Brian W. Pence

Prevalence of DSM-IV-defined mood, anxiety, and substance use disorders in an HIV clinic in the southeastern United States

Background: Mood and anxiety disorders, particularly depression, and substance abuse (SA) commonly co-occur with HIV infection. Appropriate policy and program planning require accurate prevalence estimates. Yet most estimates are based on screening instruments, which are likely to overstate true prevalence. Setting: Large academic medical center in Southeast. Participants: A total of 1,125 patients, representing 80% of HIV-positive patients seen over a 2.5-year period, completed the Substance Abuse-Mental Illness Symptoms Screener, a brief screening instrument for probable mood, anxiety, and SA disorders. Separately, 148 participants in a validation study completed the Substance Abuse-Mental Illness Symptoms Screener and a reference standard diagnostic tool, the Structured Clinical Interview for DSM-IV. Methods: Using the validation study sample, we developed logistic regression models to predict any Structured Clinical Interview for DSM-IV mood/anxiety disorder, any SA, and certain specific diagnoses. Explanatory variables included sociodemographic and clinical information and responses to Substance Abuse-Mental Illness Symptoms Screener questions. We applied coefficients from these models to the full clinic sample to obtain 12-month clinic-wide diagnosis prevalence estimates. Results: We estimate that in the preceding year, 39% of clinic patients had a mood/anxiety diagnosis and 21% had an SA diagnosis, including 8% with both. Of patients with a mood/anxiety diagnosis, 76% had clinically relevant depression and 11% had posttraumatic stress disorder. Conclusions: The burden of psychiatric disorders in this mixed urban and rural clinic population in the southeastern United States is comparable to that reported from other HIV-positive populations and significantly exceeds general population estimates. Because psychiatric disorders have important implications for clinical management of HIV/AIDS, these results suggest the potential benefit of routine integration of mental health identification and treatment into HIV service sites.

Psychiatric illness and virologic response in patients initiating highly active antiretroviral therapy.

Background:Mental illness (MI) and substance abuse (SA) are common in HIV-positive patients. MI/SA consistently predict poorer antiretroviral adherence, suggesting that affected patients should be at higher risk of poor virologic and immunologic response to highly active antiretroviral therapy (HAART). Participants:198 HAART-naive patients initiated HAART at an academic medical center serving a heterogeneous population. Methods:Participants were assigned a predicted probability from 0 to 1 of having each of the following: (1) any mood, anxiety, or substance use disorder; (2) clinically relevant depression; (3) alcohol abuse/dependence; and (4) drug abuse/dependence. Probabilities were based on responses to questions on an MI/SA screening instrument (Substance Abuse and Mental Illness Symptoms Screener [SAMISS]) and other clinical and sociodemographic characteristics and were derived using predictive logistic regression modeling from a separate validation study of the SAMISS compared with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnoses. Using survival analysis techniques, we assessed baseline predicted probability of psychiatric illness as a predictor of time from HAART initiation to virologic suppression (first viral load [VL] <400 copies/mL), from HAART initiation to overall virologic failure (first VL ≥400 copies/mL after suppression, time set to 0 for patients never achieving suppression), from virologic suppression to virologic rebound (first VL ≥400 copies/mL), and from HAART initiation to immunologic failure (first CD4 cell count lower than baseline). Results:A higher predicted probability of any psychiatric disorder was associated with a slower rate of virologic suppression (adjusted hazard ratio [aHR] = 0.86 per 25% increment, 95% confidence interval [CI]: 0.75 to 0.98) and a faster rate of overall virologic failure (aHR = 1.22, 95% CI: 1.06 to 1.40). Associations with other outcomes were consistent in direction but not statistically significant. Predicted probability of depression was associated with slower virologic suppression (aHR = 0.79, 95% CI: 0.63 to 0.98), and predicted probabilities of alcohol and drug abuse/dependence was associated with faster overall virologic failure (aHR = 1.37, 95% CI: 1.08 to 1.74 and aHR = 1.18, 95% CI: 1.00 to 1.39, respectively). Conclusions:These results are consistent with an inferior virologic response to first HAART among patients with concurrent mood, anxiety, and substance use disorders, suggesting a clinical benefit to identification and treatment of psychiatric illness among patients initiating antiretroviral therapy.

The impact of mental health and traumatic life experiences on antiretroviral treatment outcomes for people living with HIV/AIDS

Potent antiretroviral therapy (ART) has transformed HIV from a death sentence to a chronic illness. Accordingly, the goal of HIV care has shifted from delaying death to achieving optimal health outcomes through ART treatment. ART treatment success hinges on medication adherence. Extensive research has demonstrated that the primary barriers to ART adherence include mental illness, especially depression and substance abuse, as well as histories of traumatic experiences such as childhood sexual and physical abuse. These psychosocial factors are highly prevalent in people living with HIV/AIDS (PLWHA) and predict poor ART adherence, increased sexual risk behaviours, ART treatment failure, HIV disease progression and higher mortality rates. The efficacy of standard mental health interventions, such as antidepressant treatment and psychotherapy, has been well-defined, and a small but growing body of research demonstrates the potential for such interventions to improve ART adherence and reduce sexual risk behaviours. Despite this evidence, mental disorders in PLWHA frequently go undiagnosed and untreated. Challenges to the provision of mental healthcare for PLWHA in HIV clinical settings include time and resource constraints, lack of expertise in psychiatric diagnosis and treatment, and lack of available mental health referral services. Future research should prioritize the evaluation of mental health interventions that are cost-effective and feasible for widespread integration into HIV clinical care; the impact of such interventions on ART adherence and clinical outcomes; and interventions to identify individuals with histories of traumatic experiences and to elucidate the mechanisms through which such histories pose barriers to effective HIV treatment.

Depression, Sexually Transmitted Infection, and Sexual Risk Behavior Among Young Adults in the United States

OBJECTIVE To measure associations among depression, sexual risk behaviors, and sexually transmitted infection (STI) among white and black youth in the United States. DESIGN Analysis of prospective cohort study data. Wave I of the National Longitudinal Study of Adolescent Health occurred in 1995 when participants were in grades 7 through 12. Six years later, all Wave I participants who could be located were invited to participate in Wave III and to provide a urine specimen for STI testing. SETTING In-home interviews in the continental United States, Alaska, and Hawaii. PARTICIPANTS Population-based sample. A total of 10 783 Wave I (adolescence) and Wave III (adulthood) white and black respondents with sample weight variables. Main Exposures Chronic depression (detected at Waves I and III) and recent depression (detected at Wave III only) vs no adult depression (not detected at Wave III). OUTCOME MEASURES Multiple sexual partners and inconsistent condom use in the past year and a current positive test result for Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis (adulthood). RESULTS Recent or chronic depression in adulthood was more common for blacks (women, 19.3%; men, 11.9%) than for whites (women, 13.0%; men, 8.1%). Among all groups (white men and women, and black men and women), adult depression was associated with multiple partners but not with condom use. Among black men, depression was strongly associated with STI (recent: adjusted prevalence ratio, 2.36; 95% confidence interval, 1.26-4.43; chronic: adjusted prevalence ratio, 3.05; 95% confidence interval, 1.48-6.28); having multiple partners did not mediate associations between depression and STI. CONCLUSIONS Integration of mental health and STI programs for youth is warranted. Further research is needed to elucidate how depression may influence the prevalence of STI among black men.

Mental Health Treatment to Reduce HIV Transmission Risk Behavior: A Positive Prevention Model

Secondary HIV prevention, or “positive prevention,” is concerned with reducing HIV transmission risk behavior and optimizing the health and quality of life of people living with HIV/AIDS (PLWHA). The association between mental health and HIV transmission risk (i.e., sexual risk and poor medication adherence) is well established, although most of this evidence is observational. Further, a number of efficacious mental health treatments are available for PLWHA yet few positive prevention interventions integrate mental health treatment. We propose that mental health treatment, including behavioral and pharmacologic interventions, can lead to reductions in HIV transmission risk behavior and should be a core component of secondary HIV prevention. We present a conceptual model and recommendations to guide future research on the effect of mental health treatment on HIV transmission risk behavior among PLWHA.

A Comparison of the Wellbeing of Orphans and Abandoned Children Ages 6–12 in Institutional and Community-Based Care Settings in 5 Less Wealthy Nations

Background Leaders are struggling to care for the estimated 143,000,000 orphans and millions more abandoned children worldwide. Global policy makers are advocating that institution-living orphans and abandoned children (OAC) be moved as quickly as possible to a residential family setting and that institutional care be used as a last resort. This analysis tests the hypothesis that institutional care for OAC aged 6–12 is associated with worse health and wellbeing than community residential care using conservative two-tail tests. Methodology The Positive Outcomes for Orphans (POFO) study employed two-stage random sampling survey methodology in 6 sites across 5 countries to identify 1,357 institution-living and 1,480 community-living OAC ages 6–12, 658 of whom were double-orphans or abandoned by both biological parents. Survey analytic techniques were used to compare cognitive functioning, emotion, behavior, physical health, and growth. Linear mixed-effects models were used to estimate the proportion of variability in child outcomes attributable to the study site, care setting, and child levels and institutional versus community care settings. Conservative analyses limited the community living children to double-orphans or abandoned children. Principal Findings Health, emotional and cognitive functioning, and physical growth were no worse for institution-living than community-living OAC, and generally better than for community-living OAC cared for by persons other than a biological parent. Differences between study sites explained 2–23% of the total variability in child outcomes, while differences between care settings within sites explained 8–21%. Differences among children within care settings explained 64–87%. After adjusting for sites, age, and gender, institution vs. community-living explained only 0.3–7% of the variability in child outcomes. Conclusion This study does not support the hypothesis that institutional care is systematically associated with poorer wellbeing than community care for OAC aged 6–12 in those countries facing the greatest OAC burden. Much greater variability among children within care settings was observed than among care settings type. Methodologically rigorous studies must be conducted in those countries facing the new OAC epidemic in order to understand which characteristics of care promote child wellbeing. Such characteristics may transcend the structural definitions of institutions or family homes.

HIV/AIDS in the Southern USA: A disproportionate epidemic

This research synthesis examined HIV/AIDS surveillance and health care financing data and reviewed relevant research literature to describe HIV epidemiology, outcomes, funding, and contributing factors to the HIV epidemic in the Southern USA with particular focus on a group of Southern states with similar demographic and disease characteristics and comparable HIV epidemics (Alabama, Georgia, Florida, Los Angeles, Mississippi, North Carolina, South Carolina, Tennessee, and Texas). These states are hereafter referred to as “targeted Southern states.” Eight of the 10 states with the highest HIV diagnosis rates in 2011 were in the Southern USA; six were targeted states. Forty-nine percent of HIV diagnoses were in the South in 2011, which contains only 37% of the US population. The targeted states region had the highest HIV diagnosis rate than any other US region in 2011. The South was also found to have the highest HIV-related mortality and morbidity rates in the USA. The high levels of poverty, HIV-related stigma, and STDs found in the South, particularly in the targeted Southern states, likely contribute to greater HIV incidence and mortality. The disproportionate impact of HIV in the South, particularly among targeted states, demonstrates a critical need to improve HIV prevention and care and address factors that contribute to HIV disease in this region.

A case-control study of community-associated Clostridium difficile infection: no role for proton pump inhibitors.

BACKGROUND The epidemiology of community-associated Clostridium difficile infection is not well known. We performed a multicenter, case-control study to further describe community-associated C. difficile infection and assess novel risk factors. METHODS We conducted this study at 5 sites from October 2006 through November 2007. Community-associated C. difficile infection included individuals with diarrhea, a positive C. difficile toxin, and no recent (12 weeks) discharge from a health care facility. We selected controls from the same clinics attended by cases. We collected clinical and exposure data at the time of illness and cultured residual stool samples and performed ribotyping. RESULTS Of 1041 adult C. difficile infections, 162 (15.5%) met criteria for community-associated: 66 case and 114 control patients were enrolled. Case patients were relatively young (median 64 years), female (56%), and frequently required hospitalization (38%). Antimicrobials, malignancy, exposure to high-risk persons, and remote health care exposure were independently associated with community-associated C. difficile infection. In 40% of cases, we could not confirm recent antibiotic exposure. Stomach-acid suppressants were not associated with community-associated infection, and 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors appeared protective. Prevalence of the hypervirulent NAP-1/027 strain was infrequent (17%). CONCLUSIONS Community-associated C. difficile infection resulted in a substantial health care burden. Antimicrobials are a significant risk factor for community-associated infection. However, other unique factors also may contribute, including person-to-person transmission, remote health care exposures, and 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors. A role for stomach-acid suppressants in community-associated C. difficile infection is not supported.

Minorities, the poor, and survivors of abuse: HIV-infected patients in the US deep South

Background: The HIV/AIDS epidemic in the U.S. South is undergoing a marked shift toward a greater proportion of new HIV/AIDS cases in women, African-Americans, and through heterosexual transmission. Methods: Using consecutive sampling, 611 participants were interviewed from eight Infectious Diseases clinics in five southeastern states in 2001 to 2002. Results: Sixty four percent of participants were African-American, 31% were female, and 43% acquired HIV through heterosexual sex; 25% had private health insurance. Eighty-one percent were on antiretroviral therapy, and 46% had HIV RNA viral loads (VL) <400. Women and racial/ethnic minorities were less likely to be on antiretrovirals and to have VL <400. Probable psychiatric disorders (54%) and history of childhood sexual (30%) and physical abuse (21%) were common. Conclusions: Prevention and care systems need to address the HIV epidemic’s shift into poor, minority, and female populations. High levels of trauma and probable psychiatric disorders indicate a need to assess for and address these conditions in HIV clinical care.

Overload: impact of incident stressful events on antiretroviral medication adherence and virologic failure in a longitudinal, multisite human immunodeficiency virus cohort study.

Objective: To examine the influence of incident stressful experiences on antiretroviral medication adherence and treatment outcomes. Past trauma history predicts poorer medication adherence and health outcomes. Human immunodeficiency virus (HIV)-infected individuals experience frequently traumatic and stressful events, such as sexual and physical assault, housing instability, and major financial, employment, and legal difficulties. Methods: We measured prospectively incident stressful and traumatic events, medication adherence, and viral load over 27 months in an eight-site, five-state study. Using multivariable logistic and generalized estimating equation modeling, we assessed the impact of incident stressful events on 27-month changes in self-reported medication adherence and virologic failure (viral load = ≥400 c/mL). Results: Of 474 participants on antiretroviral therapy at baseline, 289 persons were interviewed and still received treatment at 27 months. Participants experiencing the median number of incident stressful events (n = 9) had over twice the predicted odds (odds ratio = 2.32) of antiretroviral medication nonadherence at follow-up compared with those with no events. Stressful events also predicted increased odds of virologic failure during follow-up (odds ratio = 1.09 per event). Conclusions: Incident stressful events are exceedingly common in the lives of HIV-infected individuals and negatively affect antiretroviral medication adherence and treatment outcomes. Interventions to address stress and trauma are needed to improve HIV outcomes. ARV = antiretroviral therapy; ASI = Addiction Severity Index; BSI = Brief Symptoms Inventory; CHASE = coping with HIV/AIDS in the Southeast; CI = Confidence Interval; OR = odds ratio; PLWHA = people living with HIV/AIDS; VL = viral load.