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1.  Alcohol consumption trajectory patterns in adult women with HIV infection 
AIDS and behavior  2013;17(5):1705-1712.
HIV-infected women with excessive alcohol consumption are at risk for adverse health outcomes, but little is known about their long-term drinking trajectories. This analysis included longitudinal data, obtained from 1996–2006, from 2791 women with HIV from the Women’s Interagency HIV Study. Among these women, the proportion in each of five distinct drinking trajectories was: continued heavy drinking (3%), reduction from heavy to non-heavy drinking (4%), increase from non-heavy to heavy drinking (8%), continued non-heavy drinking (36%), and continued non-drinking (49%). Depressive symptoms, other substance use (crack/cocaine, marijuana, and tobacco), co-infection with HCV, and heavy drinking prior to enrollment were associated with trajectories involving future heavy drinking. In conclusion, many women with HIV change their drinking patterns over time. Clinicians and those providing alcohol-related interventions might target those with depression, current use of tobacco or illicit drugs, HCV infection, or a previous history of drinking problems.
doi:10.1007/s10461-012-0270-6
PMCID: PMC3534826  PMID: 22836592
Alcohol consumption; women; HIV-infection; trajectories
2.  Adolescent Substance Use in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder (ADHD) (MTA) as a Function of Childhood ADHD, Random Assignment to Childhood Treatments, and Subsequent Medication 
Objectives
To determine long-term effects on substance use and substance use disorder (SUD), up to 8 years after childhood enrollment, of the randomly assigned 14-month treatments in the multisite Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA; n=436); to test whether (a) medication at follow-up, (b) cumulative psychostimulant treatment over time, or (c) both relate to substance use/SUD; to compare substance use/SUD in the ADHD sample to the non-ADHD childhood classmate comparison group (n=261).
Method
Mixed-effects regression models with planned contrasts were used for all tests except the important cumulative stimulant treatment question, for which propensity score matching analysis was used.
Results
The originally randomized treatment groups did not differ significantly on substance use/SUD by the 8 year follow-up or earlier (M age = 17 years). Neither medication at follow-up (mostly stimulants) nor cumulative stimulant treatment was associated with adolescent substance use/SUD. Substance use at all time points, including use of two or more substances and SUD, were each greater in the ADHD than non-ADHD samples, regardless of sex.
Conclusions
Medication for ADHD did not protect from, nor contribute to, visible risk of substance use or SUD by adolescence, whether analyzed as randomized treatment assignment in childhood, as medication at follow-up, or as cumulative stimulant treatment over an 8 year follow-up from childhood. These results suggest the need to identify alternative or adjunctive adolescent-focused approaches to substance abuse prevention and treatment for boys and girls with ADHD, especially given their increased risk for use and abuse of multiple substances that is not improved with stimulant medication. Clinical trial registration information—Multimodal Treatment Study of Children with Attention Deficit and Hyperactivity Disorder (MTA); http://clinical trials.gov/; NCT00000388.
doi:10.1016/j.jaac.2012.12.014
PMCID: PMC3589108  PMID: 23452682
attention-deficit/hyperactivity disorder (ADHD); substance uses
3.  TB Diagnostic Capacity in Sub-Saharan African HIV Care Settings 
As HIV care services continue to scale-up in sub-Saharan Africa, adequate tuberculosis diagnostic capacity is vital to reduce mortality among HIV-infected persons. A structured survey was administered at 663 health facilities providing HIV care to 908,043 patients in across 9 sub-Saharan African countries to estimate the proportion of facilities and HIV patients at these facilities with access TB-related diagnostic tests. Sputum smear microscopy was available at 87% of facilities (representing 97% of patients), chest x-ray at 26% of facilities (representing 56% of patients), tuberculin skin tests were available at 12% of facilities (representing 33% of patients). Acid-fast bacillus culture was available on-/off-site at 53% of facilities (representing 77% of patients). Primary health facilities had lower availability of tuberculosis diagnostic tests compared with secondary and tertiary health facilities. As HIV care continues to decentralize to primary health facilities, a corresponding expansion of diagnostic capacity to lower levels of the health system will be essential.
doi:10.1097/QAI.0b013e3182638ec7
PMCID: PMC3890234  PMID: 22732465
tuberculosis diagnostics; laboratory capacity; TB/HIV integration; HIV care; implementation science; resource-limited settings
4.  HIV Prevention in Care and Treatment Settings: Baseline Risk Behaviors among HIV Patients in Kenya, Namibia, and Tanzania 
PLoS ONE  2013;8(2):e57215.
HIV care and treatment settings provide an opportunity to reach people living with HIV/AIDS (PLHIV) with prevention messages and services. Population-based surveys in sub-Saharan Africa have identified HIV risk behaviors among PLHIV, yet data are limited regarding HIV risk behaviors of PLHIV in clinical care. This paper describes the baseline sociodemographic, HIV transmission risk behaviors, and clinical data of a study evaluating an HIV prevention intervention package for HIV care and treatment clinics in Africa. The study was a longitudinal group-randomized trial in 9 intervention clinics and 9 comparison clinics in Kenya, Namibia, and Tanzania (N = 3538). Baseline participants were mostly female, married, had less than a primary education, and were relatively recently diagnosed with HIV. Fifty-two percent of participants had a partner of negative or unknown status, 24% were not using condoms consistently, and 11% reported STI symptoms in the last 6 months. There were differences in demographic and HIV transmission risk variables by country, indicating the need to consider local context in designing studies and using caution when generalizing findings across African countries. Baseline data from this study indicate that participants were often engaging in HIV transmission risk behaviors, which supports the need for prevention with PLHIV (PwP).
Trial Registration
ClinicalTrials.gov NCT01256463
doi:10.1371/journal.pone.0057215
PMCID: PMC3581447  PMID: 23459196
5.  Incident Hyperglycaemia among older adults with or at-risk for HIV Infection 
Antiviral therapy  2011;16(2):181-188.
Background
HIV infection has been associated with development of prediabetes and diabetes. Optimum screening practices for these disorders in HIV-infected populations remain unclear.
Methods
We screened 377 adults, with- or at-risk for HIV infection, for incident hyperglycaemia (prediabetes or diabetes) using two oral glucose tolerance tests (OGTTs) a median of 18.6 months apart. We determined proportion of incident cases detected by fasting and 120-min plasma glucose levels. Independent predictors of incident hyperglycaemia were identified using logistic regression.
Results
The baseline OGTT was consistent with diabetes in 7% of participants and with prediabetes in 31%. Among 352 normoglycaemic and prediabetic participants at baseline, 19 (5%) developed diabetes on follow-up. Among participants normoglycaemic at baseline, an additional 38 (16%) developed prediabetes. Overall 52% of incident hyperglycaemia cases were detected by fasting plasma glucose alone, 33% by a 120-min glucose level alone and 15% by both. Factors independently associated with incident hyperglycaemia included age ≥50 years and body mass index ≥30 kg/m2. Neither HIV infection nor highly active antiretroviral therapy (HAART) use were associated with increased risk of diabetes.
Conclusions
Incident hyperglycaemia is common among older adults with or at-risk for HIV infection. HIV-infected individuals with classic diabetes risk factors should be screened for hyperglycaemia regardless of HAART use. OGTTs may be the preferred screening strategy in HIV-infected individuals at high risk for developing hyperglycaemia.
doi:10.3851/IMP1711
PMCID: PMC3552387  PMID: 21447867
6.  Evaluation of a Pilot Medication-Assisted Therapy Program in Kazakhstan: Successes, Challenges, and Opportunities for Scaleup 
Study Aims. Evaluate the quality and effectiveness of the medication-assisted therapy (MAT) pilot in Kazakhstan and review implementation context and related challenges. Methods. We performed a desk review of MAT policy and program documents and reviewed medical records at three MAT sites in Kazakhstan. MAT patients (n = 93) were interviewed to assess their perceptions of the program and its impact on their health, criminal, drug use, and HIV risk related behaviors as well as expenditures on nonprescribed psychoactive drugs. Persons injecting drugs who are not in treatment, MAT program staff, and other stakeholders were interviewed to obtain their perspectives on MAT. Results. Legislation supports introducing MAT as a standard of care for treatment of opioid dependence; however, its progress has been hampered by active opposition. Inadequate access and coverage, insufficient supply management, scarce infrastructure of narcological facilities, limited opportunities for staff development, and restrictive methadone dispensing policies compromise the quality of the intervention and limit its potential benefits. There were significant reductions in criminal, drug use, and HIV risk related behaviors in patients receiving MAT. Conclusions. The MAT pilot in Kazakhstan demonstrated its feasibility and effectiveness in the local context and is recommended for scaleup throughout the country.
doi:10.1155/2012/308793
PMCID: PMC3529415  PMID: 23289082
7.  The insulin-like growth factor axis and risk of liver disease in hepatitis C virus/HIV-co-infected women 
AIDS (London, England)  2008;22(4):527-531.
Objective
Insulin-like growth factor (IGF) I stimulates the proliferation of hepatic stellate cells (HSC), the primary source of extracellular matrix accumulation in liver fibrosis. In contrast, insulin-like growth factor binding protein (IGFBP) 3, the most abundant IGFBP in circulation, negatively modulates HSC mitogenesis. To investigate the role of the IGF axis in hepatitis C virus (HCV)-related liver disease among high-risk patients, we prospectively evaluated HCV-viremic/HIV-positive women.
Design
A cohort investigation.
Methods
Total IGF-I and IGFBP-3 were measured in baseline serum specimens obtained from 472 HCV-viremic/HIV-positive subjects enrolled in the Women's Inter-agency HIV Study, a large multi-institutional cohort. The aspartate aminotransferase to platelet ratio index (APRI), a marker of liver fibrosis, was assessed annually.
Results
Normal APRI levels (< 1.0) at baseline were detected in 374 of the 472 HCV-viremic/HIV-positive subjects tested, of whom 302 had complete liver function test data and were studied. IGF-I was positively associated [adjusted odds ratio comparing the highest and lowest quartiles (AORq4–q1), 5.83; 95% confidence interval (CI) 1.17–29.1; Ptrend = 0.03], and IGFBP-3 was inversely associated (AORq4–q1, 0.13; 95% CI 0.02–0.76; Ptrend = 0.04), with subsequent (incident) detection of an elevated APRI level(> 1.5), after adjustment for the CD4 T-cell count, alcohol consumption, and other risk factors.
Conclusion
High IGF-I may be associated with increased risk and high IGFBP-3 with reduced risk of liver disease among HCV-viremic/HIV-positive women.
doi:10.1097/QAD.0b013e3282f22cdf
PMCID: PMC3507535  PMID: 18301066
aspartate aminotransferase to platelet ratio index; APRI; hepatitis C virus (HCV); HIV; IGFBP-3; IGF; liver disease
8.  The Effects of Opiate Use and Hepatitis C Virus Infection on Risk of Diabetes Mellitus in the Women’s Interagency HIV Study 
Background
Opiate use is common in HIV- and hepatitis C virus (HCV)-infected individuals, however its contribution to the risk of diabetes mellitus is not well understood.
Methods
Prospective study of 1,713 HIV-infected and 652 uninfected participants from the Women’s Interagency HIV Study between October 2000 and March 2006. Diabetes defined as fasting glucose ≥126 mg/dl, or self-report of diabetes medication use or confirmed diabetes diagnosis. Opiate use determined using an interviewer-administered questionnaire. Detectable plasma HCV RNA confirmed HCV infection.
Results
Current opiate users had a higher prevalence of diabetes (15%) than non-users (10%, p=.03), as well as a higher risk of incident diabetes (adjusted relative hazard [RHadj] 1.58, 95% CI 1.01, 2.46), after controlling for HCV infection, HIV/antiretroviral therapy status and diabetes risk factors including age, race/ethnicity, family history of diabetes and body mass index. HCV infection was also an independent risk factor for diabetes (RHadj 1.61, 95% CI 1.02, 2.52). HCV-infected women reporting current opiate use had the highest diabetes incidence (4.83 cases/100 person-years).
Conclusions
Among women with or at-risk for HIV, opiate use is associated with increased diabetes risk independently of HCV infection. Diabetic screening should be part of care for opiate users, and those infected with HCV.
doi:10.1097/QAI.0b013e3181d0c911
PMCID: PMC3069645  PMID: 20190642
opiate use; diabetes mellitus; fasting glucose; Hepatitis C virus; HIV; women
9.  Glycated Hemoglobin in Diabetic Women with and Without HIV Infection: Data from the Women's Interagency HIV Study 
Antiviral therapy  2010;15(4):571-577.
Background
Limited data suggest that glycated hemoglobin (hemoglobin A1c; A1C) values may not reflect glycemic control accurately in HIV-infected individuals with diabetes.
Methods
We evaluated repeated measures of paired fasting glucose and A1C values in 315 HIV-infected and 109 HIV-uninfected diabetic participants in the Women's Interagency HIV Study. Generalized estimating equations used log A1C as the outcome variable, with adjustment for log fasting glucose concentration in all models.
Results
An HIV-infected woman on average had 0.9868 times as much A1C (that is, 1.32% lower; 95% confidence interval 0.9734-0.9904) as an HIV-uninfected woman with the same log fasting glucose concentration. In multivariate analysis, HIV serostatus was not associated, but white, other non-black race, and higher red blood cell mean corpuscular volume (MCV) were statistically associated with lower A1C values. Use of diabetic medication was associated with higher A1C values. In multivariate analysis restricted to HIV-infected women, white and other race, higher MCV, and HCV viremia were associated with lower A1C values whereas older age, use of diabetic medications and higher CD4 cell count were associated with higher A1C values. Use of combination antiretroviral therapy, protease inhibitors, zidovudine, stavudine, or abacavir was not associated with A1C values.
Conclusions
We conclude that A1C values were modestly lower in HIV-infected diabetic women relative to HIV-uninfected diabetic women after adjustment for fasting glucose concentration. The difference was abrogated by adjustment for MCV, race, and diabetic medication use. Our data suggest that in clinical practice A1C gives a reasonably accurate refection of glycemic control in HIV-infected diabetic women.
doi:10.3851/IMP1557
PMCID: PMC2943237  PMID: 20587850
10.  Housing insecurity and lack of public assistance are risk factors for tuberculin skin test conversion among persons who use illicit drugs in New York City 
Journal of addiction medicine  2009;3(3):172-177.
Background
Persons who use illicit drugs are at increased risk of new tuberculosis (TB) infection. We conducted a prospective cohort study to assess rates and risk factors for tuberculin skin test (TST) conversion among persons with a history of illicit drug use, who were enrolled in a methadone program and had a negative baseline 2-step TST (eligible participants).
Methods
TST and standardized interviews were administered to 401 eligible participants from 1995 through 1999, every 6 months for a 2-year follow-up time. Analyses were conducted in 2006.
Results
A total of 1,447 repeat TSTs were performed during 843 person-years of follow-up (median: 2.0 years). The TST conversion rate was 3.7 per 100 person-years. In multivariate analysis, participants who converted were more likely to report ever having been homeless (HR, 2.4; 95% CI, 1.2–5.0) or ever having lived in a homeless shelter (HR, 2.4; 95% CI, 1.2–4.9) at the baseline interview, and less likely to have reported receiving public assistance since the last study visit (RR, 0.15; 95% CI, 0.07–0.32).
Conclusions
This is the first study utilizing 2-step TST at baseline to measure the incidence of TST conversion among persons who use illicit drugs. Controlling for homelessness, persons with a lack of current public assistance was identified as a risk factor for TST conversion. These individuals may most benefit from annual tuberculin skin testing.
doi:10.1097/ADM.0b013e31819eac4c
PMCID: PMC2744413  PMID: 20161091
substance use; tuberculin skin test; tuberculosis; urban; New York City
11.  Self-Perception of Body Fat Changes and HAART Adherence in the Women’s Interagency HIV Study 
AIDS and behavior  2008;13(1):53-59.
To determine the association of self-perceived fat gain or fat loss in central and peripheral body sites with adherence to highly active antiretroviral therapy (HAART) in HIV-seropositive women. 1,671 women from the Women’s Interagency HIV Study who reported HAART use between April 1999 and March 2006 were studied. Adherence was defined as report of taking HAART ≥ 95% of the time during the prior 6 months. Participant report of any increase or decrease in the chest, abdomen, or upper back in the prior 6 months defined central fat gain and central fat loss, respectively. Report of any increase or decrease in the face, arms, legs or buttocks in the prior 6 months defined peripheral fat gain or peripheral fat loss. Younger age, being African-American (vs. White non-Hispanic), a history of IDU, higher HIV RNA at the previous visit, and alcohol consumption were significant predictors of HAART non-adherence (P <0.05). After multivariate adjustment, self-perception of central fat gain was associated with a 1.5-fold increased odds of HAART non-adherence compared to no change. Perception of fat gain in the abdomen was the strongest predictor of HAART non-adherence when the individual body sites were studied. Women who perceive central fat gain particularly in the abdomen are at risk for decreased adherence to HAART despite recent evidence to suggest that HIV and specific antiretroviral drugs are more commonly associated with fat loss than fat gain.
doi:10.1007/s10461-008-9444-7
PMCID: PMC2902995  PMID: 18688706
Lipodystrophy; HIV; Women; HAART adherence; body image perception
13.  Longitudinal Trends in Hazardous Alcohol Consumption Among Women With Human Immunodeficiency Virus Infection, 1995–2006 
American Journal of Epidemiology  2009;169(8):1025-1032.
Hazardous alcohol consumption among women with human immunodeficiency virus (HIV) infection is associated with several adverse health and behavioral outcomes, but the proportion of HIV-positive women who engage in hazardous drinking over time is unclear. The authors sought to determine rates of hazardous alcohol consumption among these women over time and to identify factors associated with this behavior. Subjects were 2,770 HIV-positive women recruited from 6 US cities who participated in semiannual follow-up visits in the Women's Interagency HIV Study from 1995 to 2006. Hazardous alcohol consumption was defined as exceeding daily (≥4 drinks) or weekly (>7 drinks) consumption recommendations. Over the 11-year follow-up period, 14%–24% of the women reported past-year hazardous drinking, with a slight decrease in hazardous drinking over time. Women were significantly more likely to report hazardous drinking if they were unemployed, were not high school graduates, had been enrolled in the original cohort (1994–1995), had a CD4 cell count of 200–500 cells/mL, were hepatitis C-seropositive, or had symptoms of depression. Approximately 1 in 5 of the women met criteria for hazardous drinking. Interventions to identify and address hazardous drinking among HIV-positive women are urgently needed.
doi:10.1093/aje/kwp004
PMCID: PMC2727230  PMID: 19270052
alcohol drinking; HIV; longitudinal studies; women
14.  Crack Cocaine, Disease Progression, and Mortality in a Multi-Center Cohort of HIV-1 Positive Women 
AIDS (London, England)  2008;22(11):1355-1363.
Background
Longitudinal associations between patterns of crack cocaine use and progression of human immunodeficiency virus (HIV-1) disease are poorly understood, especially among women. This paper explores relationships between crack use and HIV-1 disease outcomes in a multi-center cohort of infected women.
Methods
Subjects were 1686 HIV-seropositive women enrolled at six U.S. research centers in the Women’s Interagency HIV Study. Approximately 80% were nonwhite and 29% used crack during the study period. Cox survival and random regression analysis examined bi-annual observations made April 1996 through September 2004. Outcome measures included: death due to AIDS-related causes; CD4 cell count; HIV-1 RNA level; and newly acquired AIDS-defining illnesses.
Results
Persistent crack users were over three times as likely as nonusers to die from AIDS-related causes, controlling for use of highly active antiretroviral viral therapies self-reported at >=95% adherence, problem drinking, age, race, income, education, illness duration, study site, and baseline virologic and immunological indicators. Persistent crack users and intermittent users in active phases showed greater CD4 cell loss and higher HIV-1 RNA levels controlling for the same covariates. Persistent and intermittent crack users were more likely than nonusers to develop new AIDS-defining illnesses controlling for identical confounds. These results persisted when controlling for heroin use, tobacco smoking, depressive symptoms, Hepatitis C virus co-infection, and intravenous drug use.
Conclusions
Use of crack cocaine independently predicts AIDS-related mortality, immunologic and virologic markers of HIV-1 disease progression, and development of AIDS-defining illnesses among women.
doi:10.1097/QAD.0b013e32830507f2
PMCID: PMC2645902  PMID: 18580615
15.  Antiretroviral Therapy Adherence and Viral Suppression in HIV-Infected Drug Users: Comparison of Self-Report and Electronic Monitoring 
To compare electronically monitored (MEMS) with self-reported adherence in drug users, including the impact of adherence on HIV load, we conducted a 6-month observational study of 67 antiretroviral-experienced current and former drug users. Adherence (percentage of doses taken as prescribed) was calculated for both the day and the week preceding each of 6 research visits. Mean self-reported 1-day adherence was 79% (median, 86%), and mean self-reported 1-week adherence was 78% (median, 85%). Mean MEMS 1-day adherence was 57% (median, 52%), and mean MEMS 1-week adherence was 53% (median, 49%). One-day and 1-week estimates were highly correlated (r> .8 for both measures). Both self-reported and MEMS adherence were correlated with concurrent HIV load (r=.43–.60), but the likelihood of achieving virologic suppression was greater if MEMS adherence was high than if self-reported adherence was high. We conclude that self-reported adherence is higher than MEMS adherence, but a strong relationship exists between both measures and virus load. However, electronic monitoring is more sensitive than self-report for the detection of nonadherence and should be used in adherence intervention studies.
doi:10.1086/323201
PMCID: PMC2692641  PMID: 11550118
16.  Attitudes toward menopause in HIV-infected and at-risk women 
Clinical Interventions in Aging  2008;3(3):561-566.
Objective
To study attitudes toward menopause in women with or at risk of human immunodeficiency virus (HIV) aged 35 to 60 in New York City, NY, USA.
Design
Data were obtained at the baseline interview in a cohort study of menopause. Of 502 participating women, 92 were postmenopausal and 162 were perimenopausal.
Results
Overall, 37.5% of women had a relatively favorable attitude toward menopause. African Americans had a 72% greater odds of a positive attitude (OR = 1.72, 95% CI 1.16–2.57) than all other groups after adjusting for covariates. Hispanic women had the least favorable view of menopause. Experience of >3 menopausal symptoms and negative life events—being a witness to a murder, and the death of a child—were significantly associated with negative attitudes towards menopause (OR = 0.62, 95% CI 0.42–0.93 and OR = 0.64, 95% CI 0.43–0.93, respectively). Depressive symptoms, street drug use, and having a domestic partner, which is significant in single variable analyses, did not remain independent predictors in multivariate results. HIV status, menopause status, and age at interview were not associated with menopause attitudes.
Conclusions
HIV-infected, drug-using, low-income women showed generally unfavorable attitudes towards menopause. High stress life events coupled with a high prevalence of depressive symptoms indicate this population has special needs marked by the menopause transition into older age.
PMCID: PMC2682388  PMID: 18982926
menopause; attitudes; HIV; street drug users
17.  Decreased bone mineral density and increased fracture risk in aging men with or at risk for HIV infection 
AIDS (London, England)  2007;21(5):617-623.
Background
Osteopenia has been described in HIV-infected persons, but most studies have not focused on aging men, have not included an HIV-negative comparison group with similar risks to those of the HIV-infected men, or lacked data on fracture rates.
Methods
We analyzed bone mineral density (BMD) and incident fractures in 559 men who were ≥ 49 years old with or at-risk for HIV, including 328 with and 231 without HIV infection.
Results
Median age was 55 years, 56% were black and 89% had used illicit drugs. In unadjusted analysis, BMD was lower in HIV-infected compared with HIV-uninfected men at the femoral neck (0.97 ± 0.14 versus 1.00 ± 0.15 g/cm2; P < 0.05) and lumbar spine (1.17 ± 0.20 versus 1.20 ± 0.21 g/cm2; P = 0.06); both differences were significant (P < 0.05) after adjusting for age, weight, race, testosterone level, and prednisone and illicit drug use. Non-black race and body weight were independently associated with BMD at both measurement sites and methadone therapy was independently associated with spine BMD. Among HIV-infected men, 87% had taken antiretrovirals and 74% had taken protease inhibitors, but their use was not associated with BMD. Among men who had at least one subsequent study visit (94%), incident fracture rates per 100 person-years differed among men with normal BMD, osteopenia and osteoporosis (1.4 versus 3.6 versus 6.5; P < 0.01). A 38% increase in fracture rate among HIV-infected men was not statistically significant.
Conclusions
HIV infection is independently associated with modestly reduced BMD in aging men, and decreased BMD is associated with increased fracture risk.
doi:10.1097/QAD.0b013e3280148c05
PMCID: PMC2426821  PMID: 17314524
osteopenia; osteoporosis; bone mineral density; bone fractures; antiretroviral therapy; opiate dependence
18.  Hepatitis C Infection Is Associated with Lower Lipids and High-Sensitivity C-Reactive Protein in HIV-Infected Men 
AIDS patient care and STDs  2007;21(7):479-491.
Increased cardiovascular risk has been linked to HIV infection and combination antiretroviral therapy, but the impact of hepatitis C virus (HCV) status on indices of cardiovascular risk has not been routinely assessed in the HIV-infected population. The objective of this study was to analyze associations of HCV, HIV, and combination antiretroviral therapy with lipid levels and C-reactive protein (CRP) among older men. We measured fasting total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglyceride, and high-sensitivity CRP serum levels in a cross-sectional study of 108 HIV-infected and 74 HIV-uninfected at-risk older men. One hundred ten men (60%) had detectable HCV RNA, with no difference by HIV status (p = 0.25). The majority (88%) of men with HCV infection had a history of injection drug use. Among all men, HCV infection was independently associated with lower total cholesterol (p < 0.001), LDL-C (p < 0.001), triglycerides (p = 0.01), and CRP (p < 0.001). Among HIV-infected men, HCV infection was associated with lower total cholesterol (p < 0.001), LDL-C (p < 0.001), and CRP (p = 0.004). HCV infection was associated with lower triglycerides among men on protease inhibitors (PI) (p = 0.02) and non-PI combination antiretroviral therapy (p = 0.02), but not among antiretroviral-naïve men. These findings demonstrate an association of lower serum lipid and CRP levels with HCV infection and suggest that HCV status should be assessed as an important correlate of cardiovascular risk factors in studies of older men with or at risk for HIV.
doi:10.1089/apc.2006.0150
PMCID: PMC2423809  PMID: 17651029
19.  Hepatitis C virus infection is associated with insulin resistance among older adults with or at risk of HIV infection 
AIDS (London, England)  2007;21(5):633-641.
Objectives
To determine the associations of hepatitis C virus (HCV) infection with insulin resistance and abnormal glucose tolerance in a cohort of older adults with or at risk of HIV infection.
Design
A cross-sectional study of 267 HIV-infected and 179 at-risk-uninfected adults without a history of diabetes mellitus.
Methods
HCV antibody assays and RNA levels were performed to assess HCV status. Antiretroviral use, family history of diabetes, sedentary behavior, and sociodemographic data were obtained using standardized interviews. Fasting insulin levels and oral glucose tolerance tests were performed to assess two outcomes, the homeostasis model assessment of insulin resistance and abnormal glucose tolerance [impaired glucose tolerance (IGT) or diabetes].
Results
Of 446 participants, 265 (59%) were HCV seropositive; of these, 199 (75%) had detectable HCV-RNA levels. Insulin resistance was greater among HCV-seropositive compared with seronegative participants, adjusting for body mass index, Hispanic ethnicity, age greater than 55 years, sedentary behavior (watching television > 4 h/day), HIV status, HAART, and protease inhibitor (PI) use. Ninety-eight participants (22%) had abnormal glucose tolerance (69 with IGT and 29 with diabetes). Among HIV-infected participants, 25% were on non-PI HAART and 52% were on PI HAART, but HAART and PI use were not associated with insulin resistance or abnormal glucose tolerance. Among obese participants, abnormal glucose tolerance was more common in HCV-seropositive than seronegative individuals, whereas among non-obese participants there was no association.
Conclusion
The potential impact of HCV co-infection and obesity on glucose metabolism should be recognized in clinical care, and addressed in future research studies of HIV-infected individuals.
doi:10.1097/QAD.0b013e3280464db7
PMCID: PMC2423380  PMID: 17314526
Hepatitis C virus; HIV; impaired glucose tolerance; insulin resistance; obesity; type 2 diabetes
20.  The Relationship between Cocaine Use and Human Papillomavirus Infections in HIV-Seropositive and HIV-Seronegative Women 
Objective. Animal data suggest that cocaine has an immunosuppressive effect, but no human studies have been conducted to assess the relation of cocaine use with human papillomavirus (HPV) infection, the viral cause of cervical cancer. Since both cocaine use and HPV infection are common among HIV-positive women, we sought to determine whether use of cocaine and/or crack influences the natural history of HPV among women with or at high risk of HIV. Methods. Women enrolled in the Women's Interagency HIV Study (2278 HIV-seropositive and 826 high-risk seronegative women) were examined every six months for up to 9.5 years with Pap smear, collection of cervicovaginal lavage (CVL) samples, and detailed questionnaires regarding health and behavior, including use of crack and cocaine (crack/cocaine). CVLs were tested for HPV DNA by PCR, with genotyping for over forty HPV types. Results. In multivariate logistic regression models, censoring women treated for cervical neoplasia, crack/cocaine use within the last six months was associated with prevalent detection of oncogenic HPV DNA (odds ratio [OR] = 1.30 (1.09–1.55)), and with oncogenic HPV-positive squamous intraepithelial lesions (SIL) (OR = 1.70 (1.27–2.27)), following adjustment for age, race, HIV-serostatus, and CD4+ T-cell count, the number of sexual partners in the past six months, and smoking. In multivariate Cox models crack/cocaine use was also associated with a trend that approached significance in regard to incident detection of oncogenic HPV-positive SIL (HR = 1.51, 95% CI 0.99–2.30), and while the rate of oncogenic HPV clearance was not related to cocaine use, the clearance of any SIL was significantly lower in those with versus those without recent crack/cocaine use (HR = 0.57, 95% CI 0.34–0.97). Conclusions. Cocaine use is associated with an increased risk of detection of both prevalent and incident oncogenic HPV infection, as well as an increased risk of HPV-positive SIL over time.
doi:10.1155/2008/587082
PMCID: PMC2324195  PMID: 18437233
21.  Disorders of Glucose Metabolism in HIV-Infected Women 
Background
Abnormal glucose metabolism in HIV-infected patients has largely been attributed to protease inhibitor use. However most studies of glucose metabolism in HIV-infected patients have focused on men or have lacked appropriate controls.
Methods
We assessed factors associated with previously-diagnosed diabetes among 620 midlife women with- or at-risk for HIV infection. In a subset of 221 women without previously-diagnosed diabetes, we performed an oral glucose tolerance test (OGTT) with insulin levels, and assessed factors associated with abnormal glucose tolerance, insulin resistance, and insulin secretion.
Results
Thirteen percent had previously-diagnosed diabetes. Among women without previously diagnosed diabetes who underwent an OGTT, 6% had undiagnosed diabetes and 12% had impaired glucose tolerance (IGT). On multivariate analysis, factors associated with previously-diagnosed diabetes included current methadone treatment, body mass index, family history of diabetes, and physical inactivity. Factors independently associated with abnormal OGTT (IGT or diabetes) included age ≥50 y, family history of diabetes, physical inactivity, and pack-years of smoking. Factors independently associated with insulin resistance included waist circumference, Hispanic ethnicity, physical inactivity, and among HIV-infected women, use of non-PI HAART. Factors associated with lower insulin secretion included current opiate use (methadone or heroin) and older age.
Conclusions
Abnormal glucose metabolism is highly prevalent among midlife women with or at-risk for HIV infection, particularly those who use opiates. Women with classic diabetes risk factors, rather than solely those taking PIs, should be screened for diabetes in the primary care setting. Interventions targeting modifiable risk factors, including obesity and physical inactivity, are also warranted.
doi:10.1086/429824
PMCID: PMC2104646  PMID: 15844072
human immunodeficiency virus (HIV); diabetes mellitus; antiretroviral therapy; women; drug use
22.  Supramolecular Complexes Mediate Selenocysteine Incorporation In Vivo 
Molecular and Cellular Biology  2006;26(6):2337-2346.
Selenocysteine incorporation in eukaryotes occurs cotranslationally at UGA codons via the interactions of RNA-protein complexes, one comprised of selenocysteyl (Sec)-tRNA[Ser]Sec and its specific elongation factor, EFsec, and another consisting of the SECIS element and SECIS binding protein, SBP2. Other factors implicated in this pathway include two selenophosphate synthetases, SPS1 and SPS2, ribosomal protein L30, and two factors identified as binding tRNA[Ser]Sec, termed soluble liver antigen/liver protein (SLA/LP) and SECp43. We report that SLA/LP and SPS1 interact in vitro and in vivo and that SECp43 cotransfection increases this interaction and redistributes all three proteins to a predominantly nuclear localization. We further show that SECp43 interacts with the selenocysteyl-tRNA[Ser]Sec-EFsec complex in vitro, and SECp43 coexpression promotes interaction between EFsec and SBP2 in vivo. Additionally, SECp43 increases selenocysteine incorporation and selenoprotein mRNA levels, the latter presumably due to circumvention of nonsense-mediated decay. Thus, SECp43 emerges as a key player in orchestrating the interactions and localization of the other factors involved in selenoprotein biosynthesis. Finally, our studies delineating the multiple, coordinated protein-nucleic acid interactions between SECp43 and the previously described selenoprotein cotranslational factors resulted in a model of selenocysteine biosynthesis and incorporation dependent upon both cytoplasmic and nuclear supramolecular complexes.
doi:10.1128/MCB.26.6.2337-2346.2006
PMCID: PMC1430297  PMID: 16508009
23.  Nuclear Assembly of UGA Decoding Complexes on Selenoprotein mRNAs: a Mechanism for Eluding Nonsense-Mediated Decay? 
Molecular and Cellular Biology  2006;26(5):1795-1805.
Recoding of UGA from a stop codon to selenocysteine poses a dilemma for the protein translation machinery. In eukaryotes, two factors that are crucial to this recoding process are the mRNA binding protein of the Sec insertion sequence, SBP2, and the specialized elongation factor, EFsec. We sought to determine the subcellular localization of these selenoprotein synthesis factors in mammalian cells and thus gain insight into how selenoprotein mRNAs might circumvent nonsense-mediated decay. Intriguingly, both EFsec and SBP2 localization differed depending on the cell line but significant colocalization of the two proteins was observed in cells where SBP2 levels were detectable. We identify functional nuclear localization and export signals in both proteins, demonstrate that SBP2 undergoes nucleocytoplasmic shuttling, and provide evidence that SBP2 levels and localization may influence EFsec localization. Our results suggest a mechanism for the nuclear assembly of the selenocysteine incorporation machinery that could allow selenoprotein mRNAs to circumvent nonsense-mediated decay, thus providing new insights into the mechanism of selenoprotein translation.
doi:10.1128/MCB.26.5.1795-1805.2006
PMCID: PMC1430236  PMID: 16478999
24.  Gender Differences in Factors Associated with Adherence to Antiretroviral Therapy 
Journal of General Internal Medicine  2004;19(11):1111-1117.
OBJECTIVE
To identify gender differences in social and behavioral factors associated with antiretroviral adherence.
DESIGN
Prospective cohort study.
SETTING
Methadone maintenance program.
PARTICIPANTS
One hundred thirteen HIV-seropositive current or former opioid users.
MEASUREMENTS AND MAIN RESULTS
Participants were surveyed at baseline about social and behavioral characteristics and at monthly research visits about drug and alcohol use and medication side effects. Electronic monitors (MEMS) were used to measure antiretroviral adherence. Median adherence among women was 27% lower than among men (46% vs. 73%; P < .05). In gender-stratified multivariate models, factors associated with worse adherence in men included not belonging to an HIV support group (P < .0001), crack/cocaine use (P < .005), and medication side effects (P = .01). Among women, alcohol use (P = .005), heroin use (P < .05), and significant medication side effects (P < .005) were independently associated with worse adherence. In a model including both men and women, worse adherence was associated with lack of long-term housing (P < .005), not belonging to any HIV support groups (P < .0005), crack or cocaine use (P < .01), and medication side effects (P < .0005). In addition, worse adherence was associated with the interaction between female gender and alcohol use (P ≤ .05).
CONCLUSIONS
In this cohort of current and former opioid users, gender-stratified analysis demonstrated that different social and behavioral factors are associated with adherence in men and women. Among both men and women, worse adherence was associated with lack of long-term housing, not belonging to an HIV support group, crack/cocaine use, and medication side effects. Among women only, alcohol use was associated with worse adherence.
doi:10.1111/j.1525-1497.2004.30445.x
PMCID: PMC1196356  PMID: 15566440
adherence; gender; alcohol; antiretroviral therapy; electronic monitors
25.  Validity of a Self-reported History of a Positive Tuberculin Skin Test 
Journal of General Internal Medicine  2004;19(10):1039-1044.
OBJECTIVE
To define the prevalence of and factors associated with having a negative purified protein derivative (PPD) among persons who self-report a prior positive PPD and to define the safety of repeat testing in such persons.
DESIGN
Observational cohort study.
SETTING
Methadone maintenance program with onsite primary care.
PATIENTS/PARTICIPANTS
Current or former drug users enrolled in methadone maintenance treatment.
INTERVENTIONS
Structured interview, tuberculin skin testing regardless of self-reported PPD status, and anergy testing.
MEASUREMENTS AND MAIN RESULTS
Nearly one third (31%) of participants who self-reported a prior positive PPD had a negative measured PPD, despite receipt of a “booster” PPD. A single participant (0.5%) blistered in response to the PPD without lasting ill effect. Participants with PPD results discordant from their history were more likely to be HIV-seropositive and nonreactive to the anergy panel. The discordance rate among HIV-infected participants was 43%, and was largely attributable to immune dysfunction. Among HIV-seronegative participants, the discordance rate was 27%. Recent crack-cocaine use was independently associated with discordance in the absence of HIV infection.
CONCLUSIONS
We confirmed that planting a PPD in patients who self-report a positive PPD history confers minimal risk. Substantial rates of discordance exist between self-reported history of a positive PPD and measured PPD status. Further research is needed to define the optimal management of PPD-negative patients who self-report a prior positive PPD and who have not received prior treatment for latent tuberculosis.
doi:10.1111/j.1525-1497.2004.30424.x
PMCID: PMC1492579  PMID: 15482557
tuberculin skin testing; PPD; tuberculosis screening; drug users

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