Preliminary Validation of an Unannounced Telephone Pill Count Protocol to Measure Medication Adherence Among Young Adults With Perinatal HIV Infection

Unannounced telephone pill counts are an objective antiretroviral therapy adherence measurement tool, but this method has not been validated in young adults (YA) living with perinatal HIV infection. Perinatally infected YA, recruited from the Child and Adolescent Self-Awareness and Health Study, agreed to unannounced telephone pill counts to measure medication adherence over 4 months and phlebotomy to measure viral load (VL). Differences in pill count adherence scores among YA with a VL of ≤20 versus >20, and demographic differences were assessed. Participants (N = 62) were, on average, 24 years old; 57% were African American, and 40% were Latino. Participants with VL of ≤20 (60%) had significantly higher adherence scores (85% versus 62%; p = .004). Associations were not significant among older YA (range, 25-28 years) or Latinos. Unannounced telephone pill counts are a valid measure of antiretroviral therapy adherence in YA with perinatal HIV infection. Studies with larger samples are needed.

Psychiatric Disorders, Antiretroviral Medication Adherence and Viremia in a Cohort of Perinatally HIV-Infected Adolescents and Young Adults

BACKGROUND

Perinatally HIV-infected (PHIV+) adolescents and young adults (AYA) are at risk for suboptimal antiretroviral therapy (ART) adherence and mental health and substance use problems that, in HIV-infected adults, predict nonadherence. Studies on the relationship between psychiatric and substance use disorders (SUD) and adherence among PHIV+ AYA are limited, but may be important for informing evidence-based interventions to promote adherence.

METHODS

Data were analyzed from 3 annual follow-up interviews (FU2-FU4, N = 179) in a longitudinal study of PHIV+ AYA. Psychiatric disorders (anxiety, disruptive behavior, mood and SUD) were assessed with the Diagnostic Interview Schedule for Children. Adherence was self-reported missed ART doses within the past week. Viral load (VL) results were abstracted from medical charts. Multiple logistic regression analyzed cross-sectional associations between psychiatric disorders and (1) missed ART dose and (2) VL > 1000 copies/mL. Multiple linear regression assessed associations between psychiatric disorders and proportion of VL values >1000 copies/mL over time.

RESULTS

At FU2, 53% of PHIV+ AYA had any psychiatric disorder, 35% missed an ART dose in the past week and 47% had a VL > 1000 copies/mL. At FU2, behavioral disorders were associated with missed dose (P = 0.009) and VL > 1000 (P = 0.019), and mood disorders were associated with missed dose (P = 0.041). At FU4, behavioral disorders were associated with missed dose (P = 0.009). Behavioral disorders (P = 0.041), SUD (P = 0.016) and any disorder (P = 0.008) at FU2 were associated with higher proportion of VLs >1000 across FU2-FU4.

CONCLUSIONS

Addressing psychiatric disorder and SUD among PHIV+ AYA may improve ART adherence outcomes in this population. Targeted interventions should be developed and tested.

Association Between Psychiatric Disorders, Substance Use, and Sexual Risk Behaviors in Perinatally HIV-Exposed Youth

As youth with perinatally acquired HIV infection age, there is a need for studies that identify predictors and correlates of sexual risk behaviors. We examined the association between psychiatric disorders and substance use disorders (SUD) with sexual risk behaviors in youth with perinatally acquired HIV infection and perinatally HIV-exposed but uninfected youth. Participants were recruited from four medical centers in New York City. The Diagnostic Interview Schedule for Children and the Adolescent Sexual Behavior Assessment were administered to assess psychiatric disorders and sexual behaviors, respectively. SUD and behavior disorders were correlated with either ever having had penetrative sex or recent condomless sex for participants with perinatally acquired HIV infection only. Results suggest that clinicians should screen and treat patients for SUD and behavioral disorders to reduce sexual risk behaviors in youth with perinatally acquired HIV infection.

Use of Unannounced Telephone Pill Counts to Measure Medication Adherence Among Adolescents and Young Adults Living With Perinatal HIV Infection

Objective

To examine unannounced telephone pill counts as a measure of adherence to antiretroviral therapy among adolescents and young adults living with perinatal HIV infection.

Methods

Participants were recruited from an ongoing longitudinal study to complete four monthly, unannounced telephone pill counts. Detailed notes concerning participants' medication habits surrounding adherence were recorded.

Results

Two-thirds of 102 eligible participants aged 18-27 years participated; 57% were female, 69% were Black. Blacks and participants with viral loads >40 and >1,000 copies/ml were less likely to participate. Average adherence across calls was 77%. Those who completed all calls averaged significantly higher adherence scores than those who did not. Calls revealed adherence barriers at individual (e.g., medication disorganization), social (e.g., limited support), and system (e.g., pharmacy problems) levels.

Conclusions

Despite challenges, this procedure can be implemented with this population and can help identify adherence barriers important for interventions that address medication-taking behaviors.

RAS signalling through PI3-Kinase controls cell migration via modulation of Reelin expression

RAS signalling through phosphoinositide 3-kinase (PI3-Kinase) has been shown to have an essential role in tumour initiation and maintenance. RAS also regulates cell motility and tumour invasiveness, but the role of direct RAS binding to PI3-Kinase in this remains uncertain. Here, we provide evidence that disruption of RAS interaction with PI3-Kinase p110α decreases cell motility and prevents activation of Rac GTPase. Analysis of gene expression in cells lacking RAS interaction with p110α reveals increased levels of the extracellular matrix glycoprotein Reelin and activation of its downstream pathway resulting in upregulation of E-cadherin expression. Induction of the Reelin/E-cadherin axis is also observed in Kras mutant lung tumours that are regressing due to blockade of RAS interaction with PI3-Kinase. Furthermore, loss of Reelin correlates with decreased survival of lung and breast cancer patients. Reelin thus plays a role in restraining RAS and PI3-kinase promotion of cell motility and potentially tumour metastasis.

Marijuana Use and Psychiatric Disorders in Perinatally HIV-Exposed Youth: Does HIV Matter?

OBJECTIVE

 To examine longitudinal reciprocal relationships between marijuana use and psychiatric disorders, and identify the role of HIV in a sample (N = 340) of youth perinatally infected with HIV (PHIV+) and youth perinatally exposed but uninfected with HIV (PHIV-) (60.6% PHIV+; 9-16 years at baseline; 51% female). 

METHODS

 Cross-lagged structural equation modeling was used to examine longitudinal associations between changes in marijuana use and changes in any behavioral, mood, and anxiety disorders at three time points across adolescence. 

RESULTS

 Marijuana use predicted behavioral and mood disorders in youth, regardless of HIV status. Behavioral and mood disorders predicted marijuana use for PHIV- youth; behavioral disorders predicted marijuana use for PHIV+ youth. Anxiety disorders and marijuana use were not associated for either group. 

CONCLUSIONS

 For PHIV+ and PHIV- youth, interventions that target early marijuana use may reduce later psychiatric disorders. Similarly, treatment for early behavioral disorders may prevent subsequent marijuana use.

Enhancing Lay Counselor Capacity to Improve Patient Outcomes with Multimedia Technology

Multimedia technologies offer powerful tools to increase capacity of health workers to deliver standardized, effective, and engaging antiretroviral medication adherence counseling. Masivukeni-is an innovative multimedia-based, computer-driven, lay counselor-delivered intervention designed to help people living with HIV in resource-limited settings achieve optimal adherence. This pilot study examined medication adherence and key psychosocial outcomes among 55 non-adherent South African HIV+ patients, on antiretroviral therapy (ART) for at least 6 months, who were randomized to receive either Masivukeni or standard of care (SOC) counseling for ART non-adherence. At baseline, there were no significant differences between the SOC and Masivukeni groups on any outcome variables. At post-intervention (approximately 5-6 weeks after baseline), -clinic-based pill count adherence data available for 20 participants (10 per intervention arm) showed a 10 % improvement for-participants and a decrease of 8 % for SOC participants. Masivukeni participants reported significantly more positive attitudes towards disclosure and medication social support, less social rejection, and better clinic-patient relationships than did SOC participants. Masivukeni shows promise to promote optimal adherence and provides preliminary evidence that multimedia, computer-based technology can help lay counselors offer better adherence counseling than standard approaches.

HIV treatment adherence measurement and reporting concordance in youth with perinatally acquired HIV infection and their caregivers

We examined youth-caregiver adherence report concordance and association of different adherence self-report items with HIV RNA viral load (VL) in perinatally HIV-infected adolescents assessed in 2003-2008. Youth (n=194; 9-19 years) and their caregivers completed a multi-step 2-day recall, one item on last time medications were missed, and one item on responsibility for managing youths' medications. Across early (9-12 years), middle (13-15 years), and late (16+years) adolescence, both youth and caregivers reported having primary responsibility for youths' medication regimens and demonstrated poor to moderate youth-caregiver concordance on adherence items. Responses to the last-time-missed item had greater association with VL than did the 2-day recall, particularly for longer times (e.g., past month). By age group, significant associations with VL were found for caregiver reports in early adolescence, caregiver and youth reports in middle adolescence, and youth reports in late adolescence, suggesting that caregivers offer better reports of youth adherence during early adolescence, but by later adolescence, youth are better informants. Although design limitations preclude definitive conclusions about the reliability and validity of specific adherence items, this study suggests important issues related to age group, caregiver vs. youth informants of adherence, and recall periods for child adherence assessment that warrant further research.

Asking only "Did you use a condom?" underestimates the prevalence of unprotected sex among perinatally HIV infected and perinatally exposed but uninfected youth

Among young adults who use condoms, incomplete condom use (putting a condom on after beginning or taking a condom off before finishing sex) and condom failure (condom breaking or slipping off during sex) are common. Therefore, sexual behavior surveys that ask only if a condom was used are likely to underestimate the actual prevalence of unprotected sex. This study examined data from 135 sexually active perinatally HIV-infected (PHIV+) youth and perinatally exposed but uninfected (PHIV-) youth, ages 13 to 24. Participants were asked whether they used a condom on their first and their most recent occasion of vaginal sex. Youth who reported using a condom were asked a follow-up question about whether there was any time during that occasion when sex was not protected by a condom. This follow-up question identified additional participants--almost double the proportions who initially said they did not use a condom--who had unprotected sex. Incomplete condom use was similar among PHIV+ and PHIV-youth, boys and girls, Latinos and African Americans, and younger and older youth. These findings illustrate the importance of asking specifically about whether any unprotected behavior occurred from start to finish of sex to achieve more valid estimates of sexual risk behavior.

Masivukeni: development of a multimedia based antiretroviral therapy adherence intervention for counselors and patients in South Africa

Effective medical treatment for HIV/AIDS requires patients' optimal adherence to antiretroviral therapy (ART). In resource-constrained settings, lack of adequate standardized counseling for patients on ART remains a significant barrier to adherence. Masivukeni ("Let's Wake Up" in Xhosa) is an innovative multimedia-based intervention designed to help people living with HIV in resource-limited settings achieve and maintain high levels of ART adherence. Adapted from a couples-based intervention tested in the United States (US), Masivukeni was developed through community-based participatory research with US and South African partners and informed by Ewart's Social Action Theory. Innovative computer-based multimedia strategies were used to translate a labor- and training-intensive intervention into one that could be readily and widely used by lay counselors with relatively little training with low-literacy patients. In this paper, we describe the foundations of this new intervention, the process of its development, and the evidence of its high acceptability and feasibility.

Moving From Theory to Research to Practice

There is a dearth of evidence on the relative efficacy of intervention modalities to improve and maintain patient adherence to antiretroviral medications. Although empiric findings from research on HIV/AIDS, other diseases, and chronic medical conditions consistently demonstrate that social support plays an important role in facilitating adherence, few HIV/AIDS interventions have directly targeted this factor. Ewart's social action theory emphasizes the role of social relationships in behavior change and provides a comprehensive and useful guide to the development of interventions for adherence. We describe the development, content, and testing of SMART Couples, an effective antiretroviral adherence intervention that is grounded in social action theory and designed to enhance social support for ART adherence. Finally, we discuss some of the challenges of translating findings from the randomized clinical trial of this intervention into clinical practice and offer recommendations for integration of lessons learned into ongoing clinical care.

Exoenzyme S of Pseudomonas aeruginosa is not able to induce apoptosis when cells express activated proteins, such as Ras or protein kinase B/Akt

Intracellular targeting of the Pseudomonas aeruginosa toxins, such as exoenzyme S (ExoS), cause cell death, as well as morphological and physiological changes in various tissue culture cells and animal models. In this report we have investigated the mechanism behind ExoS-mediated cell death. In order to address this issue, we have used cell lines expressing activated forms of various components of the Ras signalling pathway in order to evaluate the importance of the Ras pathway for viability and survival upon ExoS infection. Here we show that activated Ras is able to protect cells against cell death, regardless of whether it has been ADP-ribosylated by ExoS. Further, an activated form of protein kinase B (PKB)/Akt also leads to decreased level of cell death in response to ExoS infection, indicating that an important ExoS survival target is located upstream of Raf-1 and PKB/Akt. Moreover, we show that ExoS infection inhibits phosphorylation of FOXO3a, and induces caspase-3 activity, which are hallmarks for induction of cell death. In conclusion, we suggest that Ras proteins are an important cellular target for the P. aeruginosa toxin ExoS, which induces cell death during pathogenesis as a means of defending the bacterium against eukaryotic phagocytosis.

Plasma homovanillic acid in schizotypal personality disorder

Schizotypal patients were found to have a significantly higher mean plasma HVA concentration than normal comparison subjects. Furthermore, plasma HVA concentration positively correlated with "psychotic-like" schizotypal symptoms. These results implicate dopaminergic mechanisms modulating the psychotic-like symptoms of schizotypal personality disorder.

CD2 antigen mediated activation of the guanine nucleotide binding proteins p21ras in human T lymphocytes

T cell stimulation via the TCR complex (TCR/CD3 complex) results in activation of the guanine nucleotide binding proteins encoded by the ras protooncogenes (p21ras). In the present study we show that the activation state of p21ras in T lymphocytes can also be controlled by triggering of the CD2 Ag. The activation state of p21ras is controlled by GTP levels on p21ras. In T cells stimulation of protein kinase C is able to induce an accumulation of "active" p21ras-GTP complexes due to an inhibitory effect of protein kinase C stimulation on the intrinsic GTPase activity of p21ras. The regulatory effect of protein kinase C on p21ras GTPase activity appears to be mediated via regulation of GAP, the GTPase activating protein of p21ras. In the present report, we demonstrate that the TCR/CD3 complex and the CD2 Ag control the accumulation of p21ras-GTP complexes via a regulatory effect on p21ras GTPase activity. The TCR/CD3 complex and CD2 Ag are also able to control the cellular activity of GAP. These data demonstrate that p21ras is part of the signal transduction responses controlled by the CD2 Ag, and reveal that the TCR/CD3 complex and CD2 Ag control the activation state of p21ras via a similar mechanism.

CD2 antigen mediated activation of the guanine nucleotide binding proteins p21ras in human T lymphocytes

T cell stimulation via the TCR complex (TCR/CD3 complex) results in activation of the guanine nucleotide binding proteins encoded by the ras protooncogenes (p21ras). In the present study we show that the activation state of p21ras in T lymphocytes can also be controlled by triggering of the CD2 Ag. The activation state of p21ras is controlled by GTP levels on p21ras. In T cells stimulation of protein kinase C is able to induce an accumulation of "active" p21ras-GTP complexes due to an inhibitory effect of protein kinase C stimulation on the intrinsic GTPase activity of p21ras. The regulatory effect of protein kinase C on p21ras GTPase activity appears to be mediated via regulation of GAP, the GTPase activating protein of p21ras. In the present report, we demonstrate that the TCR/CD3 complex and the CD2 Ag control the accumulation of p21ras-GTP complexes via a regulatory effect on p21ras GTPase activity. The TCR/CD3 complex and CD2 Ag are also able to control the cellular activity of GAP. These data demonstrate that p21ras is part of the signal transduction responses controlled by the CD2 Ag, and reveal that the TCR/CD3 complex and CD2 Ag control the activation state of p21ras via a similar mechanism.

Changes in plasma homovanillic acid concentrations in schizophrenic patients following neuroleptic discontinuation

Changes in plasma levels of the dopamine metabolite homovanillic acid have been reported to correlate with changes in the severity of schizophrenic symptoms during neuroleptic administration and after neuroleptic discontinuation. This study examined the effects of discontinuation of neuroleptic treatment on plasma homovanillic acid levels in 23 patients with chronic schizophrenia. It was hypothesized that clinical decompensation would be associated with increased plasma homovanillic acid levels. Plasma homovanillic acid was measured during administration of neuroleptic medication and during a subsequent 6-week drug-free period. Nine patients decompensated during the drug-free period and 14 patients did not. Following drug discontinuation, plasma homovanillic acid concentrations were higher in schizophrenic patients who decompensated than in those who did not. Furthermore, peak plasma homovanillic acid elevation after discontinuation of neuroleptic medication was significantly correlated with peak Brief Psychiatric Rating Scale increase. The data suggest that, in some schizophrenic patients, symptomatic decompensation after discontinuation of neuroleptic treatment is associated with increases in dopamine turnover.

The effects of sodium sulphate and sodium chloride on growth, morphology, photosynthesis, and water use efficiency of Chenopodium rubrum

The effects of sodium sulphate and sodium chloride salinity on the anatomy, water relations, and photosynthesis of Chenopodium rubrum L. were compared. Low concentrations of either salt stimulated growth, but higher concentrations resulted in large decreases in dry weight and leaf area. Leaf succulence and the number of layers of palisade cells were increased, but these effects were more pronounced with NaCl than with Na2SO4. Stomatal density was reduced at low to moderate salinities, but then increased again at high salinity. Stomatal size was reduced at all salinities. Increasing salinity had no great effect on photosynthetic rates except with older plants grown at the highest level of Na2SO4. Stomatal conductance decreased at all salinities. This reduced transpiration and led to increased intrinsic water use efficiency. Total tissue stable carbon isotope ratios also indicated that water use efficiency was improved. Chenopodium rubrum adjusted osmotically by accumulating electrolytes from the nutrient solution and by synthesizing glycinebetaine. Plants in NaCl limited osmotic adjustment more than those growing in Na2SO4. Despite this, Na2SO4 was more damaging than NaCl and caused earlier leaf senescence at high concentrations.

Fluorescent location of ornithine decarboxylase employing derivatives of the specific inhibitor alpha-difluoromethyl ornithine

Two fluorescent derivatives have been made from alpha-difluoromethyl ornithine by linking the carboxyl group of the ornithine derivatives to fluorescent amines. alpha-difluoromethyl ornithine is a potent inhibitor of ornithine decarboxylase, an enzyme which plays an essential role in cell division. We have used these fluorescent derivatives as probes for ornithine decarboxylase in frozen sections of skin to locate the epithelial cells which are known to contain ornithine decarboxylase. The probes also located squamous cell carcinoma cells in human skin.