Rebecca M. Schwartz

Crack cocaine, disease progression, and mortality in a multicenter cohort of HIV-1 positive women.

Background:Longitudinal associations between patterns of crack cocaine use and progression of HIV-1 disease are poorly understood, especially among women. This study explores relationships between crack use and HIV-1 disease outcomes in a multicenter cohort of infected women. Methods:Subjects were 1686 HIV-seropositive women enrolled at six US research centers in the Womens Interagency HIV Study. Approximately 80% were non-white and 29% used crack during the study period. Cox survival and random regression analysis examined biannual observations made April 1996 through September 2004. Outcome measures included death due to AIDS-related causes, CD4 cell count, HIV-1 RNA level, and newly acquired AIDS-defining illnesses. Results:Persistent crack users were over three times as likely as non-users to die from AIDS-related causes, controlling for use of HAART self-reported at 95% or higher adherence, problem drinking, age, race, income, education, illness duration, study site, and baseline virologic and immunologic indicators. Persistent crack users and intermittent users in active and abstinent phases showed greater CD4 cell loss and higher HIV-1 RNA levels controlling for the same covariates. Persistent and intermittent crack users were more likely than non-users to develop new AIDS-defining illnesses controlling for identical confounds. These results persisted when controlling for heroin use, tobacco smoking, depressive symptoms, hepatitis C virus coinfection, and injection drug use. Conclusion:Use of crack cocaine independently predicts AIDS-related mortality, immunologic and virologic markers of HIV-1 disease progression, and development of AIDS-defining illnesses among women.

The impact of mental health and substance abuse factors on HIV prevention and treatment.

The convergence of HIV, substance abuse (SA), and mental illness (MI) represents a distinctive challenge to health care providers, policy makers, and researchers. Previous research with the mentally ill and substance-abusing populations has demonstrated high rates of psychiatric and general medical comorbidity. Additionally, persons living with HIV/AIDS have dramatically elevated rates of MI and other physical comorbidities. This pattern of co-occurring conditions has been described as a syndemic. Syndemic health problems occur when linked health problems involving 2 or more afflictions interact synergistically and contribute to the excess burden of disease in a population. Evidence for syndemics arises when health-related problems cluster by person, place, or time. This article describes a research agenda for beginning to understand the complex relations among MI, SA, and HIV and outlines a research agenda for the Social and Behavioral Science Research Network in these areas.

Perinatal Depressive Symptoms in HIV-Infected Versus HIV-Uninfected Women: A Prospective Study from Preconception to Postpartum

OBJECTIVE Depression is common among HIV-infected women, predicts treatment nonadherence, and consequently may impact vertical transmission of HIV. We report findings from a study evaluating preconception, pregnancy, and postpartum depressive symptoms in HIV-infected vs. at-risk, HIV-uninfected women. METHODS We examined the prevalence and predictors of elevated perinatal (i.e., pregnancy and/or postpartum) depressive symptoms using a Center for Epidemiological Studies-Depression (CES-D) scale score of ≥16 in 139 HIV-infected and 105 HIV-uninfected women (62% African American) from the Womens Interagency HIV Study (WIHS). RESULTS The prevalence of elevated perinatal depressive symptoms did not differ by HIV serostatus (HIV-infected 44%, HIV-uninfected 50%, p=0.44). Among HIV-infected women, the strongest predictor of elevated symptoms was preconception depression (odds ratio [OR] 5.71, 95% confidence interval [CI] 2.67-12.19, p<0.001); crack, cocaine, and/or heroin use during preconception was marginally significant (OR 3.10, 95% CI 0.96-10.01, p=0.06). In the overall sample, additional significant predictors of perinatal depression included having multiple sex partners preconception (OR 2.20, 95% CI 1.12-4.32, p=0.02), use of preconception mental health services (OR 2.51, 95% CI 1.03-6.13, p=0.04), and not graduating from high school (OR 1.92, 95% CI 1.06-3.46, p=0.03). CONCLUSIONS Elevated perinatal depressive symptoms are common among HIV-infected and at-risk HIV-uninfected women. Depressive symptoms before pregnancy were the strongest predictor of perinatal symptoms. Findings underscore the importance of early and ongoing assessment and treatment to ensure low vertical transmission rates and improving postpregnancy outcomes for mothers and children.

HIV Infection and Women's Sexual Functioning

Objective:To compare sexual problems among HIV-positive and HIV-negative women and describe clinical and psychosocial factors associated with these problems. Design:Data were collected during a study visit of the Womens Interagency HIV Study (WIHS). The WIHS studies the natural and treated history of HIV among women in the United States. Methods:Between October 01, 2006, and March 30, 2007, 1805 women (1279 HIV positive and 526 HIV negative) completed a study visit that included administration of the Female Sexual Function Index. In addition, the visit included completion of standardized interviewer-administered surveys, physical and gynecological examinations, and blood sample collection. Results:Women with HIV reported greater sexual problems than did those without HIV. Women also reported lower sexual function if they were classified as menopausal, had symptoms indicative of depression, or if they reported not being in a relationship. CD4+ cell count was associated with Female Sexual Function Index scores, such that those with CD4 ≤199 cells per microliter reported lower functioning as compared with those whose cell count was 200 or higher. Conclusions:Given research documenting relationships between self-reported sexual problems and both clinical diagnoses of sexual dysfunction and womens quality of life, greater attention to this issue as a potential component of womens overall HIV care is warranted.

Association Between Living With Children and Adherence to Highly Active Antiretroviral Therapy in the Women's Interagency HIV Study

OBJECTIVE. The purpose of this work was to evaluate whether living with children adversely affects adherence to highly active antiretroviral therapy in HIV-infected women. PARTICIPANTS AND METHODS. We conducted a prospective cohort study between October 1998 and September 2005. The study outcome was ≥95% adherence to highly active antiretroviral therapy evaluated at 5832 semiannual visits among 1366 HIV-infected women in the Womens Interagency HIV Study. The primary exposure defined at the visit immediately before outcome ascertainment was the number of children ≤18 years of age reported living in the household. RESULTS. The percentage of women who reported ≥2 children in the household who also reported ≥95% adherence ranged from 68% to 75% compared with adherence when either 1 child or no children were reported. Each additional child reported living in the household was associated with a 6% decrease in the odds of ≥95% adherence. CONCLUSION. The impact of living with a child on the ability to take medications by HIV-infected women has not been examined thoroughly. Our data suggest that adherence to highly active antiretroviral therapy is inversely associated with the number of children living in the household.

Predictors of Partner Notification for C. trachomatis and N. gonorrhoeae: An Examination of Social Cognitive and Psychological Factors

Efforts to control chlamydial and gonococcal infections include notifying eligible sexual partners of possible infection, primarily by asking the diagnosed patient to notify their partners. This approach, known as patient referral, is widely used but poorly understood. The current study examined psychosocial and cognitive factors associated with patient referral among an urban, minority sample of 168 participants recently diagnosed with Chlamydia trachomatis or Neisseria gonorrhoeae. At a follow-up interview 1-month from diagnosis, participants were more likely to have notified all eligible partners if they had greater intention to notify at baseline (OR = 3.72; 95% CI = 1.34, 10.30) and if they had only one partner at baseline (OR = 4.08; 95% CI = 1.61, 10.31). There were also gender differences as well as differences based on type of partner (i.e., regular, casual, one-time). The implications of these findings for the design of programs to promote patient referral for sexually transmitted infections are discussed.

Depressive symptoms are increased in the early perimenopausal stage in ethnically diverse human immunodeficiency virus-infected and human immunodeficiency virus-uninfected women.

ObjectiveThe risk of clinically significant depressive symptoms increases during perimenopause. With highly active antiretroviral treatment (HAART), more human immunodeficiency virus (HIV)–infected women survive to transition through menopause. In a cross-sectional analysis, we evaluated the association of menopausal stage and vasomotor symptoms with depressive symptoms in an ethnically diverse cohort of women with a high prevalence of HIV. MethodsParticipants included 835 HIV-infected women and 335 HIV-uninfected controls from the Women’s Interagency HIV Study (63% African American). The Center for Epidemiologic Studies Depression Scale was used to screen for elevated depressive symptoms. Menopausal stages were defined according to standard definitions. Logistic regression analysis was used to identify predictors of elevated depressive symptoms. ResultsCompared with premenopausal women, early perimenopausal women (OR [odds ratio], 1.74; 95% CI, 1.17-2.60), but not late perimenopausal or postmenopausal women, were more likely to show elevated depressive symptoms in adjusted analyses. The odds were similar in HIV-infected and HIV-uninfected women. Persistent vasomotor symptoms also predicted elevated depressive symptoms in HIV-infected and HIV-uninfected women (OR, 1.45; 95% CI, 1.02-2.06). In HIV-infected women, menopausal stage interacted with antiretroviral use (P = 0.02); the likelihood of elevated depressive symptoms in early perimenopause compared with premenopause was especially high in HAART-untreated women (OR, 3.87; 95% CI, 1.57-9.55). ConclusionsIn HIV-infected and HIV-uninfected women, the odds of elevated depressive symptoms were significantly higher during early perimenopause. Elevated depressive symptoms were associated with nonadherence to HAART, underscoring the importance of screening and treating depressive symptoms in HIV-infected women who have experienced a change in the regularity of their menstrual cycles.

Impact of surgery for stage IA non-small-cell lung cancer on patient quality of life.

BACKGROUND There is a paucity of literature comparing quality of life (QoL) before and after surgery in stage IA lung cancer, where surgical resection is the recommended curative treatment. OBJECTIVE To assess the impact of surgery on physical and mental health-related QoL in patients with stage IA lung cancer treated with surgical resection. METHODS Participants in the I-ELCAP cohort who were diagnosed with their first primary pathologic stage IA non-small-cell lung cancer, underwent surgery, and provided follow-up information on QoL 1 year later were included in the present analysis (N = 107). QoL information was collected using the SF-12 (12-item Short Form Health Survey), which generates 2 component scores related to mental health and physical health. RESULTS Statistical analyses indicated that physical health QoL was significantly worsened from before surgery to after surgery, whereas mental health QoL marginally improved from before to after surgery. Physical health QoL worsened for women from baseline to follow-up, but not for men. Only lobectomy (not limited resection) had an impact on QoL from before to after surgery. LIMITATIONS Results are considered preliminary given the small sample size and multiple comparisons. CONCLUSIONS The current study findings have implications for lung cancer health care professionals in regard to how they can most effectively present the possible impact of surgery on quality of life to this subset of patients in which disease has not yet significantly progressed.

Decisional regret after robotic-assisted laparoscopic prostatectomy is higher in African American men

OBJECTIVES Longitudinal studies report racial disparities in prostate cancer (PCa) including greater incidence, more aggressive tumor biology, and increased cancer-specific mortality in African American (AA) men. Regret concerning primary treatment selection is underevaluated in patients with PCa. We investigated the relationships between clinicopathologic variables across racial and socioeconomic lines following robotic-assisted laparoscopic prostatectomy. MATERIALS AND METHODS We assessed treatment decisional regret using a validated questionnaire in a total of 484 white and 72 AA patients with PCa who were followed up for a median of 16.6 months post-robotic-assisted laparoscopic prostatectomy. Socioeconomic status (SES) information was aggregated from 2010 US census zip code data. Perioperative clinicopathologic characteristics and functional outcomes were compared between groups. Univariate and multivariate regression analyses were used to evaluate the influence of race, aggregate SES, and other clinical and demographic characteristics on decisional regret. RESULTS The majority (87.7%) of the population was not regretful of their decision to undergo treatment. However, a greater proportion of AA vs. white patients were regretful (20.6% vs. 11.2%, respectively; P = 0.03). AA and white men were similar on all functional, clinical, and pathologic features with the exception of younger age among AA men (56 vs. 60 y, respectively; P<0.001). Although there were significant differences in SES by race (P<0.001), regret did not differ by SES (β =-1.53; P = 0.15). Race, postoperative sexual dysfunction, pad usage, and length of hospital stay, however, were significantly associated with decisional regret. CONCLUSIONS AA men were more regretful than white men, after adjusting for clinicopathologic characteristics and postoperative functional outcomes.

Measurement of retention in care among adults infected with HIV in an urban clinic

Abstract Adults infected with HIV live longer when they receive regular medical care, yet many adults are not retained in care. Providers measure retention in order to evaluate interventions to improve retention and quality of HIV care. However, multiple measures for retention exist. This study compares two methods of operationalizing retention and evaluates the contribution of individual characteristics on the likelihood of retention. A chart review was performed for a random sample of 212 active clients of an urban HIV primary care clinic. Data on clinic utilization, sex, age, race, mental illness, substance use, AIDS diagnosis, language, and housing were collected for each participant. Clinic utilization data were used to classify participants for retention status and to score them by frequency of visits. Binary logistic regression analysis was compared with ordinal logistic regression analysis, using distinct retention measures as outcome variables. In the binary model, those with a history of substance use were about half as likely to be retained (OR 0.52, 95% CI 0.29–0.94) and those with an AIDS diagnosis were more than twice as likely to be retained (OR 2.18, 95% CI 1.17–4.09). These characteristics were significant predictors in the ordinal model, with the additional finding that those reporting English as a primary language were less likely to have higher retention scores (OR 0.40, 95% CI 0.19–0.84). An ordinal score for retention can identify unexpected predictors, but a dichotomous measure of retention may be easier to use and interpret for providers involved in retention-related quality improvement activities.