Durable Viral Suppression Among Young Adults Living with HIV Receiving Ryan White Services in New York City

Identifying factors associated with durable viral suppression (DVS) can inform interventions to support young adults living with HIV (YALWH) in sustaining optimal health. We examined associations between client characteristics and DVS among YALWH aged 18-29 who completed an intake assessment and received ≥ 1 Ryan White Part A service in New York City from 1/2017 to 12/2019. Individuals were classified as achieving DVS at least once if they had ≥ 2 suppressed viral load test results ≥ 90 days apart with: (a) no intervening unsuppressed viral load test results in a 12-month period; and (b) no unsuppressed viral load test results after achieving DVS in that 12-month period. Of 2208 YALWH, 92.1% (n = 2034) had sufficient data in the New York City HIV Surveillance Registry to ascertain DVS status. Of these, 68% achieved DVS at least once. Controlling for ART prescription status at intake, YALWH with higher incomes were significantly more likely to achieve DVS at least once. YALWH with lifetime and recent histories of incarceration and/or drug use were significantly less likely to achieve DVS. Our findings underscore the potential role of tailored harm reduction and post-incarceration programs in reducing health inequities among YALWH.

A process and impact evaluation of a peer-led HIV self-management program

There is evidence that people with HIV (PWH) receive health-related benefits from having peer support and learning self-management skills. This evaluation assessed the effect of The Positive Life Workshop (TPLW)-a 7-session peer-led HIV self-management program-on psychosocial and HIV treatment outcomes. The overall sample included 1360 PWH who completed TPLW during 3/2015-2/2019. Surveys were administered before and after the program, and three months following program completion. Analyses examined changes in outcomes from pre-test to both post-test and 3-month follow-up using non-parametric tests. Subgroup analyses were conducted for 406 participants with ≥ 1 characteristic of the priority population for TPLW (i.e., recent HIV diagnosis, not taking antiretroviral therapy (ART), suboptimal ART adherence, unsuppressed viral load). In the overall sample, there were statistically significant improvements in HIV-related knowledge, social support, patient self-advocacy, and confidence in self-management between pre-test and post-test/3-month follow-up assessment. Analyses for the priority population showed significant increases from pre-test to 3-month follow-up in the proportion of participants who were ≥ 90 % adherent to ART (59-83 %, p < 0.01) and virally suppressed (42 % to 66 %, p < 0.01). The findings suggest the importance of ensuring HIV self-management interventions reach vulnerable populations of PWH who struggle with initiating and maintaining HIV-related health-promoting behaviors.

Associations between drug use patterns and viral load suppression among HIV-positive individuals who use support services in New York City

BACKGROUND

Drug use (DU) represents a significant barrier to maintaining physical health among people living with HIV (PLWH). Few studies, however, have examined the relationship between DU over time and HIV treatment outcomes. Such studies are needed because an individual's risk of poor health outcomes may vary with their DU behaviors. We examined associations between DU patterns over time and unsuppressed viral load (VL).

METHODS

The sample included 7896 PLWH in New York City who completed ≥3 substance use assessments over a 24-month period. DU was defined as crystal methamphetamine, crack/cocaine, heroin, and/or recreational prescription medication use in the last three months. Four behavior patterns were constructed: (1) persistent use (DU reported on each assessment); (2) intermittent use-active (DU reported on the third, but not all previous assessments); (3) intermittent use-inactive (DU reported previously with no DU reported on the third assessment); (4) persistent non-use (no DU reported on any assessment). Unsuppressed VL (>200 copies/mL) was assessed based on the last VL value in the New York City HIV Surveillance Registry in the 12 months following an individual's third DU assessment.

RESULTS

Compared with persistent non-users, individuals with intermittent use-inactive (aOR = 1.24, 95% CI = 1.03-1.49), intermittent use-active (aOR = 1.68, 95% CI = 1.36-2.06), and persistent use (aOR = 2.21, 95% CI = 1.69-2.89) were significantly more likely to have unsuppressed VL.

CONCLUSIONS

While providers may be more likely to intervene with persistent or active drug users, our findings suggest the importance of addressing the risk of poor HIV treatment outcomes among those with any DU behavior.

Identifying Key Elements to Inform the Development of an HIV Health Behavior Maintenance Intervention

PURPOSE

To collect information that will inform the development of an intervention to support the maintenance of HIV-related health-promoting behaviors.

DESIGN

Focused, in-depth individual and group interviews.

SETTING

The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) and DOHMH-funded community-based organizations that primarily serve low-income people living with HIV within the five boroughs of NYC.

PARTICIPANTS

A total of 42 individuals who had participated in The Positive Life Workshop-an HIV self-management intervention adapted and implemented by the NYC DOHMH.

METHOD

Purposive sampling was used to recruit study participants. Five 60- to 90-minute focus groups (n = 38) and 4 individual interviews were conducted to assess motivations for and barriers to maintaining HIV-related health-promoting behaviors and to elicit feedback on the content and format for the proposed maintenance intervention. Thematic analysis was used to summarize the data.

RESULTS

Participants reported that relationships with family, a responsibility to protect others from HIV, and faith/spirituality supported the maintenance of health-promoting behaviors. Barriers to behavior maintenance included substance use and mental health issues. Meeting in small groups was also highlighted as a motivator to sustaining health behaviors, particularly in decreasing isolation and receiving affirmation from others.

CONCLUSION

Participants identified several factors that could be incorporated into an intervention to support HIV-related health-promoting behavior maintenance that could supplement existing HIV self-management interventions.

Recent Tobacco Smoking is Associated with Poor HIV Medical Outcomes Among HIV-Infected Individuals in New York

Tobacco smoking is associated with adverse health effects among people living with HIV (PLWH), including a higher risk of cancer and cardiovascular problems. Further, there is evidence that PLWH are two to three times more likely to smoke than the general population. The aim of this study was to examine the association between tobacco smoking and biomarkers of HIV disease progression, including unsuppressed viral load (viral load >200 copies/mL) and low CD4 cell count (<200 cells/mm(3)). Recent tobacco smoking was reported by 40 % (n = 5942) of 14,713 PLWH enrolled in Ryan White Part A programs in the New York City metropolitan area. In multivariate analyses controlling for sociodemographic and clinical characteristics, recent tobacco smoking was independently associated with unsuppressed viral load (AOR = 1.38, CI 1.26-1.50) and low CD4 cell count (AOR = 1.12, CI 1.01-1.24). Findings suggest the importance of routine assessments of tobacco use in clinical care settings for PLWH.

Crystal methamphetamine use and HIV medical outcomes among HIV-infected men who have sex with men accessing support services in New York

BACKGROUND

Drug use poses multiple challenges to maintaining physical health among HIV-infected individuals, particularly with regard to disease progression. Few studies, however, have examined the association between the use of crystal methamphetamine ("crystal meth") and HIV disease progression specifically among HIV-infected men who have sex with men (MSM). Understanding this relationship among HIV-infected MSM is particularly critical because of the high rates of crystal meth use reported in the population.

METHODS

Associations between recent crystal meth use and poor HIV medical outcomes (viral load>200 copies/mL, CD4 count <350 cells/mm(3)) were analyzed for 2896 HIV-infected MSM enrolled in Ryan White Part A programs in the greater New York metropolitan area between November 2010 and June 2012.

RESULTS

Crystal meth use (reported by 4%) was independently associated with unsuppressed viral load (AOR=1.8, CI=1.1-2.9) in multivariate analyses controlling for sociodemographic characteristics. There was no significant relationship between crystal meth use and low CD4 counts.

CONCLUSIONS

To date, little research has examined how crystal meth use influences HIV medical outcomes among HIV-infected MSM. This analysis showed a significant independent association between crystal meth use and unsuppressed viral load among MSM in an HIV service population. Future studies should examine biological and psychosocial mediators, moderators and confounders of this relationship to inform intervention development for MSM crystal meth users in HIV care settings.

Is there life after DEBI? Examining health behavior maintenance in the diffusion of effective behavioral interventions initiative

The evidence-based interventions that are identified, packaged, and disseminated by the Division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention as part of the Diffusion of Effective Behavioral Interventions (DEBI) initiative-commonly referred to the "DEBIs"-currently represent a primary source of HIV prevention interventions for community-based providers. To date, little attention has focused on whether the intended outcomes of the DEBIs, i.e., reductions in HIV-related risk behaviors, are maintained over time. This review summarized evidence for the sustainability of the effects of the DEBIs on HIV sexual risk behavior and intravenous drug use from studies of original and adapted DEBIs. Evidence of intervention decay or a lack of any intervention effect was identified in several original and adapted versions of the DEBIs included in this review. Recommendations include modifications to current criteria for inclusion in the DEBI portfolio, in addition to the development of remediation strategies to address intervention decay. Further, theoretical models that specify the processes that underlie the maintenance of health behaviors over time should be used in developing HIV prevention interventions.

Evaluation of a system designed to link people living with HIV/AIDS with mental health services at an AIDS-service organization

This study evaluated the Rapid Response System, an initiative designed to link people living with HIV/AIDS with mental health services at an AIDS service organization. Data were extracted from agency records for 314 clients who had contact with the Rapid Response System over a 6-month period. Of the 281 clients who scheduled an appointment for an evaluation to initiate mental health services, 64% completed the evaluation. In the multivariate analysis, Latinos were significantly less likely than whites to complete the mental health evaluation. Further, there was a significant decrease in the likelihood of completing the mental health evaluation as the number of days between the Rapid Response System contact and the date of the evaluation appointment increased. Strategies that reduce the period of time between the initial referral and initiation of services may facilitate linkage with mental health treatment, particularly in the context of larger multi-service organizations.

A group intervention to improve body image satisfaction and dietary habits in gay and bisexual men living with HIV/AIDS

A healthy diet is essential to maintaining a strong immune system for people living with HIV and AIDS. Prior studies have shown that HIV-positive gay and bisexual men are more susceptible to poor body image, which can negatively impact dietary habits. Interventions that simultaneously address body image and nutrition are therefore critical for this population. This paper describes the curriculum for a 14-week group designed to improve body image satisfaction and dietary habits in gay and bisexual men living with HIV/AIDS.

A critical literature review to identify possible causes of higher rates of HIV infection among young black and Latino men who have sex with men

Black and Latino young men who have sex with men (YMSM) are disproportionately impacted by HIV infection; however, the reason for this disparity is unclear. To identify possible causes of the higher rates of HIV infection in this population, data from studies of HIV infection and risk-related behaviors among black and Latino YMSM were used to evaluate a series of hypotheses adapted from Millett et al's literature review that might explain the disparity. High rates of HIV infection might be attributable to unrecognized HIV infection, social/sexual networks, and a history of childhood sexual abuse; however, they were not attributable to risk-related behaviors. More research is needed to understand the risk factors for HIV infection and how to address them in HIV prevention interventions.

Comorbidity and age of onset of eating disorders in gay men, lesbians, and bisexuals

This study examines the prevalence of psychiatric disorders among lesbian, gay, and bisexual (LGB) men with eating disorders. A total of 388 white, black, and Latino LGB men and women were sampled from community venues. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of anorexia, bulimia, and binge eating disorder were assessed using the World Health Organization's Composite International Diagnostic Interview. Gay and bisexual men with eating disorders were more likely to have an anxiety or substance abuse disorder than gay and bisexual men without eating disorders, whereas lesbian and bisexual women with eating disorders were more likely to have a mood disorder than lesbian and bisexual women without an eating disorder. For individuals diagnosed with an eating and anxiety or major depressive disorder, the onset of the psychiatric disorder was more likely to precede the onset of the eating disorder. Researchers should study potential explanations of the relationship between eating and psychiatric disorders among LGB men and women.

Intimate partner violence and HIV sexual risk behavior among Latino gay and bisexual men: the role of situational factors

Using a probability sample of 912 Latino gay and bisexual men at bars in 3 U.S. cities (Los Angeles, Miami, New York), this study examines how participation in difficult sexual situations with interpersonal (e.g., wanting to please partner) and circumstantial constraints (e.g., sex in partner's home) may explain associations between dimensions of intimate partner violence (IPV) and HIV sexual risk behavior (unprotected anal intercourse with nonmonogamous partner). Findings suggest that all IPV types contribute to greater participation in sexual situations with circumstantial constraints, and that psychological and sexual IPV are also associated with higher likelihood of unprotected receptive anal intercourse with a nonmonogamous partner. Circumstantial constraints fully mediate the difference attributable to psychological IPV and partially mediate the difference attributable to sexual IPV. Intimacy concerns were unrelated to either IPV or HIV risk behavior. Results suggest HIV prevention and research should investigate immediate circumstances of the sexual encounter that may make engaging in HIV sexual risk behavior more likely.

Childhood abuse and eating disorders in gay and bisexual men

OBJECTIVE

This study examines the association between eating disorders and a history of childhood abuse in gay and bisexual men, and how substance abuse and depression might impact this relationship.

METHOD

193 white, black, Latino gay, and bisexual men were sampled from community venues. DSM-IV diagnoses of anorexia, bulimia, and binge eating disorder were assessed using the World Health Organization's Composite International Diagnostic Interview.

RESULTS

Men with a history of childhood sexual abuse are significantly more likely to have subclinical bulimia or any current full-syndrome or subclinical eating disorder compared with men who do not have a history of childhood sexual abuse. A history of depression and/or substance use disorders did not mediate this relationship.

CONCLUSION

Researchers should study other potential explanations of the relationship between a history of childhood abuse and eating disorders in gay and bisexual men. Clinicians working with gay and bisexual men who have a history of childhood abuse should assess for disordered eating as a potential mechanism to cope with the emotional sequelae associated with abuse.

Eating disorders in diverse lesbian, gay, and bisexual populations

OBJECTIVE

This study estimates the prevalence of eating disorders in lesbian, gay, and bisexual (LGB) men and women, and examines the association between participation in the gay community and eating disorder prevalence in gay and bisexual men.

METHOD

One hundred and twenty six white heterosexuals and 388 white, black, Latino LGB men and women were sampled from community venues. DSM-IV diagnoses of anorexia, bulimia, and binge eating disorder were assessed using the World Health Organization's Composite International Diagnostic Interview.

RESULTS

Gay and bisexual men had significantly higher prevalence estimates of eating disorders than heterosexual men. There were no differences in eating disorder prevalence between lesbian and bisexual women and heterosexual women, or across gender or racial groups. Attending a gay recreational group was significantly related to eating disorder prevalence in gay and bisexual men.

CONCLUSION

Researchers should study the causes of the high prevalence of eating disorders among gay and bisexual men.

Terminal illness in a psychiatric patient--issues and ethics

A woman with paranoid psychosis and terminal breast cancer refused palliative radiation, demanding pain-killers and permission to leave hospital to go into the mountains and die on her own. Was it ethical to allow her to do so, or should a court order have been sought to impose hospital treatment on her? Should she have been persuaded to accept hospital care? When do those in charge deem a terminally ill patient unable to understand the issues, and dictate treatment? Our aim in this article is to highlight a number of ethical matters regarding patient care, as well as to try and determine the role a hospice should play with regard to the terminally ill patient with associated psychiatric disorder.