care under Treat All in Rwanda-A qualitative study.

PLoS One 2021 13;16(5):e0251645. Epub 2021 May 13.

Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, United States of America.

Introduction: HIV treatment guidelines recommend that all people living with HIV (PLWH) initiate antiretroviral therapy (ART) as soon as possible after diagnosis (Treat All). As Treat All is more widely implemented, an increasing proportion of PLWH are likely to initiate ART when they are asymptomatic, and they may view the relative benefits and risks of ART differently than those initiating at more advanced disease stages. To date, patient perspectives of initiating care under Treat All in sub-Saharan Africa have not been well described.

Methods: From September 2018 to March 2019, we conducted individual, semi-structured, qualitative interviews with 37 patients receiving HIV care in two health centers in Kigali, Rwanda. Data were analyzed using a mixed deductive and inductive thematic analysis approach to describe perceived barriers to, facilitators of and acceptability of initiating and adhering to ART rapidly under Treat All.

Results: Of 37 participants, 27 were women and the median age was 31 years. Participants described feeling traumatized and overwhelmed by their HIV diagnosis, resulting in difficulty accepting their HIV status. Most were prescribed ART soon after diagnosis, yet fear of lifelong medication and severe side effects in the immediate period after initiating ART led to challenges adhering to therapy. Moreover, because many PLWH initiated ART while healthy, taking medications and attending appointments were visible signals of HIV status and highly stigmatizing. Nonetheless, many participants expressed enthusiasm for Treat All as a program that improved health as well as health equity.

Conclusion: For newly-diagnosed PLWH in Rwanda, initiating ART rapidly under Treat All presents logistical and emotional challenges despite the perceived benefits. Our findings suggest that optimizing early engagement in HIV care under Treat All requires early and ongoing intervention to reduce trauma and stigma, and promote both individual and community benefits of ART.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0251645PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8118273PMC
October 2021

Higher circulating intermediate monocytes are associated with cognitive function in women with HIV.

JCI Insight 2021 06 8;6(11). Epub 2021 Jun 8.

Department of Psychiatry and Behavioral Sciences, and.

BACKGROUNDIdentifying a quantitative biomarker of neuropsychiatric dysfunction in people with HIV (PWH) remains a significant challenge in the neuroHIV field. The strongest evidence to date implicates the role of monocytes in central nervous system (CNS) dysfunction in HIV, yet no study has examined monocyte subsets in blood as a correlate and/or predictor of neuropsychiatric function in virally suppressed PWH.METHODSIn 2 independent cohorts of virologically suppressed women with HIV (vsWWH; n = 25 and n = 18), whole blood samples were obtained either in conjunction with neuropsychiatric assessments (neuropsychological [NP] test battery, self-report depression and stress-related symptom questionnaires) or 1 year prior to assessments. Immune cell subsets were assessed by flow cytometry.RESULTSA higher proportion of intermediate monocytes (CD14+CD16+) was associated with lower global NP function when assessing monocytes concurrently and approximately 1 year before (predictive) NP testing. The same pattern was seen for executive function (mental flexibility) and processing speed. Conversely, there were no associations with monocyte subsets and depression or stress-related symptoms. Additionally, we found that a higher proportion of classical monocytes was associated with better cognition.CONCLUSIONAlthough it is widely accepted that lentiviral infection of the CNS targets cells of monocyte-macrophage-microglial lineage and is associated with an increase in intermediate monocytes in the blood and monocyte migration into the brain, the percentage of intermediate monocytes in blood of vsWWH has not been associated with neuropsychiatric outcomes. Our findings provide evidence for a new, easily measured, blood-based cognitive biomarker in vsWWH.FUNDINGR01-MH113512, R01-MH113512-S, P30-AI094189, R01-MH112391, R01-AI127142, R00-DA044838, U01-AI35004, and P30-MH075673.
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http://dx.doi.org/10.1172/jci.insight.146215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8262276PMC
June 2021

Reducing time to differentiated service delivery for newly diagnosed people living with HIV in Kigali, Rwanda: study protocol for a pilot, unblinded, randomised controlled study.

BMJ Open 2021 04 24;11(4):e047443. Epub 2021 Apr 24.

Division of General Internal Medicine, Montefiore Health System, Bronx, New York, USA.

Introduction: Current HIV guidelines recommend differentiated service delivery (DSD) models that allow for fewer health centre visits for clinically stable people living with HIV (PLHIV). Newly diagnosed PLHIV may require more intensive care early in their treatment course, yet frequent appointments can be burdensome to patients and health systems. Determining the optimal parameters for defining clinical stability and transitioning to less frequent appointments could decrease patient burden and health system costs. The objectives of this pilot study are to explore the feasibility and acceptability of (1) reducing the time to DSD from 12 to 6 months after antiretroviral therapy (ART) initiation,and (2) reducing the number of suppressed viral loads required to enter DSD from two to one.

Methods And Analyses: The present study is a pilot, unblinded trial taking place in three health facilities in Kigali, Rwanda. Current Rwandan guidelines require PLHIV to be on ART for ≥12 months with two consecutive suppressed viral loads in order to transition to less frequent appointments. We will randomise 90 participants to one of three arms: entry into DSD at 6 months after one suppressed viral load (n=30), entry into DSD at 6 months after two suppressed viral loads (n=30) or current standard of care (n=30). We will measure feasibility and acceptability of this intervention; clinical outcomes include viral suppression at 12 months (primary outcome) and appointment attendance (secondary outcome).

Ethics And Dissemination: This clinical trial was approved by the institutional review board of Albert Einstein College of Medicine and by the Rwanda National Ethics Committee. Findings will be disseminated through conferences and peer-reviewed publications, as well as meetings with stakeholders.

Trial Registration Number: NCT04567693.
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http://dx.doi.org/10.1136/bmjopen-2020-047443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8074553PMC
April 2021

HIV, hepatitis C virus and risk of new-onset left ventricular dysfunction in women.

AIDS 2021 08;35(10):1647-1655

Cardiology Section, San Francisco VA Healthcare System and Department of Medicine, University of California San Francisco, San Francisco, CA.

Background: HIV and HCV have each been linked with cardiac dysfunction. Studies of HIV have often lacked appropriate controls and primarily involved men, whereas data for HCV are sparse.

Methods: We performed repeat echocardiography over a median interval of 12 years in participants from the Women's Interagency HIV Study in order to evaluate the relationships of HIV and HCV with incident left ventricular (LV) dysfunction (systolic or diastolic).

Results: Of the 311 women included (age 39 ± 9), 70% were HIV-positive and 20% HCV-positive. Forty three participants (13.8%) developed LV dysfunction, of which 79.1% was diastolic. Compared with participants with neither infection, the group with HIV--HCV coinfection showed a significantly increased risk of incident LV dysfunction after adjustment for risk factors [RR = 2.96 (95% CI = 1.05-8.31)], but associations for the HCV monoinfected and HIV monoinfected groups were not statistically significant [RR = 2.54 (0.83-7.73) and RR = 1.66 (0.65-4.25), respectively]. Comparison of HCV-positive and HCV-negative women showed a significantly increased risk independent of covariates [RR = 1.96 (1.02-3.77)] but this was not the case for HIV-positive vs. HIV-negative women [RR = 1.43 (0.76-2.69)]. There was no evidence of HCV-by-HIV interaction. A more restrictive definition of LV diastolic dysfunction led to fewer incident cases, but a similar, though nonsignificant, risk estimate for HCV.

Conclusion: Among mostly middle-aged women, HCV but not HIV infection was associated with a pronounced risk of incident LV dysfunction. Although the influence of residual confounding cannot be excluded, these findings bolster the potential benefits that could be realized by adopting recent recommendations for expanding HCV screening and treatment.
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http://dx.doi.org/10.1097/QAD.0000000000002920DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8286303PMC
August 2021

A genomic variant of ALPK2 is associated with increased liver fibrosis risk in HIV/HCV coinfected women.

PLoS One 2021 11;16(3):e0247277. Epub 2021 Mar 11.

Department of Oncology, Georgetown University, Washington, DC, United States of America.

HIV coinfection is associated with more rapid liver fibrosis progression in hepatitis C (HCV) infection. Recently, much work has been done to improve outcomes of liver disease and to identify targets for pharmacological intervention in coinfected patients. In this study, we analyzed clinical data of 1,858 participants from the Women's Interagency HIV Study (WIHS) to characterize risk factors associated with changes in the APRI and FIB-4 surrogate measurements for advanced fibrosis. We assessed 887 non-synonymous single nucleotide variants (nsSNV) in a subset of 661 coinfected participants for genetic associations with changes in liver fibrosis risk. The variants utilized produced amino acid substitutions that either altered an N-linked glycosylation (NxS/T) sequon or mapped to a gene related to glycosylation processes. Seven variants were associated with an increased likelihood of liver fibrosis. The most common variant, ALPK2 rs3809973, was associated with liver fibrosis in HIV/HCV coinfected patients; individuals homozygous for the rare C allele displayed elevated APRI (0.61, 95% CI, 0.334 to 0.875) and FIB-4 (0.74, 95% CI, 0.336 to 1.144) relative to those coinfected women without the variant. Although warranting replication, ALPK2 rs3809973 may show utility to detect individuals at increased risk for liver disease progression.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0247277PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7951908PMC
August 2021

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

Front Neurol 2021 11;12:604984. Epub 2021 Feb 11.

Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.

Cognitive impairment remains frequent and heterogeneous in presentation and severity among virally suppressed (VS) women with HIV (WWH). We identified cognitive profiles among 929 VS-WWH and 717 HIV-uninfected women from 11 Women's Interagency HIV Study sites at their first neuropsychological (NP) test battery completion comprised of: Hopkins Verbal Learning Test-Revised, Trail Making, Symbol Digit Modalities, Grooved Pegboard, Stroop, Letter/Animal Fluency, and Letter-Number Sequencing. Using 17 NP performance metrics (T-scores), we used Kohonen self-organizing maps to identify patterns of high-dimensional data by mapping participants to similar nodes based on T-scores and clustering those nodes. Among VS-WWH, nine clusters were identified (entropy = 0.990) with four having average T-scores ≥45 for all metrics and thus combined into an "unimpaired" profile ( = 311). Impaired profiles consisted of weaknesses in: (1) sequencing (; = 129), (2) speed (; = 144), (3) learning + recognition (; = 137), (4) learning + memory (; = 86), and (5) learning + processing speed + attention + executive function (; = 122). Sociodemographic, behavioral, and clinical variables differentiated profile membership using Random Forest models. The top 10 variables distinguishing the combined impaired vs. unimpaired profiles were: clinic site, age, education, race, illicit substance use, current and nadir CD4 count, duration of effective antiretrovirals, and protease inhibitor use. Additional variables differentiating each impaired from unimpaired profile included: depression, stress-symptoms, income (); depression, employment (); depression, integrase inhibitor (INSTI) use (); employment, INSTI use, income, atazanavir use, non-ART medications with anticholinergic properties (); and marijuana use (). Findings highlight consideration of NP profile heterogeneity and potential modifiable factors contributing to impaired profiles.
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http://dx.doi.org/10.3389/fneur.2021.604984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928382PMC
February 2021

Type-specific persistence, clearance and incidence of high-risk HPV among screen-positive Rwandan women living with HIV.

Infect Agent Cancer 2021 Feb 19;16(1):16. Epub 2021 Feb 19.

Albert Einstein College of Medicine, Bronx, NY, USA.

Background: Persistent infection with high-risk human papillomavirus (hrHPV) is a critical step in cervical carcinogenesis. We report on type-specific hrHPV persistence, clearance and incidence among screen-positive Rwandan women living with HIV (WLWH).

Methods: This was a nested analysis from a large cervical cancer screening study of ~ 5000 Rwandan WLWH. Women who tested positive for hrHPV and/or visual inspection with acetic acid were referred to colposcopy. For a subset of women (n = 298) who were ≥ 6 months delayed in receiving colposcopy, we tested their screening and colposcopy visit specimens using the AmpFire HPV genotyping assay that tests 14 hrHPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68) individually.

Results: The mean, median (interquartile range [IQR]) and range of time between the screening and colposcopy visits were 644, 650 (490-820.5) and 197-1161 days, respectively. Mean, median (IQR) and range of age at the screening visit were 38, 37 (34-43) and 30-54 years, respectively. Two-hundred eighty-three (95.0%) had CD4 count (cells per mm) data available at baseline with mean, median (IQR) and range of 592, 513 (346-717) and 0-7290, respectively. Two-hundred thirty-five WLWH were positive for at least one hrHPV type at the screening visit, of whom 50.2% had at least one HPV type-specific infection persist; 37.2% of all HPV infections detected at the screening visit persisted. Compared to all other HPV types in aggregate, HPV16 (vs. non-HPV16 types) (47.7%, p = 0.03) and HPV33 (vs. non-HPV33 types) (56.7%, p = 0.03) were significantly more likely, and HPV39 (vs. non-HPV39 types) (6.7%, p = 0.01), HPV51 (vs. non-HPV51 types) (15.6%, p < 0.01), and HPV66 (vs. non-HPV66 types (17.9%, p = 0.04) were significantly less likely, to persist. Lower CD4 counts were associated with having any persistent hrHPV infection (p = 0.04) and multiple persistent hrHPV infections (p = 0.04).

Conclusion: There is a significant proportion of WLWH with persistent hrHPV infection, emphasizing the need to vaccinate them against HPV prior to becoming sexually active.
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http://dx.doi.org/10.1186/s13027-021-00355-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7893720PMC
February 2021

Challenges and opportunities associated with cervical cancer screening programs in a low income, high HIV prevalence context.

BMC Womens Health 2021 02 18;21(1):74. Epub 2021 Feb 18.

Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA.

Background: Cervical cancer is a leading cause of death among Cameroon women. The burden of cervical cancer is in part traceable to the inadequate understanding of socio-contextual determinants of access to screening and prevention opportunities. We explored multilevel individual, community and structural factors that facilitate or inhibit cervical cancer prevention in women at risk in a low-income, high HIV prevalence context.

Methods: We utilized an exploratory qualitative approach to obtain data through focus group discussions and in-depth interviews from May to August, 2018. A two-stage purposive sampling strategy was used to select 80 women and 20 men who participated in 8 focus group discussions and 8 in-depth interviews. The socio-ecological model guided data analyses to identify micro-, meso-, and macro-level determinants of cervical cancer screening.

Results: Micro-level factors including lack of awareness and knowledge about cervical cancer, lack of access to information, excessive cost of cervical cancer screening, low risk perceptions, and poor health seeking behaviors were major barriers for women seeking cervical cancer screening. Meso-level factors, such as social networks, socio-cultural norms, perceptions of the role of men and HIV-related stigma when screening is integrated into HIV care, also engender negative attitudes and behaviors. Macro-level barriers to cervical cancer screening included poorly equipped health facilities and a lack of national cancer prevention policies and programs.

Conclusion: In the context of the call for elimination of cervical cancer as a public health problem, our findings highlight challenges and opportunities that should be considered when implementing interventions to increase uptake of cervical cancer screening in low-middle income settings.
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http://dx.doi.org/10.1186/s12905-021-01211-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7890622PMC
February 2021

Comparison of cohort characteristics in Central Africa International Epidemiology Databases to Evaluate AIDS and Demographic Health Surveys: Rwanda and Burundi.

Int J STD AIDS 2021 05 3;32(6):551-561. Epub 2021 Feb 3.

Department of Epidemiology & Biostatistics, 436523City University of New York (CUNY) School of Public Health, New York, NY, USA.

Clinical health record data are used for HIV surveillance, but the extent to which these data are population representative is not clear. We compared age, marital status, body mass index, and pregnancy distributions in the Central Africa International Databases to Evaluate AIDS (CA-IeDEA) cohorts in Burundi and Rwanda to all people living with HIV and the subpopulation reporting receiving a previous HIV test result in the Demographic and Health Survey (DHS) data, restricted to urban areas, where CA-IeDEA sites are located. DHS uses a probabilistic sample for population-level HIV prevalence estimates. In Rwanda, the CA-IeDEA cohort and DHS populations were similar with respect to age and marital status for men and women, which was also true in Burundi among women. In Burundi, the CA-IeDEA cohort had a greater proportion of younger and single men than the DHS data, which may be a result of outreach to sexual minority populations at CA-IeDEA sites and economic migration patterns. In both countries, the CA-IeDEA cohorts had a higher proportion of underweight individuals, suggesting that symptomatic individuals are more likely to access care in these settings. Multiple sources of data are needed for HIV surveillance to interpret potential biases in epidemiological data.
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http://dx.doi.org/10.1177/0956462420983783DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8058267PMC
May 2021

Awareness and Willingness to Use HIV Pre-exposure Prophylaxis Among Men Who Have Sex With Men in Rwanda: A Cross-Sectional Descriptive Survey.

J Assoc Nurses AIDS Care 2021 Jan 13. Epub 2021 Jan 13.

Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Gad Murenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA.

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http://dx.doi.org/10.1097/JNC.0000000000000228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8610030PMC
January 2021

Cognitive changes during the menopausal transition: a longitudinal study in women with and without HIV.

Menopause 2021 01 11;28(4):360-368. Epub 2021 Jan 11.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Objective: To assess longitudinal changes in cognitive performance across menopause stages in a sample comprised primarily of low-income women of color, including women with HIV (WWH).

Methods: A total of 443 women (291 WWH; 69% African American; 18% Hispanic; median age = 42 y) from the Women's Interagency HIV Study completed tests of verbal learning and memory, attention/working memory, processing speed, verbal fluency, motor skills, and executive function first at an index premenopausal visit and thereafter once every 2 years for up to six visits (mean follow-up = 5.7 y). General linear-mixed effects regression models were run to estimate associations between menopause stages and cognition, in the overall sample and in WWH. We examined both continuous scores and categorical scores of cognitive impairment (yes/no >1 standard deviation below the mean).

Results: Adjusting for age and relevant covariates, the overall sample and WWH showed longitudinal declines in continuous measures of learning, memory, and attention/working memory domains from the premenopause to the early perimenopause and from the premenopause to the postmenopause, Ps < 0.05 to < 0.001. Effects on those same domains were also evident in categorical scores of cognitive impairment, with the increased odds of impairment ranging from 41% to 215%, Ps < 0.05 to < 0.001. The increase in predicted probability of impairment by menopausal stage (% affected) ranged from 4% to 13%.

Conclusions: Menopause stage was a key determinant of cognition in a sample of low-income women of color, including WWH. Many of these changes reached a clinically significant level of cognitive impairment.
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http://dx.doi.org/10.1097/GME.0000000000001725DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8576848PMC
January 2021

Menopausal status and observed differences in the gut microbiome in women with and without HIV infection.

Menopause 2021 01 11;28(5):491-501. Epub 2021 Jan 11.

Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY.

Objective: Gut microbiota respond to host physiological phenomena, yet little is known regarding shifts in the gut microbiome due to menopausal hormonal and metabolic changes in women. HIV infection impacts menopause and may also cause gut dysbiosis. We therefore sought to determine the association between menopausal status and gut microbiome composition in women with and without HIV.

Methods: Gut microbiome composition was assessed in stool from 432 women (99 premenopausal HIV+, 71 premenopausal HIV-, 182 postmenopausal HIV+, 80 postmenopausal HIV-) via 16S rRNA gene sequencing. We examined cross-sectional associations of menopause with gut microbiota overall diversity and composition, and taxon and inferred metagenomic pathway abundance. Models were stratified by HIV serostatus and adjusted for age, HIV-related variables, and other potential confounders.

Results: Menopause, ie post- versus premenopausal status, was associated with overall microbial composition only in women with HIV (permutational MANOVA of Jensen Shannon Divergence: P = 0.01). In women with HIV, menopause was associated with enrichment of gram-negative order Enterobacteriales, depletion of highly abundant taxa within Prevotella copri, and alterations in other low-abundance taxa. Additionally, menopause in women with HIV was associated with enrichment of metagenomic pathways related to Enterobacteriales, including degradation of amino acids and phenolic compounds, biosynthesis of enterobactin, and energy metabolism pathways. Menopause-related differences in some low-abundance taxa were also observed in women without HIV.

Conclusions: A changing gut microbiome may be an overlooked phenomenon of reproductive aging in women with HIV. Longitudinal assessments across all reproductive stages are necessary to confirm these findings and identify health implications.
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http://dx.doi.org/10.1097/GME.0000000000001730DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8068580PMC
January 2021

Clinical Outcomes and Inflammatory Markers by HIV Serostatus and Viral Suppression in a Large Cohort of Patients Hospitalized With COVID-19.

J Acquir Immune Defic Syndr 2021 02;86(2):224-230

Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Health System, Bronx, NY.

Background: Limited data exist about clinical outcomes and levels of inflammatory and immune markers among people hospitalized with COVID-19 by HIV serostatus and by HIV viral suppression.

Setting: Large tertiary care health system in the Bronx, NY, USA.

Methods: We conducted a retrospective cohort study of 4613 SARS-CoV-2 PCR-positive patients admitted between March 10, 2020, and May 11, 2020. We examined in-hospital intubation, acute kidney injury (AKI), hospitalization length, and in-hospital mortality by HIV serostatus, and by HIV-viral suppression and CD4 counts among people living with HIV (PLWH) using adjusted competing risks regression. We also compared immune and inflammatory marker levels by HIV serostatus and viral suppression.

Results: Most patients were either non-Hispanic Black (36%) or Hispanic (37%); 100/4613 (2.2%) were PLWH, among whom 15 had detectable HIV viral load. PLWH compared to patients without HIV had increased intubation rates (adjusted hazard ratio 1.73 [95% CI: 1.12 to 2.67], P = 0.01). Both groups had similar rates of AKI, length of hospitalization, and death. No (0%) virally unsuppressed PLWH were intubated or died, versus 21/81 (26%, P = 0.04) and 22/81 (27%, P = 0.02) of virally suppressed PLWH, respectively. Among PLWH, higher CD4 T-cell counts were associated with increased intubation rates. C-reactive protein, IL-6, neutrophil counts, and ferritin levels were similar between virally suppressed PLWH and patients without HIV, but significantly lower for unsuppressed PLWH (all P < 0.05).

Conclusions: PLWH had increased risk of intubation but similarly frequent rates of AKI and in-hospital death as those without HIV. Findings of no intubations or deaths among PLWH with unsuppressed HIV viral load warrant further investigation.
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http://dx.doi.org/10.1097/QAI.0000000000002578DOI Listing
February 2021

Plasma Lipidomic Profiles and Risk of Diabetes: 2 Prospective Cohorts of HIV-Infected and HIV-Uninfected Individuals.

J Clin Endocrinol Metab 2021 03;106(4):999-1010

Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA.

Objectives: Antiretroviral therapy (ART) use is associated with disrupted lipid and glucose metabolism in people with HIV infection. We aimed to identify plasma lipid species associated with risk of diabetes in the context of HIV infection.

Research Design And Methods: We profiled 211 plasma lipid species in 491 HIV-infected and 203 HIV-uninfected participants aged 35 to 55 years from the Women's Interagency HIV Study and the Multicenter AIDS Cohort Study. Cox proportional hazards model was used to examine associations between baseline lipid species and incident diabetes (166 diabetes cases were identified during a median follow-up of 12.6 years).

Results: We identified 11 lipid species, representing independent signals for 8 lipid classes/subclasses, associated with risk of diabetes (P < 0.05 after FDR correction). After adjustment for multiple covariates, cholesteryl ester (CE) (22:4), lysophosphatidylcholine (LPC) (18:2), phosphatidylcholine (PC) (36:4), phosphatidylcholine plasmalogen (34:3), and phosphatidylethanolamine (PE) (38:2) were associated with decreased risk of diabetes (HRs = 0.70 to 0.82 per SD increment), while diacylglycerol (32:0), LPC (14:0), PC (38:3), PE (36:1), and triacylglycerol (50:1) were associated with increased risk of diabetes (HRs = 1.26 to 1.56 per SD increment). HIV serostatus did not modify any lipid-diabetes associations; however, most of these lipid species were positively associated with HIV and/or ART use, including 3 diabetes-decreased ( CE [22:4], LPC [18:2], PE [38:2]) and all 5 diabetes-increased lipid species.

Conclusions: This study identified multiple plasma lipid species associated with incident diabetes. Regardless of the directions of their associations with diabetes, most diabetes-associated lipid species were elevated in ART-treated people with HIV infection. This suggests a complex role of lipids in the link between ART and diabetes in HIV infection.
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http://dx.doi.org/10.1210/clinem/dgab011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7993589PMC
March 2021

Incident Non-AIDS Comorbidity Burden Among Women With or at Risk for Human Immunodeficiency Virus in the United States.

Clin Infect Dis 2021 10;73(7):e2059-e2069

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

Background: Human immunodeficiency virus (HIV) infection may accelerate development of aging-related non-AIDS comorbidities (NACMs). The incidence of NACMs 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) or onward were included, with outcomes measured through 31 March 2018. Sociodemographics, clinical covariates, and prevalent NACM were determined at enrollment. We used Poisson regression models to determine incident NACM burden (number of NACMs accrued through most recent WIHS visit out of 10 total NACMs assessed) by HIV serostatus and age.

Results: There were 3129 participants (2239 WLWH, 890 HIV seronegative) with 36 589 person-years of follow-up. At enrollment, median age was 37 years, 65% were black, and 47% currently smoked. In fully adjusted analyses, WLWH had a higher incident NACM rate compared with HIV-seronegative women (incidence rate ratio, 1.36 [95% confidence interval (CI), 1.02-1.81]). Incident NACM burden was higher among WLWH vs HIV-seronegative women in most age strata (HIV × age interaction: P = .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
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8492222PMC
October 2021

Factors Predicting Detrimental Change in Declarative Memory Among Women With HIV: A Study of Heterogeneity in Cognition.

Front Psychol 2020 15;11:548521. Epub 2020 Oct 15.

Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.

Objective: Statistical techniques used to study cognitive function in HIV typically yield normative estimates and can mask the heterogeneity in cognitive trajectories over time. We applied a novel statistical approach to identify clusters of individuals with distinct patterns of change in declarative memory in HIV-seropositive (HIV+) and HIV-seronegative (HIV-) women.

Methods: 1731 women from the Women's Interagency HIV Study, a multi-center, prospective cohort study, completed the Hopkins Verbal Learning Test-Revised (HLVT-R) at >2 visits. To derive subgroups with similar patterns of decline by HIV-serostatus, we used a mixed-effects framework that modeled the trajectory of multiple declarative memory outcomes over time, while simultaneously clustering individuals.

Results: Of the 1731 participants, 1149 were HIV+ (70% Black/African American [AA]; 30% White/Other [W/O]) and 582 were HIV- (68% AA; 32% W/O). Race stratification was necessary to optimize clustering. Among HIV+AA's, four subgroups emerged: a subgroup with minimal decline, two with accelerated decline, and one with stable but low performance. In HIV- AA, three subgroups emerged: one with minimal decline and two with accelerated decline. In multivariable-adjusted models among HIV+, individuals with accelerated decline were less educated ( < 0.001) and more likely to have a history of depression ( < 0.001) versus those with minimal decline. Similar subgroups were identified in W/O HIV+ and W/O HIV- participants.

Conclusion: We identified clinically meaningful subgroups of women with distinct phenotypes of declarative memory decline, which depend on race and HIV-serostatus using a data driven approach. Identification of underlying mechanisms and risk factors contributing to the observed differences are warranted. More broadly our modeling approach could be other populations to identify risk factors for accelerated cognitive decline and to personalize interventions.
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http://dx.doi.org/10.3389/fpsyg.2020.548521DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7594511PMC
October 2020

Primary HPV and Molecular Cervical Cancer Screening in US Women Living With Human Immunodeficiency Virus.

Clin Infect Dis 2021 05;72(9):1529-1537

Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA.

Background: Primary human papillomavirus (HPV) screening (PHS) utilizes oncogenic human papillomavirus (oncHPV) testing as the initial cervical cancer screening method and typically, if positive, additional reflex-triage (eg, HPV16/18-genotyping, Pap testing). While US guidelines support PHS usage in the general population, PHS has been little studied in women living with HIV (WLWH).

Methods: We enrolled n = 865 WLWH (323 from the Women's Interagency HIV Study [WIHS] and 542 from WIHS-affiliated colposcopy clinics). All participants underwent Pap and oncHPV testing, including HPV16/18-genotyping. WIHS WLWH who tested oncHPV[+] or had cytologic atypical squamous cells of undetermined significance or worse (ASC-US+) underwent colposcopy, as did a random 21% of WLWH who were oncHPV[-]/Pap[-] (controls). Most participants additionally underwent p16/Ki-67 immunocytochemistry.

Results: Mean age was 46 years, median CD4 was 592 cells/µL, 95% used antiretroviral therapy. Seventy WLWH had histologically-determined cervical intraepithelial neoplasia grade 2 or greater (CIN-2+), of which 33 were defined as precancer (ie, [i] CIN-3+ or [ii] CIN-2 if concurrent with cytologic high grade squamous intraepithelial lesions [HSILs]). PHS had 87% sensitivity (Se) for precancer, 9% positive predictive value (PPV), and a 35% colposcopy referral rate (Colpo). "PHS with reflex HPV16/18-genotyping and Pap testing" had 84% Se, 16% PPV, 30% Colpo. PHS with only HPV16/18-genotyping had 24% Colpo. "Concurrent oncHPV and Pap Testing" (Co-Testing) had 91% Se, 12% PPV, 40% Colpo. p16/Ki-67 immunochemistry had the highest PPV, 20%, but 13% specimen inadequacy.

Conclusions: PHS with reflex HPV16/18-genotyping had fewer unnecessary colposcopies and (if confirmed) could be a potential alternative to Co-Testing in WLWH.
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http://dx.doi.org/10.1093/cid/ciaa1317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8096228PMC
May 2021
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