Cohort Profile: The Women's Interagency HIV Study (WIHS)

Right Censoring and Mortality in the Multicenter AIDS Cohort Study and Women's Interagency HIV Study

BACKGROUND

Epidemiologists frequently employ right censoring to handle missing outcome, covariate, or exposure data incurred when participants have large gaps between study visits or stop attending study visits entirely. But, if participants who are censored are more or less likely to experience outcomes of interest than those not censored, such censoring could introduce bias in estimated measures.

METHODS

We examined how censoring after two consecutive missed visits may affect mortality results from the Multicenter AIDS Cohort Study (MACS) and Women's Interagency HIV Study (WIHS). MACS and WIHS provide linkages to vital statistics registries, such that mortality data were available for all participants, regardless of whether they attended study visits.

RESULTS

In a gold standard analysis that did not censor after two consecutive missed visits, 10-year mortality was 23% (95% CI: 22, 24) in MACS and 21% (95% CI: 20, 23) in WIHS. Estimated mortality was modestly reduced by 0%-5% across subgroups when censoring at missed visits. Applying inverse probability of censoring weights partially removed this attenuation.

CONCLUSIONS

While mortality was slightly elevated after two consecutive missed visits in MACS and WIHS, censoring at two consecutive missed visits did not substantially alter estimated mortality, particularly after applying inverse probability of censoring weights.

Patterns of Cannabis Use among Women With HIV in the United States

Cannabis legalization in the United States changed cannabis product potency and consumption modalities. Women with HIV are an aging population with prevalent cannabis use twice that of national estimates. Because cannabis use may confer both health benefits and risks, it is important to understand cannabis use patterns among women with HIV. This analysis characterized prevalence, frequencies, and modes (smoking, vaping, eating) of cannabis use among 1,246 women with HIV in the Women's Interagency HIV Study over 18 months (2018-2019). We compared participant characteristics using chi-square tests and Wilcoxon rank-sum tests. We illustrated flow between cannabis use frequency categories with a Sankey diagram. Median participant age was 52 years (interquartile range: 46, 58). 65% of participants identified as Black/African American; 50% had annual household incomes <$12,000. The period prevalence was 27% for any cannabis use and 15% for daily or more use. 50% reported varying use frequencies. Among women using cannabis, 96% reported smoking, 30% consumed edibles, and 18% vaped. Compared with women not using cannabis, greater proportions of women using cannabis reported alcohol (69% vs. 37%, p < 0.01), cigarette (61% vs. 29%, p < 0.01) and other drug use (16% vs. 4%, p < 0.01). Compared to those with no high potency use, a higher proportion of women using high potency products were in a state legalizing cannabis sales. Cannabis use among women with HIV is common and of variable frequency. Future work should characterize patterns of use, product choice motivations, and associated health impacts in the context of aging and HIV.

High and Rapid Uptake of COVID-19 Vaccine Among Chicago Women with and Without HIV

Background

Chicago sustained substantial COVID-19 morbidity and mortality with greatest burdens among low-income communities of color. We sought to determine the prevalence and predictors of vaccine uptake and refusal over 3 years among a long-term cohort of Chicago women with/without HIV (WWH/WWoH).

Methods

Research staff provided outreach and collected data on COVID-19 knowledge, vaccine intent, uptake, and refusal quarterly during 2020 and then semiannually through 2023. 146 women (102 WWH and 44 WWoH) participated.

Results

Among 146 women, mean age was 54.4 years, 70% were WWH; predominantly Black (63%), unemployed (73%), 58% had ≤$18,000 annual household income, 63% had a high school education or less, and 65% had one or more comorbidities. Initially, 46% of women reported no intent to be vaccinated and were more likely to be employed, report medical mistrust and not living with HIV. By September 2023, 88% of women received at least one vaccination and 86% received the full series of doses. Vaccine uptake was lowest among those who were younger, less educated, heavier drinkers and marijuana users, and had fewer comorbidities including lower BMI and diabetes.

Conclusions

While initial vaccination non-intent was high, we observed higher-than-expected and more rapid COVID-19 vaccine uptake among vulnerable women of color engaged in a long-term research initiative relative to Chicago residents overall. Lower education, higher alcohol and marijuana use, and lower COVID morbidity and mortality risks were predictors of not receiving COVID vaccination. Understanding and addressing factors associated with vaccine refusal should be a key component of future pandemic preparedness initiatives.

Healthy Aging and the Gut Microbiome in People With and Without HIV

BACKGROUND

Aging-related comorbidities are more common in people with human immunodeficiency virus (HIV) compared to people without HIV. The gut microbiome may play a role in healthy aging; however, this relationship remains unexplored in the context of HIV.

METHODS

16S rRNA gene sequencing was conducted on stool from 1409 women (69% with HIV; 2304 samples) and 990 men (54% with HIV; 1008 samples) in the MACS/WIHS Combined Cohort Study. Associations of age with gut microbiome diversity, uniqueness, and genus-level abundance were examined in women and men separately, followed by examining relationships of aging-related genera with frailty (Fried frailty phenotype) and mortality risk (Veterans Aging Cohort Study [VACS] index).

RESULTS

Older age was associated with greater microbiome diversity and uniqueness, greater abundance of Akkermansia and Streptococcus, and lower abundance of Prevotella and Faecalibacterium, among others; findings were generally consistent by sex and HIV status. An aging-related microbiome score, generated via combination of 18 age-related genera, significantly increased with age in both women and men independently of demographic, behavioral, and cardiometabolic factors. In general, age was more strongly related to microbiome features (eg, diversity, microbiome score) in men without compared to with HIV, but age-microbiome associations were similar in women with and without HIV. Some age-related genera associated with healthy/unhealthy aging, such as Faecalibacterium (related to reduced frailty) and Streptococcus (related to higher VACS index).

CONCLUSIONS

Age is associated with consistent changes in the gut microbiome in both women and men with or without HIV. Some aging-related microbiota are associated with aging-related declines in health.

Exploring the role of motherhood in healthcare engagement for women living with HIV in the USA

Mothers living with HIV are faced with managing their own complex healthcare and wellness needs while caring for their children. Understanding the lived experiences of mothers living with HIV, including grandmothers and mothers with older children - who are less explicitly represented in existing literature, may guide the development of interventions that best support them and their families. This study sought to explore the role of motherhood and related social/structural factors on engagement with HIV care, treatment-seeking behaviour, and overall HIV management among mothers living with HIV in the USA to inform such efforts. Semi-structured interviews were conducted between June and December 2015 with 52 mothers living with HIV, recruited from the Women's Interagency HIV Study (WIHS) sites in four US cities. Five broad themes were identified from the interviews: children as a motivation for optimal HIV management; children as providing logistical support for HIV care and treatment; the importance of social support for mothers; stressors tied to responsibilities of motherhood; and stigma about being a mother living with HIV. Findings underscore the importance of considering the demands of motherhood when developing more effective strategies to support mothers in managing HIV and promoting the overall health and well-being of their families.

Brief Report: The Implications of Removing Race From Interpretation of Pulmonary Function Among Persons With or Without HIV

BACKGROUND

Studies suggest that the use of race-specific pulmonary function reference equations may obscure racial inequities in respiratory health. Whether removing race from the interpretation of pulmonary function would influence analyses of HIV and pulmonary function is unknown.

SETTING

Pulmonary function measurements from 1067 men (591 with HIV) in the Multicenter AIDS Cohort Study and 1661 women (1175 with HIV) in the Women's Interagency HIV Study were analyzed.

METHODS

Percent-of-predicted values for spirometry and single-breath diffusing capacity of carbon monoxide (DLCO) measurements were generated with race-specific reference equations derived from the National Health and Nutrition Examination Survey and with the race-neutral application of reference equations derived from the Global Lung Function Initiative database. Regression models were used to evaluate the association between HIV and percent-of-predicted measures of pulmonary function. Alpaydin's F test was used to compare how well these values predicted self-reported respiratory health-related quality of life.

RESULTS

Persons with HIV were observed to have significantly lower percent-of-predicted diffusing capacity for carbon monoxide (DLCO) than those without HIV but no significant differences in spirometric measures of pulmonary function, regardless of whether a race-specific or race-neutral approach was used. Among men, but not women, the race-neutral application of reference equations to generate percent-of-predicted DLCO values performed better for predicting respiratory-related quality of life.

CONCLUSIONS

The race-neutral application of pulmonary function reference equations continues to identify lung function impairment in persons with or at risk for HIV and, for DLCO, may be superior to the use of race-specific reference equations in identifying clinically relevant impairments.

Short and Long-term Body Weight Change Following the Switch to or the Addition of Integrase Inhibitors in Persons With HIV Differs by Sex

BACKGROUND

Sex-specific, long-term, body weight change in persons with human immunodeficiency virus (PWH) following switch to regimens containing integrase strand transfer inhibitors (INSTIs) is unknown.

METHODS

We compared PWH enrolled in the MACS/WIHS Combined Cohort Study (2007-2020) who switched/added an INSTI to their antiretroviral therapy (ART) regimen to those remaining on non-INSTI ART and to people without human immunodeficiency virus (PWOH), by sex. Follow-up time was time since switch visit (or comparable visit in controls). Linear regression mixed-effects models assessed the effects of sex, group, and time upon weight and anthropometric measurements.

RESULTS

Of 3464 participants included, women (411 INSTI, 709 non-INSTI, 818 PWOH) compared to men (223 INSTI, 412 non-INSTI, 891 PWOH) were younger (47.2 vs 54.5 years), were majority non-Hispanic Black (65% vs 23%), and had higher mean body mass index (31.5 vs 26.9 kg/m2), respectively. Women switching to INSTIs experienced greater absolute and percentage weight gain compared to men at 5 years: +3.0 kg (95% confidence interval [CI], 2.1-3.9) versus +1.8 kg (95% CI, .7-2.9) and +4.6% (95% CI, 3.5%-5.7%) versus +2.3% (95% CI, 1.0%-3.6%), respectively ([sex × time × group interaction, P < .01). Compared to men, women switching to INSTIs experienced greater hip and thigh circumference gain at 5 years: +2.6 cm (95% CI, 1.6-3.6) versus +1.2 cm (95% CI, .3-2.1) and +1.5 cm (95% CI, .7-2.2) versus -0.2 cm (95% CI, -.9 to .5), respectively.

CONCLUSIONS

Weight change among PWH over 5 years after switch to INSTI was 2-fold higher in women than men. The cardiometabolic implications of this difference in weight gain remain unknown.

Cognitive Predictors of Everyday Functioning in Older Virally Suppressed Women with HIV in the Women's Interagency HIV Study

In the Women's Interagency HIV Study, we examined the association between objective cognitive test performance and the self-rated Lawton and Brody scale of Independent Activities of Daily Living (IADL) in 754 older (50+) women with HIV (WWH; 84% virally suppressed). To handle this longitudinal data, weighted logistic mixed effect models examined associations between cognitive domain performance (predictor) and functional outcomes (IADL item level scores). In the total sample, poorer motor performance was associated with impairments in home repairs, housekeeping, and laundry and poorer executive functioning was associated with impairment in planning social activities. Among older virally suppressed-WWH, poorer motor performance was associated with deficits in home repair and poorer executive performance was associated with deficits in planning social activities. Since motor and executive performance were related to impairments in certain IADLs, strategies such as cognitive training targeting these domains could improve everyday functioning.

Aberrant DNA methylation of genes regulating CD4+ T cell HIV-1 reservoir in women with HIV

BACKGROUND

The HIV-1 reservoir in CD4+ T cells (HRCD4) pose a major challenge to curing HIV, with many of its mechanisms still unclear. HIV-1 DNA integration and immune responses may alter the host's epigenetic landscape, potentially silencing HIV-1 replication.

METHODS

This study used bisulphite capture DNA methylation sequencing in CD4+ T cells from the blood of 427 virally suppressed women with HIV to identify differentially methylated sites and regions associated with HRCD4.

RESULTS

The average total HRCD4 size was 1409 copies per million cells, with most proviruses defective and only a small proportion intact. The study identified 245 differentially methylated CpG sites and 85 regions linked to HRCD4 size, with 52% of significant sites in intronic regions. Genes associated with HRCD4 were involved in viral replication, HIV-1 latency and cell growth and apoptosis. HRCD4 size was inversely related to DNA methylation of interferon signalling genes and positively associated with methylation at known HIV-1 integration sites. HRCD4-associated genes were enriched on the pathways related to immune defence, transcription repression and host-virus interactions.

CONCLUSIONS

These findings suggest that HIV-1 reservoir is linked to aberrant DNA methylation in CD4+ T cells, offering new insights into epigenetic mechanisms of HIV-1 latency and potential molecular targets for eradication strategies.

KEY POINTS

Study involved 427 women with HIV. Identified 245 aberrant DNA methylation sites and 85 methylation regions in CD4+ T cells linked to the HIV-1 reservoir. Highlighted genes are involved in viral replication, immune defence, and host genome integration. Findings suggest potential molecular targets for eradication strategies.

Non-invasive markers of hepatic steatosis and fibrosis following INSTI initiation in women with HIV

BACKGROUND

The impact of integrase strand-transfer inhibitors (INSTIs) on steatotic liver disease in women with HIV (WWH) is unknown.

METHODS

Using data collected in the Women's Interagency HIV Study from 2007-2020, change in Fibrosis-4 index (FIB4), aspartate aminotransferase to platelet ratio index (APRI), and non-alcoholic fatty liver disease fibrosis score (NFS) over 5 years was compared between virologically-suppressed WWH who switched to or added an INSTI to their antiretroviral therapy (ART) and WWH remaining on non-INSTI ART. In participants with transient elastography (TE) measures, estimates of hepatic steatosis (controlled attenuation parameter, CAP), fibrosis (liver stiffness, LS), and steatohepatitis (FibroScan-aspartate aminotransferase scores, FAST) were compared by group.

RESULTS

A total of 872 WWH (323 INSTI, 549 non-INSTI) were included, and 280 (146 INSTI, 134 non-INSTI) had TE. Of these, 61% were Non-Hispanic Black; mean age was 47 years and body mass index was 31.4 kg/m2. Among non-obese women, those in the INSTI compared to the non-INSTI group had a greater increase in NFS (but not FIB4 or APRI) over time (study group*time, p=0.015). Those in the INSTI compared to non-INSTI group also had greater CAP (+25, 95%CI:0.28-49, p=0.048), LS (+1.23, 1.01-1.49, p=0.038), and FAST scores (+1.97, 1.17-3.31, p=0.011) and a 3.7 (1.2-11.4, p=0.021) greater odds of having hepatic steatosis (CAP≥248 dB/m) within 1 year of starting an INSTI.

CONCLUSIONS

Hepatic steatosis risk was increased only within the first year following INSTI initiation among WWH. Longitudinal hepatic assessments are warranted to evaluate whether these changes are associated with clinically significant liver disease.

Posttraumatic Stress Disorder Is Associated With Endothelial Dysfunction in Women With HIV

BACKGROUND

HIV induced endothelial dysfunction (ED) contributes to cardiovascular disease (CVD) in women with HIV (WWH). Although psychosocial stress has been implicated in the development of CVD in HIV, its impact on ED in WWH remains unknown.

OBJECTIVES

The authors hypothesized that posttraumatic stress disorder (PTSD) and HIV interact to contribute to ED in WWH.

METHODS

We enrolled 87 women from the Women's Interagency HIV Study in Atlanta, Georgia, who reported previous trauma and completed the PTSD Checklist: Civilian Version (PCL-C), which assesses PTSD symptom severity (PCL-C score) and PTSD status (PCL-C >44). Brachial artery flow-mediated dilation (FMD) was measured to assess endothelial function. The impact of PTSD, HIV, and their interaction on endothelial function was evaluated using linear regression models adjusted for demographics, CVD risk factors, depressive symptoms, and statin use.

RESULTS

Overall, 55 (63.2%) had HIV, 24 (27.5%) had PTSD, and 13 (14.9%) had both. Those with PTSD were more likely to smoke (18 [75%] vs 28 [44.4%], P = 0.02) and have depressive symptoms (14 [58.3%] vs 18 [28.6%], P = 0.02) than those without PTSD. In adjusted models, the HIV-PTSD (severity and status) interaction effect on FMD was significant (P = 0.01). Both PTSD severity (β per 10-point increase: -0.72% [95% CI: -1.22 to -0.21], P = 0.01) and PTSD status (β: -2.51% [95% CI: -4.21 to -0.77], P = 0.01) were independently associated with lower FMD in WWH but not in those without HIV.

CONCLUSIONS

PTSD is independently associated with ED in WWH. Whether treatment for PTSD improves ED and CVD in WWH needs further study.

Understanding the psychosocial context of employment and occupational productivity among women living with HIV: A mixed-methods study

BACKGROUND

Women living with HIV (WLHIV) are particularly vulnerable to poor employment outcomes, impacting their socioeconomic independence and personal sense of empowerment.

OBJECTIVE

This article presents the results of a mixed methods study, which examined the personal, clinical, and socioeconomic contexts associated with employment and occupational productivity among employed WLHIV (n = 164) in the Southern United States.

METHODS

The Stanford Presenteeism Scale-6 was used to assess the perceived impact of HIV disease on the ability to maintain focus and complete tasks at work. Correlational and hierarchical regression techniques were applied to examine the relationships between personal, clinical, and socioeconomic contexts and occupational productivity.

RESULTS

In this sample, 62% of women perceived no impact on their ability to work or capacity to complete work related to living with HIV. In multivariable modeling, empowerment, neurocognition, socioeconomic status, and psychological health were associated with occupational productivity. In-depth interviews (n = 29) provided rich contexts and meaning surrounding employment among WLHIV, and indicated that quality of life, work-life balance, empowerment, social support, and psychological health influenced the experience of work.

CONCLUSION

Psychosocial and structural interventions are needed to improve occupational outcomes in this vulnerable population.

Development of a refined harmonization approach for longitudinal cognitive data in people with HIV

OBJECTIVES

The aim of this study was to develop a refined method for harmonizing longitudinal cognitive data across several large-scale studies in people with HIV (PWH), in whom cognitive complications are common and heterogeneous in presentation.

STUDY DESIGN AND SETTING

We developed a refined method for harmonizing longitudinal cognitive data across five large-scale studies in PWH that used different cognitive batteries with only some overlapping tests-Women's Interagency HIV Study (WIHS), Multicenter AIDS Cohort Study, CNS HIV Antiretroviral Therapy Effects Research (CHARTER), National NeuroAIDS Tissue Consortium, and the HIV Neurobehavioral Research Program. Traditional data harmonization methods using latent variable models focus on cross-sectional data and require the presence of common cognitive tests to serve as "linking" assessments. However, the absence of such common tests for certain cognitive domains can preclude the direct application of these traditional techniques. To address these challenges, we developed a harmonization method that leveraged a second-order factor model, which capitalized on the structural relationships among cognitive domains.

RESULTS

Our approach yielded harmonized cognitive domain scores that are demographically consistent across different cohorts and exhibit strong correlations with the raw or log transformed (eg, timed outcomes) cognitive test scores. These harmonized scores accurately reflected variations according to age, educational status, and other demographic factors, while preserving participants' longitudinal cognitive trajectories.

CONCLUSION

Our harmonization methods are essential for future analyses of large-scale, retrospective data to understand the heterogeneity in cognitive complications in PWH. These methods can be applied to harmonize new datasets with similar measures.

Association of experienced stigma in healthcare settings with health outcomes among Black women living with HIV: Mediating roles of internalized stigma, anticipated stigma, and trust in HIV care

BACKGROUND

Black women living with HIV (WLHIV) often have suboptimal ART adherence due to a multitude of social and structural barriers, including HIV-related stigma. Trust in healthcare providers plays a significant role in adhering to ART and is likely lower among Black WLHIV compared to their White counterparts. This study examined the relationship between experienced stigma in healthcare settings and ART adherence and viral suppression through anticipated stigma in healthcare settings, internalized stigma, and medical mistrust.

PARTICIPANTS/PROCEDURES

Participants included Black WLHIV from the Women's Interagency HIV Study (WIHS). We conducted serial mediation analyses where experienced HIV stigma in healthcare settings is associated with higher anticipated or internalized HIV stigma, leading to higher mistrust in HIV care providers, and ultimately, to lower ART adherence and viral suppression, adjusting for demographic and clinical covariates.

RESULTS

Of the 1,060 WLHIV, approximately 84% achieved optimal ART adherence, and 65% had an undetectable viral load. Serial mediation analyses suggested significant indirect associations between experienced stigma in healthcare settings and ART adherence or viral suppression. Specifically, experienced stigma was associated with higher anticipated or internalized stigma, which was associated with mistrust in HIV care providers, resulting in lower ART adherence and reduced likelihood of undetectable viral load.

CONCLUSIONS

Interventions could focus on training healthcare providers to address implicit biases and create supportive healthcare environments. Integrating mental health support to reduce internalized stigma and using community engagement and education to address anticipated stigma may further improve trust in providers, leading to better health behaviors and outcomes.

Serum NFL and neuropsychological performance over ∼8 years in women with and without HIV: a longitudinal repeated measures study

Background

Blood-based biomarkers of Alzheimer's disease (AD) and stroke, including serum neurofilament light chain (sNFL), are understudied in women living with and without HIV.

Methods

We assessed cross-sectional and longitudinal change in sNFL between 2008 and 2019 associated with neuropsychological performance (NP) among women living with HIV (WLWH) and without HIV (WLWOH) age ≥40 years in the Women's Interagency HIV Study. Baseline and repeated ∼8-year fasting sNFL levels were measured using Simoa. Sociodemographically-adjusted NP T-scores (attention, working memory, executive function, processing speed, learning, verbal fluency and global) were calculated. Multivariable linear regression analyses stratified by HIV serostatus examined cross-sectional baseline and follow-up associations, and ∼8-year change in sNFL level related to global and domain-specific NP T-scores.

Findings

417 participants (290 WLWH, 127 WLWOH), African American/Black (55%), ≥high school education (69%), current/former smokers (79%), and overweight/obese (BMI ≥25.0 kg/m2, 74%) were included. Compared to WLWOH at baseline, WLWH performed worse on memory and global NP. WLWH versus WLWOH had higher baseline (p ≤ 0.001) and follow-up median (p < 0.0001) sNFL levels and ∼8-year change (46.5% in WLWH versus 24.4% in WLWOH, p < 0.0001). Among WLWH, higher baseline sNFL was associated with poorer processing speed, learning, memory and verbal fluency. Among WLWOH, higher baseline sNFL was associated with poorer executive function, processing speed and verbal fluency. Among WLWH, higher follow-up sNFL was associated with poorer executive function. Among WLWOH, higher follow-up sNFL was associated with poorer executive function, processing speed, attention, memory, and global NP. ∼8-year increase in sNFL occurred in both WLWH and WLWOH and was associated with poorer executive function, processing speed, memory, and global performance at follow-up among WLWOH, and poorer executive function in WLWH. Adjustment for multiple comparisons showed associations at cross-sectional follow-up and ∼8-year increase in sNFL in WLWOH, only. Higher sNFL was associated with poorer baseline processing speed in WLWH only.

Interpretation

Higher levels and greater ∼8-year increases in sNFL were associated with poorer NP by domain in WLWH and WLWOH differentially over time.

Funding

The contents of this publication are solely the responsibility of the authors and do not represent the official views of the National Institutes of Health (NIH). MACS/WIHS Combined Cohort Study (MWCCS) (Principal Investigators: Bronx CRS (Kathryn Anastos, David Hanna, and Anjali Sharma), U01-HL146204; Brooklyn CRS (Deborah Gustafson and Tracey Wilson), U01-HL146202; Data Analysis and Coordination Center (Gypsyamber D'Souza, Stephen Gange and Elizabeth Topper), U01-HL146193; Chicago-Cook County CRS (Mardge Cohen and Audrey French), U01-HL146245; Northern California CRS (Bradley Aouizerat, Jennifer Price, and Phyllis Tien), U01-HL146242; Metropolitan Washington CRS (Seble Kassaye and Daniel Merenstein), U01-HL146205. The MWCCS is funded primarily by the National Heart, Lung, and Blood Institute (NHLBI), with additional co-funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institute on Aging (NIA), National Institute of Dental and Craniofacial Research (NIDCR), National Institute of Allergy and Infectious Diseases (NIAID), National Institute of Neurological Disorders and Stroke (NINDS), National Institute of Mental Health (NIMH), National Institute on Drug Abuse (NIDA), National Institute of Nursing Research (NINR), National Cancer Institute (NCI), National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute on Deafness and Other Communication Disorders (NIDCD), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institute on Minority Health and Health Disparities (NIMHD), and in coordination and alignment with the research priorities of the National Institutes of Health, Office of AIDS Research (OAR). MWCCS data collection is also supported by UL1-TR000004 (UCSF CTSA), UL1-TR003098 (JHU ICTR), UL1-TR001881 (UCLA CTSI).

Brief Report: Internalized Poverty-Related Stigma and Interpersonal Violence Among Women Living With HIV in the United States

BACKGROUND

Interpersonal violence (IPV) affects half of women living with HIV (WLHIV) in the United States and has important consequences for mental health and HIV outcomes. Although different types of stigmas (eg, HIV- or sexual identity-related) are associated with increased risk of IPV, the relationship between poverty-related stigma and IPV is unclear, even though poverty frequently co-occurs with IPV.

METHODS

Data from up to 4 annual visits (2016-2020) were collected from 374 WLHIV enrolled in a substudy of the Women's Interagency HIV Study (now known as Multicenter AIDS Cohort Study/Women's Interagency HIV Study Combined Cohort Study) at 4 sites across the United States. A validated measure of the perceived stigma of poverty was used, along with questions on recent experiences of IPV. We used a mixed-effects model to assess the association between internalized poverty stigma and IPV.

RESULTS

The unadjusted model with internalized poverty stigma and recent IPV as independent and dependent variables, respectively, suggested that the 2 were associated (prevalence ratio 1.29 [95% CI: 1.02 to 1.62, P = 0.033]). After adjusting for income and education, we found an independent association between internalized poverty-related stigma and recent IPV, with a prevalence ratio of 1.35 (95% CI: 1.07 to 1.71, P = 0.011).

CONCLUSION

Our findings suggest that reducing the psychologic consequences of poverty may better situate WLHIV to escape or avoid IPV. The usefulness of screening WLHIV who may be experiencing poverty-related stigma for IPV should be investigated. Interventions that address internalized poverty-related stigma may provide an avenue for reducing the harms caused by IPV in addition to interventions aiming to reduce violence itself.

Heterogeneous depressive symptom trajectories among women with type 2 diabetes: findings from the Women's Interagency HIV Study

BACKGROUND

Depression affects 33% of women with type 2 diabetes (T2D) and leads to increased risks of premature mortality. Fluctuation and variation of depressive presentations can hinder clinical identification.

PURPOSE

We aimed to identify and examine subgroups characterized by distinct depressive symptom trajectories among women with T2D.

METHODS

This retrospective analysis leveraged the Women's Interagency HIV Study data to identify depressive symptom trajectories based on the Center for Epidemiological Studies Depression scores (2014-2019) among women with and without HIV. Descriptive statistics characterized sample demographics (eg, age, race, income), clinical indices (eg, hemoglobin A1C [HbA1c], BMI, HIV status), and psychosocial experiences (eg, discrimination, social support, anxiety, pain). We used growth mixture modeling to identify groups defined by distinct depressive symptom trajectories and parametric and non-parametric tests to examine demographic, clinical, and psychosocial differences across subgroups.

RESULTS

Among the 630 women included, the mean age was 50.4 (SD = 8.3) years, 72.4% identified as Black and non-Hispanic, and 68.2% were living with HIV. Five subgroups were identified and distinguished by severity and symptom type. Participants with lower incomes (P = .01), lower employment (P < .0001), lower social support (P = .0001), and experiences of discrimination (P < .0001) showed greater membership in threshold, moderate, and severe depressive subgroups. Subgroup membership was not associated with metabolic indices (BMI, HbA1c) or HIV status. Anxiety, pain, and loneliness (all P = .0001) were worse in subgroups with higher depressive symptoms.

CONCLUSIONS

Among women with T2D, depressive symptom trajectories differ across clinical and social contexts. This study advances precision by delineating subgroups within a broad clinical category.

Does cognitive intra-individual variability predict change in everyday functioning performance in women with and without HIV in the Women's Interagency HIV Study?

This study examined the association between cognitive intra-individual variability (IIV), a non-mean-based indicator of underlying neuropathology, and self-reported everyday functioning of 1,086 women with HIV (WWH) and 494 socio-demographically similar women without HIV (WWoH). Objective cognitive performance across seven domains and the self-rated Lawton & Brody scale of Instrumental Activities of Daily Living (IADL) were assessed among participants of the Women's Interagency HIV Study. Two types of cognitive IIV were calculated by taking the standard deviation across seven cognitive domains to calculate dispersion: 1) intra-individual standard deviation (denoted as sdIIV) and 2) coefficient of variation (denoted as covIIV). To account for the longitudinal nature of the data, generalized linear mixed effect models were conducted to examine associations between the dispersion coefficient of cognitive IIV (predictor (sdIIV and covIV)) and functional outcomes (item level scores). Models were conducted in the overall sample (WWH + WWoH), WWH only, virally suppressed (VS)-WWH, and WWoH. sdIIV and covIIV were not associated with any of the IADL items among WWoH but were for WWH and VS-WWH. In WWH covIIV was predictive of poorer functional performance on twice as many IADL items (10 items-money and bills, buying groceries, getting where you need to go, using the phone, home repairs, dressing, laundry, taking/keeping track of medications, taking care of children, work) than sdIIV (5 items). In this study, cognitive IIV predicts functional impairment and different calculations of IIV produce differential predictive value, especially for WWH.

A simple phylogenetic approach to analyze hypermutated HIV proviruses reveals insights into their dynamics and persistence during antiretroviral therapy

Hypermutated proviruses, which arise in a single Human Immunodeficiency Virus (HIV) replication cycle when host antiviral APOBEC3 proteins introduce extensive guanine to adenine mutations throughout the viral genome, persist in all people living with HIV receiving antiretroviral therapy (ART). However, hypermutated sequences are routinely excluded from phylogenetic trees because their extensive mutations complicate phylogenetic inference, and as a result, we know relatively little about their within-host evolutionary origins and dynamics. Using >1400 longitudinal single-genome-amplified HIV env-gp120 sequences isolated from six women over a median of 18 years of follow-up-including plasma HIV RNA sequences collected over a median of 9 years between seroconversion and ART initiation, and >500 proviruses isolated over a median of 9 years on ART-we evaluated three approaches for masking hypermutation in nucleotide alignments. Our goals were to (i) reconstruct phylogenies that can be used for molecular dating and (ii) phylogenetically infer the integration dates of hypermutated proviruses persisting during ART. Two of the approaches (stripping all positions containing putative APOBEC3 mutations from the alignment or replacing individual putative APOBEC3 mutations in hypermutated sequences with the ambiguous base R) consistently normalized tree topologies, eliminated erroneous clustering of hypermutated proviruses, and brought env-intact and hypermutated proviruses into comparable ranges with respect to multiple tree-based metrics. Importantly, these corrected trees produced integration date estimates for env-intact proviruses that were highly concordant with those from benchmark trees that excluded hypermutated sequences, supporting the use of these corrected trees for molecular dating. Subsequent molecular dating of hypermutated proviruses revealed that these sequences spanned a wide within-host age range, with the oldest ones dating to shortly after infection. This indicates that hypermutated proviruses, like other provirus types, begin to be seeded into the proviral pool immediately following infection and can persist for decades. In two of the six participants, hypermutated proviruses differed from env-intact ones in terms of their age distributions, suggesting that different provirus types decay at heterogeneous rates in some hosts. These simple approaches to reconstruct hypermutated provirus' evolutionary histories reveal insights into their in vivo origins and longevity toward a more comprehensive understanding of HIV persistence during ART.

Switch to Integrase Strand Transfer Inhibitors during the Menopausal Transition is Associated with Accelerated Body Composition Change in Women with HIV

BACKGROUND

Integrase strand transfer inhibitors (INSTIs) and the menopausal transition have separately been associated with body composition changes in women with HIV (WWH), but their interaction is unknown.

METHODS

From 2006-2019, 1131 non-pregnant WWH with viral suppression [(419 who switched to INSTI (INSTI+); 712 who did not switch (INSTI-)] and 887 women without HIV (WWOH) from the Women's Interagency HIV Study were included. Mixed effect models were used to evaluate change in waist circumference (WC) and BMI by menopausal phase defined using anti-Müllerian hormone, a biomarker of ovarian reserve.

RESULTS

During premenopause, WWH had increases in WC (INSTI+: 0.01cm per 6 month (mo); 95%CI:-0.29,0.32 and INSTI-: 0.22cm per 6mo;95%CI:-0.01,0.44) that were not statistically significantly different from WWOH; there was also little difference by INSTI status. In late perimenopause, INSTI+ had faster increases in WC (0.37cm per 6mo;95%CI:0.15,0.60) while INSTI- had smaller increases (0.14cm per 6mo;95%CI:-0.06,0.34) compared to WWOH. In menopause, INSTI+ had faster increases peaking at 43mo then declining while INSTI- had smaller increases (0.14cm per 6mo;95%CI:-0.02,0.30). Compared to INSTI-, in late perimenopause, INSTI+ had 0.26 cm per 6mo (95%CI:0.02,0.50) faster linear increases in WC and in menopause, INSTI+ was associated with faster increases peaking at 41mo. BMI trajectories were similar to WC in late peri- and menopausal women.

CONCLUSIONS

Switching to an INSTI-based regimen during late peri- and menopause is associated with faster increases in WC and BMI when compared to women who did not switch. Menopausal status should be considered when switching to an INSTI.

Consequences of low-level viremia among women with HIV in the United States

OBJECTIVE

Investigate the outcomes of women with HIV (WWH) with low-level viremia (LLV).

DESIGN

The prevalence of LLV and potential clinical sequelae, such as virologic failure and non-AIDS comorbidity (NACM) development, are poorly characterized among WWH.

METHODS

We analyzed data from the Women's Interagency HIV Study among WWH enrolled from 2003 to 2020 who reported antiretroviral therapy use at least 1 year followed by an HIV-1 viral load less than 200 copies/ml. Consecutive viral load measurements from four semi-annual visits were used to categorize women at baseline as having: virologic suppression (all viral load undetectable), intermittent LLV (iLLV; nonconsecutive detectable viral load up to 199 copies/ml), persistent LLV (pLLV; at least two consecutive detectable viral load up to 199 copies/ml), or virologic failure (any viral load ≥200 copies/ml). Adjusted hazard ratios quantified the association of virologic category with time to incident virologic failure and multimorbidity (≥2 of 5 NACM) over 5-year follow-up.

RESULTS

Of 1598 WWH, baseline median age was 47 years, 64% were Black, 21% Hispanic, and median CD4 + cell count was 621 cells/μl. After excluding 275 women (17%) who had virologic failure at baseline, 58, 19, and 6% were categorized as having virologic suppression, iLLV, and pLLV, respectively. Compared with WWH with virologic suppression, the adjusted hazard ratio [aHR; 95% confidence interval (CI)] for incident virologic failure was 1.88 (1.44-2.46) and 2.51 (1.66-3.79) for iLLV and pLLV, respectively; and the aHR for incident multimorbidity was 0.81 (0.54-1.21) and 1.54 (0.88-2.71) for iLLV and pLLV, respectively.

CONCLUSION

Women with iLLV and pLLV had an increased risk of virologic failure. Women with pLLV had a trend towards increased multimorbidity risk.

The prevalence and correlates of biomarker positive unhealthy alcohol use among women living with and without HIV in San Francisco, California

The objective of this study was to identify the prevalence and correlates of phosphatidylethanol (PEth) levels suggestive of unhealthy alcohol use among women living with and without HIV who self-reported no or low-risk drinking. We analyzed data from a cross-sectional study among women enrolled in the San Francisco Bay Area site of the Women's Interagency HIV Study (WIHS). Between October 2017 and March 2018, PEth was tested from dried blood spots in 192 women enrolled in the San Francisco site of the WIHS. Using multivariable logistic regression, we identified the correlates of PEth levels suggestive of unhealthy alcohol use (>50 ng/ml) among the 168 women who reported no or low-risk drinking (<7 drinks per week) in the past six months, while controlling for age in years and race/ethnicity. Among the 168 women in the analysis sample, the median age was 55; 51% identified as Black/African American, 47% were living with HIV and 28% had PEth levels ≥50 ng/ml which are suggestive of unhealthy alcohol use. Factors independently associated with PEth levels ≥50 ng/ml in adjusted models were: identifying as Black/African American (adjusted odds ratio [aOR] = 8.34, 95% CI = 2.06-33.72), having an alanine transaminase to aspartate aminotransferase ratio > 1 (aOR = 3.10, 95% CI = 1.18-8.13), higher high-density lipoprotein levels (aOR = 1.31 per 10 mg/dL increase, 95% CI = 1.01-1.70), and consuming a greater number of drinks per week in the past six months (aOR = 1.40, 95% CI = 1.10-1.78). Nearly a third of women in this study had PEth levels suggestive of unhealthy alcohol use and potentially under-reported their use. To optimize alcohol related health care, there is a need to consider approaches to improve ascertainment of unhealthy alcohol use, especially among Black/African American women and those living with liver disease, so that interventions can be initiated.

A Bayesian approach for investigating the pharmacogenetics of combination antiretroviral therapy in people with HIV

Combination antiretroviral therapy (ART) with at least three different drugs has become the standard of care for people with HIV (PWH) due to its exceptional effectiveness in viral suppression. However, many ART drugs have been reported to associate with neuropsychiatric adverse effects including depression, especially when certain genetic polymorphisms exist. Pharmacogenetics is an important consideration for administering combination ART as it may influence drug efficacy and increase risk for neuropsychiatric conditions. Large-scale longitudinal HIV databases provide researchers opportunities to investigate the pharmacogenetics of combination ART in a data-driven manner. However, with more than 30 FDA-approved ART drugs, the interplay between the large number of possible ART drug combinations and genetic polymorphisms imposes statistical modeling challenges. We develop a Bayesian approach to examine the longitudinal effects of combination ART and their interactions with genetic polymorphisms on depressive symptoms in PWH. The proposed method utilizes a Gaussian process with a composite kernel function to capture the longitudinal combination ART effects by directly incorporating individuals' treatment histories, and a Bayesian classification and regression tree to account for individual heterogeneity. Through both simulation studies and an application to a dataset from the Women's Interagency HIV Study, we demonstrate the clinical utility of the proposed approach in investigating the pharmacogenetics of combination ART and assisting physicians to make effective individualized treatment decisions that can improve health outcomes for PWH.

Substance use and menopausal symptoms among people with and without HIV in the US, 2008-2020

OBJECTIVE

The aim of the study is to assess associations between substance use and menopausal symptoms among US people living with and without HIV in a longitudinal cohort.

METHODS

We analyzed self-reported menopausal symptoms and substance use from biannual Women's Interagency HIV Study (WIHS) visits from 2008-2020. Substance use since the last visit or lifetime cumulative use included tobacco, alcohol, marijuana, crack/cocaine, and opioids. Logistic regression quantified associations between each substance use and menopausal symptom frequency (vasomotor, mood, and musculoskeletal), adjusting for other substance use, HIV status, demographics, comorbidities, and trauma.

RESULTS

A total of 1,949 participants contributed early perimenopausal, late perimenopausal, or postmenopausal study visits. Across reproductive-aging stages, based on menstrual history, and among participants with and without HIV, participants reported frequent vasomotor (range 22-43%), mood (18-28%), and musculoskeletal (25-34%) symptoms. Many reported ever using tobacco (72%), heavy alcohol (75%), marijuana (73%), crack (50%), and opioids (31%). Current heavy alcohol use (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.10-1.37), cumulative marijuana use (OR: 1.15, 95% CI: 1.01-1.32), and cumulative tobacco use (OR: 1.06, 95% CI: 1.01-1.12) were associated with a higher frequency of vasomotor symptoms; current heavy alcohol use (OR: 1.20, 95% CI: 1.04-1.39) and current opioid use (OR: 1.13; 95% CI: 1.01-1.25) were associated with mood symptoms; and current opioid use (OR: 1.11, 95% CI: 1.00-1.23) was associated with musculoskeletal symptoms. All other associations were found to be null.

CONCLUSIONS

Current and prior substance use may independently affect symptoms experienced during the menopausal transition and may indicate potential to benefit from additional intervention and referral to menopause specialty care.

Depressive Symptoms and Left Ventricular Diastolic Dysfunction Among Men and Women with HIV

Background and Aim

The prevalence of depressive symptoms and major depressive disorder is high among adults living with HIV. Depressive symptoms are associated with increased cardiovascular disease risk. This study examined the association between depressive symptoms and echocardiographic indices of left ventricular diastolic dysfunction (LVDD) among men and women living with and without HIV.

Methods

Cross-sectional analysis included individuals in the Multicenter AIDS Cohort Study (MACS) and Women's Interagency HIV Study (WIHS) who participated in transthoracic echocardiogram substudies and completed measures of depressive symptoms at the same visit as, or up to 6 months prior to, the transthoracic echocardiogram visit. Participants had helper T cells (CD4) >350 cells/mm3 and HIV RNA viral load <499 copies/mL. The presence of LVDD was defined according to the Characterizing Heart Function on Antiretroviral Therapy (CHART) criteria. Secondary outcomes were continuous values of each component of the CHART criteria: left ventricular ejection fraction >50%, septal e' velocity, lateral e' velocity, left atrial volume index, left ventricular mass index, and relative wall thickness. Logistic and linear regression were used to adjust for sociodemographic, behavioural, cardiometabolic, and HIV-related factors.

Results

Among 874 men (51% with HIV) and 1,191 women (76% with HIV), in whom the overall prevalence of LVDD was 22.5% and depressive symptoms 30.8%, depressive symptoms were not significantly associated with LVDD. The associations between individual LVDD components and depression were in the small to medium range, though generally not significant.

Conclusion

Findings warrant further research regarding the association between LVDD and depressive symptoms in the era of combination antiretroviral therapy.

Awareness, treatment, and control of hypertension among women at risk or living with HIV in the US South

OBJECTIVES

Timely control of hypertension is vital to prevent comorbidities. We evaluated the association of race/ethnicity and HIV infection with incident hypertension outcomes, including awareness, treatment, and control.

DESIGN

We evaluated cisgender women living with HIV and sociodemographically matched women living without HIV recruited into four Southern sites of the Women's Interagency HIV Study (WIHS) (2013-2019).

METHODS

We calculated measurements of the time to four events or censoring: incident hypertension, hypertension awareness, hypertension treatment, and hypertension control. Hazard ratios for race/ethnicity and HIV status were calculated for each outcome using Cox proportional-hazards models adjusted for sociodemographic, behavioral, and clinical risk factors.

RESULTS

Among 712 women, 56% were hypertensive at baseline. Forty-five percentage of the remaining women who were normotensive at baseline developed incident hypertension during follow-up. Non-Hispanic white and Hispanic women had faster time to hypertension control compared with non-Hispanic black women ( P  = 0.01). In fully adjusted models, women living with HIV who were normotensive at baseline had faster time to treatment compared with normotensive women living without HIV ( P  = 0.04).

CONCLUSION

In our study of women in the US South, non-Hispanic black women became aware of their hypertension diagnosis more quickly than non-Hispanic white and Hispanic women but were slower to control their hypertension. Additionally, women living with HIV more quickly treated and controlled their hypertension compared with women living without HIV.

EXPOSURE EFFECTS ON COUNT OUTCOMES WITH OBSERVATIONAL DATA, WITH APPLICATION TO INCARCERATED WOMEN

Causal inference methods can be applied to estimate the effect of a point exposure or treatment on an outcome of interest using data from observational studies. For example, in the Women's Interagency HIV Study, it is of interest to understand the effects of incarceration on the number of sexual partners and the number of cigarettes smoked after incarceration. In settings like this where the outcome is a count, the estimand is often the causal mean ratio, i.e., the ratio of the counterfactual mean count under exposure to the counterfactual mean count under no exposure. This paper considers estimators of the causal mean ratio based on inverse probability of treatment weights, the parametric g-formula, and doubly robust estimation, each of which can account for overdispersion, zero-inflation, and heaping in the measured outcome. Methods are compared in simulations and are applied to data from the Women's Interagency HIV Study.

HIV, HIV-Specific Factors, and Myocardial Disease in Women

BACKGROUND

People with human immunodeficiency virus (HIV) (PWH) have an increased risk of cardiovascular disease (CVD). Cardiac magnetic resonance (CMR) has documented higher myocardial fibrosis, inflammation, and steatosis in PWH, but studies have mostly relied on healthy volunteers as comparators and focused on men.

METHODS

We investigated the associations of HIV and HIV-specific factors with CMR phenotypes in female participants enrolled in the Women's Interagency HIV Study's New York and San Francisco sites. Primary phenotypes included myocardial native (n) T1 (fibro-inflammation), extracellular volume fraction (fibrosis), and triglyceride content (steatosis). Associations were evaluated with multivariable linear regression, and results pooled or meta-analyzed across centers.

RESULTS

Among 261 women with HIV (WWH, N = 362), 76.2% had undetectable viremia at CMR. For the 82.8% receiving continuous antiretroviral therapy (ART) in the preceding 5 years, adherence was 51.7%, and 69.4% failed to achieve persistent viral suppression (40.7% with peak viral load <200 cp/mL). Overall, WWH showed higher nT1 than women without HIV after full adjustment. This higher nT1 was more pronounced in those with antecedent or current viremia or nadir CD4+ count <200 cells/μL, with the latter also associated with higher extracellular volume fraction. WWH and current CD4+ count <200 cells/μL had less cardiomyocyte steatosis. Cumulative exposure to specific ART showed no associations.

CONCLUSIONS

Compared with sociodemographically similar women without HIV, WWH on ART exhibit higher myocardial fibro-inflammation, which is more prominent with unsuppressed viremia or CD4+ lymphopenia. These findings support the importance of improved ART adherence strategies, along with better understanding of latent infection, to mitigate cardiac end-organ damage in this population.

Tryptophan-Kynurenine Pathway Activation and Cognition in Virally Suppressed Women With HIV

BACKGROUND

Immune and cognitive dysfunction persists even in virally suppressed women with HIV (VS-WWH). Since inflammation and HIV proteins induce the enzyme indoleamine 2,3-dioxygenase (IDO), converting tryptophan (T) to kynurenine (K) while producing downstream neurotoxic metabolites, we investigated IDO activation (KT ratio) in relation to cognition in VS-WWH and demographically similar women without HIV (WWoH).

METHODS

Ninety-nine VS-WWH on stable antiretroviral therapy and 102 WWoH (median age 52 vs 54 years; 73% vs 74% Black, respectively) from the New York and Chicago sites of the Women's Interagency HIV Study (WIHS) completed a neuropsychological test battery assessing motor function, processing speed, attention/working memory, verbal fluency, verbal learning and memory, and executive function and had plasma measured for tryptophan-kynurenine metabolites through liquid chromatography-tandem mass spectrometry and monocyte-derived [soluble cluster of differentiation-14 (sCD14), soluble cluster of differentiation-163 (sCD163), monocyte chemoattractant protein-1 (MCP-1)] plus general inflammatory markers [tumor necrosis factor alpha-2 receptor (TNF-R2), high-sensitivity C-reactive protein, high-sensitivity interleukin-6] through enzyme-linked immunosorbent assays between 2017 and 2020.

RESULTS

VS-WWH had a higher KT ratio (P < 0.01) and higher sCD14 levels (P < 0.05) compared with WWoH. Higher sCD163 was associated with higher KT ratio (R = 0.29, P < 0.01) and worse fine motor function in VS-WWH; after adjusting for sCD163 and sCD14 in multivariable regressions, higher KT ratio remained significantly associated with impaired fine motor function in VS-WWH only (standardized β = -0.29, P < 0.05). IDO activation was not associated with cognition in WWoH.

CONCLUSIONS

IDO activation (K:T) was associated with worse fine motor control in VS-WWH independent of measured systemic inflammation. Further studies investigating biological mechanisms linking IDO activation to fine motor function among VS-WWH are warranted.

Population Density and Health Outcomes in Women with HIV in the Southern United States: A Retrospective Longitudinal Analysis

Purpose: Published studies have revealed challenges for people with human immunodeficiency virus (HIV) living in rural areas compared to those in urban areas, such as poor access to HIV care, insufficient transportation, and isolation. The purpose of this study was to examine associations between population density and multiple psychosocial and clinical outcomes in the largest cohort of women with HIV (WWH) in the United States. Methods: Women's Interagency HIV Study (WIHS) participants from Southern sites (n = 561) in 2013-2018 were categorized and compared by population density quartiles. The most urban quartile was compared with the most rural quartile in several psychosocial and clinical variables, including HIV viral load suppression, HIV medication adherence, HIV care attendance, depression, internalized HIV stigma, and perceived discrimination in healthcare settings. Results: Although women in the lowest density quartile were unexpectedly more highly resourced, women in that quartile had greater odds of not attending an HIV care visit in the last six months (odds ratio [OR] = 0.64, 95% confidence interval [CI] [0.43-0.95]), yet higher odds for having fully suppressed HIV when compared to women in the highest density quartile (OR = 1.64, 95% CI [1.13-2.38]). Highly urban WWH had greater likelihood of unsuppressed HIV, even after controlling for income, employment, and health insurance, despite reporting greater HIV care adherence and similar medication adherence. Discussion: Further investigation into the reasons for these disparities by population density is needed, and particular clinical attention should be focused on individuals from high population density areas to help maximize their health outcomes.

Health Outcomes around Pregnancy and Exposure to HIV/Antiretrovirals (HOPE) study protocol: a prospective observational cohort study of reproductive-aged women living with HIV

INTRODUCTION

Over 265 000 women are living with HIV in the USA, but limited research has investigated the physical, mental and behavioural health outcomes among women living with HIV of reproductive age. Health status during the reproductive years before, during and after pregnancy affects pregnancy outcomes and long-term health. Understanding health outcomes among women living with HIV of reproductive age is of substantial public health importance, regardless of whether they experience pregnancy. The Health Outcomes around Pregnancy and Exposure to HIV/Antiretrovirals (HOPE) study is a prospective observational cohort study designed to investigate physical and mental health outcomes of young women living with HIV as they age, including HIV disease course, engagement in care, reproductive health and choices and cardiometabolic health. We describe the HOPE study design, and characteristics of the first 437 participants enrolled as of 1 January 2024.

METHODS AND ANALYSIS

The HOPE study seeks to enrol and follow 1630 women living with HIV of reproductive age, including those with perinatally-acquired HIV, at 12 clinical sites across 9 US states and Puerto Rico. HOPE studies multilevel dynamic determinants influencing physical, mental and social well-being and behaviours of women living with HIV across the reproductive life course (preconception, pregnancy, post partum, not or never-pregnant), informed by the socioecological model. Key research areas include the clinical course of HIV, relationship of HIV and antiretroviral medications to reproductive health, pregnancy outcomes and comorbidities and the influence of racism and social determinants of health. HOPE began enrolling in April 2022.

ETHICS AND DISSEMINATION

The HOPE study received approval from the Harvard Longwood Campus Institutional Review Board, the single institutional review board of record for all HOPE sites. Results will be disseminated through conference presentations, peer-reviewed journals and lay summaries.

DNA methylation-based telomere length is associated with HIV infection, physical frailty, cancer, and all-cause mortality

Telomere length (TL) is an important indicator of cellular aging. Shorter TL is associated with several age-related diseases including coronary heart disease, heart failure, diabetes, osteoporosis, and cancer. Recently, a DNA methylation-based TL (DNAmTL) estimator has been developed as an alternative method for directly measuring TL. In this study, we examined the association of DNAmTL with cancer prevalence and mortality risk among people with and without HIV in the Veterans Aging Cohort Study Biomarker Cohort (VACS, N = 1917) and Women's Interagency HIV Study Cohort (WIHS, N = 481). We profiled DNAm in whole blood (VACS) or in peripheral blood mononuclear cells (WIHS) using an array-based method. Cancer prevalence was estimated from electronic medical records and cancer registry data. The VACS Index was used as a measure of physiologic frailty. Models were adjusted for self-reported race and ethnicity, batch, smoking status, alcohol consumption, and five cell types (CD4, CD8, NK, B cell, and monocyte). We found that people with HIV had shorter average DNAmTL than those without HIV infection [beta = -0.25, 95% confidence interval (-0.32, -0.18), p = 1.48E-12]. Greater value of VACS Index [beta = -0.002 (-0.003, -0.001), p = 2.82E-05] and higher cancer prevalence [beta = -0.07 (-0.10, -0.03), p = 1.37E-04 without adjusting age] were associated with shortened DNAmTL. In addition, one kilobase decrease in DNAmTL was associated with a 40% increase in mortality risk [hazard ratio: 0.60 (0.44, 0.82), p = 1.42E-03]. In summary, HIV infection, physiologic frailty, and cancer are associated with shortening DNAmTL, contributing to an increased risk of all-cause mortality.

Menopause and Estrogen Associations With Gut Barrier, Microbial Translocation, and Immune Activation Biomarkers in Women With and Without HIV

OBJECTIVES

Estrogens may protect the gut barrier and reduce microbial translocation and immune activation, which are prevalent in HIV infection. We investigated relationships of the menopausal transition and estrogens with gut barrier, microbial translocation, and immune activation biomarkers in women with and without HIV.

DESIGN

Longitudinal and cross-sectional studies nested in the Women's Interagency HIV Study.

METHODS

Intestinal fatty acid binding protein, lipopolysaccharide binding protein, and soluble CD14 (sCD14) levels were measured in serum from 77 women (43 with HIV) before, during, and after the menopausal transition (∼6 measures per woman over ∼13 years). A separate cross-sectional analysis was conducted among 72 postmenopausal women with HIV with these biomarkers and serum estrogens.

RESULTS

Women in the longitudinal analysis were a median age of 43 years at baseline. In piecewise, linear, mixed-effects models with cutpoints 2 years before and after the final menstrual period to delineate the menopausal transition, sCD14 levels increased over time during the menopausal transition (Beta [95% CI]: 38 [12 to 64] ng/mL/yr, P = 0.004), followed by a decrease posttransition (-46 [-75 to -18], P = 0.001), with the piecewise model providing a better fit than a linear model (P = 0.0006). In stratified analyses, these results were only apparent in women with HIV. In cross-sectional analyses, among women with HIV, free estradiol inversely correlated with sCD14 levels (r = -0.26, P = 0.03). Lipopolysaccharide binding protein and intestinal fatty acid binding protein levels did not appear related to the menopausal transition and estrogen levels.

CONCLUSIONS

Women with HIV may experience heightened innate immune activation during menopause, possibly related to the depletion of estrogens.

A simple phylogenetic approach to analyze hypermutated HIV proviruses reveals insights into their dynamics and persistence during antiretroviral therapy

Hypermutated proviruses, which arise in a single HIV replication cycle when host antiviral APOBEC3 proteins introduce extensive G-to-A mutations throughout the viral genome, persist in all people living with HIV receiving antiretroviral therapy (ART). But, the within-host evolutionary origins of hypermutated sequences are incompletely understood because phylogenetic inference algorithms, which assume that mutations gradually accumulate over generations, incorrectly reconstruct their ancestor-descendant relationships. Using > 1400 longitudinal single-genome-amplified HIV env-gp120 sequences isolated from six women over a median 18 years of follow-up - including plasma HIV RNA sequences collected over a median 9 years between seroconversion and ART initiation, and > 500 proviruses isolated over a median 9 years on ART - we evaluated three approaches for removing hypermutation from nucleotide alignments. Our goals were to 1) reconstruct accurate phylogenies that can be used for molecular dating and 2) phylogenetically infer the integration dates of hypermutated proviruses persisting during ART. Two of the tested approaches (stripping all positions containing putative APOBEC3 mutations from the alignment, or replacing individual putative APOBEC3 mutations in hypermutated sequences with the ambiguous base R) consistently normalized tree topologies, eliminated erroneous clustering of hypermutated proviruses, and brought env-intact and hypermutated proviruses into comparable ranges with respect to multiple tree-based metrics. Importantly, these corrected trees produced integration date estimates for env-intact proviruses that were highly concordant with those from benchmark trees that excluded hypermutated sequences, indicating that the corrected trees can be used for molecular dating. Use of these trees to infer the integration dates of hypermutated proviruses persisting during ART revealed that these spanned a wide age range, with the oldest ones dating to shortly after infection. This indicates that hypermutated proviruses, like other provirus types, begin to be seeded into the proviral pool immediately following infection, and can persist for decades. In two of the six participants, hypermutated proviruses differed from env-intact ones in terms of their age distributions, suggesting that different provirus types decay at heterogeneous rates in some hosts. These simple approaches to reconstruct hypermutated provirus' evolutionary histories, allow insights into their in vivo origins and longevity, towards a more comprehensive understanding of HIV persistence during ART.

"As I Grew Older, My Life Got Better": Conceptions of Successful Aging among Older Women Living with or at Risk of HIV

Successful aging (SA) is an important target for HIV care. However, we have insufficient understanding of how older women living with HIV (OWLH) in the US define SA. We explored conceptions of SA by OWLH and older women at risk of HIV and examined whether SA conceptions differed by (1) HIV serostatus, and (2) participation in the Women's Interagency HIV Study (WIHS). These analyses were part of a larger mixed-methods study with a sequential design. Participants were recruited at two clinical WIHS sites. We enrolled both WIHS participants and non-WIHS clinic patients. Our sample was 84% Black and included 29 OWLH and 15 older women at risk of HIV. We conducted 21 semi-structured interviews and four focus groups. The dataset was analyzed using descriptive, comparative, and relational analysis. We found four interlinked themes: life course perspective, accepting and celebrating aging, taking care of yourself, and looking good. The life course perspective was a core theme: participants assessed their aging in comparison to their earlier life hardships. These themes were similarly present among OWLH and older women at risk of HIV, although OWLH emphasized taking care of HIV. SA conceptualizations by OWLH did not differ whether or not they participated in the WIHS. Women living with or at risk of HIV may experience severe hardships throughout their lives. Overcoming these hardships may be linked to SA. Assessing the needs and connecting women to resources and programs are critical for SA promotion.

Hepatitis C Virus Clearance and Diffusing Capacity for Carbon Monoxide in Women With and Without Human Immunodeficiency Virus

Hepatitis C virus (HCV) infection is associated with extrahepatic effects, including reduced diffusing capacity of the lungs. It is unknown whether clearance of HCV infection is associated with improved diffusing capacity. In this sample of women with and without human immunodeficiency virus, there was no association between HCV clearance and diffusing capacity.

Microbial Translocation and Gut Damage Are Associated With an Elevated Fast Score in Women Living With and Without HIV

Background

Steatohepatitis is common in persons living with HIV and may be associated with gut microbial translocation (MT). However, few studies have evaluated the gut-liver axis in persons living with HIV. In the Women's Interagency HIV Study, we examined the associations of HIV and circulating biomarkers linked to MT and gut damage using the FibroScan-aspartate aminotransferase (FAST) score, a noninvasive surrogate for steatohepatitis with advanced fibrosis.

Methods

Among 883 women with HIV and 354 without HIV, we used multivariable regression to examine the associations of HIV and serum biomarkers linked to MT and gut damage (kynurenine and tryptophan ratio, intestinal fatty acid-binding protein, soluble CD14, and soluble CD163) with a log-transformed FAST score after adjusting for key covariates. We used a path analysis and mediation models to determine the mediating effect of each biomarker on the association of HIV with FAST.

Results

HIV infection was associated with a 49% higher FAST score. MT biomarker levels were higher in women with HIV than women without HIV (P < .001 for each). MT biomarkers mediated 13% to 32% of the association of HIV and FAST score.

Conclusions

Biomarkers linked to MT and gut damage are associated with a higher FAST score and mediate the association of HIV with a higher FAST score. Our findings suggest that MT may be an important mechanism by which HIV increases the risk of steatohepatitis with advanced fibrosis.

Metabolic and inflammatory perturbation of diabetes associated gut dysbiosis in people living with and without HIV infection

BACKGROUND

Gut dysbiosis has been linked with both HIV infection and diabetes, but its interplay with metabolic and inflammatory responses in diabetes, particularly in the context of HIV infection, remains unclear.

METHODS

We first conducted a cross-sectional association analysis to characterize the gut microbial, circulating metabolite, and immune/inflammatory protein features associated with diabetes in up to 493 women (~ 146 with prevalent diabetes with 69.9% HIV +) of the Women's Interagency HIV Study. Prospective analyses were then conducted to determine associations of identified metabolites with incident diabetes over 12 years of follow-up in 694 participants (391 women from WIHS and 303 men from the Multicenter AIDS Cohort Study; 166 incident cases were recorded) with and without HIV infection. Mediation analyses were conducted to explore whether gut bacteria-diabetes associations are explained by altered metabolites and proteins.

RESULTS

Seven gut bacterial genera were identified to be associated with diabetes (FDR-q <  0.1), with positive associations for Shigella, Escherichia, Megasphaera, and Lactobacillus, and inverse associations for Adlercreutzia, Ruminococcus, and Intestinibacter. Importantly, the associations of most species, especially Adlercreutzia and Ruminococcus, were largely independent of antidiabetic medications use. Meanwhile, 18 proteins and 76 metabolites, including 3 microbially derived metabolites (trimethylamine N-oxide, phenylacetylglutamine (PAGln), imidazolepropionic acid (IMP)), 50 lipids (e.g., diradylglycerols (DGs) and triradylglycerols (TGs)) and 23 non-lipid metabolites, were associated with diabetes (FDR-q <  0.1), with the majority showing positive associations and more than half of them (59/76) associated with incident diabetes. In mediation analyses, several proteins, especially interleukin-18 receptor 1 and osteoprotegerin, IMP and PAGln partially mediate the observed bacterial genera-diabetes associations, particularly for those of Adlercreutzia and Escherichia. Many diabetes-associated metabolites and proteins were altered in HIV, but no effect modification on their associations with diabetes was observed by HIV.

CONCLUSION

Among individuals with and without HIV, multiple gut bacterial genera, blood metabolites, and proinflammatory proteins were associated with diabetes. The observed mediated effects by metabolites and proteins in genera-diabetes associations highlighted the potential involvement of inflammatory and metabolic perturbations in the link between gut dysbiosis and diabetes in the context of HIV infection.

Association of Androgen Hormones, Sex Hormone-Binding Globulin, and the Menopausal Transition With Incident Diabetes Mellitus in Women With and Without HIV

BACKGROUND

HIV is associated with alterations in androgen hormone levels and sex hormone-binding globulin (SHBG) in women. Higher SHBG has been associated with a lower risk of diabetes in the general population, but the contribution of HIV, androgen hormones, SHBG, and menopausal phase to diabetes is unclear.

METHODS

From April 2003 through February 2020, 896 women with HIV (WWH) and 343 women without HIV (WWOH) from the Women's Interagency HIV Study with morning total testosterone, dehydroepiandrosterone sulfate (DHEAS), and SHBG levels were followed to assess for incident diabetes. Parametric regression models were used with age as the time scale and relative times (RT) as the measure of association of hormone level and menopausal phase with incident diabetes. Analyses incorporated time-dependent androgen hormone, SHBG levels, and menopausal phase and were adjusted for race/ethnicity, enrollment year, smoking status, BMI, hepatitis C virus status, and HIV-related factors.

RESULTS

In total, 128 (14%) WWH and 47 (14%) WWOH developed diabetes. In WWH, a doubling of SHBG and DHEAS were associated with a 7% (RT = 1.07 [95% CI: 0.82 to 1.40] and 15% (RT = 1.15 [95% CI: 0.95 to 1.39]) longer time to diabetes, respectively; in WWOH, a doubling of SHBG and DHEAS were associated with 84% (RT = 1.84 [95% CI: 0.89 to 3.82]) and 41% (RT= 1.41 [95% CI: 0.82 to 2.44]) longer times to diabetes. Total testosterone was not associated. In WWH, later menopausal phase was associated with shorter times to diabetes.

CONCLUSIONS

Despite alterations in androgen hormone and SHBG levels in HIV, regardless of HIV status, higher SHBG and DHEAS were associated with nonstatistically significant slower progression to diabetes. The menopausal transition may be a better hormonal indicator of diabetes risk in WWH.

Brief Report: Substance Use Care Continuum in Women With and Without HIV in the Southern United States

BACKGROUND

Substance use (SU) contributes to poor outcomes among persons living with HIV. Women living with HIV (WWH) in the United States are disproportionately affected in the South, and examining SU patterns, treatment, and HIV outcomes in this population is integral to addressing HIV and SU disparities.

METHODS

WWH and comparable women without HIV (WWOH) who enrolled 2013-2015 in the Women's Interagency HIV Study Southern sites (Atlanta, Birmingham/Jackson, Chapel Hill, and Miami) and reported SU (self-reported nonmedical use of drugs) in the past year were included. SU and treatment were described annually from enrollment to the end of follow-up. HIV outcomes were compared by SU treatment engagement.

RESULTS

At enrollment, among 840 women (608 WWH, 232 WWOH), 18% (n = 155) reported SU in the past year (16% WWH, 24% WWOH); 25% (n = 38) of whom reported SU treatment. Over time, 30%, 21%, and 18% reported SU treatment at 1, 2, and 3 years, respectively, which did not significantly differ by HIV status. Retention in HIV care did not differ by SU treatment. Viral suppression was significantly higher in women who reported SU treatment only at enrollment ( P = 0.03).

CONCLUSIONS

We identified a substantial gap in SU treatment engagement, with only a quarter reporting treatment utilization, which persisted over time. SU treatment engagement was associated with viral suppression at enrollment but not at other time points or with retention in HIV care. These findings can identify gaps and guide future strategies for integrating HIV and SU care for WWH.

Tryptophan-kynurenine metabolic pathway and daytime dysfunction in women with HIV

Sleep disturbances are prevalent in women with HIV (WWH). Tryptophan-kynurenine (T-K) pathway metabolites are associated with alterations in actigraphy derived sleep measures in WWH, although may not always correlate with functional impairment. We investigated the relationship between T-K pathway metabolites and self-reported daytime dysfunction in WWH and women without HIV (WWoH). 141 WWH on stable antiretroviral therapy and 140 demographically similar WWoH enrolled in the IDOze Study had targeted plasma T-K metabolites measured using liquid chromatography-tandem mass spectrometry. We utilized the daytime dysfunction component of the Pittsburgh Sleep Quality Index (PSQI) to assess functional impairment across HIV-serostatus. Lower levels of 5-hydroxytryptophan and serotonin were associated with greater daytime dysfunction in all women. In WWH, daytime dysfunction was associated with increased kynurenic acid (R = 0.26, p < 0.05), and kynurenic acid-tryptophan (KA-T) ratio (R = 0.28, p < 0.01). WWH with daytime dysfunction had a 0.7 log fold increase in kynurenic acid compared to WWH without daytime dysfunction. Kynurenic acid levels and the KA-T ratio were associated with daytime dysfunction in WWH but not in WWoH. Longitudinal studies are needed to establish a causal relationship and directionality between T-K metabolic changes and sleep impairment in WWH.

Subclinical Atherosclerosis Across the Menopausal Transition in Women With and Without HIV

The menopausal transition is a pivotal time of cardiovascular risk, but knowledge is limited in HIV. We studied longitudinal carotid artery intima-media thickness (CIMT) in the Women's Interagency HIV Study (2004-2019; 979 women/3247 person-visits; 72% with HIV). Among women with HIV only, those who transitioned had greater age-related CIMT progression compared to those remaining premenopausal (difference in slope = 1.64 µm/year, P = .002); and CIMT increased over time in the pretransition (3.47 µm/year, P = .002) and during the menopausal transition (9.41 µm/year, P < .0001), but not posttransition (2.9 µm/year, P = .19). In women with HIV, menopause may accelerate subclinical atherosclerosis as measured by CIMT.

Association of HIV and HCV Infection With Carotid Artery Plaque Echomorphology in the MACS/WIHS Combined Cohort Study

BACKGROUND

HIV and hepatitis C virus (HCV) are associated with increased risk of carotid artery atherosclerotic plaque and stroke. We examined associations of HIV- and HCV-related factors with echomorphologic features of carotid artery plaque.

METHODS

This cross-sectional study included participants from the MACS (Multicenter AIDS Cohort Study)/WIHS (Women's Interagency HIV Study) Combined Cohort Study who underwent high-resolution B-mode carotid artery ultrasound. Plaques were characterized from 6 areas of the right carotid artery. Poisson regression controlling for demographic and cardiometabolic risk factors determined adjusted prevalence ratios (aPRs) and 95% CIs for associations of HIV- and HCV-related factors with echomorphologic features.

RESULTS

Of 2655 participants (65% women, median age 44 [interquartile range, 37-50] years), 1845 (70%) were living with HIV, 600 (23%) were living with HCV, and 425 (16%) had carotid plaque. There were 191 plaques identified in 129 (11%) women with HIV, 51 plaques in 32 (7%) women without HIV, 248 plaques in 171 (28%) men with HIV, and 139 plaques in 93 (29%) men without HIV. Adjusted analyses showed that people with HIV and current CD4+ count <200 cells/µL had a significantly higher prevalence of predominantly echolucent plaque (aPR, 1.86 [95% CI, 1.08-3.21]) than those without HIV. HCV infection alone (aPR, 1.86 [95% CI, 1.08-3.19]) and HIV-HCV coinfection (aPR, 1.75 [95% CI, 1.10-2.78]) were each associated with higher prevalence of predominantly echogenic plaque. HIV-HCV coinfection was also associated with higher prevalence of smooth surface plaque (aPR, 2.75 [95% CI, 1.03-7.32]) compared with people without HIV and HCV.

CONCLUSIONS

HIV with poor immunologic control, as well as HCV infection, either alone or in the presence of HIV, were associated with different echomorphologic phenotypes of carotid artery plaque.

Computationally inferred cell-type specific epigenome-wide DNA methylation analysis unveils distinct methylation patterns among immune cells for HIV infection in three cohorts

BACKGROUND

Epigenome-wide association studies (EWAS) have identified CpG sites associated with HIV infection in blood cells in bulk, which offer limited knowledge of cell-type specific methylation patterns associated with HIV infection. In this study, we aim to identify differentially methylated CpG sites for HIV infection in immune cell types: CD4+ T-cells, CD8+ T-cells, B cells, Natural Killer (NK) cells, and monocytes.

METHODS

Applying a computational deconvolution method, we performed a cell-type based EWAS for HIV infection in three independent cohorts (Ntotal = 1,382). DNA methylation in blood or in peripheral blood mononuclear cells (PBMCs) was profiled by an array-based method and then deconvoluted by Tensor Composition Analysis (TCA). The TCA-computed CpG methylation in each cell type was first benchmarked by bisulfite DNA methylation capture sequencing in a subset of the samples. Cell-type EWAS of HIV infection was performed in each cohort separately and a meta-EWAS was conducted followed by gene set enrichment analysis.

RESULTS

The meta-analysis unveiled a total of 2,021 cell-type unique significant CpG sites for five inferred cell types. Among these inferred cell-type unique CpG sites, the concordance rate in the three cohorts ranged from 96% to 100% in each cell type. Cell-type level meta-EWAS unveiled distinct patterns of HIV-associated differential CpG methylation, where 74% of CpG sites were unique to individual cell types (false discovery rate, FDR <0.05). CD4+ T-cells had the largest number of unique HIV-associated CpG sites (N = 1,624) compared to any other cell type. Genes harboring significant CpG sites are involved in immunity and HIV pathogenesis (e.g. CD4+ T-cells: NLRC5, CX3CR1, B cells: IFI44L, NK cells: IL12R, monocytes: IRF7), and in oncogenesis (e.g. CD4+ T-cells: BCL family, PRDM16, monocytes: PRDM16, PDCD1LG2). HIV-associated CpG sites were enriched among genes involved in HIV pathogenesis and oncogenesis that were enriched among interferon-α and -γ, TNF-α, inflammatory response, and apoptotic pathways.

CONCLUSION

Our findings uncovered computationally inferred cell-type specific modifications in the host epigenome for people with HIV that contribute to the growing body of evidence regarding HIV pathogenesis.

Declining Prevalence of Trichomonas vaginalis Diagnosed by Wet Mount in a Cohort of U.S. Women With and Without HIV

Background: Women living with HIV (WLWH) are often coinfected with Trichomonas vaginalis (TV), and annual screening is recommended. Our goal was to assess differences in TV prevalence at study entry and over time in enrollment cohorts of the Women's Interagency HIV Study. Methods: In a multisite study, TV was diagnosed by wet mount microscopy. Prevalence was determined across four enrollment waves: 1994-1995, 2001-2002, 2011-2012, and 2013-2015. Generalized estimating equation multivariable logistic regression models assessed changes in visit prevalence across waves after controlling for HIV disease severity and other risks. Results: At 63,824 person-visits (3,508 WLWH and 1,262 women without HIV), TV was diagnosed by wet mount at 1979 visits (3.1%). After multivariable adjustment, HIV status was not associated with TV detection, which was more common among younger women, women with multiple partners, and irregular condom use. All enrollment waves showed a decline in TV detection over time, although p-value for trend did not reach significance for most recent waves. To explore the potential utility of screening among WLWH, we assessed rates of TV detection among women without appreciable vaginal discharge on examination. Initial TV prevalence among asymptomatic women was 3.5%, and prevalence decreased to 0.5%-1% in the most recent wave (2013-2015) (p-trend <0.0001). Conclusions: In this cohort, TV rates are low among WLWH, and HIV does not increase TV risk. Screening may benefit newly diagnosed WLWH, women with risk factors, or those receiving care sporadically but is unlikely to further reduce the low rate of TV among women in care, especially older women without multiple partners. The clinical trials registration number for WIHS is NCT00000797.

The replication-competent HIV reservoir is a genetically restricted, younger subset of the overall pool of HIV proviruses persisting during therapy, which is highly genetically stable over time

Within-host HIV populations continually diversify during untreated infection, and this diversity persists within infected cell reservoirs during antiretroviral therapy (ART). Achieving a better understanding of on-ART proviral evolutionary dynamics, and a better appreciation of how the overall persisting pool of (largely genetically defective) proviruses differs from the much smaller replication-competent HIV reservoir, is critical to HIV cure efforts. We reconstructed within-host HIV evolutionary histories in blood from seven participants of the Women's Interagency HIV Study who experienced HIV seroconversion, and used these data to characterize the diversity, lineage origins, and ages of proviral env-gp120 sequences sampled longitudinally up to 12 years on ART. We also studied HIV sequences emerging from the reservoir in two participants. We observed that proviral clonality generally increased over time on ART, with clones frequently persisting long term. While on-ART proviral integration dates generally spanned the duration of untreated infection, HIV emerging in plasma was exclusively younger (i.e., dated to the years immediately pre-ART). The genetic and age distributions of distinct proviral sequences remained stable during ART in all but one participant, in whom there was evidence that younger proviruses had been preferentially eliminated after 12 years on ART. Analysis of the gag region in three participants corroborated our env-gp120-based observations, indicating that our observations are not influenced by the HIV region studied. Our results underscore the remarkable genetic stability of the distinct proviral sequences that persist in blood during ART. Our results also suggest that the replication-competent HIV reservoir is a genetically restricted, younger subset of this overall proviral pool.IMPORTANCECharacterizing the genetically diverse HIV sequences that persist in the reservoir despite antiretroviral therapy (ART) is critical to cure efforts. Our observations confirm that proviruses persisting in blood on ART, which are largely genetically defective, broadly reflect the extent of within-host HIV evolution pre-ART. Moreover, on-ART clonal expansion is not appreciably accompanied by the loss of distinct proviral lineages. In fact, on-ART proviral genetic composition remained stable in all but one participant, in whom, after 12 years on ART, proviruses dating to around near ART initiation had been preferentially eliminated. We also identified recombinant proviruses between parental sequence fragments of different ages. Though rare, such sequences suggest that reservoir cells can be superinfected with HIV from another infection era. Overall, our finding that the replication-competent reservoir in blood is a genetically restricted, younger subset of all persisting proviruses suggests that HIV cure strategies will need to eliminate a reservoir that differs in key respects from the overall proviral pool.

Tryptophan metabolism, gut microbiota, and carotid artery plaque in women with and without HIV infection

OBJECTIVE

The perturbation of tryptophan (TRP) metabolism has been linked with HIV infection and cardiovascular disease (CVD), but the interrelationship among TRP metabolites, gut microbiota, and atherosclerosis remain unclear in the context of HIV infection.

METHODS

We included 361 women (241 HIV+, 120 HIV-) with carotid artery plaque assessments from the Women's Interagency HIV Study, measured 10 plasma TRP metabolites and profiled fecal gut microbiome. TRP metabolite-related gut bacteria were selected through the Analysis of Compositions of Microbiomes with Bias Correction method. Associations of TRP metabolites and related microbial features with plaque were examined using multivariable logistic regression.

RESULTS

Although plasma kynurenic acid (KYNA) [odds ratio (OR) = 1.93, 95% confidence interval (CI): 1.12-3.32 per one SD increase; P  = 0.02) and KYNA/TRP [OR = 1.83 (95% CI 1.08-3.09), P  = 0.02] were positively associated with plaque, indole-3-propionate (IPA) [OR = 0.62 (95% CI 0.40-0.98), P  = 0.03] and IPA/KYNA [OR = 0.51 (95% CI 0.33-0.80), P  < 0.01] were inversely associated with plaque. Five gut bacterial genera and many affiliated species were positively associated with IPA (FDR-q < 0.25), including Roseburia spp ., Eubacterium spp., Lachnospira spp., and Coprobacter spp.; but no bacterial genera were found to be associated with KYNA. Furthermore, an IPA-associated-bacteria score was inversely associated with plaque [OR = 0.47 (95% CI 0.28-0.79), P  < 0.01]. But no significant effect modification by HIV serostatus was observed in these associations.

CONCLUSION

In a cohort of women living with and without HIV infection, plasma IPA levels and related gut bacteria were inversely associated with carotid artery plaque, suggesting a potential beneficial role of IPA and its gut bacterial producers in atherosclerosis and CVD.

Common antiretroviral combinations are associated with somatic depressive symptoms in women with HIV

OBJECTIVE

While modern antiretroviral therapy (ART) is highly effective and safe, depressive symptoms have been associated with certain ART drugs. We examined the association between common ART regimens and depressive symptoms in women with HIV (WWH) with a focus on somatic vs. nonsomatic symptoms.

DESIGN

Analysis of longitudinal data from the Women's Interagency HIV Study.

METHODS

Participants were classified into three groups based on the frequency of positive depression screening (CES-D ≥16): chronic depression (≥50% of visits since study enrollment), infrequent depression (<50% of visits), and never depressed (no visits). Novel Bayesian machine learning methods building upon a subset-tree kernel approach were developed to estimate the combined effects of ART regimens on depressive symptoms in each group after covariate adjustment.

RESULTS

The analysis included 1538 WWH who participated in 12 924 (mean = 8.4) visits. The mean age was 49.9 years, 72% were Black, and 14% Hispanic. In the chronic depression group, combinations including tenofovir alafenamide and cobicistat-boosted elvitegravir and/or darunavir were associated with greater somatic symptoms of depression, whereas those combinations containing tenofovir disoproxil fumarate and efavirenz or rilpivirine were associated with less somatic depressive symptoms. ART was not associated with somatic symptoms in the infrequent depression or never depressed groups. ART regimens were not associated with nonsomatic symptoms in any group.

CONCLUSIONS

Specific ART combinations are associated with somatic depressive symptoms in WWH with chronic depression. Future studies should consider specific depressive symptoms domains as well as complete drug combinations when assessing the relationship between ART and depression.

Collection of menopause data in studies of women living with HIV: A systematic literature review

OBJECTIVES

An increasing number of women living with HIV are transitioning through midlife and menopause. Women living with HIV may experience earlier menopause and a higher symptom burden than women without HIV, but more evidence is needed. Data collection on menopause in women living with HIV is scarce and often not standardized. We sought to assess how menopause data are collected in cohorts and studies of women living with HIV.

METHODS

This was a literature review conducted within the PubMed database. We included original studies and cohorts assessing menopause and/or menopausal symptoms in women living with HIV. Study characteristics and menopause data collection, including the definition of menopause, symptom assessment tools, and measurement of biomedical parameters, were noted and summarized systematically in data tables.

RESULTS

We included 40 articles describing 37 separate studies published between 2000 and 2023; 27 of these were conducted in high-income countries, the majority in the USA (n = 16). Ten studies were from low- and middle-income countries; four of these were conducted in Brazil. In 20 studies, menopause was defined according to the World Health Organization's definition of over 12 months of amenorrhea. Twelve studies used the Menopause Rating Scale to characterize menopausal symptoms, five studies used other specified symptom assessment tools, and 12 studies used a study-specific tool.

CONCLUSIONS

Menopause data collection in women living with HIV is heterogeneous. We propose that standardized tools should be used to enable comparisons between studies and countries, thereby improving the quality of research and clinical treatment. Further research into the validity of menopausal symptom scoring tools is warranted.