Psychosocial correlates of HIV-monoinfection and HIV/HCV-coinfection among men who have sex with men

Structural Inequities, Syndemics, and Resilience: The Critical Role of Social Support in Overcoming Barriers and Empowering Engagement in HIV Care for Young Black Sexual-Minority Men in the US South

Young Black sexual minority men (YBSMM) living in the US South are among those most disproportionately impacted by HIV in the USA. This health inequity is, in part, due to lower rates of sustained engagement in the HIV care continuum, resulting in a lower prevalence of viral suppression and higher overall community-level viral load. Social, structural, and economic inequities have previously been linked with poorer HIV care engagement among YBSMM. HIV-related social support, individual-level resilience, and healthcare empowerment have been shown to be independently associated with improved HIV care engagement. The current study sought to assess the relative contribution of individual, structural, and economic factors on engagement in HIV care and to elucidate the potentially mediating role of healthcare empowerment. Data from 224 YBSMM with HIV in the US South indicated that greater levels of socioeconomic distress, intimate partner violence, and depressive symptoms were associated with lower levels of engagement in HIV care, while greater levels of individual-level resilience and healthcare empowerment were associated with higher levels of HIV care engagement. Importantly, healthcare empowerment mediated the association between resilience and engagement in HIV care and the association between social support and engagement in HIV care. Findings emphasize the critical role that HIV-related social support plays in fostering resilience and overcoming syndemic factors to promote empowerment and engagement in HIV care for YBSMM in the USA.

"I'm Gay With an Asterisk": How Intersecting Identities Influence LGBT Strengths

Research attributes health disparities between sexual minority (those whose sexual orientation and/or practices differ from society, [SM]) and heterosexual populations to social marginalization. LGBT strengths (e.g., resiliency derived from LGBT identity) may reduce the impact of social marginalization. However, it is unclear how LGBT strengths are impacted by SMs' other identities (e.g., racial/ethnic and/or gender). To address this knowledge gap, the present study examined data from the LGBT Stress/Strength project, a qualitative research study investigating minority stress and LGBT strengths in relation to drinking. Participants (N = 22) were self-identified SMs in the northeastern U.S. Transcripts from in-depth interviews were coded using thematic analysis. Participants reported social support from other SMs and empathy toward others were forms of LGBT strength. Sampled SMs assigned female at birth had more intergenerational friendships and relied more on social support than those assigned male at birth. In addition, Black, indigenous, and people of color (BIPOC) participants described social marginalization from within the LGBT community, which reduced their reliance on social support. Our results suggest that LGBT strengths are influenced by LGBT community members intersecting identities. More research can expand upon these results by investigating how the confluence of SMs identities and LGBT strengths impact health disparities.

Care of Sexual and Gender Minorities in the Emergency Department: A Scoping Review

STUDY OBJECTIVE

This scoping review was conducted to collate and summarize the published research literature addressing sexual and gender minority care in the emergency department (ED).

METHODS

Using PRISMA-ScR criteria, an electronic search was conducted of CINAHL, Embase, Ovid Medline, and Web of Science for all studies that were published after 1995 involving sexual and gender minorities, throughout all life stages, presenting to an ED. We excluded non-US and Canadian studies and editorials. Titles and abstracts were screened, and full-text review was performed independently with 4 reviewers. Abstraction focused on study design, demographics, and outcomes, and the resulting data were analyzed using an ad hoc iterative thematic analysis.

RESULTS

We found 972 unique articles and excluded 743 after title and abstract screening. The remaining 229 articles underwent full-text review, and 160 articles were included. Themes identified were HIV in sexual and gender minorities (n=61), population health (n=46), provider training (n=29), ED avoidance or barriers (n=23), ED use (n=21), and sexual orientation/gender identity information collection (n=9).

CONCLUSION

The current literature encompassing ED sexual and gender minority care cluster into 6 themes. There are considerable gaps to be addressed in optimizing culturally competent and equitable care in the ED for this population. Future research to address these gaps should include substantial patient stakeholder engagement in all aspects of the research process to ensure patient-focused outcomes congruent with sexual and gender minority values and preferences.

Prevalence and predictors of medication non-adherence among people living with multimorbidity: a systematic review and meta-analysis

OBJECTIVES

This systematic review aimed to describe medication non-adherence among people living with multimorbidity according to the current literature, and synthesise predictors of non-adherence in this population.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses. PubMed, EMBASE, CINAHL and PsycINFO were searched for relevant articles published in English language between January 2009 and April 2019. Quantitative studies reporting medication non-adherence and/or predictors of non-adherence among people with two or more chronic conditions were included in the review. A meta-analysis was conducted with a subgroup of studies that used an inclusive definition of multimorbidity to recruit participants, rather than seeking people with specific conditions. Remaining studies reporting prevalence and predictors of non-adherence were narratively synthesised.

RESULTS

The database search produced 10 998 records and a further 75 were identified through other sources. Following full-text screening, 178 studies were included in the review. The range of reported non-adherence differed by measurement method, at 76.5% for self-report, 69.4% for pharmacy data, and 44.1% for electronic monitoring. A meta-analysis was conducted with eight studies (n=8949) that used an inclusive definition of multimorbidity to recruit participants. The pooled prevalence of non-adherence was 42.6% (95% CI: 34.0 - 51.3%, k=8, I²=97%, p<0.01). The overall range of non-adherence was 7.0%-83.5%. Frequently reported correlates of non-adherence included previous non-adherence and treatment-related beliefs.

CONCLUSIONS

The review identified a heterogeneous literature in terms of conditions studied, and definitions and measures of non-adherence used. Results suggest that future attempts to improve adherence among people with multimorbidity should determine for which conditions individuals require most support. The variable levels of medication non-adherence highlight the need for more attention to be paid by healthcare providers to the impact of multimorbidity on chronic disease self-management.

PROSPERO REGISTRATION NUMBER

CRD42019133849.

Estimating an individual-level deprivation index for HIV/HCV coinfected persons in Canada

Background

HIV-HCV coinfected individuals are often more deprived than the general population. However, deprivation is difficult to measure, often relying on aggregate data which does not capture individual heterogeneity. We developed an individual-level deprivation index for HIV-HCV co-infected persons that encapsulated social, material, and lifestyle factors.

Methods

We estimated an individual-level deprivation index with data from the Canadian Coinfection Cohort, a national prospective cohort study. We used a predetermined process to select 9 out of 19 dichotomous variables at baseline visit to include in the deprivation model: income >$1500/month; education >high school; employment; identifying as gay or bisexual; Indigenous status; injection drug use in last 6 months; injection drug use ever; past incarceration, and past psychiatric hospitalization. We fitted an item response theory model with: severity parameters (how likely an item was reported), discriminatory parameters, (how well a variable distinguished index levels), and an individual parameter (the index). We considered two models: a simple one with no provincial variation and a hierarchical model by province. The Widely Applicable Information Criterion (WAIC) was used to compare the fitted models. To showcase a potential utility of the proposed index, we evaluated with logistic regression the association of the index with non-attendance to a second clinic visit (as a proxy for disengagement) and using WAIC compared it to a model containing all the individual parameters that compose the index as covariates.

Results

We analyzed 1547 complete cases of 1842 enrolled participants. According to the WAIC the hierarchical model provided a better fit when compared to the model that does not consider the individual’s province. Values of the index were similarly distributed across the provinces. Overall, past incarceration, education, and unemployment had the highest discriminatory parameters. However, in each province different components of the index were associated with being deprived reflecting local epidemiology. For example, Saskatchewan had the highest severity parameter for Indigenous status while Quebec the lowest. For the secondary analysis, 457 (30%) failed to attend a second visit. A one-unit increase in the index was associated with 17% increased odds (95% credible interval, 2% to 34%) of not attending a second visit. The model with just the index performed better than the model with all the components as covariates in terms of WAIC.

Conclusion

We estimated an individual-level deprivation index in the Canadian Coinfection cohort. The index identified deprivation profiles across different provinces. This index and the methodology used may be useful in studying health and treatment outcomes that are influenced by social disparities in co-infected Canadians. The methodological approach described can be used in other studies with similar characteristics.

The prevalence of depression in men who have sex with men (MSM) living with HIV: A meta-analysis of comparative and epidemiological studies

BACKGROUND

Men who have sex with men (MSM) living with Human Immunodeficiency Virus (HIV) are more likely to suffer from depressive symptoms (depression hereafter). This is a comprehensive meta-analysis of the prevalence of depression in HIV-infected MSM.

METHODS

Relevant publications were systematically searched in PubMed, PsycINFO, EMBASE, Cochrane Library and Web of Science. Comparative and epidemiological studies with prevalence of depression as measured by the Center for Epidemiological Studies Depression Scale (CES-D) were included. The prevalence of depression was pooled using the random-effects model.

RESULTS

A total of 18 studies with 7653 MSM with HIV and 3395 MSM without HIV were included in the meta-analysis. The pooled prevalence of depression in MSM living with HIV was 43% (95%CI: 32%-53%). Compared to MSM without HIV, MSM living with HIV were more likely to be depressed (OR = 1.46, 1.05-2.03). Subgroup and meta-regression analyses revealed that different CES-D cut-off values and survey year had significant moderating effects on the prevalence of depression.

CONCLUSIONS

Depression was common in MSM living with HIV. Considering the negative effects of depression on health outcomes and wellbeing, regular screening for depression and effective treatment and interventions should be developed for this vulnerable population.

Depression in HIV and HCV co-infected patients: a systematic review and meta-analysis

The aim of this study was to carry out a systematic review and meta-analysis of the differences in the prevalence of depression and presence of depressive symptoms between HIV/HCV co-infection, HIV mono-infection, and hepatitis C virus (HCV) mono-infection. A systematic electronic search of bibliographic databases was performed to locate articles published from the earliest available online until December 2014. Outcomes of depression were based on clinical interviews and validated self-reported measures of depression/depressive symptoms. Of the 188 records initially screened, 29 articles were included in the descriptive systematic review and six were included in the meta-analysis. The meta-analytic results indicated that, as measured by self-reported measures of depression, HIV/HCV co-infected patients were significantly more likely to report depressive symptoms than either HIV (SMD = .24, 95% CI: .03-.46, p = .02) or HCV mono-infected (SMD = .55, 95% CI: .17-.94, p = .005) patients. The variability of the results of the reviewed studies, largely dependent on the samples' characteristics and the methods of assessment of depression, suggests that a clear interpretation of how depression outcomes are affected by the presence of HIV/HCV co-infection is still needed. Failing to diagnose depression or to early screen depressive symptoms may have a significant impact on patients' overall functioning and compromise treatments' outcomes.

Differential predictors of ART adherence among HIV-monoinfected versus HIV/HCV-coinfected individuals

Although adherence is an important key to the efficacy of antiretroviral therapy (ART), many people living with HIV (PLWH) fail to maintain optimal levels of ART adherence over time. PLWH with the added burden of Hepatitis C virus (HCV) coinfection possess unique challenges that potentially impact their motivation and ability to adhere to ART. The present investigation sought to (1) compare ART adherence levels among a sample of HIV/HCV-coinfected versus HIV-monoinfected patients, and (2) identify whether ART-related clinical and psychosocial correlates differ by HCV status. PLWH receiving ART (N = 215: 105 HIV/HCV-coinfected, 110 HIV-monoinfected) completed a comprehensive survey assessing ART adherence and its potential correlates. Medical chart extraction identified clinical factors, including liver enzymes. Results demonstrated that ART adherence did not differ by HCV status, with 83.7% of coinfected patients and 82.4% of monoinfected patients reporting optimal (i.e., ≥95%) adherence during a four-day recall period (p = .809). Multivariable logistic regression demonstrated that regardless of HCV status, optimal ART adherence was associated with experiencing fewer adherence-related behavioral skills barriers (AOR = 0.56; 95%CI = 0.43-0.73), lower likelihood of problematic drinking (AOR = 0.15; 95%CI = 0.04-0.67), and lower likelihood of methamphetamine use (AOR = 0.14; 95%CI = 0.03-0.69). However, among HIV/HCV-coinfected patients, optimal adherence was additionally associated with experiencing fewer ART adherence-related motivational barriers (AOR = 0.23; 95%CI = 0.08-0.62) and lower likelihood of depression (AOR = 0.06; 95%CI = 0.00-0.84). Findings suggest that although HIV/HCV-coinfected patients may face additional, distinct barriers to ART adherence, levels of adherence commensurate with those demonstrated by HIV-monoinfected patients might be achievable if these barriers are addressed.

Hepatitis C virus infection as a traumatic experience

OBJECTIVE

The purpose of this study was to evaluate whether individuals consider their HCV infection to be a potentially traumatic experience. Additionally, we investigated its association with Post-Traumatic Stress Disorder (PTSD) and the impact of PTSD diagnosis on health-related quality of life (HRQoL) in HCV infected subjects.

METHODS

We conducted a cross-sectional survey of 127 HCV-infected outpatients recruited at a University Hospital in Salvador, Brazil. All subjects answered an orally-administered questionnaire to gather clinical and socio-demographic data. We investigated traumatic experiences and the subject's perception of the disease using the Trauma History Questionnaire. PTSD and other psychiatric diagnoses were assessed through the Mini International Neuropsychiatric Interview-Brazilian Version 5.0.0 (M.I.N.I. PLUS). HRQoL was assessed using Short-Form 36 (SF-36).

RESULTS

Approximately 38.6% of the patients considered hepatitis C to be a traumatic experience. Of these, 60.7% had a PTSD diagnosis. PTSD was associated with significant impairment in quality of life for individuals in seven SF-36 domains as shown bymultivariate analysis: Role-Physical (β: -24.85; 95% CI: -42.08; -7.61), Bodily Pain (β: -19.36; 95% CI: -31.28; -7.45), General Health (β: -20.79; 95% CI: -29.65; -11.92), Vitality (β: -11.92; 95% CI: -20.74; -3.1), Social Functioning (β: -34.73; 95% CI: -46.79; -22.68), Role-Emotional (β: -26.07; 95% CI: -44.61; -7.53), Mental Health (β: -17.46; 95% CI: -24.38; -10.54).

CONCLUSION

HCV is frequently a traumatic experience and it is strongly associated with PTSD diagnosis. PTSD significantly impaired HRQoL.

Significant differences in clinical outcomes between HIV-hepatitis C virus coinfected individuals with and without injection drug use history

OBJECTIVE

Studies focusing on HIV-hepatitis C virus (HCV) coinfected individuals without a history of IDU are limited. It is plausible that poorer clinical outcomes in HIV-HCV coinfection are due to factors associated with IDU, not from HCV itself. This study compares HIV treatment outcomes and survival between HIV-HCV coinfected individuals with and without IDU history.

DESIGN

Observational cohort study.

METHODS

We analyzed data from a multisite Canadian cohort study of HIV-positive individuals initiating combination antiretroviral therapy (ART) after 1 January 2000. This analysis was restricted to 1254 participants with HCV coinfection and known IDU history. Cox proportional hazards regression was used to evaluate time from ART initiation to virologic suppression (two consecutive measures <250 copies/ml) and CD4 cell count recovery (+100 cells/μl). In order to account for loss to follow-up (LTFU), competing risk analysis was used to evaluate time to death.

RESULTS

A total of 1254 participants (31% women) were included. During a median follow-up time of 3.8 years (interquartile range = 2.1-6.2), 217 deaths were reported and 148 participants were LTFU. In adjusted multivariable analysis, individuals with IDU history were significantly less likely to achieve virologic suppression [adjusted hazard ratio (AHR) = 0.78, 95% confidence interval (CI) = 0.64-0.95]; marginally less likely to have CD4 cell count recovery (AHR = 0.82, 95% CI = 0.66-1.00); and had a significantly higher risk of death (AHR = 2.15, 95% CI = 1.25-3.70).

CONCLUSION

IDU history independently elevates risk for poorer clinical outcomes, separate from HCV coinfection. HIV-HCV coinfected persons are not homogeneous in characteristics or outcomes, suggesting care should be taken during statistical analyses if attributing poorer HIV-specific outcomes solely to HCV coinfection.

Depression and HIV Risk Taking among Men Who Have Sex with Other Men (MSM) and Who Use the Internet to Find Partners for Unprotected Sex

PURPOSE

This study examines the prevalence of depression in a sample of MSM who are at high risk for HIV. It examines the relationship between depressive symptomatology and involvement in HIV risk behaviors, and the factors associated with greater depressive symptomatology.

METHODS

The data come from a national random sample of 332 MSM who used any of 16 websites to identify men with whom they could engage in unprotected sex. Data were collected via telephone interviews.

RESULTS

Depression was more prevalent in this population (26.7%) than among men in the general population. Depression was not related directly to any of the HIV risk behaviors examined, but it was related to men's attitudes toward condom use, which was the strongest predictor of their involvement in risky behaviors. Five factors were identified as being associated with greater depression: lower educational attainment, greater discrimination based on sexual orientation, greater eroticizing of ejaculatory fluids, experiencing more substance abuse problems, and greater childhood maltreatment.

CONCLUSIONS

Depression is a consequential problem in this population. Although depression does not appear to be related directly to HIV risk practices in this population, its influence cannot be discounted because of its effects on other key predictors of risk involvement.

Anti-retroviral drugs do not facilitate hepatitis C virus (HCV) infection in vitro

An estimated 4 to 5 million people are co-infected with HIV/HCV worldwide. Recently observed outbreaks of acute HCV infection among HIV-positive men who have sex with men (MSM) have been linked to behavioral factors such as high risk sexual practices and recreational drug use. However, at the molecular level, many drugs such as glucocorticoids or cyclosporine A have been found to modulate viral replication. Thus, it is conceivable that drugs used in highly active antiretroviral therapy (HAART) may heighten susceptibility to HCV infection and contribute to the recent outbreaks. We therefore performed a comprehensive screen of antiretroviral drugs covering all available drug classes both individually and in typical combinations used during HAART to probe for direct effects on HCV cell entry, replication, new particle assembly and release. Importantly, no significant enhancement or inhibition of HCV cell entry, replication or new particle production was detected. While raltegravir and ritonavir boosted atazanavir reduce HCV replication, a tenfold reduction of HCVcc entry by the CCR5 antagonist maraviroc was observed. In conclusion, commonly used HAART agents do not specifically enhance HCV replication. Thus recent epidemic outbreaks of acute HCV in HIV-infected MSM are unlikely to be related to enhancing effects of HAART drugs.